Kearny County Hospital Ltcu

The facility reported a census of 25 residents. Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 25 residents. Findings included: - During an interview on 10/22/24 at 09:15 AM, Administrative Staff A revealed the facility did not employ a qualified IP. Administrative Staff A reported the IP in the hospital would answer questions for Administrative Nurse D and Administrative Nurse E when needed. Administrative Staff A reported that neither Administrative Nurse D nor Administrative Nurse E have completed an Infection Prevention and Control Program (IPCP). During an interview on 10/24/24 at 10:20 AM, Administrative Nurse D confirmed she had not started a IPCP at this time. The facility's policy Infection Prevention Plan dated 05/2021, documented the designated IP would be responsible for the day-to-day functions 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.

The facility reported a census of 25 residents. Based on interview and record review, the facility failed to ensure four of the five Certified Nurse Aides (CNA) sampled lacked the required 12 hours per year in-service training. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - On 10/24/24 at 10:00 AM, review of training records for five CNAs employed by the facility for more than one year revealed four CNAs had less than 12 hours of documented in-service training for the previous 12 months as follows: CNA N had 10 hours and 38 minutes of documented training. CNA R had nine hours and 32 minutes of documented training. CNA Y had 10 hours and six minutes of documented training. Social Services Designee (SSD)/CNA X had nine hours and 24 minutes of documented training. On 10/24/24 at 10:00 AM, Administrative Staff A confirmed that CNAs were required to have 12 hours of training annually and stated there were no records of additional training for those CNAs. The facility did not provide a policy related to CNA continuing education…

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 The facility reported a census of 25 residents, with 12 residents sampled and reviewed for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure five resident's advanced directives were thoroughly completed. Resident (R)124 had a Do Not Resuscitate (DNR- or no code, a legal document that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest) form that was only located in the Code Status binder at nurse's station. However, the electronic health record (EHR) lacked a DNR order and lacked the uploaded DNR document for R124. Additionally, R15 had no order for a DNR in the EHR. R21 and R20 had a durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer…

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.

The facility reported a census of 25 residents. The sample included 12 residents. Based on observation and staff interviews, the facility failed to promote a clean homelike environment for five residents. Resident (8) had a chair seat repaired with duct tape and R124 had a bureau drawer, which had lacked part of the veneer on the drawer facing and the remaining veneer was loose and brittle. Additionally, R2, R74, R23 and R124 had fall mats, which were cracked and had worn down surfaces all that were identified as non-cleanable surfaces and a non-home-like environment. These deficient practices had the potential to spread possible infections to the residents in the facility. Findings included: During an observation on 10/23/24 at 01:21 PM. R124 had a fall mat on her floor in her room, which had several cracks, tears and worn-down surfaces. During an interview on 10/24/24 at 08:38 AM, Housekeeping Staff II reported she would clean the fall mats with disinfectant cleaner and that it was not her job to report the fall mat that were worn down. Housekeeping Staff II reported she would…

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 The facility had a census of 25 residents. The sample included 12 residents with three reviewed for discharge. Based on observation, interview, and record review the facility failed to provide written notice to the resident or resident representative for facility-initiated transfers for Residents (R)18, R12, and R23 when they transferred to the hospital. The facility also failed to send a copy of the notice to the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of R18, R12, or R23's discharge. This placed the residents at risk of uninformed care choices. Findings included: - Review of the Electronic Health Record (EHR) census log for R18 revealed a discharge from the facility to a hospital on [DATE] and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to this discharge/transfer. Review of the EHR census log…

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 The facility had a census of 25 residents. The sample included 12 residents with three reviewed for discharge. Based on observation, record review, and interviews, the facility failed to provide a written bed hold policy notice to Residents (R)18, R12, and R23, or the resident's representatives, when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R18, R12 and R23. Findings included: - Review of the Electronic Health Record (EHR) census log for R18 revealed a discharge from the facility to a hospital on [DATE] and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to this discharge/transfer. Review of the EHR census log for R12 revealed a discharge from the facility to a hospital on [DATE] and readmitted to the facility on [DATE]. The EHR lacked documentation related to written…

