The Haven Of Tuscola

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications as ordered for four (R2, R9 R28 and R33) of four residents reviewed for medication administration from a total sample list of 32 residents. Findings include: The facility provided Medication Administration Policy dated 11/18/17 documents that medications must be prepared and administered within one hour of the designated time or as ordered. Document any medications not administered for any reason by circling initials and documenting on the back of the medication administration record, the date, the time, the medication and the dosage, and the reason for the omission and initials. 1.) R2's undated care plan documents a diagnosis of Autoimmune Thyroiditis. R2's Medication Administration Record dated 1/26/25 documents an order for Levothyroxine 75 micrograms, and that R2 did not receive her 5:00AM dose. On 1/26/24 at 3:35PM, V4 Licensed Practical Nurse stated that she was calling the doctor now to let them know that the night nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer pneumococcal vaccination to four of five residents (R1, R4, R28, R31) reviewed for immunizations in the sample list of 32. Findings include: The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 documents it is recommended that adults age [AGE] or older with no prior pneumococcal vaccination should be given PCV20 (pneumococcal conjugate vaccine), or be given PCV15 followed by PPSV23 (pneumococcal polysaccharide vaccine) a year later. Adults age [AGE] or older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of 65 and in consultation with their provider may choose to administer PCV20 five years after their last pneumococcal vaccination. The facility's Influenza and Pneumococcal Immunizations policy dated November 2016 documents residents will be educated on the pneumococcal vaccine and will be given the opportunity to accept or refuse the vaccine.…

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 assess for the ability to self administer medications for one of one resident (R4) reviewed for self administration of medications in the sample list of 32. Findings include: The facility's Medication Administration policy dated 11/18/17 documents to observe the resident consume and swallow medications, never leave prepared medications unattended, and medications should not be left at the bedside unless there is a physician order to do so. The facility's Self Medication Administration Assessment form documents to assess the resident's cognition, decision making ability, vision, physical ability, coordination, and eligibility to self administer medications. On 1/26/25 at 9:00 AM R4 was in a wheelchair in R4's room. There was a Wixela inhaler, a bottle of Fluticasone, and a medication cup containing several pills on R4's bedside table. R4 stated R4 self administers one puff of the inhaler daily and the medications were R4's morning…

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 correct size brief was available for a resident to prevent skin breakdown for one of one resident (R33) reviewed for skin care from a total sample list of 32 residents. Findings include: The facility provided Skin Condition Monitoring Policy dated 1/2018 documents that it is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. R33's care plan dated 4/23/24 documents that R33 is at an increased risk for skin abnormalities and requires weekly monitoring and safety measures to prevent dermatologic reactions. R33's wound assessment and plan dated 1/23/25 documents a new left abdominal fold wound with an order to cleanse with wound cleanser, apply honey coated absorbent dressing then cover with bordered gauze dressing daily and as needed. R33's nurse's notes dated 1/27/25 document wound culture results show infection in the wound with new orders received to provide Levofloxacin 250mg daily for three days. On 1/27/25 at 3:40PM V11…

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 complete a safe full mechanical lift transfer, thoroughly investigate a fall and document details of a fall and physician notification in the resident's medical record for one of two residents (R31) reviewed for falls in the sample list of 32. Findings include: On 1/26/25 at 8:36 AM R31 was lying in bed and stated within the last few months R31 was dropped out of the full mechanical lift sling during a transfer. R31 stated R31 was sent to the hospital due to R31 hitting his head during the fall but did not sustain any injuries. R31 stated there were two certified nursing assistants (CNAs) during the transfer, but the straps of the sling weren't secure and came off of the lift causing the fall. On 1/27/25 at 9:12 AM R31 was sitting in a wheelchair in R31's room with a full body cloth sling positioned underneath of R31. R31 stated this was not the type of sling that was used during R31's fall, which hasn't been used since the fall occurred.…

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 hygienic incontinence care to one (R7) of one residents reviewed for incontinence care from a total sample list of 29 residents. Findings include: The facility policy dated 12/2017 documents that the purpose of the policy is to eliminate odor, prevent irritation and infection and to enhance resident's self esteem. Directions include washing pubic area including the upper inner aspect of both thighs as well as the penis and scrotum by retracting the foreskin and washing carefully to remove secretions and washing the area under the scrotum. The area should be rinsed after washing and dried and the anal area should be washed with changing gloves and washing hands when going from contaminated to clean areas. R7's care plan dated 10/23/24 documents that R7 is dependent for toileting. On 1/28/25 at 9:36AM, V13 Certified Nursing Assistant (CNA) provided incontinence care for R7. During incontinence care, V13 CNA failed to cleanse R7's pubic area thoroughly, failed to retract R7's foreskin to cleanse the area,…

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 monitor an enteral feeding including inputs and outputs and failed to monitor the weights of a resident receiving enteral feedings for one (R30) of one resident reviewed for enteral feedings from a total sample list of 32 residents. Findings include: The facility provided Enteral Feeding Closed System Ready to Hang Product documents that the enteral feeding amounts and other related information is to be documented on the flow record and or treatment/medication administration record. R30's Medication Administration Record dated January 2025 documents a tube feeding order for Jevity 1.5 calorie to be given at 65 milliliters per hour for 23 hours, to be held one hour before the administration of Levothyroxine and flushed with 100 cubic centimeters of water every four hours. R30's care plan dated 10/16/24 documents that tube placement and gastric contents/residual volume is to be checked and documented. Additionally, R30's care plan documents that R30 will maintain adequate nutrition and hydration status as evidenced by stable…

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 gradual dose reduction for one (R1) resident of five residents reviewed for psychotropic medications from a total sample list of 32 residents. Findings include: The facility psychotropic medication policy dated 6/17/22 documents that psychotropic medications shall not be used without proper monitoring. Additionally, residents who use antipsychotic medications will receive a gradual dose reduction at least twice in a year. R1's January 2025 Physician Order Summary documents orders for Sertraline (antidepressant) 75 milligrams (mg) by mouth daily since 11/27/23. The facility's Pharmacy Consultation Summary Report dated 9/27/24 documents R1 has ongoing antidepressant use and to attempt a gradual dose reduction (GDR). There is no documentation in R1's medical record that a GDR was attempted as recommended. On 1/27/25 at 1:42 PM V2 Assistant Director of Nursing reviewed the pharmacy report and confirmed R1 should have had a GDR attempted in September 2024. V2 stated usually pharmacy gives us a form to send 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 ensure three residents (R1, R3, R4) were free from abuse by another resident (R2). This failure affects five (R1, R2, R3, R4, R5) residents reviewed for abuse in the sample of four. Findings Include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely cognitively impaired and was independently mobile with a wheelchair. R2's Care plan reviewed 8/15/24 documents R2 has behavioral problem: Physical behaviors related to Parkinson's Disease. The facility's Incident Report dated 10/21/24 documents (R1) alleged (R2) struck (R1) with (R2's) foot on the front porch. Residents immediately separated pending investigation. All parties notified. R2's AIMS for Wellness note dated 10/25/24 documents, transferred to hospital for increased aggressive behaviors. On 11/13/24 at 1:00PM V3, [NAME] stated Dietary staff go outside with residents and observe the smokers after lunch. On 10/21/24 I was outside with residents and so was (V4)…

