Colony Center For Health And Rehabilitation

Based on interview and record review, the facility failed to implement policies and procedures for bruises of unknown origin for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #2, to ensure a large bruise of unknown origin on the right side of the Resident's head was fully investigated to prevent potential further injury; and 2. Resident #12, to ensure bruises to the left elbow and wrist were fully investigated to prevent potential further injury. Findings include: Review of the facility's policy titled Clinical Services: Abuse, dated 3/2023, indicated but was not limited to the following: -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the Administrator and Director of Nursing (DNS) of the facility utilizing the chain of command. -Staff will follow the facility policy and procedure on investigation of abuse, mistreatment, or neglect. -Any…

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

Based on interview and record review, the facility failed to report bruises of unknown origin to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS-a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) as required for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed to report bruises of unknown origin within the required timeframe to the State Survey Agency for: 1. Resident #2's large bruise to the right side of the head; and 2. Resident #12's bruises to the left elbow and hand. Findings include: Review of the facility's policy titled Clinical Services: Abuse, dated 3/2023, indicated but was not limited to the following: -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the administrator and director of nursing (DNS) of the facility utilizing the chain 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 interview and record review, the facility failed to fully investigate bruises of unknown origin for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed to investigate: 1. Resident #2's large bruise to the right side of the head; and 2. Resident #12's bruises to the left elbow. Findings include: Review of the facility's policy titled Clinical Services: Abuse, dated 3/2023, indicated but was not limited to the following: -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the administrator and director of nursing (DNS) of the facility utilizing the chain of command. -Staff will follow the facility policy and procedure on investigation of abuse, mistreatment, or neglect. -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Investigation: The administrative staff or nursing supervisor…

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

Based on observation, record review, and interview, the facility failed to provide treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body), for one Resident (#26), out of a total sample of 18 residents. Specifically, the facility failed to ensure the physician's orders were followed and the correct size indwelling catheter balloon was implemented for Resident #26. Findings include: Review of the facility's policy titled Catheter Care, Urinary, undated, indicated but was not limited to the following: The following information should be recorded in the resident's medical record: -The date and time that catheter care was given. -All assessment data obtained when giving catheter care. -Any problems or complaints made by the resident related to the procedure. Resident #29 was admitted to the facility in July 2023 with diagnoses which included overactive bladder, benign prostate hyperplasia with lower urinary tract symptoms, and acute cystitis with hematuria (bleeding), calculus of ureter, and after…

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 develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#61, #29) with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, undated, included but was not limited to: - To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. - All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. - Social Service staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. - Trauma informed care is culturally sensitive and person-centered. - As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma 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 monitor for signs/symptoms of adverse consequences (i.e., side effects) of an anticoagulant agent (blood thinner) prescribed for one Resident (#12), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Anticoagulation-Clinical Protocol, undated, indicated but was not limited to the following: -As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with recent history of deep vein thrombosis (DVT), or heart valve replacement atrial fibrillation, or those who have had recent joint replacement surgery. -The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. -If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Resident #12 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 interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Findings include: Review of the facility's policy titled QAPI Program, dated 10/2017, included but was not limited to the following: Policy: -Identify and use data to monitor our performance -Established goals and thresholds for our performance measurement -Identify and prioritize problems and opportunities for improvement -Systematically analyze underlying causes of systemic problems and adverse events -Develop corrective action or performance improvement activities -Our organization strives to employ evidence-based practices related to performance excellence in all management practices, clinical care and resident and family satisfaction. -The Quality Council will review data from areas the facility believes…

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 Facility Assessment, interview, and staff education record review, for 7 out of 8 direct care employees reviewed, the facility failed to ensure that the training on effective communication was included as mandatory training for direct care staff per facility assessment. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in services. - Additionally, the facility offers training topics by 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 Quality Assurance and Performance Improvement (QAPI) program, interview, and staff education record review, for seven out of eight direct care employees reviewed, the facility failed to ensure that the training on the facility's Quality Assurance Performance Improvement (QAPI) program was included as part of the mandatory training for all staff per facility policy. Findings include: Review of the facility's QAPI Program, dated 10/2017, indicated but was not limited to: -Training and Orientation QAPI principles and staff responsibilities related to QAPI and ongoing quality improvement will be included in orientation for all new employees. All staff will participate in ongoing annual QAPI training which will include quality improvement principles and practices, how to identify areas for improvement, and communication procedures to the Quality Council, updates on current performance improvement projects, and how staff can be involved in performance improvement projects. Review of the staff education/competency records for seven out of the eight sampled employee's…

