Waters Of Rockport Skilled Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure residents received food at safe and appetizing temperatures for 1 of 1 meal trays tested for taste and temperature of food. Finding includes: During an observation on 1/23/25 at 7:19 A.M., staff was pushing the enclosed meal tray cart from the kitchen to the [NAME] Hall. During an observation on 1/23/25 at 7:31 A.M., staff was passing the last meal tray for the hall. At that time, a meal tray was obtained to test for the taste and temperatures of the food. The scrambled eggs tested 89.0 degrees Fahrenheit and felt cold. The bacon tested at 76.3 degrees Fahrenheit and felt cold. During an interview on 1/23/25 at 8:06 A.M., Resident H indicated the temperature and variety of food was an ongoing problem. During an interview on 1/23/25 at 8:12 A.M., Resident F indicated the breakfast served to them this morning was barely warm. During an interview on 1/23/25 at 8:19 A.M., Resident J indicated the food was going downhill from when they were first admitted . Meals were either cold, overdone, or raw in 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 interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 4 of 4 residents reviewed for pharmacy services. After the facility's contracted pharmacy failed to deliver routine medications, residents missed multiple prescribed daily medications. (Resident B, Resident C, Resident D, Resident F) Findings include: 1. During an interview on 1/9/25 at 10:45 A.M., Resident B indicated that he typically receives his ordered medications, but that there was an issue with some of the medications during a recent winter storm. During an interview on 1/9/25 at 11:00 A.M., Registered Nurse (RN) 6 indicated that there was an issue with the facility's contracted pharmacy delivery some of the resident's routine medications a few days prior and that resident went about a day without some of their medications. During record review on 1/9/25 at 11:20 A.M., Resident B's diagnoses included but were not limited to, acquired absence of leg above knee, hypertension, and congestive heart failure.…

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 food service department was directed by a supervisor competent in food service management and knowledgeable in sanitation standards and food handling for 1 of 1 dietary managers reviewed. The dietary manager was not certified. (Dietary Manager) Finding includes: On 4/1/24 at 8:53 A.M., the Dietary Manager's certification and/or qualifications were requested. Employee records were provided and indicated the Dietary Manager's start date was January of 2023. During an interview on 4/4/24 at 8:00 A.M., the Administrator indicated the Dietary Manager was not certified but was enrolled in a class that started in November of 2023 and a goal completion date of November of 2024. On 4/5/24 at 10:43 A.M., the Administrator indicated there was not a policy for the Dietary Manager position requirements, but provided a current Dietary Director Job Description, dated 1/29/24, as a policy which indicated . education/experience: . be a graduate of an accredited course in dietetic training, approved by the American Dietetic…

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

Based on interview and record review, the facility failed to employ a qualified Infection Preventionist. The full time Director of Nursing was also completing the Infection Preventionist duties. Finding includes: On 4/3/24 at 1:19 P.M., the Director of Nursing (DON) indicated she was the facility's appointed Infection Preventionist (IP). On 4/5/24 at 10:08 A.M., the DON indicated although she was a full time DON, about 8 hours had been spent earlier in the week on IP duties. At that time, she indicated the amount of hours dedicated to IP duties fluctuated depending on the amount of infections in the facility, and sometimes would stay over her usual hours. Hours spent on DON and IP specific duties were not documented. On 4/1/24 at 2:40 P.M., a current non-dated Infection Prevention and Control policy was provided and indicated There will be an appointed person to spearhead the Infection Prevention and Control Program. This person will be a licensed nurse, usually the DON or ADON [Assistant Director of Nursing] On 4/5/24 at 11:48 A.M., a current non-dated Infection Control job…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 8 of 9 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident 17, Resident 30, Resident 29, Resident 8, Resident 19, Resident 21, Resident 10, Resident 7) Findings include: 1. On 4/2/24 at 8:44 A.M., Resident 7's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 1/14/24 and returned back to the facility from the hospital on 1/17/24. Resident 7's records lacked a bed hold policy. 2. On 4/2/24 at 11:55 A.M., Resident 17's clinical record was reviewed and indicated they were admitted from the facility to the hospital on [DATE] and returned back to the facility from the hospital on [DATE]. Resident 17's records lacked a bed hold policy. 3. On 4/4/24 at 1:36 P.M., Resident 8's clinical…