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 a dependent resident with dressing assistance of compression stocking for one of four residents (R1) reviewed for wounds/activities of daily living assistance on the sample list of four. Findings include: R1's Physician Order Summary sheet (POS) dated 10/1/24 - 10/31/24 documents the following: Diabetes Mellitus Type II, Other Sequela Of Cerebral Infarction With Diabetic Neuropathy, Unspecified, Morbid (Severe) Obesity Due to Excess Calories. R1's same POS documents the following treatment orders: Elevate Legs after each meals, (name brand) Compression hose, On in am off at HS (bedtime). R1's Wound Assessment and Plan dated 10/24/24 documents the following: Diabetic Wound, Dorsal Aspect of Left Foot. Wound Onset: 08/17/24 Healing Status: Healing. Depth of Tissue Involvement: Full Thickness: with Fat Layer Exposed Wound Measurement: 4cm (centimeters). Length x 5.6cm. Width x <0.1 cm. Depth Wound Bed Tissue Composition at Beginning…

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 prevent cross contamination between wounds, during wound treatment for one of four residents (R3) reviewed for wounds on the sample list of four. Findings include: R3's Physician Order Sheet (POS) dated 10/01/24-10/31/24 documents the following: Site; Right Buttock Cleanse with NSS (Normal Saline) and apply a thin layer of Hydrogel and Zinc Cream every shift and prn (as needed). The same POS documents: R (right) Breast, clean w (with) wound cleanser and cover w (with) bordered gauze (dressing), daily and prn. R3's Wound Assessment and Plan signed by V9, Wound Nurse Practitioner documents the following: Visit Date: October 24, 2024 Discussed care and course of treatment and obtained general consent to evaluate and treat. Wound Visit Type: Active/Initial Phase of Treatment Wound Location: right breast Wound Type: Other abscess Depth of Tissue Involvement: Part Thk (thickness): Limited To Exposed Epidermis/Dermis Wound Measurement: 0.5cm.…

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 post infection control/contact isolation precaution sign to alert staff and visitors to wear personal protective equipment, and failed to wear personal protective gowns during high risk personal care care These failures affected one of four (R3) residents reviewed for wound/infection control on the sample list of four. Findings include: R3's Physician Order Sheet (POS) dated 10/01/24-10/31/24 documents the following: Site; Right Buttock Cleanse with NSS (Normal Saline) and apply a thin layer of Hydrogel and Zinc Cream every shift and prn (as needed). The same POS documents: R (right) Breast, clean w (with) wound cleanser and cover w (with) bordered gauze (dressing), daily and prn. R3's Wound Assessment and Plan signed by V9, Wound Nurse Practitioner documents the following: Visit Date: October 24, 2024 Discussed care and course of treatment and obtained general consent to evaluate and treat. Wound Visit Type: Active/Initial Phase of Treatment…

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 five (R1, R2, R5, R6, R7) residents received timely Physician visits out of five residents reviewed for Physician visits in a sample list of seven residents. Findings include: 1.) R1's Face Sheet documents R1 was admitted to facility on 6/21/24. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being dependent on staff for dressing, toileting and personal hygiene. This same MDS documents R1 requires the assistance of two staff members and a total body mechanical lift for transfers. R1's Medical Record does not document a Physician visit since admission. On 8/14/24 at 9:30 AM R1 stated I have not been seen by any Physician since I have been here (facility). 2.) R2's undated Face Sheet documents R2 admitted to facility on 7/3/24. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired. R2's Cognitive assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain a residents' dignity by not providing timely incontinence care for one (R1) of three residents reviewed for incontinence care in a sample of seven residents. Findings include: R1's Face Sheet documents R1 was admitted to facility on 6/21/24. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being dependent on staff for dressing, toileting and personal hygiene. This same MDS documents R1 requires the assistance of two staff members and a total body mechanical lift for transfers. a.) On 8/14/24 at 10:15 AM R1 stated I had to lay in my own urine all night long. I put on my call light four times that night (8/7/24). (V23) Certified Nurse Aide (CNA) answered my call light each time, turned it off and left my room. (V23) did not change my incontinence brief or pad underneath me. I had to lay in urine all night. On the fourth time I put on my call light…

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 residents' preferences for personal care (toileting) were honored. This failure affects one (R5) of three residents reviewed for dignity in a sample list of seven residents. Findings include: R5's undated Face Sheet documents R5 admitted to facility on 12/1/2023. R5's Physician Order Sheet (POS) dated August 2024 documents R5's medical diagnoses as Hypertension, Hypothyroidism, Gastroesophageal Reflux Disease (GERD), Restless Leg Syndrome, Cerebral Palsy, Asthma and Sleep Apnea. R5's Cognitive assessment dated [DATE] documents R5 as cognitively intact. R5's Care Plan intervention dated 2/22/24 documents R5 requires the assistance of two staff members and a total body mechanical lift for transfers. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as dependent on staff for toileting and requires maximum assistance for lower body dressing and bathing. On 8/14/24 and 8/15/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely incontinence care for a resident dependent on staff assistance with toileting and a history of skin breakdown. This failure affects one (R1) of three residents reviewed for incontinence care in a sample of seven residents. Findings include: R1's Face Sheet documents R1 was admitted to facility on 6/21/24. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Medical Record documents R1's medical diagnoses as Acute Systolic Heart Failure, Anxiety Disorder, Chronic Kidney Disease Stage 3, Stage II Left Buttock Pressure Ulcer, History of Falls, Human Metapneumovirus, Morbid Obesity, Paroxysmal Atrial Fibrillation, Stage 3 Right Buttock Pressure Ulcer and Unsteadiness on Feet. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being dependent on staff for dressing, toileting and personal hygiene. This same MDS documents R1 requires the assistance of two staff members and a total body mechanical…

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 prevent cross contamination during incontinence care for one (R1) resident out of three residents reviewed for incontinence care in a sample list of seven residents. Findings include: R1's Face Sheet documents R1 was admitted to facility on 6/21/24. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Medical Record documents R1's medical diagnoses as Acute Systolic Heart Failure, Anxiety Disorder, Chronic Kidney Disease Stage 3, Stage II Left Buttock Pressure Ulcer, History of Falls, Human Metapneumovirus, Morbid Obesity, Paroxysmal Atrial Fibrillation, Stage 3 Right Buttock Pressure Ulcer and Unsteadiness on Feet. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being dependent on staff for dressing, toileting and personal hygiene. This same MDS documents R1 requires the assistance of two staff members and a total body mechanical lift for transfers. On 8/14/24 at 1:15 PM V10 and V16 Certified Nurse Aides…

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 four (R1, R2, R3, ,R4) residents have a homelike, clean environment out of four residents reviewed for Physical Environment in a sample list of six residents. Findings include: Resident Council Minutes dated 3/18/24 document a nursing concern of Aides (CNA) putting clothes on floor, beds not being made, call lights not answered in timely manner, sheets not changed, bed pans need to be put out of sight and in a bag and housekeeping needs improvement with picking up trash, mopping floors and cleaning bathrooms. Resident Council Minutes dated 4/15/24 document concerns of residents ask for beds being made and report weekend trash issues. 1. R1's undated Medical Diagnosis List documents R1's medical diagnoses as Acute Kidney Injury, Chronic Depression, Trans Ischemic Attack (TIA), Vitamin B12 Deficiency, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus Type II. R1's Cognitive assessment…

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 staff to resident mental abuse to the State Agency for one (R5) of three residents reviewed for abuse in a sample list of six residents. Findings include: R5's Physician Order Sheet (POS) dated June 2024 documents R5's medical diagnoses as Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm and Cerebral Vascular Accident (CVA). R5's Cognitive assessment dated [DATE] documents R5 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as requiring maximum assist for transfers, bed mobility, personal hygiene and toileting. R5's Grievance Report dated 6/6/24 documents V10 Certified Nurse Aide (CNA) allegedly was mentally abusive to R5. The facility was unable to provide documentation of R5's allegation of abuse being reported to the State Agency. On 6/8/24 at 3:55 PM V1 Administrator stated R5's allegation of abuse was not reported to the State Agency. V1…

