Regency House Of Alexandria

Based on observation and interview, the facility failed to ensure that the planned menus were followed to meet the nutritional needs of the residents requiring a pureed diet. The facility failed to follow the established recipe during the preparation of pureed foods, which did not ensure the nutritional adequacy of the meals provided to residents who required a pureed diet. This had the potential to affect a total of two residents who received pureed diets. Findings:Review of a policy with a revision date of 09/01/2024 titled Puree Food Preparation read in part.It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance.5. Do not use water as an additive to prepare puree foods.7. Puree Food Preparation Guidelines per Serving:Meats: Add 1 teaspoon of beef broth or beef gravyVegetables (leaf, stem, or flower): Add 2 teaspoons of mashed potato flakes On 03/02/2026 at 11:11 a.m., an observation was made of S3DM preparing pureed diets. S3DM added several scoops of cabbage, three pieces…

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, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were dated with an open date. This deficient practice had the potential to affect 43 residents who received meals served from the kitchen. Findings:An observation on 03/02/2026 at 6:08 a.m. of the facility pantry and refrigerator revealed one undated, open package of brown gravy mix, one undated, open bag of potato chips, and one undated, open package of sliced ham. On 03/02/2026 at 6:20 a.m., S3DM confirmed all opened food items stored in the pantry or refrigerator should be labeled with the date the item was opened. S3DM further confirmed that the items listed above should have been labeled with an open date, but were not.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development of communicable diseases and infection for 1 (Resident #49) of 1 resident reviewed for infection control. The facility failed to ensure:EBP were utilized as ordered; andA peripheral IV site was changed every 3 days.Review of the facility's policy titled Enhanced Barrier Precautions revised 09/01/2024 revealed, in part. 2b) An order for enhanced barrier precautions will be obtained for residents with.feeding tubes. 3a) Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray. 3b) PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. 4d) High-contact resident care activities include providing hygiene. 6) Therapists should use gown and gloves when 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.

Based on interview and record review, the facility failed to provide care and services that met professional standards of quality for 1(Resident #1) of 3 residents by failing to ensure controlled medications that were ordered for Resident R1 were not administered to Resident #1. The facility census was 47.Findings: Review of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part.Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines:10. Ensure that the six rights of medication administration are followed:a. Right Residentf. Right documentation12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.23. Correct any discrepancies and report to nurse manager. Review of Resident #1's medical record revealed an admit date of 11/18/2025 with the following diagnoses: Chronic Obstructive Pulmonary Disease Unspecified, Type II Diabetes…

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

Based on interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure the acquiring and dispensing of a controlled medication (Hydrocodone-Acetaminophen) to meet the needs of the resident for 1 (Resident #1) of 3 sampled residents. Total facility census was 47.Findings: Review on 12/15/2025 at 11:10 a.m. of the facility's policy and procedure with a review date of 09/01/2024, and titled Controlled Substance Administration and Accountability read in part.Policy Explanation and Compliance Guidelines:3. Ordering and Receiving Controlled Substances:The amount on hand is checked against the amount used daily from the documentation records;The designated order form is completed and sent to the appropriate pharmacy making sure it contains the following:a. Unit/Wing ordering the medication;b. Signature of person making the request;c. Date;d. Medications and quantities required. Review of Resident #1's medical record revealed an admit date of 11/18/2025 with the following diagnoses: Chronic Obstructive Pulmonary Disease Unspecified, Type…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an injury of unknown origin and a serious bodily injury of an unknown origin were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#1 and #2) of 3 (#1, #2 and #3) sampled residents reviewed for accidents. The facility failed to: 1. Ensure injury of unknown origin of Resident #1 was reported within 2 hours in accordance with State law through established procedures. 2. Ensure serious bodily injury and injury of unknown origin of Resident #2 was reported within 2 hours in accordance with State law through established procedures. Findings Review of the facility undated policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation read in part . This policy is concerned with all incidents and accidents involving residents. Certain incidents and accidents involving residents must also be reported to the appropriate state agencies.…

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 implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure a CNA staff reported Resident #1's complaint of pain to the nurse as indicated in the plan of care. Findings: Review of facility policy titled Pain Management, with a revision date of 12/31/2024 on 03/17/2025, read in part .Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Pain Management and Treatment: 2.The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal. Record Review revealed Resident #1 was admitted 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.