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

Based on review of the Facility Assessment, interview, and staff education record review, for eight out of eight employee records reviewed, the facility failed to ensure that the training on compliance and ethics was included as part of the mandatory training for all staff per facility assessesment. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in services. - Additionally, the facility offers training topics…

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 records reviewed for four Residents (#27, #72, #28, and #41), of 20 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented. Specifically, the facility failed to ensure: 1. For Resident #27, a care plan was developed to address the Resident's history of Post-Traumatic Stress Disorder (PTSD, occurs in some individuals who have encountered a shocking, scary, or dangerous situation. Symptoms usually begin early, within three months of the traumatic incident, but sometimes they begin years afterward); 2. For Resident #72, his/her fall care plan was updated after a fall and was inclusive of new interventions; 3. For Resident #28, a care plan was developed to address the Resident's recent history of suicidal ideation; and 4. For Resident #41, his/her care plan was individualized to include the use of a cast boot and weight bearing status to his/her left lower extremity. Findings include: Review of…

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

Based on records reviewed and interviews, for one Resident (#22), of 20 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Findings include: Review of the facility's policy titled Physician Visits, dated 4/2017, indicated but was not limited to: -The attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident's admission, and then at least every sixty days thereafter -The attending physician must perform relevant tasks at the time of each visit including a review of the resident's total program of care and appropriate documentation Resident #22 was admitted to the facility in August 2019 with the following diagnoses: dementia and atrial fibrillation (irregular heart rhythm). Review of the Minimum Data Set (MDS) assessment, dated 10/19/23, indicated Resident #22 had impaired short- and long-term memory. Review of the medical…

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, policy review, and interview, the facility failed to ensure for four Residents (#11, #28, #71, and #72), out of a total sample of 18 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure: 1. For Resident #11, the use of antipsychotic medication was managed and monitored for movement disorders to promote the Resident's highest practicable mental, physical, and psychosocial well-being; 2. For Resident #28, that psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 3. For Resident #71, that psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 4. For Resident #72, a. that Hydroxyzine (used for anxiety) ordered as needed (PRN) was reviewed by the Physician with a documented rationale for its continued use, and b. failed to monitor for potential side effects of psychotropic…

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 Arbitration Agreement presented to residents as part of the admission packet included the required information for one Resident (#46), out of a sample of one record reviewed. Specifically, the facility failed to ensure the Resident had a full thirty days to rescind the Arbitration Agreement after signing it as required. Findings include: On 1/11/24 at 1:10 P.M., the facility Administrator provided the requested list of residents, who currently are residing in the facility, that have entered into a binding arbitration agreement on or after September 16, 2019. The list included one Resident (#46). Review of the facility's admission Packet, Attachment C: Arbitration Agreement, undated, indicated but was not limited to the following: -Right to Change Your Mind. This Arbitration Agreement may be revoked (i.e., rescinded or canceled) by written notice sent certified mail by any Party within thirty (30) days from the date the Resident moves in and takes occupancy of his/her Suite. However, if the alleged acts…

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 documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on one (West unit) of two units. Findings include: During a Resident Group Meeting with the surveyor on 1/12/24 at 10:30 A.M., seven of the seven residents in attendance said they all have seen mice in their rooms. The residents said staff come in rooms and set traps and hope it gets better. Three of the residents in attendance resided on the [NAME] unit. During an interview on 1/11/24 at 12:23 P.M., Resident #41 said he/she saw a mouse in their room. The Resident said the mouse ran to the corner and pointed to the far corner of the room. The surveyor observed a mouse hole in the corner, with visible mice droppings. During an interview on 1/11/24 at 4:22 P.M., Family Member (FM) #3 said he/she sees a mouse run across the room everyday he/she visits. FM #3 said he/she is in the building multiple times every week 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 review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in services. -…

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 Facility Assessment, interview, and staff education record review, for four employees (Nurse #4, Nurse #6, Nurse #7, and Certified Nursing Assistant (CNA) #4), out of eight employees reviewed, the facility failed to ensure that the training on resident rights was included as mandatory training for all staff per facility assessment. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in…

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

Based on review of the Facility Assessment, interview, and staff education record review, for three employees (Nurse #4, Nurse #6, and Certified Nursing Assistant (CNA) #4) out of eight employees reviewed, the facility failed to ensure that the training on abuse, neglect, and exploitation was included as mandatory training for all staff per facility assessment. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in…

