Cornerstone at the Ranch

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 1(#3) of 3(#1,#2, and #3) sampled residents as evidenced by failure to ensure documentation of bowel charting was accurate. The deficient practice had the potential to effect a total census of 71. Findings: A review of the facility's policy titled, Charting and Documentation with a last reviewed status of 01/15/2024, read in part, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. Review of Resident #3's record revealed she was admitted to the facility on [DATE] with a…

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 reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 2 (#2, #3) of 3 (#1-#3) sampled residents by failing to ensure: 1. An accurate assessment of edema, and mood/behaviors was documented for Resident #2; and 2. An accurate assessment of edema was documented for Resident #3. Findings: 1. Review of the Resident #2's Electronic Medical Record revealed she was admitted to the facility on [DATE] and had diagnoses including Diabetes Mellitus Type II, Cellulitis Right Lower Extremity, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder and Congestive Heart Failure. Review of Resident #2's September 2024 physician orders revealed an order to monitor edema every shift, and monitor mood and behaviors every shift starting on 07/22/2024. Review of a facility document titled, ___ Med Progress Note, dated 08/13/2024 read in part peripheral 2 plus edema to lower extremity. Resident had increased bilateral edema 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 observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure the walls were clean in resident rooms for 2 (#3 ,#R2) out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: Review of the facility's policy titled Homelike Environment, with a last updated date of 03/12/2024, read in part: . The facility, staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. On 08/27/2024 at 10:43 a.m., an observation was made of Resident #3 and #R2's shared room. Upon entering the residents' room, the lower portion of the wall to the left of the residents' bathroom door was observed with tan stains that were in a drip-like pattern. Further observation of the room revealed the wall to the left of Resident #3's bed had light browns stains, in a drip-like pattern, that spanned from the top to the bottom of the wall, as well as dark brown and rust colored…

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 and interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to promptly respond to a resident's call for assistance for 1 (#R1) out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: On 08/27/2024, a review of the facility's policy titled Answering the Call Light with a last reviewed date of 07/29/2023 read in part: 8. Answer the call light as soon as possible. Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Other Acute Osteomyelitis, Cellulitis of Right Lower Limb, and Other Chronic Pain. Review of Resident #R1's baseline care plan revealed she required 1 person assist for transfers, walking, grooming, and hygiene. On 08/27/2024 at 8:42 a.m., an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#3) out of 5 (#1, #2, #3, #R1, #R2) sampled residents as evidenced by failure to: 1. ensure weekly skin assessments were completed; 2. accurately document the staging of a resident's wound; 3. update the resident's clinical record with an accurate wound status; 4. obtain physician orders to continue or discontinue wound care orders; and 5. notify the physician or Nurse Practitioner (NP) of a deteriorating wound. Findings: On 08/27/2024, a review of the facility's policy titled, Skin and Body Audit, with a last reviewed date of 01/12/2024, read in part .Policy: .2. Residents are considered high risk for skin injury if the Braden assessment score is less than 19. 3. Body audit will be performed weekly for all residents at risk for skin injury by…

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, record review and interview, the facility failed to provide a safe and sanitary, environment to help prevent the development and transmission of communicable diseases and infections by failing to remove contaminated gloves and perform hand hygiene during wound care for 1 (#3) resident out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: On 08/27/2024, a review of the facility's policy titled, Handwashing/Hand Hygiene, with a last review date of 01/12/2024, read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc.i. After contact with a resident's intact skin .m. After removing gloves. Review of Resident #3's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia, Dysphagia, Aphasia, and Lack of Coordination.…

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 develop and implement a comprehensive person-censtered plan of care for each resident as evidenced by: 1. failing to address Resident #38's Major Depression with Severe Psychotic Symptoms, 2. failing to ensure Resident #58's catheter tubing was cleaned as ordered, 3. failing to ensure Resident #70's diabetic sensor was implemented as ordered for blood sugar checks and, 4. failing to address Resident #50's communication, 5. failing to address Resident #62's need for feeding assistance for 5 (#38, #50, #62, #70, #58) out 41 sampled residents. Findings: 1. Resident #38. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Major Depressive Disorder, Recurrent with Severe Psychotic Symptoms. Review of the resident's physician's orders revealed an order for Celexa (antidepressant medication) 20 mg (milligrams) one by mouth every day. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#70) out of 41 sampled residents. Findings: On 07/10/2024, review of the facility's policy titled Quality of Life - Dignity with a last updated date of 06/26/2023 read in part: 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered . Review of Resident #70's EHR (Electronic Health Record ) revealed he was admitted to the facility on [DATE] with diagnoses including Acute Kidney failure, Benign Prostatatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflex Uropathy. Review of Resident #70's plan of care revealed the following problems : -Requires assist with ADLs (Activities of Daily Living ) related to dressing, grooming, bathing, and hygiene related to left…

