Mary Goss Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychosocial needs. The facilitly failed to ensure 1) residents' care plan were developed for restraints and interventions for pelvic restraints (#31, #136); and 2) residents' care plan was not implemented regarding monitoring for bleeding (#24). Resident #31 Review of the record for resident #31 revealed date of admission on [DATE] with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis,and heart failure. Review of the Annual MDS (Minimal Data Set) assessment dated [DATE] revealed resident #31 was assessed to be severely cognitively impaired and was totally dependent on staff for activities of daily living. Further review of the MDS for resident #31 dated 05/20/2024 revealed the following:…

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 ensure the residents' care plans were revised to meet the residents' needs, by failing to ensure the resident's care plan was revised to include all new fall interventions in a timely manner for 2 (#2, and #24) of 4 (#2, #7, #24, and #31) residents reviewed for falls. Findings: Resident #2 Review of the record for resident #2 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, paranoid schizophrenia, spinal stenosis, muscle wasting and atrophy, age-related cognitive decline, hallucinations, generalized anxiety disorder, and osteoporosis. Review of resident #2's 07/05/2024 Annual Minimum Data Set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 00, which indicated resident #2 was severely cognitively impaired. Further review revealed she required limited to extensive assistance for most activities of daily living. Review of the facility incident report dated 6/20/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure residents remained as free of accident hazards as possible for 2 (#2, #31) of 4 (#2, #7, #24, and #31) residents reviewed for accidents. The facility failed to ensure: 1) a thorough investigation was conducted for a resident's falls, staff placed a resident's fall mat in proper place, the resident's care plan was revised to include all new fall interventions in a timely manner, and the fall interventions were appropriate for the type of incident that occurred (#2); and 2) an investigation was conducted for an injury of unknown origin (#31). Findings: Resident #2 Review of the facility policy Accidents and Incidents - Investigating and Reporting revised July 2017 revealed the following in part: Policy Statement: All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator. Review of the record for resident #2 revealed she was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 3 (#236, #27, and #186) of 3 (#236, #27, and #186) residents records reviewed. The facility failed by 1) not having documentation of sites for administration of insulin and by having omitted medications for resident #236, 2) not having a fall mat and bed alarm in place for resident #27 as ordered by the physician, and 3) not having documentation of accucheck results for resident #186 as ordered by the physician. Findings: Review of the Administering Medication Policy and Procedure revised April 2019, revealed in part 4. Medications are administered in accordance with prescriber orders, including any required time frames 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, 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 review of the personnel records, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed. Findings: Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Review revealed there was documentation of a State Adverse Actions check 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 observations, review of the policy, and interview, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an open medication cart, unlocked and drawers open with medications in direct view and staff not present. The medication cart was in a place where residents and unauthorized staff could access the medication cart. Findings: Review of facility's policy and procedure for Administering Medications (revised April 2019) revealed the following: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 07/17/2024 at 7:08 a.m. revealed the medication cart for hall A was located in the hallway. Further observation revealed the cart was unlocked, and drawers were opened with medications in direct view. No nurse or staff members were present on the hallway at that time. Resident #306 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 observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidence by, 1) having dirty serving trays on a rolling cart, 2) having a grime build up on the kitchen cabinets, shelves, and window ledge, 3) storing an expired nutritional supplement in the refrigerator, and 4) storing food items that belonged to an employee in the storage room and available for resident use. Findings: During an initial tour of the kitchen on 07/15/2024 at 8:10 a.m., an observation revealed a rolling cart located near the steam table. Further observation revealed there were six serving (meal) trays that had old dried food particles on the trays. Further observations revealed there were large amounts of thick, black grime build up on shelves that were located in the bottom and top cabinets throughout the kitchen. The dirty shelves had various cooking pots, pans, and /or eating utensils stored on them. After the initial tour of the kitchen was completed, a tour of the outside storage room revealed one,…

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 interviews and review of the facility's Infection Control Records, the facility failed to ensure the Infection Preventionist, who is responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS), had completed specialized training in infection prevention and control. An interview with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) on 7/16/2024 at 1:30 p.m. revealed she had not completed the Infection Preventionist Training. An interview with S2Director of Nursing on 7/17/2024 at 3:10 p.m. confirmed S3LPN/MDS had not completed the Infection Preventionist Training.

Based on observation and interview, the facility failed to maintain all mechanical equipment in safe operating condition by having shavings on the manual can opener. Findings: During an initial tour of the kitchen on 07/15/2024 at 8:10 a.m., an observation revealed a large can opener with a buildup of metal shavings on the blade. Further observation revealed S16Dietary [NAME] began opening a large can of canned sweet green peas, for the lunch service. She was notified of the buildup of the metal shavings and confirmed that the can opener blade needed to be cleaned. On 07/15/2024 at approximately 8:45 a.m., S1Administrator was notified of the above findings.