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 thoroughly/timely investigate an allegation of staff to resident mental abuse and failed to remove the accused staff member from resident care during the investigation for one of three residents (R5) reviewed for abuse on the sample of six residents. Findings include: R5's Physician Order Sheet (POS) dated June 2024 documents R5's medical diagnoses as Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm and Cerebral Vascular Accident (CVA). R5's Cognitive assessment dated [DATE] documents R5 as cognitively intact. R5's Grievance Report dated 6/6/24 documents V10 Certified Nurse Aide (CNA) allegedly was mentally abusive to R5. The facility was unable to provide documentation of R1's allegation of abuse being investigated timely. On 6/8/24 at 11:45 AM V1 Administrator stated V1 interviewed R5 on the morning of 6/6/24 after V14 Social Service Director (SSD) reported R5's allegation to V1. V1…

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 individual functioning call lights to two (R1, R2) residents out of six residents reviewed for call lights in a sample list of six residents. Findings include: R1's undated Medical Diagnosis List documents R1's medical diagnoses as Acute Kidney Injury, Chronic Depression, Trans Ischemic Attack (TIA), Vitamin B12 Deficiency, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus Type II. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R2's undated Medical Diagnosis List documents R2's medical diagnoses as Osteoarthritis of both Knees, Urinary Incontinence, Cerebral Meningioma, Restrictive Lung Disease, Restless Leg Syndrome, Fibromyalgia, Degenerative Disc Disease, Hypertension, Depression, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Obesity and Anxiety. R2's Cognitive assessment dated [DATE] documents R2 as cognitively intact. On 6/8/24 at 12:15…

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 employ a clinically qualified director of food and nutrition services. This failure has the potential to affect all 38 residents residing in the facility. Findings include: The facility daily census report dated 4/25/24 documents 38 residents residing in facility. On 4/25/24 from 10:00 AM-4:00 PM there was no Dietary Manager (DM) or Certified Dietary Manager (CDM) onsite. On 4/26/24 from 10:00 AM-4:00 PM there was no Dietary Manager (DM) or Certified Dietary Manager (CDM) onsite. On 4/25/24 V1 Administrator stated the facility does not have a CDM or DM. V1 stated the previous CDM left the facility in February 2024 and has not been replaced.

Based on observation, interview, and record review the facility failed to employ dietary staff who had completed safe food handling training. This failure has the potential to affect all 38 residents residing in facility. Findings include: The Facility Daily Census Report dated 4/25/24 documents 38 residents reside in facility. During observations made in the dietary department from 4/25/24-4/30/24 there were no dietary staff or ancillary staff assisting in the dietary department who had completed basic safe food handling training. On 4/25/24 at 12:00 PM V20 Housekeeper assisted in the dietary department in the kitchen during lunch service. On 4/25/24 from 11:00 AM-1:30 PM V3 Cook, V6 Cook, V7 Cook, V4 Dietary Aide and V20 Housekeeper confirmed they do not have their Food Handler's Certificate. On 4/26/24 at 2:00 PM V1 Administrator stated the facility does not have any employees who work in the dietary department who have the required Food Handler's Certificate. V1 Administrator stated the facility has had major changes in the dietary staff'. V1 Administrator stated the training…

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 expired food products were disposed of and not served to residents, monitor food temperatures, monitor freezer and refrigerator temperatures, prevent cross contamination during food service, properly label and store foods, maintain a sanitary kitchen environment, store chemicals and soiled cleaning equipment away from food storage areas, and monitor temperatures/sanitizer levels for the dishwasher to ensure dishes were sanitized prior to resident use. These failures have the potential to affect all 38 residents residing in the facility. Findings include: The Facility Census Report dated 4/25/24 documents 38 residents reside in facility. 1. On 4/26/24 at 12:22 PM V6 [NAME] removed tartar sauce from a gallon container dated 3/29/24 and placed the tartar sauce on resident lunch plates. V6 [NAME] stated We (facility) are so far behind getting lunch out I don't have time to put the tartar sauce in fancy little cups. I just have to get the trays out. On 4/26/24 at 12:25 PM V7 [NAME] confirmed the tartar sauce…

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 serve foods that were palatable to five (R1, R2, R3, R5, R9) residents out of five residents reviewed for Dietary Services in a sample list of nine residents. Findings include: 1.) R9's Cognitive assessment dated [DATE] documents R9 as cognitively intact. On 4/26/24 at 1:12 PM R9 was sitting in her wheelchair at the dining room table. R9 was attempting to cut through a breaded fish filet. R9 stated I might as well give up. This thing is rock hard, burnt and cold. R9 picked up the fish filet showing the bottom side which was blackened. R9 gently tossed the fish filet back onto her plate and it made a 'clink' sound as it hit the plate. 2.) R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. On 4/25/24 at 12:45 PM R1 stated R1 is the Resident Council President. R1 stated the residents have had multiple complaints about the quality of the foods served. R1 stated The meat is cold; the drinks are room temperature, and the…

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

Based on observation, interview, and record review the facility failed to prepare the safe texture of pureed food for three residents (R6, R7, R8) out of three residents reviewed for pureed diet orders in the sample list of nine. Findings include: On 4/26/24 at 12:30 PM V6 [NAME] removed three large trays of prepared cups of coleslaw from the reach in cooler. V6 [NAME] placed R6, R7, R8's coleslaw on their perspective plates. The coleslaw appeared lumpy and had many bits of slaw that were not pureed texture. V6 [NAME] stated Coleslaw doesn't puree very well. You can never get those little pieces pureed like they should be. Pureed foods should be like pudding. It does taste just like coleslaw though. 1.) R8's Physician Order Sheet (POS) dated April 2024 documents a physician order for R8 to receive pureed foods. On 4/26/24 at 1:30 PM R8 was sitting at a table in the dining room eating lumpy coleslaw. R8 began coughing when swallowing the coleslaw. 2.) R7's Physician Order Sheet (POS) dated April 2024 documents a physician order for R7 to receive pureed foods. On 4/26/24 at 1:28 PM R7…

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 employer a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility. Findings include: On 2/20/24 at 9:00AM, V1 Administrator/Acting [NAME] stated that V10 Dietary Manager is not a clinically qualified nutrition professional. Throughout the duration of this survey, from 2/20/24 through 2/22/24, V10 Dietary Manager was not present in the facility. Throughout the duration of the survey, from 2/20/24 through 2/22/24, the facility failed to properly label opened refrigerator items, failed to check the steam table food temperatures for safety (TCS) foods, failed to properly label time and temperature control for safety (TCS) foods, failed to test the dishwasher for sanitation purposes and failed to use pasteurized eggs when serving soft, cooked eggs. The Facility assessment dated [DATE] documents that the facility will employ a full time clinically qualified…