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 staff were completed with the CNA (Certified Nursing Aide) training program and evaluation within 4 months of their hire date for 5 of 5 staff that completed the CNA training program at the facility. The facility lacked information and supplies related to the CNA training program. Findings include: 1. A list of staff that had completed the CNA training program at the facility was provided by the Administrator on 4/2/24 at 11:30 A.M., and indicated the following: On 4/3/24 at 9:47 A.M., employee records were reviewed. Nurse Aide 41 had a start date of 3/23/23 and was not certified. Nurse Aide 43 had a start date of 6/21/23 and was not certified. Nurse Aide 45 had a start date of 8/14/21 and was not certified. Nurse Aide 51 had a start date 9/6/23 and was not certified. Nurse Aide 63 had a start date 6/21/23 and was not certified During an interview on 4/4/24 at 10:45 A.M., Nurse Aide (NA) 45 indicated she performed all CNA duties by herself, but did not take the test to be certified after the CNA class. During an…

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 adequate monitoring and supervision was done to keep a resident's drug regimen free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications. A resident was getting narcotic pain medications from an outside physician. (Resident 29) Finding includes: On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting, and taking an opiod. Physician's Orders included, but were not limited to, the following: oxycodone-acetaminophen (Percocet-pain medication) 10-325 mg (milligram), give 1 tablet by mouth every hours as needed for pain, ordered 12/29/23 by the facility Nurse Practitioner (NP) The MARs (Medication Administration Record) were reviewed from September 2023…

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 proper storage and disposal of medications for 2 of 3 medications carts and 1 of 1 medication storage rooms observed. A bottle of medication in the medication cart was not labeled, expired medications and medications of discharged residents were observed in the medication storage room, and medication carts were observed unlocked. (Resident 86, Resident 87, Resident 21, Resident 88, Resident 33, Resident 11, Resident 5, Resident 2, Resident 22, Resident 8) Findings include: 1. During an observation of the East Hall Medication Cart on 4/5/24 at 8:20 A.M., there was a plastic pill container in the locked narcotic box with 2 tablets inside of it. The label of the container was observed with Resident 29's name, oxy-apap [Percocet] 10/325 mg [milligram], and dated 12-15-23. During an interview on 4/5/24 at 10:55 A.M., RN 3 indicated when a narcotic medication came in a bottle from the resident or pharmacy, the staff would put them into the plastic containers because they were numbered and easier to do…

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

Based on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Foods were not labeled and open to air. Facial masks were adjusted with hands and food was prepped without sanitizing hands. Plate warmer lids and food containers were held against clothing. Bottom of shoe rested on shelf under table where food serving trays were stored. (Kitchen) Findings include: During the initial tour on 4/1/24 at 8:53 A.M., the following was observed in the kitchen: Refrigerator: Water was on the floor throughout an opened bag of pepperoni, not labeled an opened bag of roast beef meat, with 3/31 wrote on the bag in permanent marker 2 full bags of cabbage, with best if used by dates of 3/11/24 and 3/22/24 a full tray of individually wrapped green colored cake with white icing, not labeled a tray of dessert, not labeled Freezer: a ziploc bag of freezer burnt chicken thighs, with a preparation date of 9/20/23 a full tray of ice cream individually prepped and covered, 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.

Based on interview and record review, the facility failed to ensure residents were informed of the benefits of influenza and pneumococcal vaccines, consents or refusals were obtained for vaccines, and vaccines were offered based on resident preference for 5 of 5 residents reviewed for vaccines. (Resident 1, Resident 15, Resident 3, Resident 23, Resident 26) Findings include: 1. On 4/2/24 at 7:59 A.M., Resident 1's clinical record was reviewed. Diagnosis included, but were not limited to, history of stroke and depression. The most recent Annual MDS (Minimum Data Set) Assessment, dated 3/12/24, indicated no cognitive impairment and no behaviors. A nurses note, dated 11/3/23 at 8:54 P.M., indicated Resident 1 received a flu shot with no adverse reactions. Resident 1's clinical record lacked a consent for the flu vaccine administered on 11/3/23. 2. On 4/2/24 at 9:54 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but were not limited to, history of fracture and osteoarthritis. The most recent Quarterly MDS Assessment, dated 1/4/24, indicated no cognitive impairment…