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 the cleanliness of wheelchairs for 2 (#30 and #35) out of 2 (#30 and #35) residents investigated for a safe, clean, comfortable and homelike environment, out of a total sample size of 41 residents. Findings: On 07/10/2024, a review of the facility's policy titled Wheelchair Cleaning with a last reviewed date of 01/07/2024 read in part, Policy: The purpose of this policy is to establish cleanliness of resident's wheelchairs .4.) Wheelchairs are to be cleaned weekly, when soilage, or upon request . Resident #30: Resident #30 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Muscle Weakness, Unspecified Lack of Coordination, and Occlusion and Stenosis of Right Posterior Cerebral Artery. A review of Resident #30's quarterly MDS dated [DATE], revealed in section C that she had a BIMS (Basic Interview for mental Status) of 14, indicating her cognition was intact. Further review revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a baseline care plan that addressed pain for 1(#178) out of 41 sampled residents. Findings: Resident #178. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hyperlipidemia, Diabetes, Hypertension, and Fracture Upper end of Right Humerus. Review of the resident's physician's orders revealed an order for Oxycodone 10 mg (milligrams) 1 po (by mouth) every 4 hours prn (as needed) pain. Review of the resident's baseline care plan dated 06/26/2024 revealed no evidence pain was addressed in the plan. On 07/10/2024 at 2:06 p.m., an interview was conducted with S3MDS (Minimum Data Set Coordinator). S3MDS stated that she could not provide documentation that a pain assessment was initiated on the resident. S3MDS reviewed the resident's baseline care plan and confirmed that pain was not addressed in the plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#36, and #66) out of 2 residents (#36 and #66) investigated for respiratory care, by failing to: 1. label and properly store Resident #36's oxygen tubing; and 2. label and properly store Resident #66's oxygen tubing, and obtaining an order for administering oxygen. Findings: On 07/10/2024, a review of the facility's policy titled Oxygen Administration with last reviewed date of 01/07/2024 read in part, Policy: Oxygen shall only be administered by physician order, except in an emergency .Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and prn. All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly . Resident #36: Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to End Stage Renal Failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that pain management was provided to residents complaining of pain for 1 (#178) out of 41 sampled residents. Findings: Resident #178. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hyperlipidemia, Diabetes, Hypertension, and Fracture Upper end of Right Humerus. On 07/10/2024 at 10:30 a.m., an interview was conducted with the resident. The resident stated that his right arm was broken and that he was having a lot of pain. The resident stated that it was painful to move his right arm and shoulder. The resident stated he was requesting pain medication for 2 days and had not received anything. The resident stated he was told that the facility ran out of his pain medication and were waiting for an order for more. Review of the resident's physician's orders revealed an order for Oxycodone 10 mg (milligrams) 1 po (by mouth) every 4 hours prn (as needed)…

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 and interviews, the facility failed to ensure staff provided services to meet the needs of residents, as evidenced by facility nursing staff failing to respond to call lights in a timely manner for 2 (#58 and #61) out of 8 (#15, #30, #35, #36, #58, #61, #62, and #178) residents investigated for sufficient staffing out of a total sample of 41 residents. Findings: Resident #58 Review of Resident #58's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Sepsis, Neuromuscular Dysfunction of Bladder, Urinary Tract Infection, Acute Cystitis with Hematuria and Quadriplegia. Review of the Resident's AM5 (5 day scheduled admission) Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating his cognition was intact. On 07/09/2024 at 4:53 p.m., an observation was made of Resident #58's suprapubic catheter tubing closest to the urinary drainage bag with…

