Maplewood Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2b. For Resident #9 the facility failed to ensure skin assessments were implemented in accordance with the medical plan of care. Resident #9 was admitted to the facility in August 2012 and has diagnoses that include but are not limited to metabolic encephalopathy, bipolar disorder, moderate protein malnutrition, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 scored a 7 out of 15 on the Brief Interview for Mental Stats exam which indicated he/she as having severe cognitive impairment, requires partial/moderate assistance for self-care activities including bathing and dressing. Further review of the MDS indicated Resident #9 is at risk for developing pressure ulcers/injuries. Review of Resident #9's medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcers, dated 10/22/24 as high risk. Review of the physician's order dated 3/14/23 indicated: -Weekly skin assessment on TUESDAY 3-11 shift. Document on PCC (electronic medical record) under…

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 medications were stored in locked compartments on one nursing unit. Findings include: Review of the facility policy titled, Storage of Medications, dated as revised April 2007, indicated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Only persons authorized to prepare and administer medications shall have access to the medication room, including keys. On 6/4/25 at 9:14 A.M., the surveyor observed the medication storage room was unlocked and unattended on the first floor Unit 1. The surveyor was able to open the door and gain access into the medication storage room. There were no staff present in or around the medication storage room. Residents were observed walking around…

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 ensure that the Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP), including a corrective action plan with effective monitoring for Pressure ulcers, infection control surveillance plan, adequate Nursing staffing, and annual wound competencies. Specifically, (i) the facility failed to develop and implement an action plan after Nursing staff failed to implement recommendations for treatment received from the wound consultant, resulting in the deterioration of a wound for one Resident, #24 (ii) develop and implement an action plan for infection control surveillance planning for identifying, tracking, monitoring, reporting infections, and communicable diseases (iii) failed to develop and implement and action plan ensuring there was sufficient and qualified staff at all times to provide Nursing and related services to meet the resident's needs safely in a manner that promotes each resident's rights, physical, mental and psychosocial well-being (iv) failed to develop 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 record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to three out of a sample of five employees. Specifically, the facility failed to offer COVID-19 vaccinations during the new hire orientation. Findings include: Review of the Facility assessment dated [DATE], indicated the following: -Infection prevention and control. COVID-19 Response - Follow all CDC and DPH Guidelines. A review of five employee health records indicated three out of the five employees had not been vaccinated for COVID-19. During an interview and record review on 6/5/25 at 8:32 A.M., the Human Resources Director said she will request copies of COVID-19 vaccination cards and notify the Director of Nurses if a staff member does not have one and said she does not keep track of vaccinations and does not know if staff have been offered the COVID-19 vaccination during their new hire orientation. During an interview on 6/25/25 at 8:55 A.M., the Director of Nurses (DON) said all immunizations…

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 document review and interview, the facility failed to maintain records of Certified Nurse Aide (CNA) trainings for continuing competency that included no less than 12 hours of mandatory trainings per year for each CNA employed by the facility for two out of five CNAs reviewed. Findings include: During an interview on 6/5/25 at 1:48 P.M., the Director of Nurses (DON) said all staff education is tracked by the Human Resource Director (HR) to ensure the education is completed. On 6/4/25 at 10:14 A.M., the survey team requested proof of 12 hours of CNA training time for five employees. Review of the education records, for CNA #2 failed to indicate education had been completed and documented as required. Review of the education records, for CNA #3 failed to indicate education had been completed and documented as required. During an interview on 6/5/25 at 8:39 A.M., the DON said she was unable to provide the surveyor with additional education records for CNA #2 or CNA #3. The DON said she would expect any education and training to be kept in the employee folders. During 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 notify the physician of a refusal of a medication for one Resident (#55), out of a total sample of 24 residents. Specifically, the facility failed to notify the physician of Resident #55's refusals of his/her ordered furosemide (a medication that removes fluid). Findings include: Review of the facility policy titled, Administering Medications, dated as revised December 2012, indicated: Medications are administered in a safe and timely manner, and as prescribed. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. Review of the facility policy titled, Notification of Changes, dated August 2024, indicated notification to the resident's attending physician will be made with a need to alter treatment significantly or to commence a new form of treatment. Resident #55 was admitted to the facility in May 2025 with diagnoses including Chronic…

