Colfax Nursing and Rehab, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents while smoking for 1 (#34) of 1 Residents reviewed for smoking in a total sample of 43 Residents. Findings: Review of the Facility's undated policy titled Smoking Policy read in part.For safety reasons, this policy is in place to ensure increased safety and decreased fire and burn risk for our residents. The facility provides appropriate ashtrays and supervision. Protective items such as burn aprons, extenders, or smoking gloves may be utilized if deemed necessary to prevent burns. Review of Resident #34's medical record revealed an admit date of 10/28/2015 with a readmission on [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, Squamous Cell Carcinoma of Skin, Chronic Pain Syndrome, Alzheimer's Disease with Early Onset, Chronic Kidney Disease, Acute Chronic Diastolic Disease, Stage 3, Major…

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 necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment was stored properly for 1 (Resident #30) of 1 residents reviewed for respiratory care. The total sample size was 43 residents.Findings:The facility could not provide an oxygen storage policy. Review of Resident #30's medical record revealed an admission date of 03/04/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Heart Failure, and Essential (Primary) Hypertension. Review of Resident #30's Quarterly MDS with an ARD of 06/04/2025 revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident #30 was independent with bed mobility and personal hygiene and required supervision assistance with oral and toileting hygiene. Review of Resident #30's medical record revealed no documentation in the current plan of care regarding refusal of oxygen storage…

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 provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administration of medications to meet the needs of each resident for 1 (Hall X) of 2 (Hall X and Hall Z) medication carts reviewed for narcotic reconciliation. Findings:A review of the facility's policy dated 11/2022, titled Controlled Substances, read in part.1) Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2) The system of reconciling the receipt, dispensing, and deposition of controlled substances includes the following:a) Records of personal access and usage;b) Medication administration records;c) Declining inventory records; andd) Destruction, waste, and return to pharmacy records.Review of Resident #80's 08/2025 Physician Orders read in part:- Lorazepam Oral Tablet 2 MG (milligrams), Give 2 mg by mouth every 6 hours as needed for anxiety related to Generalized Anxiety Disorder…

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 observations, interviews and record reviews the facility failed to ensure each resident's environment remained free of accident hazards. The facility failed to ensure hot water temperatures did not exceed 120 degrees for 15 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]., room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 28 resident rooms. Findings: Review of the facility's 12/2009 policy titles Water Temperatures, Safety of read in part . Policy: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Observation on 06/30/2025 at 9:15 a.m. revealed the hot water temperature in the conference room bathroom sink felt hot to surveyor touch. Observation on 06/30/2025 at 10:55 a.m. of S3 Maintenance Supervisor measuring the water temperature in room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 resident's right to have access to the facility patio area outside of smoking times for 3 (#2, #3, and #R1) of 4 (#1, #2, #3, and #R1) sampled resident. Findings: Review of the Facility's undated policy titled Resident's [NAME] of Rights read in part . A. All nursing homes shall adopt and make public a statement of the rights and responsibilities of the residents residing therein and shall treat such resident in accordance with the provisions of the statement. The statement shall ensure each resident the following: 1. The right to civil and religious liberties, including but not limited to knowledge of their available choices, the right to independent personal decision, and the right to encouragement and assistance from staff of the facility in the fullest possible…

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 maintain a sanitary and comfortable homelike environment for all residents in the facility by failing to ensure the facility was free of odor. The facility census was 73. Findings: Review of the facility's undated policy titled Homelike Environment read in part Residents are provided a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: f. pleasant, neutral scents. Observation upon entrance on 06/30/2025 at 8:15 a.m. revealed a strong urine odor throughout facility. Review of the Resident council minutes for 04/03/2025 revealed resident complained of the hall ways smelling bad. The follow up response made to the resident council grievance read .The rooms and hallways are cleaned, but there are a couple residents that change themselves and leave…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents. The facility failed to: 1. Ensure S3 CNA and S4 CNA reported Resident #5's aggressive behaviors, and increased agitation to the nurse; and 2. Ensure Resident #4 was not physically abused by Resident #5. Findings: Review of the facility's undated policy titled Seven Step Abuse Prevention Policy, revealed in part .It is the policy of the facility to have a seven (7) step Plan to assist in preventing abuse, neglect, misappropriation of resident's property, and to keep residents as safe as possible. The policy consists of seven (7) areas: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. Physical abuse defined: the willful infliction of injury, unreasonable confinement (involuntary seclusion), intimidation, or punishment of a person with resulting physical harm or pain…