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 sufficient dietary staff to provide meals in a timely manner. This failure has the potential to affect all 47 residents who reside at the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 2/21/24 documents 47 residents reside in the facility. The Facility assessment dated [DATE] documents that the staffing plan for the dietary department includes three food and nutrition services staff on the day shift and two food and nutrition services staff on the second shift in addition to the full time Dietary Manager. The facility provided schedule (2024) documents on the following dates: Sunday February 18, one dietary aid was scheduled for the first shift and one dietary aid was scheduled for the second shift, with no cook scheduled for either shift. Monday February 19, one dietary aid was scheduled for the day shift, no dietary aid was scheduled for the evening shift, and no cook was scheduled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label opened refrigerator items, check steam table food temperatures for safety (TCS) foods (R5, R8, R10, R12, R26, R31 and R36) properly label time and temperature control for safety (TCS) foods, test the dishwasher for sanitation purposes and use pasteurized eggs when serving soft, cooked eggs (R4, R9, R31). These failures have the potential to affect 10 (R5, R8, R10, R12, R26, R31, R4, R9, R31 and R36) of 10 residents reviewed for altered diets on the sample list of 36 and all 47 residents residing in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 2/21/24 documents 47 residents reside in the facility. 1.) The facility Food Temperature Policy dated 4/2017 documents that it is the policy of [NAME] Health Care to ensure that food is served at a temperature that is proper to prevent the growth of harmful bacteria and other food borne illnesses. Hot foods must read a minimum…

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

Based on interview and record review the facility failed to have an Infection Preventionist attend quarterly quality meetings. This failure has the potential to affect all 47 residents in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 2/21/24 documents 47 residents reside in the facility. The undated facility provided Quality Assurance Plan documents that the quality assurance plan will involve infection control monitoring. The facility provided quarterly quality meeting attendance form dated 10/18/2023 and 1/15/2024 documents no Infection Preventionist present at either meeting. On 2/20/24 at 2:00PM, V9 Infection Preventionist stated that she was responsible for the facility's infection control program for the past year. On 2/20/24 at 3:00PM, V2 Director of Nursing stated that V9 Infection Preventionist is who provides infection control information to the quality committee when she is present. On 2/20/24 at 2:18PM, V8 Regional Director of Operations confirmed that no Infection Preventionist was present at the 10/18/23 or…

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 trend the facility's monthly infections. This failure has the potential to affect all 47 residents residing in the facility. Findings include: The facility's Infection Control Surveillance and Monitoring policy with a review dated of 7/18/23 documents monitoring of the day-to-day operation of the Infection Control Program will be completed by the Director of Nursing or the Infection Control Preventionist. This policy documents that the Infection Control Log will be updated on a daily basis in order to analyze data and identify trends that would indicate the need for additional controls to prevent any further spread of an infection. The facility's Resident Infection Control and Antimicrobial Log dated January of 2024 does not document the summary for total number of infections or the type of Infections. This log is blank for the identified pattern/trend and intervention. This log does not document a summary for the infections in January 2024. On 2/21/24 at 10:45 AM, V9 Regional Infection Preventionist stated she must not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely submit Minimum Data Sets (MDSs) for six (R43, R39, R27, R16, R33, R32) of 36 residents reviewed for MDS in the sample list of 36. Findings include: R43's MDS with Assessment Reference Date (ARD) 10/13/23 documents completion date of 11/20/23 and transmission date of 12/6/23. R39's MDS with ARD 10/13/23 documents completion date of 11/8/23 and transmission date of 11/14/23. R27's MDS with ARD 10/16/23 documents completion date of 11/7/23 and transmission date of 12/6/23. R16's MDS with ARD 10/10/23 documents completion date of 11/9/23 and transmission date of 11/21/23. R33's MDS with ARD 10/6/23 documents completion date of 11/6/23 and transmission date of 11/21/23 . R32's MDS with ARD 10/11/23 documents completion date of 11/6/23 and transmission date of 12/6/23. The undated MDS report documents R43's MDS dated [DATE], R39's MDS dated [DATE], R27's MDS dated [DATE], R16's MDS dated [DATE], R33's MDS dated [DATE], and R32's MDS dated [DATE] were…

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

Based on observation, interview, and record review the facility failed to implement physician ordered nutritional supplements, document supplement intakes, and update a care plan with weight loss and nutritional interventions for four (R198, R13, R39, R4) of four residents reviewed for nutrition in the sample list of 36. Findings include: The facility's Meal and Supplement Consumption Documentation policy revised March 2020 documents supplements provided by dietary staff are recorded on the Food and Fluid Intake Sheet. 1.) R198's Dietitian Note dated 8/1/23 documents R198's weight 142 pounds (lbs), body mass index (BMI) 26, and weight fluctuation and gradual weight loss within desirable range based on BMI. R198 had recent urinary tract infection, confusion, and fair intakes. This note documents to increase frozen nutritional supplement to twice daily. R198's Dietitian Note dated 9/25/23 documents weight of 134.8 lbs which is down 12% in six months, and R198's diet includes a frozen nutritional supplement daily. R198's Dietitian Note dated 1/15/24 documents significant weight loss of…

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

Based on interview and record review the facility failed to complete psychotropic assessments, ensure psychotropic assessments were accurate, care plan for behaviors and interventions, and document behaviors to justify increasing psychotropic medications for four (R8, R24, R45, R41) of five residents reviewed for unnecessary medications in the sample list of 36. Findings include: 1.) R8's February 2024 Physician's Order Summary documents orders for Quetiapine (antipsychotic) 12.5 milligrams (mg) in the morning (2/27/23) and 50 mg at bedtime (9/6/23), and Clonazepam (antianxiety) 0.5 mg twice daily (1/3/24). This summary documents R8's diagnoses include Dementia with Lewy body, Psychosis, and Bipolar. R8's Psychotropic Medication Assessments dated 2/27/23 and 6/1/23 for Clonazepam does not identify targeted behaviors for this medication, the section to record this information is incomplete. There are no documented Psychotropic Medication Assessments for Quetiapine and Clonazepam after 6/1/23 in R8's medical record. The Pharmacy Report dated 1/29/24 document R8's Clonazepam was…

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

Based on observation, interview and record review the facility failed to document an open date of insulin upon opening a new pen/vial for five of five residents (R32, R18, R17, R22, R28) reviewed for medication storage in the sample list of 36. Findings include: The facility's Procurement and Storage of Medications policy with a Reviewed date of 3/16/23 documents, All medication containers shall be labeled with the date opened by the person breaking the container seal. R32's Physician's Order Sheet (POS) dated 2/1/24 through 2/29/24 documents orders for Insulin Aspart 100 units/milliliters (ml) give per sliding scale with an order date of 10/5/23 and an order for Lantus pen 100 units/ml inject 12 units subcutaneously (sub-q) every morning and 10 units sub-q every night at bedtime with an order date of 11/27/23. R18's POS dated 2/1/24-2/29/24 documents orders for Lantus pen 100 units/ml inject 70 units sub-q every morning with an order date of 12/8/22 and an order for Insulin Lispro (Humalog) 100 units/ml inject 15 units sub-q with morning meal with an order date of 12/14/22. R17'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 therapy services were provided for five of six residents (R17, R41, R44, R148, R149) reviewed for therapy services on the sample list of 36. Findings include: 1. On 2/20/24 at 9:34 AM, R17 was lying in bed. R17 stated, I am not getting ordered therapy due to the company not paying the bill. That is the reason I am here, is to get better and go home. Friday was my last day with therapy because they quit. R17's face sheet documents R17 was admitted to the facility on [DATE]. R17's Therapy order sheet dated 2/5/24 documents R17 will receive Occupational therapy five times a week for four weeks. 2. R41's physician's order dated 2/5/24 documents an order for physical therapy five times a week for four weeks for therapeutic exercise, therapeutic activity, Neurological Re-educations, gait training, and group therapy. On 2/22/24 at 1:38 PM, R41 was lying in bed. R41 stated she has not seen therapy this week. R41 stated they had been working…