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 review, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for one Resident #224 out of a sample of 24 residents. Specifically, (i) the facility failed to develop a substance use history base-line care plan, (ii) a suicide attempt history base-line care plan within 48 hours of the resident's admission. Findings include: A review of the facility policy titled 'Care Plans-Baseline' with a revision date December 2016 indicated the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The interdisciplinary team will review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: Social Services. -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. -The…

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

Based on record review and interviews, the facility failed to develop a comprehensive person-centered care plan for one Resident (#24) out of a total sample of 24 Residents. Specifically, the facility failed to develop a plan of care after Resident #24 developed pressure ulcers to his/her back. Findings include: Resident #24 was admitted to the facility in January 2023 with diagnoses that included fusion of spine, cervical region, protein calorie malnutrition and iron deficiency anemia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has one stage 1 pressure ulcer, and one unstageable pressure ulcer; neither of which were present on admission. Review of the medical record indicated the following: -A wound consultant note, dated 2/24/25, that initially indicated that Resident #24 had two stage 2 pressure ulcers, one to the proximal and one to the distal lower back. -Wound consultant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to provide the necessary care and services related to showers for one resident (#37), in a total sample of 24 residents. Findings include: Resident #37 was admitted to the facility in May 2020 with diagnoses including diabetes and congestive Heart Failure. Review of the most recent Minimum Data Set assessment (MDS), dated [DATE], indicated cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. During an interview on 6/3/25 at 7:57 A.M., Resident #39 said that he/she had not received a shower in about 12 weeks. Resident #39 said that he/she would like to have a shower. He/she said that it's not that he/she refuses, but that they aren't offering a shower to him/her. He/she said that it depends on who's working or how much staff they have. During an interview, on 6/4/25 at 8:05 A.M., Resident #39 said that he/she still had not received a shower. Resident #39 said that he/she would like to have a shower.…

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, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#55) out of sample of 24 residents. Specifically, the facility failed to include a physician's order for the use of oxygen in the medical record. Findings include: Review of the facility policy titled Oxygen Administration dated as revised October 2010, indicated to verify there is a physician's order for the administration of oxygen before applying. Further review indicated to review the resident's care plan to assess for any special needs of the resident. Resident #55 was admitted to the facility in May 2025 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #55's cognition is cognitively intact as evidenced by a scored 14 out of 15 on the Brief Interview for Mental Status assessment. 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 physician visits were completed as required upon admission for two residents (#50 and #66) out of a total of 24 sampled residents. Findings include: Review of the facility policy titled, Physician Services, dated April 2013, indicated: 1. The Resident's attending physician participates in the resident's assessments and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility and overseeing a relevant plan of care for the resident. 1. Resident #50 was admitted to the facility in October 2024 with diagnoses including schizophrenia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 was cognitively intact evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #50's physician and nurse practitioner visits since October 2024 indicated Resident #50 was seen by the nurse practitioner 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide behavioral health services for one Resident, (#68) out of a total of 24 sampled Residents. Specifically, the facility failed to ensure ongoing psychotherapy/talk therapy was provided for Resident #68 and failed to develop and implement a care plan related to Resident #68's diagnosis of depression and anxiety. Findings include: Resident #68 was admitted to the facility in September 2024 with diagnoses including vascular dementia, hemiplegia, and anxiety disorder and depressive disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #68 is moderately cognitively impaired evidenced by a score of 10 out of a possible 15 on the Brief Interview for Mental Status Exam. During an interview on 6/4/25 at 8:07 A.M., Resident #68 said that he/she had not been offered any counseling or therapy services while residing in the facility and that he/she was very interested in talking to someone. Review of Resident #68's care…

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 for one Resident (#13), out of 5 applicable residents, out of a total sample of 24 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations. Findings include: Resident #13 was admitted to the facility in September of 2020 and has diagnoses that include but are not limited to neurocognitive disorder with Lewy Bodies, unspecified dementia, moderate protein-calorie malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #13 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition and requires partial/moderate assistance for self-care activities. Review of Resident #13's medical record indicated the consulting pharmacist provided recommendations during the Monthly Medication Regimen Review on 2/24/25 and 4/10/25. The medical record…