Based on review of the personnel records and interviews, the facility failed to ensure all required in-service training for Certified Nurse Aides (CNA) included dementia management training for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed. Findings: Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Further review revealed there was no documentation of dementia care management training. Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Further review revealed there was no documentation of dementia care management training. Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Further review revealed there was no documentation of dementia care management training. Review of S17CNA's personnel file revealed a hire date of 03/25/2024. Further review revealed there was no documentation of dementia care management training. Review of S18CNA's personnel file revealed a hire date of 02/08/2024. Further review revealed there was no documentation…

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 all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#2) of 16 residents reviewed in the initial pool screening for advanced directives. Findings: Review of the facility Advance Directive Policy and Procedure revised [DATE] revealed in part: 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. 8. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Review of resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, and age-related cognitive decline. Review of resident #2's Annual Minimum Data Set…

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 immediately notify the physician when a resident had a change in condition for 1 (#186) of 1 (#186) residents reviewed for notification of change by, failing to immediately notify the physician when resident #186's accucheck result was greater than 400 milligrams/deciliter. Findings: Review of resident #186's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Type II diabetes mellitus with diabetic polyneuropathy. Review of the July 2024 physician's orders revealed an order dated 07/08/2024 for resident #186 to have Novolog 100 units/milliliter; give 8 units if accucheck greater than 240 and obtain accuchecks twice a day. Review of the care plans revealed a problem onset: 04/05/2022, altered blood sugars due to diabetes. Further review revealed the documented approaches included accuchecks per physician orders, accuchecks twice a day and to notify the physician if glucose is less than 60 or…

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 protect the resident's right to be free from verbal abuse by staff when staff used profanity and threatening language towards the resident. The incident involved 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. Findings: Review of the facility's current abuse policy and procedures revealed in part, the following: it is the policy of the facility to assure that its residents are free from verbal, sexual, physical and mental abuse and the misappropriation of property. Verbal aggressive behavior; such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidation. Following are examples of abuse or neglect by nurse aides: Threatening a resident with harm; yelling at or making fun of a resident. Purpose: to identify any act of abuse in our facility and to assure that it is dealt with in a timely and proper manner. Procedure: any type of abusive act is to be report to the Administrator or the DON (Director of Nursing). If the Administrator or DON is not available, it is to be…

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 that a resident received adequate supervision to prevent accidents and incidents for 2 (#1 and #2) of 3 (#1, #2, and #3) sampled residents reviewed for incidents and accidents. The facility failed to ensure resident #1 and #2 received increased supervision after an altercation with each other. Findings: Resident #1 Review of the record for resident #1 revealed an admission date of 02/03/2022 with diagnoses including neuralgia and neuritis, morbid obesity, edema, cerebral infarction due to thrombus of left middle vertebral artery, hemiplegia affecting left non-dominant side, and major depressive disorder Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review of the MDS revealed resident #1 has a history of behavioral symptoms. Review of resident #1's care plan dated 10/22/2023 revealed resident had episodes of verbal and physical abuse…

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 implement the plan of care and follow policy and procedures related to resident refusal of medication. The facility failed to ensure nursing staff reported resident refusal of treatment to their supervisor, director of nurses, physician, or responsible party for 1 (#14) of 23 sampled residents. Findings: Review of the Refusal of Treatment Policy and Procedure revealed in part the following: -when resident refuses a medication, the refusal is to be immediately reported to the witnessing employee's supervisor and the exact refusal documented in the resident's clinical record; and -the physician will be notified as per pharmacy policies and procedures upon refusal of medication, and nurse will inform the DON, Medical Doctor, and responsible party as necessary. Review of the record for resident #14 revealed a readmit date of 10/21/2022 with diagnoses including human immunodeficiency virus, pressure ulcer of sacral region stage 4, and type 2 diabetes mellitus. Review of the Annual Minimum Data Set for resident #14 revealed 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 review and interview, the pharmacist failed to identify irregularities to the attending physician and the facility's medical director and director of nursing for 2 (#14, #40) of 7 (#6,#9,#11,#14,#18,#34,#40) sampled residents reviewed for unnecessary medications and insulin administration. Findings: Resident #14 Review of the record for resident #14 revealed a readmit date of 10/21/2022 with diagnoses including human immunodeficiency virus, pressure ulcer of sacral region stage 4, and type 2 diabetes mellitus. Review of the September 2023 (current) Physician's Orders revealed an order dated 10/21/2022 for Lantus Solostar Pen 100 units/3milliliters- give 22 units into skin nightly (9PM). Review of the August 2023 Medication Administration Record (MAR) revealed no documentation of Lantus (insulin) Solostar Pen 100 units/milliliters 22 units into skin nightly from 08/01/2023 through 08/29/2023. Review of the Pharmacy Consultant Review dated 08/29/2023 revealed pharmacist reviewed resident #14'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 adequate monitoring was recorded for 1(#40) of 5(#9,#11,#18,#34,#40) residents reviewed for unnecessary medications. On 09/19/23 at 02:01 p.m., Resident # 40 was observed in his room. Socks and shoes were on both of Resident # 40`s feet. Resident #40 was not sure if his feet had swelling. Record review revealed Resident # 40 was re-admitted to the facility on [DATE] with diagnoses that included alcoholic cardiomyopathy, respiratory failure, congestive heart failure (CHF), chronic kidney disease, anemia, alcohol abuse, and syphilis. Review of the most recent minimum data set minimum data set (MDS) dated [DATE] revealed in section C -Cognitive Status- a brief interview of mental status (BIMS) score could not be obtained due to memory problems and his cognitive skills related to daily decision making was moderately impaired. Review of active orders for September and August 2023 included an order for Lasix 40 milligrams (mg) by mouth…