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 observations and interviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life by failing to ensure residents sitting at dining room tables were served together during mealtime. This deficient practice had the potential to affect any residents that use the facility's dining room during mealtime. Findings: Observations on 06/02/2024 at 12:20 p.m. revealed 2 resident sitting at a dining room table together. At 12:25 p.m., the 1st resident was served his tray of food. Staff were observed serving resident at other tables at this time. The 2nd resident was served his tray of food 19 minutes later at 12:44 p.m. Observations on 06/02/2024 at 12:30 p.m. revealed 2 resident sitting at a dining room table together. At 12:30 p.m., the 1st resident was served his tray of food. Staff were observed serving resident at other tables at this time. The 2nd resident was served his tray of food 9 minutes later at 12:39 p.m. Interview on 06/04/2024 at 11:05 a.m. S2 DON confirmed that residents sitting at…

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

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Findings: Review of the facility's undated policy titled Floors on 06/03/2024 at 11:14 a.m. read in part .Floors shall be maintained in a clean, safe, and sanitary manner. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures. Observation on 06/02/2024 at 9:20 a.m. of Resident #23 in Room A on Hall X revealed a large amount of food debris on the side of her bed. Room A had a large amount of brownish black substance observed throughout the room, and the floor was sticky. Resident #23 stated her room had not been cleaned since Friday 05/31/2024. Hall X was observed with a very strong urine odor throughout the hall. Observation on 06/02/2024 at 9:39 a.m. of Resident #6 in Room B on Hall X revealed the floor had black substances, a large amount of food debris, and the floor was sticky. Resident #6 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's right to be free from sexual abuse by another resident, for 1 (Resident #33) of 1 resident reviewed for abuse, in a total sample size of 38. Findings: Review of the facility's undated policy titled Seven Step Abuse Prevention Policy, read in part . Policy: It is the policy of [NAME] Nursing and Rehab to have a 7-step plan to assist in preventing abuse, neglect, misappropriate pf resident's property, and to keep residents as safe as possible. Identification: Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #33 Review of Resident #33's clinical record revealed an admit date of 02/07/2022, with diagnoses that included: Anxiety Disorder, Osteoarthritis, Peripheral Vascular Disease, Atherosclerotic Heart Disease, and Hyperlipidemia. Review of Resident #33's Quarterly MDS with an ARD of 03/06/2024, revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #75 Review of Resident #75's…

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

Based on record review and interview, the facility failed to develop and implement a person-centered care plan for each resident by failing to: 1. Develop and implement a care plan for Resident #59 related to depression, and 2. Record food intake for and notify Resident #26's physician and family of significant weight loss. There were 38 sampled residents. Findings: Resident #59 Review of Resident #59's EHR revealed an admit date of 09/02/2021 with diagnoses that included in part . Cerebral Infarction, Acute Respiratory Failure, Essential (primary) Hypertension, and Major Depressive Disorder. Review of June 2024 Physician orders revealed: 1. Torsemide 10 mg po qd 2. Aricept 10 mg po hs 3. Buspirone 5 mg po tid Review of Resident #59's quarterly MDS with an ARD of 05/08/2024 revealed the resident had a BIMS of 11, which indicated moderate cognitive impairment. Review of the MDS revealed Resident #59 received Antianxiety and Antidepressant medications with Active Diagnoses that included . CVA, Anemia, Coronary Artery Disease, ESRD, HTN, Heart Failure, Non-Alzheimer's Dementia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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 baths, shaving, and nail care to dependent residents for 5 (#6, #10, #12, #66,and #87) of 7 (#6, #10, #12, #33, #44, #66, and #87) residents reviewed for ADL's. Findings: Review of the facility policy on at 06/03/2024 at 10:35 a.m. titled: Activities of Daily Living (ADL), Supporting, revealed in part .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care , including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); Review of the facility policy on 06/03/2024 at 10:35 a.m. titled: Fingernails/Toenails, Care of General Guidelines read in part . 1. Nail care includes 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 observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu to ensure nutritional adequacy. Findings: Record review of the menu for the 06/02/2024 lunch meal revealed in part: Oven roasted turkey breast - 3 ounces Roasted turkey gravy - 2 ounces Au gratin potatoes - ½ cup Green peas - ½ cup Observations on 06/02/2024 at 12:29 p.m. of the food serving line in the kitchen, revealed S6 Dietary [NAME] preparing trays on the serving line for residents in the dining room. As the trays were prepared, they were then given to the CNAs to serve the residents. Observations revealed that roasted turkey gravy was not being served. Interview on 06/02/2024 at 12:30 p.m. with S6 Dietary Cook, confirmed that she had not served roasted turkey gravy to any of the trays that she had prepared, and there was no gravy on the serving line. Interview on 06/02/2024 at 12:30 p.m. with S5 Dietary Manager, confirmed that the menu called for 2 ounces of roasted turkey…

