St. Margaret's Daughters Home

Based on record review, the facility failed to electronically submit payroll information for direct care staffing as required. Findings included: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2024 (July 1 - September 2024) revealed, in part, the facility failed to submit staffing data for Quarter 4. There was no documented evidence and the facility did not present any documented evidence the facility's PBJ Staffing Data for FY Quarter 4 2024 (July 1 - September 30) was submitted as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility document review it was determined that the facility failed to ensure the medication error rate was not greater than 5% by having a medication error rate of 6.66 % for 2 (Resident #3 and Resident #R5) of 7 residents observed during medication administration. Findings Included: Resident #3 Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with a diagnosis of, in part, Iron Deficiency Anemia (low levels of iron in the blood). Review of Resident #3's Minimum Data Set with an Assessment Reference Date (ARD) of 09/18/2024 revealed, in part, Resident #3 had a brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. Review of Resident #3's December 2024 physician's orders revealed, in part, Ferrous Gluconate (a medication used to treat low levels of iron in the blood) oral tablet give one tablet once a day by mouth. Observation on 12/17/2024 at 8:15AM…

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, record review, facility document review, and facility policy review it was determined that the facility failed to ensure: 1. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care for 2 (Resident #R6 and Resident #R7) of 2 residents observed during incontinence care; and, 2. Clean laundry was kept separate from dirty and/or contaminated laundry for 1 (Laundry Room f) of 7 laundry rooms observed. Findings included: 1. Review of the facility's undated Handwashing policy and procedure revealed, in part, the purpose of handwashing is to prevent cross contamination and control infection. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, decontaminate hands if moving from a contaminated body site to a clean body site during patient care. Resident #R6 Review of Resident #R6's Minimum Data Set with an Assessment Reference Date (ARD) of 11/06/2024 revealed, in part, Resident #R6 was always incontinent of bowel and bladder. Further…

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, record review, facility document review, and facility policy review it was determined that the facility failed to follow a physician's order to perform a weekly skin assessment for a resident at risk for pressure ulcers for 1 (Resident #2) of 3 sampled residents reviewed. Findings: Review of the facility's undated Wound Prevention policy and procedure revealed, in part, weekly skin checks will be conducted by the licensed nurse and documented in the resident's Electronic Medical Record (EMR). Review of the facility's undated Skin Care (Decubitus Prevention and Wound Care) policy and procedure revealed, in part, a resident with a score greater than 12 on the Braden Scale with reverse numbering is considered at risk and is checked weekly by the nurse assigned to their care. Review of Resident #2's December 2024 physician orders revealed, in part, complete weekly skin assessment in the morning every Wednesday. Review of Resident #2's care plan with a review date of 02/02/2025 revealed, in part,…

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, record review, facility document review, and facility policy review it was determined that the facility failed to ensure a Resident's medication administration record was accurately documented for 1 (Resident #R5) of 5 residents reviewed for medication administration documentation. Findings included: Review of the facility's undated Liberalized Medication policy and procedure revealed, in part, the date, time, dosage, and medication administered should be recorded in the resident's medical record by the individual administering the medication. Review of Resident #R5's December 2024 physician's orders revealed, in part, Ferrous Gluconate 324 milligrams (mg) one tablet by mouth daily with breakfast was to be administered to Resident #R5. Review of Resident #R5's Medication Administration History Report revealed, in part, S8Licensed Practical Nurse (LPN) documented she administered 324 mg of Ferrous Gluconate to Resident #R5 on the following dates: - 12/11/2024 at 9:24AM; - 12/12/2024 at 8:59AM; - 12/13/2024 at 8:41AM; - 12/14/2024 at 1:07PM; - 12/15/2024 at…