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

Based on review of the Facility Assessment, interview, and staff education record review, for six out of eight direct care employees reviewed, the facility failed to ensure that the training on behavioral health was included as part of the mandatory training for all staff. Findings include: Review of the Facility Assessment, revised 10/27/23, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in services. Review of the staff education/competency records for six of the eight sampled…

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, records reviewed, and review of the facility policies for two Residents (#22 and #41), of 20 sampled residents, the facility failed to provide care and services consistent with professional standards of practice. Specifically the facility failed: 1. For Resident #22, to communicate to the physician and timely implement recommendations made by a consulting hospice nurse; and 2. For Resident #41, to follow their policy and fully investigate a fall to analyze the vulnerabilities and consider interventions to mitigate the risk of future falls. Findings include: 1. Review of the facility's policy titled Physician Services, undated, indicated but was not limited to: -Supervising the medical care of residents includes but is not limited to: providing consultation or treatment when called by the facility -The attending physician will determine the relevance of any recommended interventions from other disciplines. Resident #22 was admitted to the facility in August 2019 with the following diagnoses: dementia and atrial fibrillation (irregular heart rhythm).…

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

Based on interview, record review, and policy review, the facility failed to ensure proper care and treatment of a midline catheter (long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medication into the bloodstream) device in accordance with professional standards of practice for one Resident (#56), out of a total sample of 20 residents. Specifically, the facility failed to flush the midline to prevent blockages and change the midline dressing per physician's orders. Findings include: Review of the facility's policy titled Midline/Extended Dwell Catheter Flushing, dated January 2022, indicated but was not limited to: - Purpose: To maintain patency of the midline or extended dwell catheter. 1. A prescriber order is required for vascular access devices (VADs) flushing. The order will be specific with regards to flush solution, volume, and frequency. 2. The VAD will be flushed before and after administration, in between multiple intravenous medication administrations, and routinely, at established intervals, when the VAD is not in use. 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 records reviewed, interviews, and policy review, for one Resident (#27) with a history of trauma, of 20 sampled residents, the facility failed to ensure he/she received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess the Resident and identify triggers of trauma to prevent potential re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care, dated 7/23, indicated but was not limited to: -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. -Trauma-informed care is culturally sensitive and person-centered. -Steps in the procedure: Implement universal screening of residents for trauma. -Resident-care strategies: As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Resident #27 was admitted to the facility in July…

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 records reviewed, for two Residents (#75 and #279), of 20 sampled residents, the facility failed to provide specialized rehabilitative services, specifically speech-language pathology services, as required in the resident's comprehensive plan of care. Findings include: Review of the facility's policy titled Functional Impairment, undated, indicated but was not limited to: -the staff and physician will collaborate to identify a rehabilitative care plan to help improve function and quality of life and meet a resident/patient's goals and needs to attain other desired outcomes such as discharge to the community -the physician will order any therapy services based on the above considerations 1. Resident #75 was admitted to the facility in December 2023 with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis (weakness or loss of strength) following cerebral infarction affecting right dominant side, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, indicated Resident…

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

Based on record review and interviews, the facility failed to maintain accurate medical records for one Resident (#28), out of a total sample of 13 residents. Specifically, the facility failed to ensure staff accurately and completely documented the presence of signs and symptoms of infection of the Resident's port-a-cath (device that is usually placed under the skin in the right side of the chest. It is attached to a catheter (a thin, flexible tube that is threaded into a large vein above the right side of the heart called the superior vena cava) to deliver medication. Findings include: Resident #28 was admitted to the facility in November 2022 with diagnoses including multiple myeloma (a cancer that forms in a type of white blood cell called a plasma cell). Review of the medical record indicated Physician's Orders including but not limited to: -Monitor Right port-a-cath for signs/symptoms of infection, every shift (1/18/24) Review of the Treatment Administration Record (TAR), dated 1/18/24 through 1/31/24 and 2/1/24 through 2/17/24 reflected the order to monitor 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.