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 observation for one of two resident care units, the Facility failed to ensure the food/beverage items served to the residents were safe and at an appetizing temperature. Findings include: Review of the Resident Council Minutes indicated the following: - On 02/24/25, the residents were concerned about receiving the food being cold upon delivery by staff. - On 03/04/25, the residents continued to be concerned about the food being cold upon delivery by staff. - On 04/01/25, the residents said the kitchen was inconsistent with food temperatures, the food continued to be cold, and the Facility needed a plan to prevent the food from being cold upon delivery. During an interview on 05/08/25 at 4:10 P.M., President of Resident Council said residents continue to share with at meetings and with him/her that food meant to be hot is cold and the food was awful. The President said the Facility's food temperatures have been inconsistent when staff deliver the meal trays. Review of the Meal Delivery Times indicated the Breakfast carts are delivered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, for two of two Nourishment Kitchenettes (Main 1 and Main 2), the Facility failed to ensure that food items prepared and served to residents were done safely, securely, were properly labeled and had not expired. Findings include: Review of the Facility's Policy titled, Nourishment Kitchen Procedure, undated, provided by the Facility indicated the following: - All beverages need to be labeled with the date they are brought in, and use-by date, which includes milk, ginger ale, cola and all pitchers of juice/ice-tea-iced coffee, applesauce and bread. - All food/beverages that are not labeled need to be thrown out by staff when they are stocking and cleaning. - The Dietary staff is responsible for ensuring the fridges and cabinets are clean and tidy, using sanitizer and a clean towel. Review of the Facility's Policy titled, Labeling Procedure, undated, provided by the Facility indicated the following: - Items placed in the refrigerators must have a name and a 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 records reviewed and interviews for one of three sampled Residents (Resident #2), the Facility failed to ensure they maintained a complete and accurate Medical Record, when on 04/09/25 there was no Nursing documentation related to his/her acute Hospital transfer or return to the Facility. Findings include: The Facility's Policy titled Resident Assessment Policy and Procedure, dated 2025, indicated the Facility shall maintain supporting documentation for all diagnoses in a residents medical record to verify the accuracy of the resident assessment. The Policy indicated supporting documentation shall include, but is not limited to the following; - Evaluations of the resident's physical, behavioral, mental, and psychosocial status. - Indications of distress. - Changes in Functional status and - Resident complaints, behaviors, and symptoms. Resident #2 was admitted to the Facility in 12/2024, diagnoses included Parkinson's Disease (a disorder of the Central Nervous System that affects movement), Atrial…

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, for three of three sampled Employee Personnel Files (Nurse #1, Nurse #4, and Certified Nurse Aide #3), the Facility failed to ensure they completed and followed abuse prohibition procedures as defined in their policy when Massachusetts Nurse Aide Registry background checks were not conducted prior to hire. Findings include: Review of the Facility's Policy and Procedure titled Employee Background Checks, Reporting Requirements, and Prevention of Abuse, Neglect, Exploitation of Residents, not dated, indicated the Facility shall be thorough in its investigations of the histories of prospective staff. The Policy indicated the Facility shall check the state nurse aide registry. The Policy indicated the Facility shall screen potential employees for a history of abuse, neglect, and exploitation, or misappropriation of resident property in order to prohibit abuse. neglect, and exploitation of resident property which includes checking registries. Review of Nurse #1's Personnel File indicated she was hired on 12/18/24. Further review of the file…

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

Based on observation, record review and interview, the facility failed to ensure that nursing staff implemented standards of practice by failing to do the controlled substance count (a control measure to safeguard and maintain accurate dispensing and inventory of controlled substances), at the time of a change in shift, on one of two resident care units. Findings include: Review of the facility's policy, not titled or dated, indicated the following: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy interpretation 1. Only authorized licensed nursing and or pharmacy personnel have access to controlled drugs maintained on premises. 8. Controlled substances are reconciled upon receipt, administration, disposition, and the end of each shift. 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are…