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

Based on observations and interviews, the facility failed to: 1. Ensure a resident's room and equipment was kept clean for 2 (Resident #36 and Resident #66) of 7 (Resident #6, Resident #16, Resident #27, Resident #36, Resident #56, Resident #66, and Resident #90) and, 2. Ensure a resident's equipment was in good repair for 3 (Resident #6, Resident #27, and Resident #56) of 7 (Resident #6, Resident #16, Resident #27, Resident #36, Resident #56, Resident #66, and Resident #90) sampled residents reviewed for environment. Findings: 1. Resident #36 Observation on 08/26/2024 at 10:01 a.m., revealed large areas of a dried tan substance on the floor near Resident #36's tube feeding pole and on the base of Resident #36's tube feeding pole. Observation on 08/28/2024 at 3:05 p.m., revealed large areas of a dried tan substance on the floor near Resident #36's tube feeding pole and on the base of Resident #36's tube feeding pole. In an interview on 08/28/2024 at 3:05 p.m., S9Licensed Practical Nurse confirmed there were areas of a dried tan substance on Resident #36's floor and the base of…

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

Based on record reviews and interview, the facility failed to ensure documentation was complete and accurate for resident's Physician Progress Notes for 2 (Resident #6 and Resident #11) of all sampled resident's records reviewed for accuracy. Findings: Resident #6 Review of Resident #6's Physician Progress Notes revealed, in part, S14Nurse Practitioner (NP) documented a physician progress note for Resident #6 on 01/16/2024, 03/16/2024, 04/16/2024, 05/16/2024, and 06/18/2024. Further review revealed Resident #6's chief complaint, physical exam, diagnosis, problem list, and plan were exactly the same in all of the above mentioned notes documented by S14NP. Further review revealed S14NP's Physician Progress Notes documented on 03/16/2024, 04/16/2024, 05/16/2024 and 06/18/2024 were photocopies of Resident #6's note documented on 01/16/2024 with the date changed and handwritten in. Resident #11 Review of Resident #11's Physician Progress Notes revealed, in part, S14NP documented a physician progress note for Resident #11 on 11/15/2023, 03/15/2024, 04/15/2024, 05/15/2024, and 06/10/2024.…

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

Based on record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) had a performance review within the last 12 months for 1 (S5CNA) of 3 (S5CNA, S6CNA, and S7CNA) sampled CNAs reviewed for sufficient staff review. Findings: Review of S5CNA's personnel file revealed a date of hire of 10/17/2018. Further review revealed no documented evidence and the facility presented no documented evidence of a performance review having been completed for S5CNA within the last 12 months. In an interview on 08/27/2024 at 2:33 p.m., S3Chief Operating Officer indicated the facility did not have any documented evidence of a performance review had been completed for S5CNA.

Based on observation, interview and record review the facility failed to: 1. ensure expired food was not available for resident consumption, 2. ensure the facility's kitchen was maintained in a sanitary manner; and, 3. ensure staff checked and documented the temperature of the facility's steam tables and refrigerator/freezers. Findings: 1. Review of the facility's undated Food Storage Policy revealed, in part, the facility will ensure safe and appropriate food storage. Further review revealed appropriate foods will be covered, labeled, and dated as stored in the refrigerator or freezer. Observation on 08/26/2024 at 9:15 a.m. revealed the following: -1 opened bottle of garlic parmesan wing sauce available for use with expiration dates of 05/04/2024 and 08/21/2024 -1 opened container of solidified ground ginger available for use with an expiration date of 12/27/2022 -1 opened bottle of vanilla syrup available for use with an expiration date of 09/2023 -1 unopened bottle of cinnamon sauce available for use with an expiration date of 02/19/2023 -1 unopened gallon of regular milk…

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: 1. have documented evidence of maintaining the water management program for legionella; and, 2. have an accurate tracking and trending of all facility infections. Findings: 1. Review of the facility's Water Management Program dated 02/2024 revealed the facility shall facilitate principles of effective water management of, in part: Maintaining water temperatures outside the ideal range for Legionella growth (77-113°F); Preventing water stagnation; Ensuring adequate disinfection; and, Maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. In an interview on 08/27/204 at 11:51 a.m., S4Quality Director indicated the facility did not have documented evidence of monitoring and maintaining the water temperatures between 77-113 degrees Fahrenheit. S4Quality Director further stated the facility did not have any further documentation of monitoring of any of the components of the facility's Water Management Program. In an…