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 determine vaccinations status and offer influenza and pneumococcal vaccinations upon admission for four (R45, R41, R44, and R35) of five residents reviewed for immunizations on the sample list of 36. Findings include: 1. R45's face sheet documents R45 was admitted on [DATE]. R45's medical record contains an immunization record that is blank. R45's Influenza vaccine and Pneumonia consent in R45's chart is blank. On 2/21/24 at 10:06 AM, V2 Director of Nursing stated residents are asked upon admission if they would like to have an influenza and pneumonia vaccine. V2 stated V2 is in charge of the facility's immunizations. V2 stated she has not looked at R45's immunizations record or medical history to see if R45 would be eligible for vaccinations. V2 then looked through a consent binder and stated R45 did not have immunization consents. V2 stated she is unsure of R45's vaccination status. V2 confirmed R45 was not offered an influenza or pneumococcal…

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 obtain psychotropic medication consents for one (R8) of five residents reviewed for unnecessary medications in the sample list of 36. Findings include: R8's February 2024 Physician's Order Summary documents an order for Clonazepam (antianxiety) 0.5 milligrams (mg) twice daily dated 1/3/24. This summary documents R8's diagnoses include Dementia with Lewy body, Psychosis, and Bipolar. R8's Psychotropic Medication Consent-Antianxiety dated 6/8/23 documents signed consent for the use of Clonazepam 0.25 mg daily at bedtime omit Sundays. There is no documented consent for the increase of Clonazepam to 0.5 mg twice daily in R8's medical record. On 2/21/24 at 2:08 PM V3 Assistant Director of Nursing stated V3 provided all of R8's psychotropic medication consents and V3 is responsible for obtaining the consents. The facility's Psychotropic Medication Policy dated 6/17/22 documents Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized…

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 observe a resident consume medications during medication administration for one of one resident (R4) reviewed for self-administration of medication in the sample list of 36. Findings include: R4's Physician's Order Sheet (POS) dated 2/1/24 through 2/29/24 documents diagnosis of Macular Degeneration. This POS documents orders for Amlodipine Besylate 5 mg (milligrams) once a day, Calcium 600 - Vitamin D3 400 tablet daily, Cranberry 250 mg capsules daily, Levothyroxine 75 mcg (micrograms) take one tablet daily on an empty stomach one hour prior to eating or other medications, Omeprazole 20 mg once daily, Senna Laxative 8.6 mg take two tablets every morning, Polyethylene Glycol Powder dissolve 17 grams in liquid every other day, Benzonatate 200 mg twice daily, Fluticasone 50 mcg nasal spray use one spray in both nostrils twice daily, Gabapentin 100 mg twice daily and Acetaminophen 325 mg take one tablet three times daily. On 2/20/24 at 9:54 AM, R4 was in the doorway of R4's room and stated that she took one of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an individualized fitting wheelchair and commode for one (R45) of 16 residents reviewed for accommodation of needs on the sample list of 36. Findings include: R45's Physician's order sheet documents R45 was admitted to the facility on [DATE]. On 2/20/24 at 9:10 AM, R45 was sitting in his wheelchair. R45 stated his wheelchair and commode are too small. R45 stated it hurts when sitting in the chair. R45's sides were pushing up against the sides of the wheelchair. R45's commode was present in the room and appeared to be the same width as the wheelchair. On 2/22/24 at 11:45 AM, V2 Director of Nursing stated R45 came from home with a walker. V2 stated a nurse or Certified Nurse's Assistant should have gone to the storage room and got him a wheelchair. On 2/22/24 at 11:44 AM, V8 Regional Director of Operations stated there isn't anyone specific in the facility who would measure the chair's size for the resident.

Based on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R21) of one resident reviewed for abuse in the sample list of 36. Findings include R21's Newly Acquired Skin Conditions report dated 12/9/23, documents bruising and swelling to left hand and thumb, reported by V16 Certified Nurse Assistant (CNA) to V12 Licensed Practical Nurse (LPN), R21 reported R21 does not know how the injury occurred. No other interviews with staff and other residents were documented as being obtained for this injury of unknown origin. On 2/21/24 at 11:25 AM, V9 Regional Infection Preventionist, stated this is all we have for this while handing over a newly acquired skin condition form, AIM for wellness form, and resident investigation form. V9 stated no further investigation was completed per the abuse policy. On 2/22/24 at 9:58 AM, V1 Administrator in Training (AIT), stated there should have been an investigation for abuse done which includes interviewing other residents and other staff. The facility's Abuse Prevention Policy dated Revised…

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 develop comprehensive care plans for two (R6, R45) of 16 residents reviewed for care plans on the sample list of 36. Findings include: 1. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with a diagnosis of Hypertension, Hypothyroidism, Gastro Esophageal Reflux Disease, Cerebral Palsy, Asthma, and Sleep Apnea. R6's care plan binder did not contain a comprehensive care plan. On 2/21/24 at 11:40 AM, V11 Care Plan Coordinator stated R6 does not have a comprehensive care plan. V11 stated that the facility is behind on completing the care plans. 2. R45's face sheet documents R45 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Embolic Stroke. R45's care plan binder did not contain a comprehensive care plan. On 2/21/24 at 11:40 AM, V11 Care Plan Coordinator stated R45 does not have a comprehensive care plan. V11 stated that the facility is behind on completing the care plans.

Based on observation, interview and record review the facility failed to administer a medication according to physician's orders and manufacturers recommendations for one of one resident (R4) reviewed for following physician's orders in the sample list of 36. Findings include: The facility's Conformance with Physician Medication Orders policy with a reviewed date of 9/27/17 documents, All medications, including cathartics, headache remedies, or vitamins, etc. (etcetera), shall be given only upon the written order of a physician. These medications shall be given as prescribed and at the designated time. R4's Physician's Order Sheet dated 2/1/24 through 2/29/24 documents an order for Levothyroxine (Thyroid) 75 mcg (micrograms), take one tablet by mouth once daily on an empty stomach one hour prior to eating or other medications with an order date of 12/9/23 and this medication is scheduled to be given at 8:00 AM. On 2/20/24 at 9:54 AM, R4 was in the doorway of R4's room and stated that R4 needs cold water to take her pills. There was a cup of 10 pills on R4's bedside table. One of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide methods for communication for a resident who has limited English proficiency and failed to provide a call light (to alert staff of resident needs) to be within the resident's reach for one resident (R39) of four residents in the sample list of 36. Findings include: R39's Minimum Data Set (MDS) dated [DATE], documents R39's diagnoses as: Coronary Artery Disease, Aphasia, Cerebrovascular Infarct due to Thrombus of left middle Cerebral Artery, Hemiplegia following Cerebral Infarct affecting right dominant side, Age-related Physical Debility, and Weakness. This same MDS documents R39 is rarely/never understood and requires substantial/maximal assistance with toileting. R39's Care Plan dated 12/13/23, documents R39's refusal of care including lab draws and doctor visits, is generally related to a communication barrier; R39 has difficulty making needs and wants known for continence and encourage resident to use call light to alert 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain daily weights and failed to follow up with the medical doctor for weight gain for 2 residents (R21, R22) of two residents reviewed for daily weights in the sample list of 36. Findings include: 1. R21's Cardiology Consultation report dated 11/2/23, documents R21's diagnosis as: history of Acute Systolic Heart Failure due to Ischemic Cardiomyopathy. R21's Care Plan (CP) dated 12/14/23, documents R21 is at risk for weight shifts related to Congestive Heart Failure (CHF); daily weights related to CHF. R21's Nutritional assessment dated [DATE], documents significant weight change for five days, R21 on daily weights, continue daily weights. R21's calendars for daily weight documentation, documents November 25, 26, 29, 30, of 2023, no weights being obtained; December 11, 12, 13, 14, 29, of 2023, no weights being obtained; February 3, 4, 9, 10, 16, of 2024, no weights being obtained. On 2/21/24 at 11:16 AM, V2 Director of Nursing (DON) stated weights…