Based on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were administered and accurately documented on the MAR for 1 (#44) of 4 sampled residents (#44,#155,#157,#159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility. Findings: Review on 02/12/2025 of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part . Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: f. Right documentation 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 23. Correct any discrepancies and report…

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

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure acquiring, receiving, dispensing and administration of a non-controlled medication (Sacubitril-Valsartan) to meet the needs of the resident for 1 (Resident #44) of 4 sampled residents (#44, #155,#157 and #159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility. Findings: Review on 02/12/2025 of the facility's policy titled Medication Ordering and Receiving from Pharmacy Provider, Section 3.2: Ordering and Receiving Non-Controlled Medications dated 01/2023 read in part . Policy: Medications and related products are received from the provider pharmacy on a timely basis. Procedures: Ordering medications from provider pharmacy: Timely delivery of new orders is required so that medication administration is not delayed. 2. Receiving medications from the pharmacy: a. A licensed nurse or appropriate personnel as required by law Promptly reports…

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 their medication error rate was not 5 percent or greater. The facility had 4 medication errors (11.76%) out of 34 opportunities for errors observed. The facility had a total census of 54 residents according to the Resident List Report provided by the facility. Findings Review on 02/12/2025 of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part . Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: f. Right documentation 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 23. Correct any discrepancies and report to nurse manager. Observation of Medication Administration on 02/11/2025 at 9:30 a.m. revealed S13…

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

Based on observation, record review, and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to: (1) Implement Enhanced Barrier Precautions for Resident #206. (2) Ensure staff wore proper PPE while providing incontinent care to Resident #155. (3) Ensure that the facility's water management system was tested for Legionella. Findings: Review on 02/11/2025 of the facility's policy and procedure dated 09/01/2024, and titled Enhanced Barrier Precautions read in part . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms…

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 that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor a resident's right to request an incontinent wipe. Findings: 1. Review of a Facility Policy titled Federal Rights of Residents with an effective date of 04/08/2024 read in part . Purpose: All residents in long term care facilities have rights guaranteed to them under Federal and State law. Standard: (E) The resident has a right to be treated with respect and dignity, including. (e)(2) The right to retain and use personal possessions. (f)(2) The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of Resident #13's medical record revealed an admit date of 10/12/2018, with diagnoses which included in part . Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, and…

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

Based on observation and interview the facility failed to ensure each resident was treated with respect and dignity for 1 (Resident # 205) out 19 sampled residents. The facility failed to ensure Resident #205 had adequate clothing. Findings: Review of Resident #205's medical record revealed an admit date of 01/14/2025, with diagnoses that included in part .Major Depressive Disorder, Type 2 Diabetes Mellitus, Acute Respiratory Failure, and Unspecified Protein Calorie Malnutrition. Review of Resident # 205's admission MDS with an ARD of 01/18/2025, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #205 required supervision or touching assistance with upper body dressing, and partial/moderate assistance with lower body dressing. Review of Resident #205's Care Plan with no review date, revealed in part . 1. Resident had an ADL self-care performance deficit related to impaired balance, with approaches that included staff to supervise/assist resident with ADL's as needed. 2. Resident had a potential for cognitive decline due to Neurocognitive…

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 promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #49) of 3 (Resident #49, Resident #13, and Resident #158) residents investigated for accidents. The facility failed to notify the physician and responsible party in a timely manner after an unwitnessed fall. Findings: Review of Resident #49's medical record revealed an admission date of 12/13/2024 with diagnoses that included in part .Vascular Dementia, Moderate, With Other Behavioral Disturbance, Non-St Elevation (Nstemi) Myocardial Infarction, Lack Of Coordination, Difficulty In Walking, and Need For Assistance With Personal Care . Review of Resident #49's admission MDS with an ARD of 12/27/2024 revealed a BIMS score of 10, which indicated moderate cognitive impairment and no history of falls. Resident #49 was independent with rolling left to right, sit to lying, and lying to sitting. Resident #49 required set-up clean-up assist with chair/bed to chair transfer, with no wheelchair usage indicated. Review of Resident…