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 the nursing staff provided the care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#36) of 41 sampled residents. This was evidenced by S7LPN (Licensed Practical Nurse) not administering ordered PRN (as needed) medications to treat Resident #36's itching. Findings: Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to End Stage Renal Failure, Unspecified Diastolic Heart Failure and Obstructive Sleep Apnea. A review of Resident #36's annual MDS (Minimum Data Set) dated 05/23/2024, revealed the resident had a BIMS (Basic Interview for Mental Status) of 15, indicating his cognition was intact. A review of Resident #36's Physician orders revealed an order written on 05/16/2024 for Hydrocortisone 1% (percent) cream apply to affected areas PRN itching. Further review revealed an order written on 05/16/2024 for Benadryl…

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 expired medications were not stored in medication room A. Findings: On 07/10/2024 at 3:40 pm, an inspection was conducted in medication room A. A bottle of Vitamin B Complex with Vitamin C was observed on the shelf and was observed with an expiration date of 05/24. A bottle of Ferrous Gluconate 240 mg (Milligrams) with an expiration date of 05/24 was observed on the shelf in the medication room. S13LPN (Licensed Practical Nurse) was present during this observation and she confirmed that the 2 bottles of medication were expired.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to honor and accommodate food preferences for 1 (Resident #15) out of 41 sampled residents. This deficient practice had the potential to affect all residents who consumed meals from the kitchen. Findings: On 07/10/2024 a review of the facility's policy titled, Resident Food Preferences with a revised date of 01/07/2024 read in part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes Review of Resident #15's record revealed an admission date of 08/05/2021 with diagnoses that included Type 2 Diabetes Mellitus, Hyperlipidemia, and Vitamin Deficiency. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident's cognition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain medical records on each resident that were complete for 1 (#43) out of 41 sampled residents. Findings: Reviewed the facility's policy and procedure titled Charting and Documentation that was reviewed by facility on 01/07/2024 read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Documentation in the medical record may be electronic, manual or combination. 2. The following information is to be documented in the resident medical record: a. Objective observation; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the residents;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the updated hospice plan of care was on file and available at the facility for 1 (#52) out of 2 (#31, #52) residents investigated for hospice services. Findings: On 7/10/2024, a review of the facility's policy titled Hospice Program with a last reviewed date of 07/16/2023, read in part: 12. Our facility has designated ____ (Name)_____(Title) to coordinate care provided to the resident by our facility staff and the hospice staff He or she is responsible for the following: d. Obtaining the following information from the hospice : 1. The most recent hospice plan of care specific to each resident. Review of Resident #52's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes, Unspecified Sequalae of Cerebral Infarction, Aphasia, and Gastrostomy Status. Review of Resident #52's July 2024 physician's orders revealed an order date 01/04/2024 that read in part: Admit to ____hospice…

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 and interviews, the facility failed to ensure call systems were functioning for 3 residents (#5, #31, #66) out of a final sample of 41 residents. Findings: On 07/10/2024, a review of the facility's policy titled Answering the Call Light with a last reviewed date of 07/29/2023 read in part: 7. Report all defective call lights to the nurse supervisor promptly. Resident #31 Review of Resident #31 EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Atrial Fibrillation. Review of Resident #31's significant change MDS (Minimum Data Set ) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12 , indicating his cognition was intact. On 07/10/2024 at 8:39 a.m. Resident # 31's call bell that was hooked to his shirt was pressed. An observation was made of the screen on C hall that displayed when a resident's call bell was activated. The resident's room number was not on 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 observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an exterior window was in good repair for 1 (Resident #66) out of 41 residents sampled. Findings: On 07/08/2024 a review of the facility's policy titled, Quality of Life- Homelike Environment with an updated date of 03/12/2024 read in part, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include in part, a. Clean, sanitary and orderly environment . On 07/08/2024 at 9:20 a.m., an observation was made of two large cracks, both roughly three feet in length on left pane of Resident #66's exterior window. Seven, thick, black pieces of tape were observed over the two large cracks. On 07/09/2024 at 8:04 a.m. and interview and observation of Resident #66's exterior window was conducted with S7AIT. S7AIT confirmed that the left pane of Resident #66's exterior window was in disrepair and should not have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure a dementia resident received the appropriate treatment and services to attain or maintain his highest practicable level of well-being for 1 (Resident #1) out of 3 sampled residents by failing to: 1. Revise the comprehensive care plan to include interventions that addressed Resident #1's continued wandering; 2. Staff failing to report continued incidents of wandering into other resident rooms for Resident #1, and 3. Failing to provide adequate supervision of Resident #1 after complaints that he continued to wander in other resident rooms. Findings: Review of the facility's policy on 05/08/2024 titled Care Plans, Comprehensive Person - Centered read in part: A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will .m. aid 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to be administered in a manner that enabled its Infection Control and Prevention Program to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. The facility failed to: 1. Obtain influenza vaccines for residents when it was seasonally available until after an influenza outbreak had occurred; 2. Effectively implement the facility's infection prevention and control program's (IPCP) policies during an influenza outbreak that included surveillance, timely corrective actions and monitoring and reporting of the outbreak; 3. Annually review and/or revise the infection prevention and control program and policies. This deficient practice had the potential to affect a census of 80 residents. Findings: Review of the facility's infection control documentation revealed the first staff tested positive for influenza on 11/03/2023 and the first resident tested positive on…