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, menu review and interview the facility failed to ensure meals provided to residents on two of two resident care units for two of two meals tested, were palatable, attractive and at appetizing temperatures. Findings include: During the resident group meeting conducted with the surveyor on 6/10/24 at 2:07 P.M., the residents said the food is an on-going issue. Residents said: It is not good and I would not feed it to my dog. We don't know what we are eating many times. I think we had chili over cabbage. Hot food items are not hot. Coffee is never hot. There are no condiments for food. The residents said this has been brought up to staff and they are aware. Eight of ten residents actively participating in the meeting said hot food is not served hot. During the initial screening process on 6/10/24 starting at 7:30 A.M. 10 out of 27 residents said that the food was not good and the temperatures of the food were either to cold or to warm. Review of the menu posted on the second floor on 6/11/24 indicated the following: *Tuna Noodle Casserole *Lettuce and tomato salad…

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 their Quality Assurance Performance Improvement plan during a transition of leadership to ensure practices to support quality of care were implemented. Specifically, the facility failed to identify, and develop a plan for services provided by Registered Nurses and failed to identify and develop a plan to ensure the Director of Nursing was not working as a charge nurse. Findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Plan (QAPI), not dated indicated the following: The QAPI plan had been developed to allow our facility to achieve its mission: to provide better care, compassion and solutions to the communities we serve. The facility will effectively identify, collect and use data and information from all departments and the facility assessment. Our facility will conduct Performance Improvement Projects (PIPs) that are designated to take systemic approach to revise and improve care or services in areas that we identify as needing attention. We will conduct PIPs that…

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 policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the potential transmission of communicable diseases and infections within the facility. Specifically the facility failed to 1. track and trend infections in the facility and 2. failed to ensure a water management program was implemented to minimize the risk of Legionella and other opportunistic pathogens in building water systems by having a documented water management program. Findings include: 1. Review of the facility policy titled Infections - Clinical Protocol, not dated, failed to indicate a process for the monitoring and trending of infections in the building. During an interview on 6/12/24 at 2:25 P.M., the Director of Nursing (DON) said that she was responsible the implementation and monitoring of the infection control monitoring program. The DON then said that she did not complete the monitoring, tracking and trending of infections for the months of March 2024, April 2024 and May 2024. She then said that she could not find a policy 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 record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, not dated, indicated the following: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection Preventionist, or designee. 2. The IP, (infection Preventionist) or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain professional standards of nursing practice for four Residents, (#63, #69, #27 and #54) out of a sample of 24 residents. Specifically: For Residents #63, Resident #69 and Resident #27, the records failed to indicate that medications were administered as ordered. For Resident #54, the facility failed to follow physician's orders to re-evaluate a temporarily invoked health care proxy. Findings include: 1. Resident #63 was admitted to the facility in October 2023 with diagnoses including atrial fibrillation, complications with kidney transplant, anemia, major depressive disorder, and delusional disorders. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score. Further review of the medical record indicated a behavioral therapy note dated 6/5/24 indicating Resident #63 is alert and oriented to time, place and person. A review of the nurse's progress notes,…

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 sufficient staffing levels were maintained to provide resident care on two of two units. Findings include: Review of the Facility Assessment Tool, with the date(s) of assessment or update as 1/3/2024 and date assessment reviewed with the QAA/QAPI (Quality Assurance and Quality Assurance Performance Improvement) as 1/3/2024, indicated: Part 3 Facility Resources Needed to Provide Competent Support and Care for Our Resident Population Every Day and During Emergencies. 3.1 identify the type of staff members, other health care professionals, medical practitioners that are needed to provide support and care for residents. Further review of the facility assessment failed to indicate the staffing plan was filled out for Nurses' Aides and Licensed nurses providing direct care. Review of the facility's Payroll-Based Journal Staffing Data Report for Quarter 2 January 1, 2024, through March 31, 2024, indicated the facility triggered as having excessively low weekend staffing. During an interview on 6/10/24 at 11:17 A.M. 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.