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 that services provided or arranged in accordance with the resident's plan of care are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required. The facility failed to ensure that S6 CNA did not apply Zinc Oxide cream to Resident #206's stage 3 Sacral pressure sore. Findings: Review of Resident #206's clinical record revealed an admit date of 02/06/2025, with diagnoses that included Acquired Absence of Left Leg Below Knee; and Encounter for Change or Removal of Surgical Wound Dressing Review of Resident #206's admission MDS with an ARD of 02/12/2025, revealed a BIMS of 15, which indicated Resident #206 was cognitively intact. Resident #206 used a wheelchair as a mobility device, and required supervision or touching assistance with eating, oral hygiene, and personal hygiene; substantial/maximal assistance with toileting, lower body dressing, putting on/taking off footwear; showering/bathing; and…

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

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #156) of 2 (Resident #13 and Resident #156) sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 18. Findings: Review of the facility's policy titled, Oxygen Concentrator, dated 12/31/2024 read in part . C. Nurse responsibilities: 1. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of Resident #156's medical record revealed an admit date of 01/23/2025 with a re-entry date of 02/05/2025 with diagnoses that included in part .Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia; Chronic Systolic (Congestive) Heart Failure; Depression. Anxiety Disorder; Dependence on other Enabling Machines and Devices; Respiratory Disorders in Diseases. Review of Resident #156's 02/2025 Physician orders revealed the following orders in part .Change O2 (Oxygen) mask/nasal…

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 all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #25) of 19 sampled residents. Findings: Review of a facility policy on 02/11/2025 at 1:39 p.m. titled, Medication Storage (unknown original date) with a revised date of 09/01/2024, revealed the following part .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .1. A. All drugs and biologicals will be stored in locked compartments (medication carts) . Review of Resident #25's medical record revealed an admission date of 11/15/2023, with diagnoses that included in part .Pressure Ulcer of Sacral Region, Stage 4, Peripheral Vascular Disease, Bipolar Disorder, Schizoaffective Disorder, Bipolar Type, and Need for Assistance…

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 interviews the facility failed to ensure garbage and refuse were disposed of properly. Findings: Review of a Facility Policy on 02/12/2025, titled Disposal of Garbage and Refuse with a review/revision date of 09/01/2024 read in part . Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Observation and interview on 02/11/2025 at 8:30 a.m., of the area outside of the facility's kitchen revealed one blue dumpster. Dirty gloves and debris (old cardboard boxes), littered the ground surrounding the dumpster. S22 Dietary Manager confirmed the findings at the time of observation. Interview on 02/11/2025 at 8:33 a.m. with S23 Maintenance Director, revealed the trash was left by the sanitation employees. Interview on 02/12/2025 at 12:20 p.m. with S1…

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

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent and control the spread of COVID-19 by failing to ensure proper signage was utilized for 2 of 2 (Resident #2 and #R1) residents on Transmission Based Precautions out of a total sample of 4 (Resident #1, Resident #2, Resident #3, and #R1) residents. Findings: Review of the facility's policy titled Application of Transmission-Based Precautions dated 06/30/2023 read in part . Transmission-Based Precautions are a group of Infection Prevention and Control practices that are used in addition to Standard Precautions for residents who may be infected or colonized with infectious agents that require additional control measures to effectively prevent transmission. Transmission-Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone. Droplet Precautions: Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.…