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

Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of Influenza in the facility by: 1. Empirically isolate Resident #1 and Resident #2 who displayed signs and symptoms of influenza during an outbreak; 2. Follow up timely on collected influenza tests which delayed isolating positive residents for Resident #2; 3. Document surveillance, implementation of corrective actions and monitoring of the outbreak; Findings: Review of a policy titled Outbreak of Communicable Diseases revealed in part, Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Policy Interpretation and Implementation: 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area .4. An outbreak of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza. The facility had a total of 6 (#1, #2, #3, #4, #5, and #6) residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. The facility failed to:: 1. Obtain influenza vaccines when it became seasonally available until 11/16/2023 after an influenza outbreak occurred among residents and staff; and 2. Administer influenza vaccines to eligible residents after it was received on 11/16/2023 until 11/30/2023 This deficient practice had the potential to affect a census of 80 residents. Findings: Review of the facility's policy titled, Influenza Vaccine, revealed in part, all residents will be affected the Influenza Vaccine to aid in preventing infections that may be encountered in this facility and as recommended by the ACIP (Advisory Committee on Immunization Practices). The influenza vaccine will be offered during the flu season to all…

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's staff failed to notify the resident's representative/RP (responsible party) of a change in the resident's condition by failing to: 1. Immediately inform Resident #6's representative when Resident #6 had tested positive for Influenza Type A and 2. Immediately inform Resident #7's representative when Resident #7 sustained injuries after an incident for 2 (#6 and #7) out of 7 (#1-#7) sampled residents. Findings: Review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical /mental condition and/or status . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury . 5. Except in medical emergencies, notifications will be made within twenty-four (24)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#3 and #7) out of 9 (#1-#7, R1 and R2) sampled residents. Findings: Review of the facility's policy and procedure titled, Filing Grievances/Complaints, revealed in part: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made 1. Any resident, his or her responsible party may file a grievances or complaint concerning medical care, behaviors of other residents, staff members .without the fear of threat of reprisal in any form . 3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or person filing the grievance or complaint in behalf of the resident . Resident #3 Review of Resident #3's electronic medical record revealed the resident was admitted to the facility on [DATE] with…

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 services were provided according to the physician's orders for 1 (#5) out of 9 (#1-#7, #R1 and #R2) sampled residents, by failing to monitor the Resident #5's temperature for 72 hours after she received the Flu Vaccine. Findings: Review of the facility's policy titled Charting and Documentation, read in part: Policy Statement. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record . Resident #5 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes and Morbid Obesity. Review of physician's orders revealed an order written on 11/30/2023 at 2:00 p.m. for Fluzone High Dose 2023-24 administered to left deltoid 11/30/23. Monitor temperature Q (every) shift x (time) 72 hours. Monitor injection site for signs of infection. Report any adverse reactions to MD.…