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 residents were informed of the benefits of Covid vaccines, or consents and/or refusals were obtained for 4 of 5 residents reviewed for vaccines. (Resident 1, Resident 15, Resident 3, Resident 23) Findings include: 1. On 4/2/24 at 7:59 A.M., Resident 1's clinical record was reviewed. Diagnosis included, but were not limited to, history of stroke and depression. The most recent Annual MDS (Minimum Data Set) Assessment, dated 3/12/24, indicated no cognitive impairment and no behaviors. A Covid 2023-2024 Booster was administered on 11/27/23. Resident 1's clinical record lacked a signed consent form for the Covid vaccine administered on 11/27/23. 2. On 4/2/24 at 9:54 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but were not limited to, history of fracture and osteoarthritis. The most recent Quarterly MDS Assessment, dated 1/4/24, indicated no cognitive impairment and no behaviors. A nurses note, dated 11/9/23, indicated Resident 26 denied wanting a Covid Booster. Resident 26's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in double occupancy rooms and 100 sq. ft. in single occupancy rooms. This was evidenced in 14 of 43 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: During an interview on 4/1/24 at 12:04 P.M., the Administrator indicated the facility had room size waivers. At that time, a list of rooms and sizes was provided and were as follows: 1. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 2. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 3. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 4. room [ROOM…

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 residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents reviewed for self administering medications. A resident did not have a physician's order, care plan, or assessment to self administer medications. (Resident 29) Findings include: During an observation on 4/2/24 at 1:04 P.M., Resident 29 was observed laying in his bed asleep. On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting, and taking an opiod. Current Physician's Orders lacked an order for Resident 29 to self administer medications. The clinical record lacked a care plan related to self administering medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 1 of 1 residents reviewed for activities of daily living, 1 of 1 residents reviewed for hospice services, and 1 of 5 residents reviewed for unnecessary medications. The MDS inaccurately indicated one resident received a hypoglycemic medication, one resident had a current diagnosis of pneumonia and septicemia, and one resident did not receive hospice services. (Resident 17, Resident 21, Resident 27) Findings include: 1. On 4/1/24 at 11:58 A.M., Resident 21 was observed sitting in her wheelchair eating lunch with her husband in the room who indicated the resident was on hospice care. On 4/2/24 at 12:31 P.M., Resident 21's clinical record was reviewed. Diagnoses included, but were not limited to chronic obstructive pulmonary disease and anxiety. The most recent Significant Change MDS Assessment, dated 2/26/24, indicated Resident 21's cognition was moderately impaired, was not receiving…

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 develop care plans for 3 of 5 residents reviewed for unnecessary medications and 1 of 1 reviewed for hospice. The facility failed to develop care plans for residents on an anticoagulant, diuretic, antidepressant, risk of opioid overdose, and a resident that received hospice services. (Resident 11, Resident 29, Resident 21) Findings includes: 1. On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting, and taking an opiod, antidepressant, anticoagulant, diuretic, and antiplatelet. Current Physician's Orders included, but were not limited to, the following: oxycodone-acetaminophen (Percocet-pain medication) 10-325 mg (milligram), give 1 tablet by mouth every hours as needed for…

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

Based on observation, interview, and record review, the facility failed to ensure staff had knowledge of and appropriate training for Narcan administration for 1 of 5 residents reviewed for unnecessary medications. Staff were not educated and inserviced on the use of Narcan ordered for resident with a history of substance abuse and overdose, the drug was not available for use in the facility. (Resident 29) Finding includes: During an observation on 4/2/24 at 1:04 P.M., Resident 29 was observed laying in his bed asleep. On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting and was taking an opiod. Physician's Orders included, but were not limited to, the following: oxycodone-acetaminophen (Percocet-pain medication) 10-325 mg (milligram), give 1…

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

Based on interview and record review, the facility failed to maintain an complete, accurate clinical record for 1 of 5 residents reviewed for unnecessary medications. A narcotic pain medication was documented under the name of the Nurse Practitioner when it was ordered by an outside physician and the clinical record lacked documentation of destroying medications. (Resident 29) Finding includes: On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting and was taking an opiod and antidepressant but not an antipyschotic. Physician's Orders included, but were not limited to, the following: oxycodone-acetaminophen (Percocet-pain medication) 10-325 mg (milligram), give 1 tablet by mouth every hours as needed for pain, ordered 12/29/23 by the facility 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.