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

Based on observation, interview, and record review the facility failed to document wound measurements upon admission, document weekly skin checks, document weekly wound measurements, document that a treatment was provided as ordered by the physician and develop a pressure ulcer plan of care for one (R45) of one resident reviewed for pressure ulcers on the sample list of 36. Findings include: On 2/20/24 at 9:10 AM R45 stated his bottom is sore. On 2/21/24 at 1:54 PM, V12 Licensed Practical Nurse and V16 Certified Nurse's Assistant provided R45 with incontinence care and treatment to the left and right buttocks. R45's right and left buttocks were red and purple and had multiple healed and scarred areas to R45's right and left buttocks. R45's admission Assessment documents R45's Buttocks/Coccyx has stage 2 pressure ulcers that are open and bleeding and has multiple recently healed areas. This assessment documents R45 has sheering to the buttocks and moisture related redness to abdomen folds. This assessment documents R45's left hip fold has a recently closed area and scab to left hip…

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 complete a smoking assessment and develop a plan of care for smoking for one of one (R6) resident reviewed for smoking on the sample list of 36. Findings include: On 2/21/24 at 3:23 PM, R6 was outside smoking. R6 took a cigarette out of the pack and attempted too light it with a lighter. On 2/22/24 at 1:14 PM, R6 was outside smoking. V23 Activity Director was sitting outside at a picnic table facing away from R6. V23 stated it should state on their care plan what supervision the residents require when smoking. V23 stated V23 did not know what R6's smoking status. R6's smoking assessment dated [DATE] does not document the outcome of R6's smoking assessment. R6's baseline care plan dated 12/2/23 does not document that R6 smokes cigarettes. R6's care plan binder did not contain a comprehensive care plan. On 2/21/24 at 11:40 AM, V11 Care Plan Coordinator stated R6 does not have a comprehensive care plan. On 2/22/24 at 1:03 PM, V21 Social…

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 toileting for two (R6, R45) of 16 residents reviewed for toileting on the sample list of 36. Findings include: On 2/20/24 at 9:28 AM, R6 stated they won't transfer her to the toilet or commode and the staff make her go on a bedpan. R6 stated she doesn't like to do that. At that time a commode was present in R6's room. On 2/20/24 at 2:08 PM, V3 Assistant Director of Nursing stated the staff haven't been properly trained on how to transfer her to the toilet. V3 stated the staff can use the mechanical lift to toilet. R6's baseline care plan documents R6 is a commode with one assist. 2. On 2/20/24 at 9:08 AM, R45 states he can't get into his bathroom and the commode in his room is too small to use. R45 stated R45 doesn't get to use the toilet. At that time, a commode was sitting against the wall in R45's room. On 2/20/24 at 2:08 PM, V3 Assistant Director of Nursing stated the staff haven't been properly trained on how to transfer R45 to the toilet.

Based on observation, interview, and record review the facility failed to change oxygen and nebulizer tubing for one (R10) of two residents reviewed for respiratory care in the sample list of 36. Findings include: On 2/20/24 at 9:28 AM R10 was wearing oxygen per nasal cannula at 4 liters per minute (l/min). The oxygen tubing was dated 2/24/23. There was a nebulizer mask/tubing dated 2/4/24 on top of R10's nightstand. R10 stated R10 recently had pneumonia and has Chronic Obstructive Pulmonary Disease. On 2/21/24 at 9:55 AM R10 stated R10 gets scheduled nebulizer treatments three times daily and as needed during the night. R10's February 2024 Physician's Order Summary documents orders for oxygen at 4 l/min, DuoNeb 0.5 milligrams per 3 milliliters administer via nebulizer four times daily as needed (8/17/23), and Albuterol 2.5 milligrams per 3 milliliters administer per nebulizer four times daily as needed (9/5/23). R10's February 2024 Treatment Administration Record documents to change oxygen tubing and nebulizer tubing/mask weekly, and this was not documented as completed after…

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 the correct consistency for a pureed diet for two (R13 and R15) of two residents reviewed for pureed diets in the sample list of 36. Findings include: The facility policy dated 10/2012 documents that the Method of Pureeing food includes blending mixture to a smooth, pudding-like consistency. R13's Physician Order Sheet dated February 2024 documents R13 having the following diagnoses: Hyperlipidemia, Paroxysmal Atrial Fibrillation, Physical Debility, Abnormalities of Gait and Mobility, Chronic Kidney Disease, Spinal Stenosis, Depression, Anxiety, Dysphasia and Weakness. R13's Physician Order Sheet dated February 2024 documents R13 to have a pureed diet. R15's Physician Order Sheet dated February 2024 documents R15 having the following diagnoses: [NAME] Ataxia, Weakness, Abnormal Gait, Anxiety, Depression, Tourette's Syndrome, Dysphasia and Abnormal Weight Loss. R15's Physician Order Sheet dated February 2024 documents R15 to have…

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 offer COVID boosters for two (R45, R44) of five residents reviewed for vaccinations on the sample list of 36. Findings include: 1. R45's face sheet documents R45 was admitted on [DATE]. R45's medical record contains a blank immunizations record. On 2/21/23 at 9:39 AM, V2 Director of Nursing stated R45 is due for a COVID booster. V2 stated R45's consents for vaccinations does not appear to be completed upon admission. At 10:06 AM, V2 looked through a consent binder and stated R45 did not have immunization consents. 2. R44's face sheet documents R44 was admitted on [DATE]. R44's medical record contain an immunization record that is blank. On 2/21/23 at 9:39 AM, V2 stated R44 is a new admit, have not audited her chart for immunizations. V2 stated hospital paperwork documents R44's last COVID vaccine was given in 2021. V2 stated R44 would be due for a booster. V2 stated there are no vaccination consents in consent binder for R44.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for one of three residents (R1) reviewed for physical abuse on the sample list of three. Findings include: The facility's Final Report dated 1/2/24, documents R2, hit R1 after R1 bumped into R2 with R1's wheelchair. This report also documents R2 was placed on one-to-one supervision by staff and continual fifteen minute checks. This report also documents R2 was educated on alerting staff if needing assistance with overcrowding in common areas and that R2 verbalized understanding regarding not striking others. R1's Physician Order Sheet (POS) date 1/1/24 to 1/31/24, documents R1's diagnoses as Macular Degeneration, Anxiety, Depression and Dementia. R1's Minimum Data Set (MDS) dated [DATE], documents R1 having severe cognitive impairment. R1's Care Plan dated 1/25/24, documents R1 is at risk for physical aggression directed at her related to confusion, wandering, and lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus) during an outbreak by failing to post isolation signage to identify COVID-19 positive rooms, ensure staff wore appropriate Personal Protective Equipment (PPE) in COVID-19 positive rooms, ensure staff change PPE upon leaving COVID-19 positive rooms, and keep COVID-19 positive room doors closed. These failures affect nine (R1, R2, R3, R5, R6, R7, R8, R9, R10) of ten residents reviewed for infections in the sample list of ten residents. Findings include: The facility's COVID-19 Control Measures policy dated as revised 5/19/23 documents the following: During a COVID-19 outbreak all healthcare personnel must wear an N95 (respirator mask) and eye protection when caring for all residents or when in areas where staff will encounter residents. Additional PPE including gown and gloves will be worn to provide care for COVID-19 positive and suspected residents.…