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 pureed foods were prepared according to the approved recipe by methods which conserved nutritional value for 8 residents that are served pureed diets by the facility's kitchen. Findings: Review of the facility's policy on 06/04/2024 at 9:51 a.m. titled Standardized Recipes read in part . Policy Statement: Standardized recipes shall be developed and used in the preparation of food. Policy Interpretation: 1. Only tested, standardized recipes will be used to prepare foods. 2. Standardized recipes will be adjusted to the number of portions required for a meal. 3. The food service manager will maintain the recipe file and make it available to food service staff. Interview on 06/02/2024 at 11:45 a.m. S6 Dietary [NAME] revealed she had already pureed lunch. S6 Dietary [NAME] stated she did not measure the amount of turkey she added to the dish to be pureed. S6 Dietary [NAME] stated she did not use the recipe to prepare the pureed meal. Interview on 06/02/2024 at 12:35 p.m. S5 Dietary Manager confirmed the recipe for 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 observation, record review, and interview the facility failed to ensure residents received meals at regular times, comparable to normal meal times in the community and in accordance with residents' needs and preferences. This deficient practice had the potential to affect all residents who are served meals in the dining room. Findings: Review of the facility's undated policy titled Frequency of Meals on 06/03/2024 at 11:00 a.m. revealed in part . The facility will serve at least three meals or their equivalent daily at scheduled times. Meals will be served 4 to 6 hours apart to help assure residents receive nutritional requirements. The following meal times have been established by our facility for residents: Breakfast starts at 6:30 a.m. Lunch starts at 11:30 a.m. Dinner starts at 4:30 p.m. Observation of the lunch meal on 06/02/2024 revealed staff began serving residents in the dining room at 12:20 p.m. Observation of the breakfast meal on 06/03/2024 revealed staff began serving residents in the dining room at 8:00 a.m. Observation of the lunch meal on 06/03/2024 revealed…

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 food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Freezer and refrigerator temperatures were monitored; 2. Sanitation levels were checked in the 3 compartment sink; 3. Refrigerated food contents were labeled, dated, and stored in a sanitary manner; and 4. Kitchen equipment was clean and sanitary. Findings: Observation on 06/02/2024 at 8:45 a.m., revealed the refrigerator and freezer temperature logs had not been checked with temperatures documented, from 05/31/2024 through 06/02/2024. Observation on 06/02/2024 at 8:50 a.m., revealed the walk-in freezer had a bag of approximately 20 breadsticks, and a bag of approximately 50 breadsticks that were opened and not dated. An interview with S6 Dietary [NAME] at that time, verified the bags of breadsticks were open and not dated. Observation on 06/02/2024 at 8:59 a.m. revealed the 3-compartment sink had water in all of the compartments. There was…

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

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 84 residents who resided in the facility. Findings: Review of the facility's undated policy titled Pest Control on 06/03/2024 at 10:35 a.m. read in part . Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents. Observation on 06/02/2024 at 9:20 a.m. of Resident #23 in Room A on Hall X revealed there were multiple flies observed in the room. Resident #23 stated her room always had flies. Observation on 06/02/2024 at 9:39 a.m. of Resident #6 in Room B on Hall X revealed there were multiple flies flying around room. Resident #6 stated flies were in her room year round, and the facility could not get rid of them, likely because her room stayed dirty. Observation on 06/02/2024 at 9:41 a.m. of Room C, revealed the resident within room had 8…

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 inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#21 and #44) of 3 (#21, #44, & #240) sampled residents for Advanced Beneficiary Notice of Non-Coverage (ABN). Findings: Review of the facility's undated policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices on 06/04/2024 at 10:00 a.m. revealed in part . Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the services may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. . 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume…

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.