Based on record review and interview, the facility failed to ensure staffing included the services of a Registered Nurse for a minimum of eight consecutive hours a day, seven days a week as required and failed to ensure the Director of Nursing did not act as a charge nurse. Findings include: 1. Review of the facility's 'Payroll-Based Journal Staffing Data Report 1705D', for Quarter 2 January 1, 2024, through March 31, 2024, indicated the facility triggered as a one-star staffing rating. Review of the document 'Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-18-17-NH DATE: April 06, 2018' indicated the following: Requirement for registered nurse (RN) staffing - We are reminding nursing homes of the importance of RN staffing and the requirement to have an RN onsite 8 hours a day, 7 days a week. Nursing homes reporting 7 or more days in a quarter with no RN hours will receive a one-star rating in the staffing domain, which will drop their overall (composite) star rating by one star for a quarter. This…

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 recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for three Residents (#34, #59 and #46) out of a total sample of 24 Residents. Findings include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations dated revised 7/2023 indicated that the consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding resident's medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. 1. Resident #34 was admitted to the facility in January 2023 with diagnoses including diabetes, high blood pressure and dementia. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #34 scored a 13 out of 15 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 record review and interview, the facility failed to ensure resident issues brought forth to staff during the Resident Council Meeting were responded to and a resolution provided. Findings include: Review of the facility's policy titled Grievances dated revised March 2021, included but was not limited to the following: The Facility will support each resident's right to voice grievances and to ensure after a grievance has been received, the Grievance Official (Administrator or designee) will collaboratively work with team members to resolve the issue and provide written grievance decisions to the resident and/or the residents family. Procedure: 9. The Resident Council is an additional forum within the facility for voicing complaints/grievances. Complaints/grievances received from the Council will be acted upon in accordance with this procedure. Review of the Resident Council Meeting Agenda dated 3/6/24 indicated the following as New Business; Resident comments/Concerns/Recommendations: Quality of Care issues: 1. No condiments on tray. 2. Pepper and ketchup with breakfast…

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 accurately complete the Minimum Data Set Assessment for two Residents (#42 and #71) out of a total sample of 24 residents. Findings include: 1. Resident #42 was admitted to the facility in June 2023 with diagnoses including morbid obesity, heart disease and anemia. Review of the medical record indicated that Resident #42 sustained a significant weight loss of 10.63% between 12/2/23 and 1/1/24. Review of Minimum Data Set (MDS) assessment dated [DATE] (less than five months since the significant weight loss occurred) indicated that Resident #42 did not sustain a significant weight loss in the prior 6 months. During an interview on 6/11/24 at 10:49 A.M., the Assistant Director of Nursing said that she would expect the MDS to be accurate. During an interview on 6/12/24 at 10:50 A.M. the MDS Nurse said that she looks at the documented weights in the medical record to obtain the information she uses to document on the MDS. She then said that she made 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 interviews and records reviewed, the facility failed to develop care plans for one Resident (#27) out of a sample of 24 residents. Specifically, the facility failed to develop care plans related to a history of suicidal ideations and a history of alcohol abuse. Findings include: A review of the facility policy titled 'Care Plans-Comprehensive' with a revision date of July 2023 indicated the following: -All individualized comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident. -Each resident's care plan is designed to: (a) Incorporate identified problem areas. (b) Incorporate risk factors associated with identified problems. (c) Reflect treatment goals timetables and objectives in measurable outcomes. Resident #27 was admitted to the facility in November 2023 with diagnoses including depression. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a BIMS…

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 hearing services were provided for one Resident (#4) out of a total of 24 sampled Residents. Findings include: By end of survey the facility had not produced a policy for audiology consults, per surveyor request. Resident #4 was admitted to the facility in June 2022 with diagnoses including hearing loss, dementia and adult failure to thrive. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #4 has moderate difficulty hearing, and the speaker has to raise their voice and speak distinctly to be heard. Review of the doctor's progress note dated 1/29/24, indicated that Resident #4 was seen on 1/29/24 secondary to the family's concern of decreased hearing. Further review indicated that the ear canal was clear and without obstruction. Further review indicated that Resident #4 was unable to pass the whisper test with hearing aides in place and that a request for an audiologist evaluation of the patient and hearing aides will 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 observation, record review and interview for one Resident (#38), out of a total sample of 24 residents, the facility failed to ensure risk assessments and skin evaluations were implemented for the prevention for developing pressure ulcer/injuries. Findings include: Review of the facility's policy titled Pressure Injury Risk Assessment, not dated indicated; The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. General Guidelines: The Risk Assessment should be conducted as soon as possible after admission, but no later than eight hours after the admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as required based on the resident's condition. Resident #38 was admitted to the facility in May 2024 with diagnoses that include chronic atrial fibrillation, hemiplegia 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 observation, interview, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#40) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 24 sampled residents. Specifically, the facility failed to ensure staff labeled the enteral formula bag and water flush bag with the Resident's name, the formula used, the administration rate, duration, and initials of the staff member hanging them. Findings include: Review of the facility policy titled Enteral Tube Feeding via Continuous Pump and undated, indicated that, on the formula label document initials, date and time formula was hung/administered, and initial that the label was checked against the order. Resident #40 was admitted to the facility in February 2024 with diagnoses including dysphagia, encephalopathy and legal blindness. Review of the Minimum Data Set (MDS) assessment…