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, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program as evidenced by failing to: 1. Report an influenza outbreak to the office of public health per the facility's policy; 2. Annually review and/or revise the IP program and policies; and 3. Perform hand hygiene in between direct contact with Resident #4 and Resident #5. This had the potential to affect a census of 80 residents. Findings: Review of a policy titled Outbreak of Communicable Diseases revealed in part, Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Policy Interpretation and Implementation: 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area .4. An outbreak of influenza is defined as a single case if unusual for the facility. A single case of influenza is reportable 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 record review and interview, the facility failed to ensure there was a sufficient number of staff to care for the resident's needs as identified in the facility assessment which has the potential to affect the care for the 86 residents in the facility. Finding: Review of the facility's Facility Assessment 2023 that was dated 1/22/2023 revealed the assessment was based on a census of 53. The Facility Assessment revealed that 3 nurses were needed on the day, evening and night shift. Review of the facility's work/staff schedule revealed that on 5/14/2023 (Sunday) there were 2 LPNs on the evening shift. On 5/20/2023 (Saturday) there were 2 LPNs on the night shift. On 5/21/2023 (Sunday), there were 2 LPNs on the night shift. On 5/27/2023 (Saturday), there 2 LPNs on the night shift. On 5/28/2023 (Sunday), there were 2 LPNs on the night shift. On 6/3/2023 (Saturday) there were 2 LPNs on the evening and night shift. On 6/4/2023 (Sunday), there were 2 LPNs on the evening and night shift. On 6/24/2023 (Saturday), there were 2 LPNs on the night shift. On 6/25/2023 (Sunday), there were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program by: 1. Failing to have a description of the building water systems using text and flow diagrams, knowing the acceptable ranges of the temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread, or ways to intervene when control limits were not met. 2. Failing to use nationally recognized surveillance criteria to define infections 3. Failing to ensure that wound care ointment used on Resident #7 was stored in a sanitary manner. This deficient practice had the potential to affect the 86 residents residing in the facility. Findings 1. Review of the facility's policy titled Legionella read: Purpose: To ensure water safety from Legionella. General Guidelines: 1. No large holding tanks on premises 2. On city water 3. Weekly testing of water temperatures 4. Mixing valves on all boilers and hot water tanks 5. In lieu of a boil advisory,…

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 evaluate the mental and physical competency to self-administer medications for 1 (#84) resident out of a total of 36 sampled residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. This facilty had a census of 86 residents. Findings: Review of the facility's policy and procedure titled Self Administration of Medication revealed in part, .The purpose of this procedures is to establish uniform guidelines concerning the self -administration of drugs. 1. A Resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician .Reporting and Documentation The following information should be reported to the staff/charge nurse and should be documented in the resident's medical record: 1. The name and strength of the medication taken by the resident and the…

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

Based on record review and interview, the facility failed to consider the views of the residents and act promptly upon the grievances concerning issues of resident care and life in the facility as evidenced by the facility failing to address the complaints verbalized by multiple residents from 01/18/2023 through 06/13/2023 during the Resident Council meetings. The deficient practice had the possibility to affect the entire census of 86 residents. Findings: Review of the facility's policy titled Filing Grievances/Complaint included: Policy Statement. Our facility will help residents, their representatives, other interested family members, or resident advocates file grievances or complaints when such requests are made. The Policy Interpretation and Implementation included, in part: 1. Any resident, his or her representative (sponsor) family member or appointed advocate may file a grievance or complaint .; 3. Grievances and/or complaints may be submitted orally or in writing .; 4. The Administrator has delegated the responsibility of the grievance or complaint investigation to Social…

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

Based on observation and interview, the facility failed: 1. to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility, and complaint investigations made respecting the facility during the 3 preceding years; and 2. failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Findings: A review of surveys conducted in the facility during the last 3 years revealed the following: Complaint surveys had been conducted on 05/31/2023, 03/14/2023, 01/31/2023, 01/4/2023, 01/27/2022, 05/12/2021, 01/6/2021, 11/6/2020, and 07/24/2020; and Recertification surveys had been conducted on 05/25/2022 and 05/19/2021. On 06/27/2023 at 11:30 a.m., an observation of a binder labeled Annual Inspection/Survey Results was made in the front lobby area of the facility. The contents of the binder included only Recertification Surveys conducted on 05/25/2022 and 05/19/2021. The binder did not hold any other surveys conducted during the 3…