FACILITY Based on record review and interview, the facility failed to ensure a quarterly assessment was completed timely for 1 (#51) of 1 resident reviewed for Resident Assessments. There were 84 residents in the facility. Findings: Review of Resident #51's medical record revealed an admit date of 11/04/2021 with diagnoses that included in part .Hyperlipidemia, Seizures; Schizoaffective Disorder, Dementia, and Chronic Kidney Disease. Review of Resident #51's MDS assessments revealed a quarterly assessment was completed on 01/24/2024 with no MDS quarterly assessments accepted since that time. In an interview on 06/04/2024 at 3:52 p.m., S3 Corporate Nurse stated the facility did not have an MDS nurse at this time. S3 Corporate Nurse stated she became aware Resident #51's MDS was late and transmitted one last night. S3 Corporate Nurse confirmed Resident #51's quarterly MDS was not submitted timely.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (#23 and #30) of 38 sampled residents. The facility failed to ensure: 1. Physician's orders for referring Resident #30 to a dermatologist were followed, and 2. Abnormal lab resullts were reported to provider and urine sample was recollected for Resident #23. Findings: Resident #30 Review of Resident #30's medical record revealed an admit date of 05/12/2022 with diagnoses that included in part .Hemiplegia, Cerebral infarction, Type 2 Diabetes Mellitus, and Anxiety Disorder. Review of Resident #30's quarterly MDS with an ARD of 04/03/2024 revealed a BIMS score of 14 which indicated intact cognition. Review of the MDS revealed Resident #30 required supervision/touching assistance with eating, partial/moderate assistance with toileting hygiene and was independent with rolling left and right and sit to lying In an interview on 06/02/2024 at 9:45 a.m., Resident #30…

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 (#87) of 2 (#40, and #87) sampled residents for respiratory care. The facility failed to ensure Resident #87 had a physician's order to receive oxygen therapy. Findings: Review of the facility's undated policy titled Oxygen Administration on 06/04/2024 at 9:44 a.m. read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review of Resident #87's medical record revealed an admit date of 03/01/2024. Resident #87 had diagnoses that included in part Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease, and Coronary Artery Disease. Review of Resident #87's admission MDS with ARD of 03/14/2024 revealed Resident #87 had a BIMS of 10 (indicating moderate cognitive impairment). Review of Resident #87's Comprehensive Person Centered Care Plan revealed Resident had a potential for complications related to diagnoses of Coronary…

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 include the Medical Director or his designee in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 84. Findings: Review of the quarterly QAA meeting's sign in sheet dated 03/29/2024 revealed the Medical Director was not in attendance. In an interview on 06/04/20204 at 5:25 p.m., S3 Corporate Nurse confirmed the Medical Director did not sign the attendance sheet for the 03/29/2024 quarterly QAA meeting. S3 Corporate Nurse stated when the Medical Director doesn't attend a meeting, he reviews the information later.

Based on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall Y) of 3 (Hall X, Hall Y, and Hall Z) hallways observed in the building. This had to potential to affect 24 residents residing on Hall Y. Findings: Observation on 06/04/2024 at 2:05 p.m. of the Hall Y accompanied by S9 Maintenance Supervisor revealed loose hand rails between rooms L and M. An interview on 06/04/2024 at 2:05 p.m., S9 Maintenance Supervisor confirmed the hand rails on Hall Y between rooms L and M were not secured to provide safety and should have been.