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

Based on record review and interview, the facility failed to ensure the resident's medical record contained documentation of the education and refusal of vaccination for the influenza and pneumococcal for 4 (Resident #27, Resident #32, Resident #66, and Resident #83) of 5 (Resident #27, Resident #32, Resident #66, Resident #83, and Resident #90) sampled residents reviewed for immunizations. Findings: Review of the facility's spread sheet for vaccination revealed the following, in part: -Resident #27 had not received an influenza vaccination since 09/27/2020 with notation of refused; -Resident #32 had refused the pneumococcal vaccination; -Resident #66 had refused the influenza and pneumococcal vaccinations; and, -Resident #83 had refused the influenza and pneumococcal vaccination. Review of Resident #27, Resident #32, Resident #66, and Resident #83's records revealed no documented evidence of a refusal or consent had been signed for the above mentioned vaccinations. The facility presented the above mentioned Informed Consents for Resident #27, Resident #32, Resident #66, 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 record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA) received 12 hours of in-services annually for 3 (S5CNA, S6CNA, and S7CNA) of 3 (S5CNA, S6CNA, and S7CNA) sampled CNAs records reviewed. Findings: Review of S5CNA's personnel file revealed a date of hire of 10/17/2018. Further review revealed S5CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S5CNA annually. Review of S6CNA's personnel file revealed a date of hire of 03/15/2019. Further review revealed S6CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S6CNA annually. Review of S7CNA's personnel file revealed a date of hire of 11/10/2020. Further review revealed S7CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S7CNA annually. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect the resident's rights to be free from psychosocial abuse from S5Certified Nursing Assistant (CNA). This deficient practice was identified for 3 (Resident #1, Resident #2, Resident #3) of 3 sampled residents reviewed for abuse. Findings: Review of the facility's undated policy and procedure on Abuse Recognition, Reporting, and Investigation revealed, in part, residents of the facility are protected from any physical and mental mistreatment. Further review of the policy revealed verbal abuse was defined as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents regardless of their age, ability to comprehend, or disability. Review of the facility's required posted staffing schedule and hours dated 02/26/2024 revealed, in part, S5CNA was assigned to work 7:00 p.m. - 7:00 a.m. Resident #1 Resident #1 was admitted to 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 observation, record review, and interview the facility failed to: 1. Ensure a residents had compression stockings applied per physician orders for 1 (Resident #32) of 1 (Resident #32) sampled resident reviewed for skin conditions- non pressure; and 2. Ensure a resident had a splint applied per physician orders for 1 (Resident #40) of 1 (Resident #40) sampled resident reviewed for limited range of motion. Findings: Resident #32 Review of Resident #32's October 2023 Physician Orders revealed an order for compression stockings to Resident #32's bilateral lower extremities (legs). Further review of Resident #32's order revealed the compression stockings were to be applied at 6 a.m. and removed at 6 p.m. to prevent swelling to Resident #32's lower extremities. Observation on 10/10/2023 at 10:00 a.m. revealed Resident #32 was up in her wheelchair without compression stockings present to Resident #32's lower extremities. Left lower extremity very edematous. Observation on 10/11/2023 at 12:20 p.m. revealed Resident #32 was up in her wheelchair without compression stockings present…

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 reviews and interview, the facility failed to ensure State Registry verifications were completed prior to hire for 3 (S12Certified Nursing Assistant (CNA), S15CNA, and S18CNA) of 8 CNA personnel files reviewed for state registry verification reviews. Findings: Review of S12CNA's personnel file revealed a hire date of 02/17/2021. Further review of S12CNA's personnel file revealed no documentation of CNA Registry check. Review of S15CNA's personnel file revealed a hire date of 03/11/2020. Further review of S15CNA's personnel file revealed no documentation of CNA Registry check. Review of S18CNA's personnel file revealed a hire date of 07/21/2022. Further review of S18CNA's personnel file revealed no documentation of CNA Registry check. There was no documented evidence and the facility did not present any documented evidence of the CNA Registry check that was completed upon hire for S12CNA, S15CNA, and S18CNA. In an interview on 10/11/2023 at 2:46 p.m., S1Administrator stated the CNA registry check should have been completed upon hire for S12CNA, S15CNA, and S18CNA.