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 interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#6) out of 2 (#6, #27) sampled residents reviewed for advanced directives. The deficiency had the potential to effect a census of 86. Findings: Review of the facility's policy titled Advance Directives read in part: 7. The interdisciplinary team will review annually with the resident his or her advance directive to ensure that directives are still the wishes of the resident. Such review will be made during the annual assessment process and recorded on the MDS (Material Data Set). 9. The Director of Nursing (DON) or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included, but not limited to Edema, Morbid Obesity,…

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, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 2 (#7, #76) out of 36 sampled residents. The facility had a census of 86 residents. Findings: Resident #7. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Cerebral Infarction, Shortness of Breath, Congestive Heart Failure, Diabetes, Atrial Fibrillation, and Respiratory Failure. Correct all the dates to be consistent in form for both resident's information On 6/27/2023 at 8:36 am, the resident was observed lying down in bed during this observation. S6CNA (Certified Nursing Assistant) was observed in the room with the resident at that time. S6CNA confirmed the resident's lower extremities were contracted bilaterally. On 6/27/2023 at 10:00 am, an interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed the Resident #7's lower extremities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care for 2 (#7 and #84) residents out of a sample of 36 residents by: 1. Failing to address contractures for Resident #7; and 2. Failing to implement physician's orders for the correct infusion rate for Resident #7's tube feeding; and 3. Failing to implement physician's orders for Resident #7's left hip wound; and 4. Failing to implement physician's orders to administer a medication for Resident #84 when his feet were swelling. Findings: 1. Resident #7. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Cerebral Infarction, Shortness of Breath, Congestive Heart Failure, Diabetes, Atrial Fibrillation, and Respiratory Failure. Review of the resident's care plan revealed no care plan for contractures. On 6/27/2023 at 8:36 am, the resident was observed lying down in bed. S6CNA (Certified…

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 identify and provide the needed care and services in accordance with professional standards of practice to meet the highest practicable physical well-being of residents for 1 (#6) of 1 (#6) sample residents for skin conditions by failing to conduct weekly fully body assessment. The deficiency had the potential to affect a census of 86. Findings: Review of the facility's policy titled Pressure Injury Prevention and Management revealed in part: Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of two components: Prevention/Screening and Treatment/Evaluation. Screening: On a weekly basis, the treatment nurse will conduct a full body skin assessment on all residents . Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included in part: Edema, Morbid Obesity, Peripheral Vascular Disease and Sleep Apnea. Review of the most current MDS (Material…

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, observation and interview, the facility failed to ensure that a resident received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 1 resident (#84) out of a total of 36 sampled residents. Findings: Review of the facility's policy titled Pressure Injury Prevention and Management revealed in part: Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of two components: Prevention/Screening and Treatment/Evaluation .Screening: On a weekly basis, the treatment nurse will conduct a full body skin assessment on all residents. Resident #84 was admitted to the facility on [DATE] with the following pertinent diagnoses: Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis of Vertebra, Sacral and Sacral-Coccygeal Region and Multiple Sclerosis. Review of Resident #84's admission (Minimum Data Set) MDS dated [DATE] revealed under Section M, Skin…

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, records reviews, and interviews the facility failed to ensure respiratory equipment was properly stored when not in use and failed to ensure nursing staff changed respiratory mask and tubing per facility's protocol for 1 (#19) of 1 (#19) residents investigated for respiratory care out of a total sample of 36 residents. Findings: Review of the facility's policy titled CPAP/BiPAP Support (Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure) read in part: .9. When CPAP or BiPAP is not in use, place the face mask securely in a zip lock or plastic bag. 10. Replace CPAP or BiPAP masks, nasal pillows, and tubing are to be changed once every 3 months. Resident #19 was admitted to the facility on [DATE] with a diagnosis in part: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of Resident #19's MDS (Minimum Data Set) dated 03/09/2023 Section C revealed the Resident's BIMS score (Brief Interview for Mental Status used to score cognitive ability) was 11 which…

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 the Medical Director attended the Quality Assessment and Assurance meetings at least quarterly. This deficient practice has the potential to affect a census of 86 residents. Findings: A review of the facility's Quarterly Quality Assessment and Assurance meetings revealed meetings dated of 10/18/2022, 01/20/2023 and 04/26/2023, had no evidence or signature, indicating the medical director was in attendance of the quarterly meetings. On 06/28/2023 at 3:30 p.m., during an interview with S1ADM, he confirmed the medical director did not attend the quarterly quality assessment and assurance meetings.