Based on observation, interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 2 (#2 and #4) of 4 (#1, #2, #3, and #4) residents reviewed for ADLs. The facility failed to ensure: 1. Staff made rounds on Resident #2 every 2 hours 2. Resident #4's hands were cleaned prior to meal time. Findings: Review of the facility's policy Activities of Daily Living read in part Policy statement: Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal/oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene c. Elimination d. Dining Resident #2 Review of Resident #2's medical record revealed an admit date 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, interview and record review, the facility failed to ensure resident's right to be treated with respect and dignity for 2 (#2 and #3) of 4 (#1, #2, #3, and #4) sampled residents reviewed for dignity. Findings: Review of the Facility's policy labeled Dignity read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 12. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents. Resident #2 Review of Resident #2's medical record revealed an admit date of 03/10/2023 with diagnoses that included: Encephalopathy, Anxiety disorder, Adult Failure to Thrive, Down Syndrome, and Unspecified Mood Disorder. Review of Resident #2's Care Plan with review dated 12/20/2023 read in part . Resident has potential for impaired skin integrity related to incontinence: Incontinence care to be provided every 2…

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 designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (#4) of 4 (#1, #2, #3, #4.) sampled residents reviewed for infection control practices. The facility failed to ensure resident hands were cleaned prior to dining. Findings: Review of Resident #4's medical records revealed an admit date of 07/13/2016 with diagnoses that included: Cerebral Infarction, Unspecified Convulsions, Anxiety Disorder, Essential Hypertension, Chronic Kidney Disease, Stage 3, Vascular Dementia, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder. Review of Resident #4's Care plan with review date 11/04/2023 revealed: Resident #4 had ADL self-care deficit and required assistance with ADL's with interventions that included to encourage to participate in simple ADL's such as: wash hands, face, oral care and hair care. Resident #4 required supervision with eating. Resident #4…

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 promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident. The facility failed to honor the resident smoking preferences for 6 (#R1, #R2, #R3, #R4, #R5, and #R6) out of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, and #R6) sampled residents reviewed for smoking. Findings: Review of the facility's Resident Rights policy read in part . Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. Self- Determination g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States Resident #R6 A Review of Resident #R6 quarterly MDS with ARD of 11/23/2023 revealed a BIMS of 15 which indicated 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.

FACILITY Sufficient and Competent Nurse Staffing Based on record review and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was verified for 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) of 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) CNA personnel records reviewed. This failed practice had the potential to affect any of the 95 residents residing in the facility who may receive care and services per the CNAs. Findings: Review of the personnel record for S10 CNA revealed a hire date on 04/13/2015, a rehire date on 06/03/2016. There was no documented evidence the CNA Registry had been checked since 09/09/2016 for S10 CNA. Review of the personnel record for S11 CNA revealed a hire date on 05/23/2018. There was no documented evidence the CNA Registry had been checked since 07/05/2018 for S11 CNA. Review of the personnel record for S12 CNA revealed a hire date on 10/24/2022. There was no documented evidence the CNA Registry had been checked since 10/25/2022 for S12 CNA. Review of the personnel record for S13 CNA…

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 dispose of garbage and refuse properly. This could affect all 95 residents in the facility. Findings: Review of the facility's policy titled Food-Related Garbage and Refuse Disposal revealed the following including: Policy Interpretation and Implementation #6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. #7. Outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 06/26/2023 at 8:15 a.m. of the facility dumpster revealed multiple trash bags and 3 broken bed frames lying on the ground around the dumpster. Interview at this time with S5 Dietary confirmed the above findings. She stated the trash bags and bed frames were on the ground when she last worked on 06/22/2023. Observation on 06/26/2023 at 9:13 a.m. of the facility dumpster with S1 Administrator revealed a trash truck picking up trash from the dumpster and on the ground around the dumpster. S1 Administrator stated that the facility trash was picked up on Monday,…

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

Based on observation, interview and record review the Facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The Facility failed to ensure a Resident's urinary catheter drainage bag was covered to ensure privacy for 1 (Resident #47) of 1 resident reviewed for dignity out of a total sample of 29 residents. Findings: Review of Resident #47's medical record revealed an admit date of 07/01/2019 with diagnoses which included: Urinary Tract Infection, site not specified, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Cerebral Infarction and Pain. Review of Resident #47's Quarterly MDS with an ARD of 04/12/2023 revealed resident had a BIMS score of 15 (indicating intact cognition) and required total care for bed mobility, transfer, dressing, toilet use, and personal hygiene. Review of Resident #47's care plan with a target date of 08/05/2023 revealed a potential for complications related to the presence of a Foley catheter with interventions to ensure drainage bag is off the floor…