Based on observation and interview, the facility failed to: 1) Ensure leftover food was properly labeled in the main kitchen refrigerator; 2) Ensure food was not stored on the freezer floor; and, 3) Ensure food was properly labeled in the individual floors kitchen refrigerators. Findings: 1) Observation on 10/09/2023 at 9:30 a.m. of the walk in refrigerator in Kitchen A revealed, in part, -a container of potato casserole which was not labeled nor dated; -a container of brown gravy which was not labeled nor dated; -a pan of 12 biscuits covered with a clear wrap which was not labeled nor dated; and, -a container of mashed potatoes which was not covered nor labeled nor dated. In an interview on 10/09/2023 at 9:30 a.m., S8Dietary Manager acknowledged the food was not labeled or dated and should have been. 2) Observation on 10/09/2023 at 9:30 a.m. of Kitchen A freezer revealed an unopened case of juices which did not have a barrier/space between the floor and the case. In an interview on 10/09/2023 at 9:30 a.m., S8Dietary Manager confirmed an unopened case of juices was directly 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 ensure: 1. The resident's ice supply was maintained according to infection control practices for 1 (Ice Chest A) of 1 (Ice Chest A) observed for infection control practices; and 2. Staff were knowledgeable about the sanitation and/or disinfection procedures for the facility whirlpools for 3 (S19Certified Nursing Assistant, S20Certified Nursing Assistant, and S23Certified Nursing Assistant) of 4 (S15Certified Nursing Assistant, S19Certified Nursing Assistant, S20Certified Nursing Assistant, and S23Certified Nursing Assistant) certified nursing assistant staff interviewed for infection control practices. Findings: 1. Observation on 10/10/2023 at 10:21 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. Observation on 10/11/2023 at 8:55 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. Observation on 10/11/2023 at 11:42 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. In an interview on 10/12/2023 at 9:34 a.m., S2Director of Nursing…

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 respect a resident's right to have her fingernails untrimmed for 1 (Resident #88) of 4 (Resident #40, Resident #46, Resident #62, and Resident #88) sampled residents reviewed for Activities of Daily Living (ADL). Findings: Review of clinical record revealed, in part, a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/2023. This MDS indicated Resident #88 had a Brief Interview for Mental Status (BIMS) of 11 which suggests she was moderately impaired in cognition. Observation on 10/09/2023 at 10:50 a.m. revealed Resident #88 had clean fingernails that extended beyond the tip of her fingers on her left hand. In an interview on 10/09/2023 at 10:50 a.m., Resident #88 stated she preferred her fingernails to be as long as they were and did not want them cut. In an interview on 10/11/2023 at 11:55 a.m., Resident #88 stated, That nurse cut my nails. I did not want my nails cut. Observation on 10/11/2023 at 11:55 a.m. revealed Resident #88 opened her hand to extend her fingers to show that her nails…

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 issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner for 2 (Resident #208 and Resident #209) of 3 (Resident #208, Resident #209, and Resident #210) residents reviewed for beneficiary notification. Resident #208 Review of Resident #208's Beneficiary Notification Review revealed, in part, Resident #208's Medicare covered Part A services started on 05/26/2023 and her last Medicare Part A covered day was 07/13/2023. Review of Resident #208's NOMNC revealed, in part, Resident #208's last covered day of Medicare Part A services was 07/13/2023. Further review revealed Resident #208 signed the NOMNC on 07/13/2023 to acknowledge she received and understood the notice. Resident #209 Review of Resident #209's Beneficiary Notification Review revealed, in part, Resident #209's Medicare covered Part A services started on 08/03/2023 and her last Medicare Part A covered day was 09/27/2023. Review of Resident #209's NOMNC revealed, in part, Resident #209's last covered day of Medicare Part A services was 09/27/2023. Further…