Based on record review and interview, the facility failed to ensure there was evidence that CNAs (Certified Nursing Assistants) and LPNs (Licensed Practical Nurse), including agency or contracted CNAs and LPNs, received in-service training regarding abuse/neglect/exploitation, resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs for 4 (S18LPN, S19CNA, S20CNA, S21CNA) out of 5 (S4LPN, S18LPN, S19CNA, S20CNA, S21CNA) personnel records reviewed. Findings: Review of S18LPN's personnel record revealed that she was an agency LPN. There was no start of contract date noted in the LPN's personnel record. Further review of the LPN's personnel record revealed that there was no evidence of current training within the year on abuse/neglect/ exploitation and infection control. There was no evidence of training on resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs in the personnel record. Review of S19CNA's personnel record revealed that she was an agency CNA. There was no…

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, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 (#64) out of 36 sampled residents. The facility census was 86. Findings: Review of Resident #64's clinical record revealed that she was admitted to the facility on [DATE]. Her diagnoses include, in part, Alzheimer's Disease, Hallucination, Anxiety Disorder and Muscle Weakness. Review of the resident's Significant Change MDS (Minimum Data Set) dated 06/09/2023 revealed she had a BIMS (Brief Interview for Mental Status) score of 4, severely cognitively impaired. Further review revealed that she required limited assistance with one person physical assistance for person hygiene. She was occasionally incontinent of her bladder. She was current on hospice services. Review of the resident's plan of care revealed she was care planned for occasional episodes of urinary incontinence related 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 follow its policy and procedure in regards to tube feeding for 1 (#7) out 1 (37) resident investigated for tube feeding. This deficient practice had a potential to affect 6 residents who recieved tube feedings. Finding: Resident #7. Review of the facility's policy and procedure titled Care of Tube Feeding . revealed, .Procedure: Ready to Hang Formula . Complete and label with the following; 1. Resident Name 2. Resident Room # 3. Time & date . 4. Rate of Flow 5. Nurses Initials . On 6/26/2023 at 9:34 a.m., the resident was observed lying down bed with the head of bed up. An unlabeled bag of tube feeding was observed infusing at 30 cc (cubic centimeter)/hr. per pump. The bag of tube feeding did not include a label with the date and time the feeding started, resident name, rate of flow, nurse initials, or the name of the tube feeding. On 6/27/2023 at 8:10 a.m., the resident was observed in bed with head of bed up. An unlabeled bag of tube feeding was observed infusing at 30cc/hr. per pump. On 6/27/2023 at 9:10…

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 that nursing staff possess competencies and skill sets necessary to provide nursing services to assure residents' safety, and maintain the highest practicable physical well-being for 1 (#35) of 36 sampled residents. This was evidenced by Mucinex and Melatonin pills left at Resident #35's bedside. Findings: Review of the Facility's Medication Administration Policy read in part .Medications shall be administered in a safe and timely manner, and as prescribed .Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders, including any required time frame .9. Medications may not be prepared in advance and must be administered within (1) hour of their prescribed time, unless otherwise specified . A review of Resident #35's record revealed she was admitted to the facility on [DATE], with diagnoses including Insomnia, Hypertension, Type 2 Diabetes, and Generalized Anxiety Disorder. Review…

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 store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure kitchen staff wore hair coverings over facial hair while in the kitchen; 2. Ensure expired food items were removed from the dry goods storage room; This deficient practice had the potential to affect a census of 86 residents. Findings: Review of the facility's policy titled Refrigerators and Freezers read in part .The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .8. Supervisors will be responsible for ensuring food items in pantry, refrigerator, and freezers are not expired or past perish dates No policy for sanitary conditions/use of hair covering while in the kitchen was provided to surveyor by survey exit. On 06/26/2023 at 8:45 a.m., an observation of the kitchen was conducted with S14DM (Dietary Manager). Upon entering the kitchen, S14DM, S15DS (dietary staff)…

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