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 The facility reported a census of 25 residents. The sample included 12 residents. Based on interview and record review, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner for eight residents, Resident (R) 8, R10, R12, R17, R18, R19, R20 and R21. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - During the onsite annual survey, the surveyor identified a concern regarding the lack of quarterly MDS assessments completed in a timely manner for eight residents. Review of the Electronic Health Record (EHR) on 10/21/24 revealed the following quarterly MDS noted concerns for the following eight residents: R8's EHR recorded a quarterly MDS, dated [DATE]. R8's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/26/24 and submitted on 09/26/24. (11 days later) R10's EHR recorded a quarterly MDS, dated [DATE]. R10's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/26/24 and submitted 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 The facility reported a census of 25 residents. The sample included 12 residents. Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for ten residents. Resident (R)8, R10, R12, R15, R17, R18, R19, R20, R21 and R124. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - During the onsite annual survey, the surveyor identified a concern regarding the lack of comprehensive MDS assessments completed in a timely manner for ten residents. Review of the Electronic Health Record (EHR) on 10/21/24 revealed the following comprehensive MDS noted concerns for the following 10 residents: R8's EHR recorded a comprehensive MDS, dated [DATE]. R8's EMR recorded an Annual MDS, dated [DATE], was completed on 08/13/24 and submitted on 08/14/24. (167 days later) R10's EHR recorded a comprehensive MDS, dated [DATE]. R10's EMR recorded an Annual MDS, dated [DATE], was completed on 05/10/24 and…

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

The facility identified a census of 25 residents, which included 12 residents sampled. Based on interviews, observations, and record review, the facility failed to review and revise the care plans with appropriate interventions for eight of the sampled residents; R23 related to treatment of an area of pressure ulcer/injury and enhanced barrier precautions (EBP - a set of infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) related to wound care and urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care; R19, R15, R20, R21, R17, R12 and R18 related to development and implementation of appropriate interventions to prevent multiple falls. These deficient practices had the potential to result in uncommunicated care needs. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R)18 included diagnoses of dementia (a progressive mental disorder characterized by failing memory,…

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 The facility reported a census of 25 residents with 12 residents selected for review which included five residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards for four residents. The facility failed to ensure staff properly cleaned and stored the nebulizer (a device for administering inhaled medications) for Resident (R)12, R8, and R74. The facility failed to ensure R18's room remained free of used nebulizer equipment (from a prior discharged resident) not required for R18's medical care. Additionally, the facility failed to ensure the nasal cannula (a device to deliver low-concentration, low-pressure supplemental oxygen) were stored appropriately, sanitarily, when not in use for R12 and R8. These deficient practices had the potential to have a negative impact on the resident's physical well-being and at risk of respiratory infection. Findings included: - During an observation on [DATE]…

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.

The facility census totaled 25 residents on two halls and had two medication carts. Based on observation, interview, and record review, the facility failed to ensure the staff and secured storage of resident medications when observation onsite revealed an unlocked and unattended medication cart, not in the line of vision of the attending staff, containing oral, topical and inhaled medications. This deficient practice placed nine cognitively impaired, independently mobile residents at risk. Findings included: - On 10/22/24/24 at 07:38 AM, observation revealed an unlocked and unattended medication cart that contained oral, topical and inhaled medications in the hall between the dining area and commons area. During an interview on 10/22/24 at 07:38 AM, Certified Medication Aide (CMA) S identified the cart as her responsibility and stated the cart should be locked when not attended. CMA S stated the (medication cart) lock would not engage if the drawers were not fully closed, even if the lock appeared engaged. CMA S stated that maintenance had recently replaced the lock. CMA S stated…

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.

The facility reported a census of 25 residents with 12 residents sampled. Based on interview and record review the facility failed to provide the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) consent/declination form to five residents reviewed. (Resident (R) 8,12,18,19 and 124). Additionally, the facility failed to provide a second witness signature on R12 and 18's influenza vaccine (a vaccine designed to prevent influenza [highly contagious viral infection]) consent forms. Findings included: - Review of the Electronic Health Record (EHR) of 2023-2024 for R8, R12 and R19 lacked documentation of the pneumococcal vaccine declination form. Additionally, their EHR lacked documentation of the historical pneumococcal vaccine immunization record. R18 and 124 lacked any documentation for consent/declination of pneumococcal vaccine. Review of the EHR of 2024 - 2025 for R8,12,18,19 and 124 lacked required documentation of influenza vaccine. During an interview on 10/24/24 at 10:15 AM, Administrative…

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.

The facility reported a census of 25 residents. The sample included 12 residents. Based on interview and record review, the facility failed to treat residents in a dignified manner when it charted in the medical record that Resident (R)17 was placed at the feeder table. The facility did not honor resident's rights related to personal food preferences and food choices for Resident (R)124. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Review of the Electronic Health Record (EHR) revealed Resident (R)17 had the following diagnoses: pulmonary fibrosis (a process that causes lung scarring, in which fibrotic tissue blocks the movement of oxygen into the bloodstream and low oxygen levels), psychosis (any major mental disorder characterized by a gross impairment in reality perception), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 25 residents with 12 residents sampled that included two residents reviewed for baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan for Resident (R) 74 and R124. This deficient practice had the potential to lead to uncommunicated needs. Findings included: - The Electronic Health Record (EHR) census for Resident (R) 74 revealed that R74 was admitted to the facility on [DATE] and the EHR lacked documentation that a baseline care plan was created. Further, R74's permanent person-centered comprehensive care plan was completed on 10/15/24 (15 days after the admission). The EHR census log for R124 revealed R124 admitted to the facility on [DATE] and the EHR lacked documentation that a baseline care plan was created. R124's permanent person-centered comprehensive care plan was created on 09/17/24 but lacked initial goals based on admission orders, physician's orders, therapy services, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 25 residents. The sample included 12 residents reviewed for person-centered care plan development. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three residents, Resident (R) 74 related to psychotropic (any class of medications that alter mood or thought) medication use, opioid (a class of medications used to treat moderate to severe pain) medication use, diuretic (a class of medication to promote the formation and excretion of urine) medication use and nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication use. R124's Care plan lacked interventions related to the performance (or lack thereof) for activities of daily living (ADLs - activities such as walking, grooming, toileting, dressing and eating, etc.), psychotropic medication use, visual function, abnormal behaviors, nutritional status, and pain. R20's care plan lacked…