Based on observation, documentation review, policy review, and interview, the facility 1. Failed to implement transmission-based precautions (TBP) for a newly admitted Resident (#268) and educate the Resident's family on TBP, per the facility's policy, to help prevent the potential spread of infection throughout the facility; and 2. Failed to have an ongoing infection control and surveillance program that included consistent tracking, identifying, and monitoring of all potential or actual infections within the facility. Findings include: 1. During an initial tour on 12/1/21 at 7:37 A.M., the surveyor observed two Residents (#62 and #218) out of the unit census of 26 residents, with signs outside of their bedroom doors indicating they were on contact or TBP. During an interview on 12/1/21 at 8:52 A.M., Nurse #1 said there were currently 26 residents on the unit and to the best of her knowledge only two Residents #62 and #218 were on some type of isolation or TBP. In addition, she said Resident #268 was a new admission, but did not require any quarantine or precautions. On 12/1/21 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 record review and interviews, the facility failed to notify the physician and the Healthcare Proxy (HCP) when a resident returned to the facility with a new trauma pressure injury for one Resident (#35), out of a total sample of 17 residents. Findings include: Resident #35 was newly diagnosed with an unstageable left heel wound in August 2021. Review of Resident #35's current Physician's Orders indicated the following: -Healthcare proxy activated effective 7/16/21 Review of Resident #35's Care Plan for Alteration in Skin Integrity related to trauma on the left Achilles (tendon connecting calf muscles to the heel) was initiated 8/24/21 and indicated the following: -update family with changes in wound status Review of the initial Wound Weekly Observation Tool, dated 8/18/21, indicated the following: -Left heel, acquired 8/16/21 by trauma, first observation, granulation tissue present (beefy red), moist, small amount serous drainage. Measurement 3 centimeters (cm) length, 1.5 cm width, 0.2 cm depth, peri- wound tissue described as fragile, no swelling, no other sign 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 review, observation, interview, and policy review, the facility failed to ensure that professional standards for medication administration via a gastrostomy tube (GT) were met for one Resident (#9), out of a total sample of 17 residents. Specifically, the facility failed to ensure staff 1. Checked the GT for placement per the facility's policy; and 2. Flushed the GT with the proper amount of water, per the physician's order. Findings include: 1. Review of the facility's policy titled Gastrostomy Tube Medication Administration, dated 1/29/09, indicated, but was not limited to: - Check the medication administration record (MAR) to confirm the order: note the medication, dose, route (tube), volume of water for flushing . Note: Medication administration via tube requires flushing with water at several steps in the procedure. - With gloves on, check for proper tube placement using air and auscultation only. Never check placement with water. - Administer each medication separately and flush the tubing between each medication. Resident #9 was admitted to the facility in…

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

Based on record review and interviews, the facility failed to follow their policy by not immediately documenting the condition of a new trauma pressure injury the resident received while out of the facility at a medical appointment. In addition, they failed to notify and obtain treatment orders from the physician to start providing immediate care to the trauma pressure injury for one Resident (#35), out of a total sample of 17 residents. Findings include: Review of the facility's wound management policy titled Pressure Ulcer Prevention Management and Treatment Program, dated May 2013, indicated the following: -The registered nurse is responsible for the completion of the skin assessment on admission, re-admission and four weeks post admission and with significant change using the skin assessment tool. -The charge nurse or designee is responsible for completing the weekly Pressure Ulcer Flow Sheet and/or weekly Wound/Skin Condition Report, and implementing appropriate interventions if a skin condition or breakdown is noted. -When a pressure ulcer is identified, the nurse will notify…

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 reviews, and policy review, the facility failed to ensure professional standards were followed for residents receiving dialysis services, through ongoing communication and collaboration with the dialysis facility for two Residents (#55 and #38), out of two total residents receiving dialysis. Findings include: Review of the facility's policy for Hemodialysis, dated May 2014, indicated the following procedures: -clarify with a physician if Hemodialysis medications should be given pre-dialysis or held -the licensed nurse will document on the Hemodialysis flow sheet (communication form) whenever a resident goes and returns from dialysis -the communication book will include pertinent information on the resident (vital signs, medications given prior to dialysis) -the Unit Manager will read the communication book upon return from dialysis 1. Resident #55 was admitted to the facility in May 2018 with a diagnosis of diabetes and was receiving Hemodialysis outside of the facility. 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.

Based on interview, record review, and policy review, the facility failed for one Resident (#66), out of a total sample of 17 residents, to have documented evidence of a clinical rationale for the as needed extended use of a psychotropic medication. Findings include: Resident #66 was admitted to the facility in November 2021. Review of the medication administration record (MAR) indicated the following: 1. On 11/13/21, the Resident had a new order for Alprazolam (an anti-anxiety) 0.5 milligrams (mg) every 12 hours as needed (PRN) for anxiety; the order had a discontinuation date of 11/15/21; the medication was not used in those three days by the Resident. 2. On 11/15/21, a new order was received for Alprazolam 0.5 mg, every 12 hours PRN for anxiety for 14 days. Throughout the 14-day period the medication was administered five times out of a possible 28 times. 3. On 11/29/21, following the discontinuation of the previous order, a new order was received for Alprazolam for 0.5 mg every 12 hours PRN for anxiety. The order did not include a duration for use. During an interview 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.