2. On 4/3/24 at 11:26 A.M., Resident 27's clinical record was reviewed. Diagnosis included, but was not limited to, Covid-19 (dated 3/30/24). Current physician orders included, but were not limited to: For COVID-19 + residents record temperature, pulse, respiration, blood pressure, and oxygen saturation every shift (report immediately any temperature 99.1 degrees or higher), dated 4/1/24. Resident 27's Medication Administration Record (MAR) for April 2024 indicated a temperature reading of 100 degrees on 4/2/24 day shift, and a temperature reading of 99.1 degrees on 4/2/24 evening shift. Resident 27's clinical record lacked notification to the physician related to the temperature readings on 4/2/24. On 4/5/24 at 2:30 P.M., the Director of Nursing (DON) and Administrator indicated notification to the physician related to the temperature readings could not be located. Based on observation, interview, and record review, the facility failed to properly prevent and contain COVID-19 to ensure infection control practices were followed for 1 of 2 residents reviewed for COVID-19. 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 interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a current certified Infection Preventionist for 3 of 5 days of survey. Finding includes: During an interview on 1/3/23 at 8:48 A.M., the Administrator during the Entrance Conference, indicated the Infection Preventionist at this time was only in the facility on an as needed basis. During an interview on 1/6/23 at 8:45 A.M., the Administrator indicated the previous IP (Infection Preventionist) had not worked in the facility since 11/1/22. On 1/6/23 at 9:30 A.M., the Administrator provided a certificate that showed the DON completed the Nursing Home Infection Preventionist Training Course on 1/6/23. On 1/9/23 at 8:14 A.M., the Administrator provided a certificate that showed the ADON completed the Nursing Home Infection Preventionist Training Course on 1/6/23. On 1/9/23 at 10:42 AM, a current, undated Infection Prevention and Control Policy indicated There will be an appointed person to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the plan of care was revised for 1 of 4 residents reviewed for care planning and care plan conferences were held timely for 6 of 7 residents reviewed for care plan conferences. A resident's care plan indicated they had a current urinary tract infection but they did not and interventions were not updated. Six residents had not had timely care plan conferences. (Resident 6, Resident 9, Resident 12, Resident 17, Resident 25, Resident 26) Findings include: 1. During an interview on 1/3/23 10:53 A.M., Resident 26 indicated they had not been to or invited to any care plan conferences. On 1/4/23 at 8:28 A.M., Resident 26's clinical record was reviewed. Resident 26 was admitted on [DATE], went home on [DATE], and was readmitted [DATE]. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), anxiety, wedge compression fracture of T(Thoracic) 11-T 12 vertebra, and difficulty walking. The most recent admission MDS…

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

Based on interview, observation, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 trays tested. Finding includes: During an interview on 1/3/23 at 10:22 A.M., Resident 14 and Resident 284, both indicated their food was often cold when they received it in their rooms. On 1/6/23 at 12:28 P.M., the temperatures of the foods on a test tray from the east hall were observed to be: beef and gravy 114.3 degrees Fahrenheit noodles 103.3 degrees Fahrenheit green beans 111.8 degrees Fahrenheit mashed potatoes 113.3 degrees Fahrenheit ice cream 16.3 degrees Fahrenheit peaches 58.8 degrees Fahrenheit Mighty Shake, strawberry 47.2 degrees Fahrenheit During an interview on 1/5/23 at 1:55 P.M. kitchen manager indicated neither she nor the kitchen staff knew what the serving temperature of food served residents' rooms on the unit should be. At that time, Kitchen staff 12 performed an Internet search for temperature serving guidelines, and found that food should be served at 135 degrees F (Fahrenheit). Kitchen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in double occupancy rooms and 100 sq. ft. in single occupancy rooms. This was evidenced in 14 of 43 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: During an interview on 1/4/23 at 1:45 P.M., the Administrator indicated the facility had room size waivers. At that time, a list of rooms and sizes was provided and were as follows: 1. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 2. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 3. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 4. room [ROOM…