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 that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication, for 1 (Resident #3) of 3 sampled residents. (Resident #1, Resident #2, and Resident #3). Findings: Review of Resident #3's medical record revealed an admit date of 12/05/2024, with diagnoses that included in part .Gastrointestinal Hemorrhage Unspecified, Anal Fissure Unspecified, Chronic Atrial Fibrillation Unspecified, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of Resident #3's Significant Change MDS with an ARD of 03/30/2024, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #3 was dependent for toileting hygiene, lower body dressing and putting on/taking off footwear, and required supervision or touching assistance with oral and personal hygiene. Review of physician's orders for Resident #3 revealed the following order: 03/19/2024 - Warfarin Sodium (Coumadin) oral tablet 5 Milligrams, give 1 tablet by mouth 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 record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to: 1. Ensure Physician's orders for obtaining labs for a medication that required a drug level were followed for Resident #3; and 2. Ensure Resident #3's physician was notified of and immediately responded to abnormal lab test results for an anticoagulant. Findings: 1. Review on 04/11/2024 of the facility's policy titled Lab and Diagnostic Test Results-Clinical (with a revision date of 11/2018), read in part . Review by Nursing Staff 4. A nurse will try to determine whether the test was done: C. To monitor a drug level. 1. The reason for getting a test often affects the urgency of acting upon the result. Physician Responses 1. Time frames. A physician will respond within an appropriate time frame, based on the request from Nursing staff, and the clinical significance of the information. D. A physician should respond within one hour regarding a lab test…

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 ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall B) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms Findings: Observation on 02/14/2024 at 11:30 a.m. of the facility medication storage room accompanied by S6 ADON revealed the following items on shelves for use: (3) 44 ml bottles of Saline Nasal Spray with expiration dates of 01/2024. (1) 100 count bottle of Oyster Shell Calcium Plus D 500mg tablets with an expiration date of 04/2023. (1) 4oz. bottle of sugar free Adult Tussin DM with an expiration date of 12/2023. (1) 90 count bottle of Loratadine 10mg tablets with an expiration date of 01/2024. (4) 100 count bottles of Vitamin B-12 500mcg tablets with an expiration date of 01/2024. Observation of the Hall B medication cart accompanied by S6 ADON revealed the cart contained (1) Albuterol Sulfate 90mcg inhaler with an expiration date of 01/2024. Observation also revealed the first and second drawers of the medication cart…

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

Based on record review and interview the facility failed to provide evidence that ongoing monitoring or evaluations were being done to ensure the corrective actions put in place after identification of an increase in the number of residents with weight loss, falls, and wounds. Findings: Review of the facility policy titled: Quality Assurance and Performance Improvement Program-Governance and Leadership revealed in part .The responsibilities of the QAPI Committee are to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services, establish benchmarks and goals by which to measure performance improvement and utilize root cause analysis to help identify where identified problems point to underlying systematic problems. Interview on 02/15/2024 at 12:26 p.m. with S3 DON revealed current high risk issues identified in the facility included wounds, weights, and falls. Interview on 02/15/2024 at 12:27 p.m. with S3 DON revealed there were significant variances in…

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

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Proper hand hygiene during wound care for Resident # 14. 2. [NAME] gloves prior to administration of eye drops for Resident #251. This failed practice had the potential to affect all residents who receive medications and treatments that are managed by the facility. Findings: Review of Facility policy Clean Dressing Change read in part . Procedure: 10. Preform hand hygiene 11. put on gloves 12: remove dressing and place in trash can 13, remove gloves and perform hand hygiene 14. Put on clean gloves 15. Cleanse wound with gauze 16. Use dry gauze to pat the wound 17. Remove gloves and preform hand hygiene 1. Review of Resident #14's medical record revealed an admit date of 04/12/2019 with diagnoses that included: Unspecified Dementia, Anxiety Disorder, and Essential…

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

Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #24) of 20 sampled residents by failing to ensure resident was free of facial hair. Findings: Review of the Facility's policy Resident's Right- Respect, Dignity/Right to have Personal Property read in part Intent: It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible about how they wish to live their everyday lives and receive care. Review of Resident #24's medical records revealed an admit date of 12/16/2019 with diagnoses that included: Unspecified Dementia, Major Depressive Disorder, Coronary Artery Disease, Type 2 Diabetes, and Essential Hypertension. Review of Resident #24's MDS with ARD of 02/06/2024 revealed a BIMS score of 00, indicating severely cognitively impaired requiring partial to moderate assistance with personal hygiene. Review of Resident #24's Care plan with target completion date of 02/06/2024…