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 of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by committing 5 errors out 29 opportunities for an error rate of 17.24%. Findings: Observation of the medication pass on 09/19/2023 at 9:40 a.m. for resident #11 revealed the following medication errors. 1. Arthrotec, (non-steroidal, anti-inflammatory medication) 50mg (milligrams), 1 tablet per Peg Tube (Percutaneous Endoscopic Gastrostomy) twice daily. This medication was not administered. Review of the September 2023 physician orders for resident #11 revealed an order for Arthrotec 50mg, 1 tablet per PT (Peg Tube) twice daily. Interview on 09/19/2023 at 2:55 p.m. with S6LPN (Licensed Practical Nurse) confirmed that she did not administer the medication Arthrotec to resident #11. 2. Liquid Protein, 30 cc (cubic centimeter) per Peg Tube twice daily. This supplement was not administered. Review of the September 2023 physician orders for resident #11 revealed an order for Liquid Protein, 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 observations, review of the dietary menu, and interviews, the facility to ensure the menu was followed for 6 (#4, #8, #9, #19, #27, and #38) of 6 (#4, #8, #9, #19, #27, and #38) residents who were ordered a pureed diet and received their meals from the kitchen. The facility failed to ensure that mustard greens and cornbread were pureed, available, and offered to the residents with orders for a pureed diet and who received their meals from the kitchen during the lunch service. Findings: Review of the physician orders list revealed residents #4, #8, #9, #19, #27, and #28 were ordered pureed diets. Further review revealed there was no evidence of a reason why the residents should not have pureed mustard greens and pureed cornbread. Review of the dietary menu dated 09/18/2023 revealed the lunch service was to consist of chili beans, creamed potatoes, oven roasted chicken, mixed vegetables, mustard greens, cornbread, and cake. On 09/18/2023 at 11:45 a.m., observation during the lunch service revealed there was no pureed mustard greens and pureed cornbread on the steam table and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to store, prepare, and distribute in a sanitary manner. The facility failed to: 1) ensure that foods including ice for resident consumption was stored a refrigerator, deep freezer, and /or ice machine; 2) ensure foods stored in the refrigerator and deep freezer were properly sealed and not exposed to air; 3) ensure the kitchen cabinet doors were cleaned; and, 4) ensure that foods brought into the facility by visitors were not stored inside of the kichen deep freezer. According to review of the Physician Orders List provided by S3Dietary Manager, there was a total of 36 residents that received a meal from the kitchen and could be affected by the above mentioned failed practice. Findings: On 09/18/2023 at 8:20 a.m., observations during the initial tour with S3Dietary Manager, revealed there was old spillage, splatters, and a build-up of grime on the cabinet doors that were located next to the dishwashing machine. One large manual can opener was observed…

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 electronically submit complete and accurate direct care staffing information, based on payroll, to Centers for Medicare and Medicaid Services (CMS) as required. Findings: Review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 3 2023 (April 1-June 30) revealed triggers for the following: Failed to have licensed nursing coverage 24 hours/day. Review of the time and work schedules revealed there were temporary (Temp) workers noted as Licensed Practical Nurses, worked on the dates of 04/01/2023, 04/02/2023, 04/08/2023, 04/09/2023, and 05/06/2023. The dates worked were confirmed by review of the worker's time sheets. On 09/19/2023 at 4:00 p.m., interview with S1Administrator revealed that he (S1Administrator) was responsible for submitting the facility's PBJ information for the nursing staff which included the temporary (Temp) workers for the FY Quarter 3 2023 in April 2023 and May 2023. S1Administrator confirmed he had not included the temporary nursing staff when he submitted the PBJ information for FY…

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 review of the personnel records, training records, and interviews, the facility failed to provide the required in-service training for nurse aides that included dementia management training for 6 (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) of 6 Certified Nursing Assistants (CNA) (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) reviewed for dementia care training. Findings: Review of the personnel records revealed the following: S8CNA's date of hire: 07/27/2023; S9CNA's date of hire: 05/30/2023; S10CNA's date of hire: 08/22/2016; S11CNA's date of hire: 09/08/2023; and, S12 CNAs date of hire: 06/10/2022. Review of the personnel and training records revealed there was no documented evidence of S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA being provided with dementia management training. On 09/20/2023 at 2:10 p.m. S1Administrator reported that he was responsible for providing dementia care management training to the CNA staff. He confirmed the last time he had provided S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA with dementia management training was December 2021. Review of 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.