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 safe, functional, sanitary, and comfortable environment was maintained for 2 of 2 resident halls. Bathroom flooring was loose from the subfloor, a sink was slow to drain, paint was peeling in a resident's room as well as in the hallways, and wallpaper was peeling off the wall. (room [ROOM NUMBER], Resident 25, Resident 12, Resident 28, East Hall, [NAME] Hall) Findings include: 1. On 1/3/23 at 10:14 A.M., the bathroom in room [ROOM NUMBER] was observed with the flooring coming loose from the subfloor near the doorway. During an observation on 1/9/23 at 9:33 A.M., the same was observed in the bathroom of room [ROOM NUMBER]. 2. Observation of the east and west hallways began on 1/3/2023 at 8:30 A.M., There were splotches of paint peeling or chipped observed on the walls. On 1/9/23 at 8:45 A.M., no changes were observed to the splotches of paint peeling or chipped on the walls in the east hall and west halls. 3. Resident 25's room 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 ensure baseline care plans were initiated within forty eight hours of admission for 1 of 2 residents reviewed for baseline care plans. (Resident 26) Finding includes: On 1/4/23 at 8:28 A.M., Resident 26's clinical record was reviewed. Resident 26 was admitted on [DATE], went home on [DATE], and was readmitted [DATE]. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia, arteriosclerotic heart disease of native coronary artery without angina pectoris, pain in right and left shoulders, cervicalgia, age-related osteoporosis, generalized muscle weakness, angina pectoris, unsteadiness on feet, anxiety, unspecified mood (affective) disorder,personal history of other mental and behavioral disorders, hypothyroidism, hyperlipidemia, essential (primary) hypertension, GERD (gastro-esophageal reflux disease) without esophagitis,wedge compression fracture of T11-T12 (thoracic) vertebra,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan for 3 of 4 residents reviewed for development of care plans. (Resident 15, Resident 6, Resident 26) Findings include: 1. On 1/3/23 at 2:55 P.M. , Resident 15's clinical record was reviewed. The diagnosis included, but were not limited to, anxiety disorder, unspecified dementia, chronic obstructive pulmonary disease, difficulty walking. The most recent quarterly MDS (minimal data set) Assessment, dated 12/3/22, indicated Resident 15 was severely cognitively impaired. Current physician orders included, but were not limited to: May admit to [name] Hospice, dated 10/27/22 NM (Nursing Measure): May use urine dip stick as needed for s/s (signs and symptoms) infection; if abnormal results may send urine specimen for UA (urinalysis) w/ (with) C&S (culture and sensitivity) as needed for foul smelling urine, urinary pain or dark urine, dated 2/3/22 Bactrim (antibiotic) DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. A resident lacked an order and care plan for a CPAP (continuous positive airway pressure) machine in use, and oxygen was not administered as ordered for 3 of 3 residents reviewed for respiratory care(Resident 23, Resident 26, Resident 6) Findings include: 1. On 1/3/23 at 10:09 A.M., Resident 23 was observed to have a CPAP (Continuous Positive Airway Pressure) machine at bedside was not labeled and the tubing was taped up. On 1/5/23 at 11:20 A.M., Resident 23 was observed to have to have a CPAP (Continuous Positive Airway Pressure) machine at bedside was not labeled and the tubing was taped up. On 1/5/23 at 10:16 A.M., the clinical record was reviewed. Diagnoses included but not limited to, cerebral vascular disease, obstructive sleep apnea, and unspecified atrial flutter. The admission Minimum Data Set (MDS) 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 ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 26) Finding includes: On 1/4/23 at 8:28 A.M., Resident 26's clinical record was reviewed. Resident 26 was admitted to the facility on [DATE], went home 10/5/22, and was readmitted on [DATE]. Diagnoses included, but were not limited to, dementia and anxiety. The most current admission MDS (Minimum Data Set) Assessment, dated 10/19/22 indicated Resident 26's cognition was moderately impaired and received an anti-anxiety medication 7 of 7 days of the assessment look back period. Current physician orders included, but were not limited to, the following: lorazepam tablet 0.5 mg (milligram) 1 (one) tablet by mouth every 8 (eight) hours as needed for anxiety, dated 10/12/22. Lorazepam 0.5 mg 1 (one) tablet by mouth at bedtime for anxiety dated 10/12/22.…

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.