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 inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the provider's failure to send the Centers for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage as required for 2 (#24, #143) of 2 residents reviewed for Beneficiary Notification who required the notification. Findings: Resident #24 Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 06/28/2023 revealed Resident #24 was discharged from Medicare Part A Services on 04/12/2023 with benefit days remaining. Further review of the form revealed Form CMS-10055 had not been provided to Resident #24. Review of Resident #24's medical record revealed she was discharged from Medicare Part A Services because her goals had been met. In an interview on 06/28/2023 at 1:19 p.m., S9 Clerical reported she was the person responsible for completing the Advanced Beneficiary Notices and confirmed she had not completed and provided the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Resident Assessment Based on record review and interview, the facility failed to ensure a discharge assessment was electronically transmitted in a timely manner within 14 days of completion for 1 (#18) of 1 residents reviewed for resident assessment. Findings: Resident #18 Review of Resident 18's medical record revealed the last MDS transmitted had an ARD of 02/01/2023. Further review revealed a discharge MDS dated [DATE] with a status of open. In an interview on 06/27/2023 at 12:57 p.m., S4 LPN reported Resident #18 was discharged on 04/20/2023. S4 LPN confirmed Resident #18's discharge MDS was never transmitted and should have been.

Based on interview and record review the facility failed to maintain resident's highest practicable physical, mental and psychosocial well-being for 3 (Resident #15, Resident #42 and Resident #192) of 29 sampled residents by failing to implement their comprehensive person-centered care plan. Findings: #15 Review of Resident #15's face sheet revealed an admit date of 05/19/2023 with the following diagnoses including SOB, COPD with acute exacerbation, and Emphysema. Review of Resident #15's Care Plan with target date of 09/09/2023 for Airway clearance, Impaired potential r/t Dx COPD, Emphysema, Refuses to wear oxygen at times even though SOB. Interventions included Assess/record/report to MD prn: Tachypnea, Wheezes, Rales, Rhonchi, Crackles, Dyspnea, SOB, Orthopnea, Cough, Fever, Chills, and Cyanosis. Review of Resident #15's 06/2023 MD Orders revealed the following including: 05/19/2023 - Full set of VS every Monday night 05/30/2023 - Monitor temp and oxygen saturation each shift Review of Resident #15's EHR revealed no documentation that Resident #15's vital signs or oxygen…

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 ensure the plan of care had been revised for 1 (#52) of 21 (#15, #58, #35, #62, #23, #87, #192, #91, #42, #64, #75, #68, #6, #29, #90, #30, #33, #47, #37, #54 and #52) Residents reviewed for plan of care out of a total sample of 29. The Facility failed to revise a Resident's plan of care for dialysis. Findings: Review of Resident #52's medical record revealed an admit date of 03/18/2023 with diagnoses which included: Chronic Kidney Disease Stage 5, Dependent on Renal Dialysis and Malignant Pleural Effusion. Review of Resident #52's Significant Change MDS with an ARD of 04/19/2023 revealed resident had a BIMS score of 4 (indicating severe cognitive impairment) and required supervision and set-up assistance with meals; independent with transfer, bed mobility, locomotion, dressing toilet use and personal hygiene. Review of Resident #52's care plan with a target date of 07/18/2023 revealed a potential for complications associated with diagnosis of Chronic Renal Failure and receiving dialysis with approaches 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, record review and interview the Facility failed to maintain a medication error rate of less than 5% for 1 (Resident #71) of 3 (Resident #71, Resident #4, and Resident #25) Residents observed during medication administration. A total of 31 opportunities were observed which included 2 medication errors for a medication error rate of 6.45%. Findings: Observation on 06/27/2023 at 8:40 a.m. revealed Resident #71 was administered Fluphenazine (antipsychotic) 10 Milligram Tablet by mouth by S3 LPN. Review of Resident #71's current Medication Administration Record (June 2023) revealed an order for Fluphenazine 10 MG Tablet-2 by mouth every night (8:00 p.m.). Review of Resident #71's current Medication Administration Record (June 2023) revealed an order for Torsemide (diuretic) 10 Milligram Tablet 1 by mouth every morning (8:00 a.m.). Observation during medication administration pass on 06/27/2023 at 8:40 a.m. revealed this medication was not administered by S3 LPN. Interview on 06/27/2023 at 10:30 a.m. with S3 LPN confirmed she administered Fluphenazine 10 Milligram…

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.