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 The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately assess the nutritional status of cognitively impaired Resident (R)124 on admission, placing the resident at risk for nutritional deficits. Findings included: - Resident (R) 124's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and depression. The 09/29/24 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. R124 had a total mood severity score of one, indicating none to minimal depression and she had one behavior noted she yelled at staff. R124 required set up for eating, had broken or loose fitting dentures, and was dependent on a wheelchair for mobility. The 09/29/24 Nutritional Status Care Area Assessment (CAA) for R124 documented staff did not have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure the Physician documented and conducted the in person admission visit as required for Resident (R)124. Findings included: - Resident (R)124's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and depression. The 09/29/24 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. R124 had a total mood severity score of one, indicating none to minimal depression and she had one behavior noted she yelled at staff. R124 required set up for eating and was dependent on a wheelchair mobility. R124 had impairment noted to one upper and lower side of her body. The 09/29/24 admission MDS for R124 had no date for completion of the MDS, the CAA or submission record as of 10/21/24.…

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

The facility identified a census of 25 residents. The sample included 12 residents with the residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to support Residents (R)19 and R124 and implement care planned interventions to address dementia care needs. This deficient practice placed the residents at risk for impaired ability to achieve and/or maintain their highest practicable level of functioning and wellbeing. The facility failed to implement individualized interventions, as well as revise the care plan accordingly, to address individualized interventions related to the residents symptomology and rate of progression as evidenced by observation, record review, and/or interview. Findings included: - Review of Resident (R) 19's Electronic Health Record (EHR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), Alzheimer's disease, (progressive…

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.

The facility reported a census of 25 residents. The sample included 12 residents with six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) on 06/30/24 for Resident (R)18. The deficient practice had the potential to lead to the residents receiving unnecessary mediations. - Review of the Electronic Health Record (EHR) for Resident (R)18 included diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), epilepsy (a brain disorder characterized by repeated seizures), frontotemporal neurocognitive disorder (a brain disease that affects behavior, language and movement abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 04/22/24 Annual Minimum Data Set (MDS) completed 08/16/24, documented that the Brief Interview for Mental Status (BIMS) assessment could not be completed, and the staff assessed R18 to have severely impaired cognition. The 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 The facility reported a census of 25 residents. The sample included 12 residents with six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R)74's medication regimen remained free of as needed (PRN) psychotropic (any class of medications that alters mood or thought) medication that lacked the required 14 day stop date or clinical rationale for continued use beyond the initial 14 days. This deficient practice had the potential to lead to the resident receiving unnecessary psychotropic medications. Findings Included: - R74's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and Alzheimer's disease (a progressive mental deterioration…

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 The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accommodate a resident's preferences related to dietary preferences for one Resident (R)124. Findings included: - Resident (R) 124's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and depression. The 09/29/24 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. R124 had a total mood severity score of one, indicating none to minimal depression and she had one behavior noted she yelled at staff. R124 required set up for eating and was dependent on a wheelchair mobility. R124 had impairment noted to one upper and lower side of her body. The 09/29/24 Nutritional Status Care Area Assessment (CAA) R124 did not have an issue with her nutrition. The 10/21/24 Care Plan lacked…

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.

The facility reported a census of 29 residents. Based on record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance ([QAA] facility meetings to identify issues with care and services in the facility and develop action plans to correct the concerns) program to ensure the problems related to resident care identified and action plans developed through the QAA program to address those concerns. This had the potential to affect all residents. Findings included: - The facility failed to provide activity of daily living (ADL's) for Resident (R)15, related to lack of nail care on her long fingernails that dug into the palm of her left hand. The facility failed to provide hand splinting devices for contractures, for R2 and R15. The Consulting Pharmacist failed to report irregularities of inappropriate diagnosis for antipsychotic medication Seroquel, for R27. The facility failed to ensure antipsychotic medications had an appropriate diagnosis for R27. The facility failed to ensure facility staff hand hygiene and infection control practices…

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.