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 that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#24) of 3 (#4, #24 and #102) residents reviewed for ADL care. Findings: Review of the Facility's Activities of Daily Living policy read in part . Procedure: 1. Based on the comprehensive assessment of a resident and consistent with the residents needs and choices, the facility will provide the necessary care and services to ensure the resident's abilities in ADL's (Activities of Daily Living) do not diminish unless the resident's condition demonstrates that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living 3. The facility will provide care and services for the following ADL's: a. hygiene- bathing, dressing, grooming, and oral care. Review 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 observation, interviews and record review, the facility failed to ensure a resident received the necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice by failing to provide wound care as ordered for 1 (Resident #7) of 2 (#7, #14) residents reviewed for skin conditions. Findings: Review of the facility's policy titled Clean Dressing Change read in part Intent: It is the policy of the facility to ensure dressing are changed in accordance with state and federal regulation, and national guidelines. Procedure: 1. Verify and review physician's orders for procedure. Review of Resident #7's medical record revealed an admit date of 08/04/2021 with diagnoses that included: Diastolic Heart Failure, Need for Assistance with Personal Care, Dysphagia, Coronary Artery Disease, Chronic Kidney Disease, Type 2 Diabetes, and Anxiety. Review of Resident #7's 02/2024 Physician Orders revealed: 02/09/2024- Skin tear to dorsum left hand: Cleanse with wound cleanser and 4x4 gauze, pat dry, apply Xeroform and cover with dry…

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

Based on record review, observation, and interview, the facility failed to ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections for 1 (#39) of 1 resident reviewed for urinary catheters. The facility failed to change Resident #39's catheter every 30 days as ordered by the physician. Findings: Review of Resident #39's medical record revealed an admit date of 08/14/2023 with diagnoses that included in part Hemiplegia and Hemiparesis, Muscle Wasting and Atrophy, and Other Specified Disorder of the Bladder. Review of Resident #39's Quarterly MDS with an ARD of 02/13/2024 revealed a BIMS score of 7, which indicated moderately impaired cognition. Review of the MDS revealed Resident #39 was dependent with toileting, hygiene, and shower/bathing, had an indwelling catheter, and was always incontinent of bowel. Review of Resident #39's medical record revealed Resident #39 was care planned for alteration in elimination related to urinary retention with an 18 French indwelling catheter. Interventions included…

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 respiratory care consistent with professional standards of practice for 1 (Resident #32) of 1 sampled residents reviewed for respiratory care. Findings: Review of the Facility's policy Safety and Maintenance of Respiratory Equipment read in part Oxygen and Nebulizer (nasal cannula, 02 mask/tubing, nebulizer masks/tubing/mouthpiece) will be changed and dated weekly on night shift and PRN for residents with routine orders. Review of Resident #32's medical record revealed an admit date of 11/09/2023 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Alzheimer's Disease, Epilepsy, and Congestive Heart Failure. Review of Resident #32's care plan with review date of 02/06/2024 read in part . Resident is at risk for respiratory complications due to diagnosis of Chronic Obstructive Pulmonary Disease- Nebulizer treatment as ordered Review of Resident #32's 02/2024 Physician Orders revealed in part 11/21/2023-Albuterol nebulizer solution 2.5 mg inhale orally daily…

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 include the Medical Director or Medical Director designee in the Quality Assessment & Assurance (QAA) process. The facility's total census was 53 as per information provided by S7 Administrator. Findings: Review of the facility's QA meeting minutes revealed none of the meeting signature sheets included the signature of the facility's Medical Director. Interview on 02/15/2024 at 12:20 p.m. with S3 DON revealed QA (Quality Assurance) meetings were held twice a week on Tuesdays and Thursdays and high risk meetings were also held on Thursdays and monthly. S3 DON stated the Medical Director did not attend any of the meetings. Interview on 02/15/2024 at 1:17p.m. with S7 Administrator confirmed the Medical Director did not sign as having reviewed QA committee meeting minutes at least quarterly regarding all issues identified in the facility. S7 Administrator stated the Medical Director met with department heads and reviewed and signed meeting minutes pertaining to facility COVID initiatives only.