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 report a resident's (R2) weight gain and laboratory results to the physician. R2 is one of three residents reviewed for change in condition in a sample list of ten. Findings include: R2's Diagnosis Log documents R2 has Chronic Diastolic Heart Failure and Asthma. R2's October 2023 Physician Order Summary (POS) documents an order to weigh R2 on Mondays, Wednesdays, and Fridays, and this order does not include parameters for when to notify R2's physician. R2's October 2023 Medication Administration Record documents R2 receives Furosemide (diuretic) 20 milligrams by mouth daily. R2's laboratory results dated as reported on 10/20/23 at 12:57 PM documents R2's [NAME] Blood Cell count was 12.8 (normal range 4.5-10.8), Protein 5.4 (normal 6-8.3), and Albumin was 3.2 (normal 3.5-5.5). R2's October 2023 Daily Weight Log documents on 10/26/23 R2 weighed 219.8 pounds and on 10/27/23 R2 weighed 228.8 pounds (an increase of 4 pounds in one day). There is no documentation in R2's medical record that R2's physician was notified of R2's…

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

Based on interview and record review the facility failed to develop a care plan with problems, goals, and interventions to address Congestive Heart Failure for two (R2, R3) of three residents reviewed for changes in condition in the sample list of ten. Findings include: 1.) R2's Cumulative Diagnosis Log documents R2 has Chronic Diastolic Heart Failure. R2's October 2023 Physician Order Summary (POS) documents an order to weigh R2 on Mondays, Wednesdays, and Fridays. This order does not include parameters for weight gain and when to notify R2's physician. R2's October 2023 Medication Administration Record (MAR) documents R2 receives Furosemide (diuretic) 20 milligrams (mg) by mouth daily. R2's Care Plan revised 10/29/23 does not include a problem, goal, and interventions for Congestive Heart Failure (CHF). 2.) R3's Cumulative Diagnosis Log documents R3 has CHF. R3's Hospital After Visit Summary dated 10/18/23 documents heart failure discharge instructions including a sodium restricted diet low in fat and cholesterol, monitor weight daily and report weight gain of 3 or more pounds…

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 accurately transcribe physician orders for three (R1, R2, R3) of three residents reviewed for physician's orders in the sample list of ten. Findings include: 1.) R1's Hospital Discharge Orders dated 10/24/23 documents an order for Benzonatate 100 milligrams (mg) take one capsule three times daily as needed for cough. R1's October 2023 Physician Order Summary (POS) does not document the Benzonatate order was transcribed onto R1's POS as an active order. R1's October 2023 Medication Administration Record (MAR) documents Benzonatate was not administered prior to 10/28/23. This medication was administered on 10/28/23 at 3:30 PM, on 10/29/23 at 12:30 PM, 5:30 PM, and 7:30 PM, and on 10/30/23 at 9:00 AM. On 10/30/23 at 10:09 AM R1 stated R1 has COVID-19 with cold symptoms which started on 10/26/23. R1 stated R1 gets medication for R1's COVID-19 symptoms, but the medication doesn't seem to help. On 10/30/23 at 2:27 PM V7 Licensed Practical Nurse stated on…

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

Based on observation, interview, and record review the facility failed to ensure a COVID-19 medication was available to be administered as ordered for two (R1, R2) of three residents reviewed for physician's orders in the sample list of ten. Findings include: 1.) On 10/30/23 at 10:09 AM R1 had a loose cough and was lying in bed wearing oxygen at 2 liters per minute per nasal cannula. R1 stated R1 has COVID-19 with cold like symptoms that started on 10/26/23. R1 stated R1 receives medications for R1's COVID-19 symptoms, but the medications doesn't seem to help. R1's COVID-19 test dated 10/26/23 documents a positive result. R1's Physician Order dated 10/28/23 documents to administer Paxlovid (antiviral COVID-19 treatment) 300 milligrams (mg) twice daily for five days. R1's October 2023 Medication Administration Record (MAR) documents R1 was given Benzonatate for cough on 10/28/23 at 3:30 PM, 10/28/23 at 12:30 PM, 10/29/23 at 5:30 PM, 10/29/23 at 7:30 PM, and 10/30/23 at 9:00 AM. This MAR documents Paxlovid 300 mg was not administered 10/28/23-10/30/23. R1's Nursing Note dated 10/30/23…

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

Based on interview and record review, the facility failed to ensure the required quarterly Quality Assessment and Assurance (QAA) committee meetings were completed. This failure has the potential to affect all 44 residents in the facility. Findings include: The undated Quality Assurance Plan documents the facility's Quality Assurance Team will conduct meetings quarterly at a minimum. On 1/9/23 at 11:00 AM V1 Administrator provided two QAA Meeting Sign-in Sheets for the previous year's QAA meetings. On 1/10/23 at 4:00 PM V1 Administrator confirmed the facility only held two QAA meetings over the last year. The facility Resident Census and Conditions of Residents report dated 1/9/2023 documents 44 residents reside in the facility.

Based on observation record review the facility failed to follow their COVID-19 Control Measure policy by failing to ensure nursing staff were wearing masks and eye protection while working in the facility. This failure had the potential to affect all 44 residents residing in the facility. Findings include: The facility's COVID-19 Control Measure policy with a revision date of 11/7/22 documents, 7. For facilities residing in a county where the Community Transmission Level is substantial or high, employees providing services to resident must wear a facemask and eye protection. On 1/8/23 at 8:00 AM, V13 Licensed Practical Nurse was observed walking down the hall and was not wearing a surgical mask. V5 Registered Nurse was observed standing in the hallway at a treatment cart. V5 was observed not wearing a surgical mask. The facility's undated Community Transmission Levels log provided by V2 Director of Nursing documents that the Community Transmission Levels are high for the week of January 6, 2023. The facility's Census and Condition report dated 1/9/23 signed by V3 Minimum Data…

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

Based on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for seven (R8, R13, R14, R21, R22, R23, and R28) of 26 residents reviewed for quarterly assessments on the sample list of 26. Findings include: The facility's Comprehensive/MDS (Minimum Data Set) policy with a revision date of 11/1/17 documents, 5. The MDS shall be re-evaluated according to the following schedule. a. Quarterly - within 92 of previous ARD (assessment reference date)/MDS. The facility's Submission report dated 1/5/23 documents R8 was due for a quarterly MDS (Minimum Data Set) assessment on 11/18/22. This report documents this assessment was not completed until 12/12/22. On 11/10/23 at 2:11 PM, V12 Clinical Reimbursement Specialist stated R8's quarterly assessment was due on 11/18/22 but was not completed until 12/12/22. The facility's MDS Assessments Due List dated 1/10/23 documents R13 was due for a quarterly MDS on 12/7/22. On 1/10/23 at 2:11 PM, V12 Clinical Reimbursement Specialist stated R13's quarterly MDS assessment was due on 12/7/22…