The facility reported a census of 29 residents. Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance (QAA) committee meetings with the required members present that included the Director of Nursing Services, the Medical Director, the Nursing home administrator, owner, board member, or other individual in a leadership role, the Infection Preventionist and two other staff members, when the facility did not have at least quarterly meetings. This had the potential to affect all residents. Findings included: - On 12/05/22 at 01:30 PM, Administrative Nurse D produced sign- in sheets for quarterly QA meetings from January 2021 through December 2022. The facility lacked documentation for the required meetings for the year 2022. On 12/07/22 at 03:35 PM Administrative Nurse D, confirmed the facility had not had QAA quarterly meetings. She stated she had been trying to get them scheduled, and things kept happening to prevent her from scheduling the meetings. The facility's LTC (long term care) Quality Assessment and Assurance Program policy…

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.

The facility reported a census of 29 residents, with 12 residents sampled, including one resident sampled for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide appropriate nail care and assistance for Resident (R) 15. Findings included: - The 12/05/22 Electronic Health Record (EHR) documented R15 included the following diagnoses: osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 03/01/22 Annual Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) of seven, indicating severely impaired cognition. R15 required extensive assistance of one staff for all activities of daily living (ADL). R15 had occasional pain at four that did not interfere with sleep or ADL's. 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.

The facility reported a census of 29 residents, with 12 residents sampled, including two residents sampled for position/mobility. Based on observation, interview, and record review, the facility failed to provide care, equipment, and assistance to maintain or improve mobility with the maximum practicable independence for Resident (R) 15 and R2 by the failure to provide the provider ordered finger separator (device used to stretch and separate the fingers) for R15 and the carrots (hand contracture orthosis) for R2. Findings included: - The 12/05/22 Electronic Health Record (EHR) documented R15 included the following diagnoses: osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 03/01/22 Annual Minimum Data Set (MDS) documented a Brief Interview 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.

The facility reported a census of 29 residents with 12 sampled including two residents sampled for indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent possible urinary tract infections for Resident (R) 2 and R7. Findings included: - The 12/05/22 Electronic Health Record (EHR) documented R2 had the following diagnosis: neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The 10/24/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R2 had an indwelling catheter. The 10/24/22 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented the resident had an indwelling urinary catheter. The 11/30/22 Care Plan documented staff assisted R2 with catheter care every shift and more often as needed. The Electronic Health Record (EHR) documented as of 12/21/21, R2 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 29 residents. The sample included 12 residents, including five sampled residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported an inadequate indication for use for Resident (R) 27's anti-psychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel. This failure had the potential of unnecessary antipsychotic medication use and related side effects for R27. Findings included: - The electronic medical record (EMR) for R27 documented diagnosis of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal, and physical aggression, wandering and hoarding), frontotemporal dementia (dementia with dramatic changes in personality, socially inappropriateness, and impulsiveness), and depression (a mood disorder that…

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 The facility identified a census of 29 residents. The sample included 12 residents, including five residents sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate diagnosis for an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) for Resident (R)27's anti-psychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R27. Findings included: - The electronic medical record (EMR) for R27 documented diagnoses of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal, and physical aggression, wandering and hoarding), frontotemporal dementia (dementia with dramatic changes in personality, socially inappropriateness, and impulsiveness),…

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.

The facility reported a census of 28 residents. The facility had one main kitchen where food was stored and prepared for two dining rooms. Based on observation, interview, and record review the facility failed to properly store food items placed in a refrigerator and dry goods storage room by the failure to ensure food items in opened packages were dated and expired foods were discarded after the expiration date. The facility also failed to ensure staff followed sanitary methods of distributing food to residents. This had the potential to affect all residents in the facility. Findings included: - During the initial environmental tour of the dietary department on 05/24/21 at 09:15 AM, the following concerns were identified: 1. 20 Hormel Thick & Easy thickened dairy beverages with a Best Used by date of 05/07/21 were found on a rack. 2. Two one-pint cartons of Hi-Land 2% Reduced Fat Milk were found in refrigerator number one with an expiration date of May 20, 2021. 3. Two opened packages of angel hair pasta were found in the dry goods storage room. One package was in an undated…

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 The facility reported a census of 28 with two residents reviewed for skin conditions (non-pressure related). Based on observation, interview, and record review the facility failed to ensure nursing staff identified, documented, and followed-up on bruising for Resident (R)9. Findings included: Review of R9's Physician Orders dated 04/01/21 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and emphysema (long-term, progressive disease of the lungs characterized by shortness of breath). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R9 required limited assistance with bed mobility, transfers, walking, and locomotion. R9 required extensive assist with dressing and toilet use. There were no noted skin issues documented, and R9 did not receive an anticoagulant.…

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.