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 a Significant Change in Status Minimum Data Set (MDS) was completed within 14 days of a resident beginning hospice services for 1 (Resident #39) of 2 (Resident #39 and Resident #43) sampled residents investigated for Hospice. Findings: Review of Resident #39's October 2023 Physician Orders revealed, in part, Resident #39 was admitted to Hospice for Chronic Obstructive Pulmonary Disease and Vascular Dementia on 04/24/2023. Review of Resident #39's medical record revealed a Significant Change in Status MDS assessment was not completed within 14 days after hospice admission on [DATE]. In an interview on 10/11/2023 at 12:45 p.m., S5MDS Nurse stated when a resident is admitted to Hospice Services, a Significant Change in Status MDS assessment should be completed 7-14 days after a resident was admitted to Hospice. S5MDS Nurse confirmed Resident #39 was admitted to Hospice services on 04/24/2023 and a Significant Change in Status MDS assessment was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #71) of 1 (Resident #71) sampled residents reviewed for requiring a PASARR Level II evaluation. Findings: Resident #71'a clinical record, reveled, in part, Resident #71 was admitted to the facility on [DATE]. Further review revealed, Resident #71 had a diagnosis of bipolar disorder (a serious mental illness that causes mood swings) with an onset date of 08/30/2023 and major depressive disorder (a serious mental illness that can cause persistent sadness) with an onset date of 08/22/2023. Further review revealed, no documentation that a Level II PASARR evaluation was completed for Resident #71. Review of Resident #71's Level I PASARR evaluation prior to admission revealed, in part, Resident #71 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses 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, record reviews, and interviews, the facility failed to: 1) Ensure a resident had a comprehensive care plan that addressed Activities of Daily Living (ADL) (Resident #46); 2) Ensure a resident had a comprehensive care plan that addressed self-administration of medication (Resident #71); and, 3) Ensure a resident had a comprehensive care plan that addressed a diagnosis of anxiety and depression (Resident #81). This deficient practice was identified for 3 (Resident #46, Resident #71, and Resident #81) in a total sample of 21 residents reviewed for care planning. Findings: Resident #46 Review of Resident #46's Medical Record revealed, in part, Resident #46 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Hemiplegia, Hemiparesis and Moyamoya Disease. Review of Resident #46's Significant Change Minimum Data Set with an Assessment Reference Date of 8/07/2023 revealed, in part, Resident #46 decision making was severely impaired and was totally dependent for…

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

Based on observations, interviews, and record reviews, the facility failed to ensure nail care was provided for a dependent resident who required assistance with nail cleanliness for 1 (Resident #62) of 4 (Resident #40, Resident #46, Resident #62, and Resident #88) residents reviewed for activities of daily living (ADLs). Findings: Review of Resident #62's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/27/2023 revealed, in part, resident required total assistance from 2 people for personal hygiene and bathing. Review of Resident #62 October 2023 physician orders revealed, in part, an order to assess and trim fingernails every 7 days on Friday. Observation on 10/09/23 at 10:38 a.m. revealed a dark brown substance under the middle finger nail and ring finger nail of Resident #62's right hand. Further review revealed a dark brown substance under the nail of the middle finger nail of Resident #62's left hand. Observation on 10/10/2023 at 3:30 p.m. revealed a dark brown substance under the middle finger nail and ring finger nail of Resident #62's right…

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 post the required nurse staffing information on a daily basis. Findings: Observation on 10/10/2023 at 10:25 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/10/2023 at 2:20 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/11/2023 at 9:00 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/11/2023 at 1:00 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. In an interview on 10/11/2023 at 2:46 p.m., S1Administrator stated the facility's posting…

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.