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 R86's Physician Order Sheet dated January 2023 documents R86 was admitted to the facility on [DATE]. R86's Baseline Care Plan is dated 12/16/22. R86 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM, V3 Care Plan Coordinator confirmed R86's Comprehensive Care Plans should have been completed. R24's Physician Order Sheet dated January 2023 documents R24 was admitted to the facility on [DATE]. R24's Baseline Care Plan is dated 9/26/22. R24 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM V3 Care Plan Coordinator confirmed R24's Comprehensive Care Plans should have been completed. Based on interview and record review the facility failed to develop a Comprehensive Care Plan for four residents (R139, R136, R24, R86) the facility also failed to develop a Care Plan for Pressure Ulcers, Anticoagulant, and Pain for two residents (R17, R25). These failures affect six (R139, R136, R24, R86, R17, and R25) of 13 residents reviewed for Care Plans in the sample list of 26. Findings include: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise and update resident's Comprehensive Care Plans. This failure affected four of thirteen residents (R9, R11, R14, R25) reviewed for Care Plans on the sample list of 26. Findings include: The facility's Comprehensive Care Planning policy dated 7/20/22 documents a resident's Care Plan will be reviewed after each annual, significant change, or quarterly Minimum Data Set and will be revised as necessary to reflect the resident's current medical, nursing, mental, and psychosocial needs. R11's Physician Order Sheet (POS) dated January 2023 documents R11 was admitted to the facility on [DATE]. R11's POS documents R11 has an order for Risperidone (Antipsychotic) 0.5 milligrams. R11's Comprehensive Care Plan dated documents R11 is on an Anxiolytic Psychotropic Medication however does not document R11 is on an Antipsychotic Psychotropic Medication. On 1/11/23 at 9:30 AM V3 Care Plan Coordinator confirmed R11's Comprehensive Care Plans should have been…

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 assess the risk of entrapment for four of four residents (R9, R25, R15, R136) reviewed for side rails on the sample list of 26. Findings include: The facility's Determining Need for Use of Bed Rail/Transfer Bar dated 5/12/17 documents, a. Complete a Bed Rail/Transfer Bar Evaluation at the time of admission, when the resident has a significant change and at least every 90 days. b. Complete the Bed Rail/Transfer Bar Evaluation to determine the need, type of bed enabler, entrapment considerations, and risks versus benefits prior to initiation of any alternative device application. On 1/8/22 at 2:00 PM, there were side rails observed up times two on both sides of R9's bed. R9's last side rail assessment in R9's medical record is dated 3/2/22. On 1/8/22 at 9:07 AM, R25 was observed lying in bed and there were side rails up on both sides of the bed. R25's last side rail assessment in R25's medical record is dated 3/8/22. R136's Physician Order…

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 complete initial and quarterly Psychotropic Medication assessments. This failure effected five of five residents (R11, R86, R9, R22, R25) reviewed for unnecessary medications on the sample list of 13. Findings include: The facility's Psychotropic Medication Policy dated 6/17/22 documents a Pre-Psychotropic Medication Evaluation will be completed prior to the administration of any newly prescribed Psychotropic Medication, a Psychotropic Medication Evaluation will be completed within 14 days of admission for any residents already taking Psychotropic Medication, and any resident receiving Psychotropic Medications will have a Psychotropic Medication Evaluation done at a minimum of every quarter. R11's Physician Order Sheet dated January 2023 documents R11 is prescribed Risperidone (Antipsychotic) 0.5 milligrams at night. R11's Risperidone was first prescribed on 9/9/22. There is no Pre-Psychotropic Medication Evaluation completed for R11's Risperidone. 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 interview and record review the facility failed to complete timely admission and Annual Minimum Data Set (MDS) Assessments (Resident Assessment Instrument/RAI) for two of 13 residents (R136, R9) reviewed for MDS assessments in the sample list of 26. Findings include: The facility's Comprehensive Assessment/MDS policy with a revised date of 11/1/2017 documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining Resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each Resident with the goal of attaining or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessment and care planning. The MDS shall be re-evaluated according to the following…

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 prevent cross contamination during Pressure Ulcer dressing changes and failed to complete dressing changes as ordered for two of three residents (R139, R17) reviewed for Pressure Ulcers in the sample list of 26. Findings include: The facility's Decubitus Care/Pressure Areas policy with a revised date of 1/2018 documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any Pressure Ulcer. The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. Complete all areas of the Treatment Administration Record or Wound Documentation Record. The facility's Dressing Change policy with a revised date of 7/2007 documents, Policy: To avoid introducing organisms into a wound. Procedure: 7. Set up clean area for supplies. 8. Wash your hands. 9. Apply non-sterile gloves. 10. Remove soiled…

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 secure an Oxygen tank for one of one resident (R6) reviewed for Oxygen in the sample list of 26. Findings include: The facility's Oxygen Storage and Assembly policy with a revised date of 1/2002 documents, Policy: To properly store and assemble Oxygen tanks and accessories in a safe and correct manner. Safety and Storage of Oxygen Tanks 1. Store tanks in a cool place away from a source of heat. 2. A chain, on a cart or on a stand must secure tanks. R6's Physician Order Sheet (POS) dated 1/1/23 through 1/31/23 documents R6's most recent admission as 10/28/22. R6's POS documents diagnoses including Hypoxia, Ischemic Stroke, Acute Encephalopathy and Anxiety. This POS documents an order for Hospice care and an order for Oxygen at 2 Liters via nasal cannula as needed for comfort. On 1/08/23 at 9:42 AM, R6 was in R6's room in R6's reclining chair with the feet elevated. There was an unsecured Oxygen tank sitting on the floor next to the recliner. On 1/10/23 at 10:48 AM, the Oxygen tank in R6's room was still not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one of one resident (R136) reviewed for incontinence care in the sample list of 26. Findings include: The facility's Perineal Cleansing policy with a revised date of 9/21/10 documents, Policy: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Procedure: Female-without catheter 5. Wash pubic area including upper inner aspect of both thighs and frontal portion of perineum. a. Use long strokes from the most anterior down to the base of the labia b. After each stroke refold the cloth to allow use of another area. 11. Wash peri-anal area thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks. a. Refold cloth, as before, to provide clean area. b. Washing should alternate side to side, ending with the center anal area. 12. Place soiled items in plastic bag. 13. Rinse cloth and entire area in the same…

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

Based on interview and record review the facility failed to address pharmacy recommendations for one (R25) of 13 residents reviewed for medication monitoring reviews on the sample list of 26. Findings include: R25's pharmacy Consultation Report provided by V2 Director of Nursing dated 8/1/22 through 8/22/22 documents a recommendation to discontinue Multivitamins, Vitamin D, Magnesium, Florastor, Lipitor, and Vitamin C. R25's pharmacy Consultation Report provided by V2 dated 12/1/22 through 12/12/22 documents a recommendation to document the rationale for continuing R25's as needed Ativan. These consultations were not signed as received by the physician until 1/9/23. On 1/10/23 at 10:00 AM, V2 stated the facility had not addressed the pharmacy recommendations made by the pharmacy until 1/9/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to review a resident's medication orders to prevent duplicate therapy and the potential for excess dosage for one of 13 residents (R136) reviewed for medications in the sample list of 26. Findings include: R136's Physician's Order Sheet (POS) dated 1/1/23 through 1/31/23 documents R136 was admitted on [DATE] and documents diagnoses including Abnormal Liver Function Tests, Anasarca (Generalized Swelling), Bipolar Depression, Chronic Back Pain, Depression, Hypertension, Morbid Obesity and Abdominal Pain. R136's POS dated 1/1/23 through 1/31/22 documents an order dated 12/5/22 for Acetaminophen 325 mg (milligrams) take two tablets (650mg) by mouth four times a day for Chronic Pain. This dosage would total 2,600 milligrams in a 24-hour period. This POS also documents an order for Acetaminophen 325 mg, two tablets by mouth every four hours as needed. This dosage has the potential to total 3,900 milligrams in a 24-hour period. The total potential Acetaminophen…

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.