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, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two Residents (#34 and #46) out of a total sample of 24 Residents. Findings include: By end of survey the facility had not produced a policy for the use of as needed antipsychotic drug use, per surveyor request. 1. Resident #34 was admitted to the facility in January 2023 with diagnoses including diabetes, high blood pressure and dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #34 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated that Resident exhibited verbal behaviors directed towards others 4 to 6 days a week and refused care one to two days a week. Review of the care plan dated 1/23/23, indicated a focus of; Resident #34 uses psychotropic medications related to behavior management. Further review indicated an intervention to discuss with…

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

Based on observation, record review and interview the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed made 2 errors out of 30 opportunities resulting in a medication error rate of 6.67 %. Those errors impacted two Residents (#39 and #37), out of 5 residents observed. Findings include: Review of the facility policy titled Administering Medications, undated, indicated that medications are administered in accordance with prescriber orders. 1. For Resident #39, Nurse #3 gave the wrong dose of an ordered medication. Resident #39 was admitted to the facility in May 2023 with diagnoses including gastro-esophageal reflux disease, osteoarthritis and dementia. During medication pass on 6/11/24 at 7:49 A.M., the surveyor observed Nurse #3 give Resident #39 two tablets of Calcium Carbonate 750 mg (milligrams). Review of the doctors orders dated June 2024 indicated an order for Calcium Carbonate 500 mg give one tablet at 9:00 A.M. During an interview on On 6/11/24 at 9:45 A.M., Nurse #3 said that she gave the wrong dose…

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, policy review and interview the facility failed to 1. ensure medications and biologicals were stored in a safe and secure manner in one of two medication carts, 2. failed to ensure medications were properly labeled in two of two medication carts observed, and 3. failed to ensure medication carts were locked when unattended. Findings include: Review of the facility policy titled Storage of Medications and not dated indicated that the facility stores all drugs and biologicals in a safe, secure and orderly manner. Further review indicated that medications are not to be stored on top of the medication cart and open medication carts are to be within view of the nurse at all times. 1. On 6/11/24 at 8:09 A.M., the surveyor observed Nurse #3 leave six cards of prescription medications on top of the medication cart, walk down the hall and enter a resident's room. The surveyor observed that Nurse #3 was not in eyesight of the medication cart for two minutes. During an interview on 6/11/24 at 8:09 A.M., Nurse #3 said that she should not have left the medication on top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide dental services for one Resident (#71) out of a total of 24 residents. Findings include: By end of survey the facility had not produced a dental services policy per surveyor request. Resident #71 was admitted to the facility in January 2024 with diagnoses including multiple fractures, cerebrovascular disease and anxiety disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #71 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. On 6/10/24 at 7:40 A.M., the surveyor observed Resident #71 to have teeth missing, broken and carious teeth. During an interview on 6/10/24 at 7:40 A.M., Resident #71 said that he/she had many issues with his/her teeth and needed them to be fixed. Review of the medical record failed to indicate that an oral assessment had been completed since admission. Further review failed to indicate that Resident #71…

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 review, the facility failed to: 1. store food under sanitary conditions and 2. failed to prevent cross contamination evidenced by staff not performing hand hygiene before donning and doffing gloves. Findings include: A review of the facility policy titled 'Food Storage' with no revision date indicated the following: -Perishable food such as vegetables must be stored in the refrigerator immediately after receipt to assure nutritive value and quality. A review of the facility policy titled 'Hand hygiene' with no revision date indicated the following: -All staff shall use the hand hygiene techniques as set forth in the following procedure: (a) Before applying sterile gloves. (b)Always after removing gloves. 1. On 6/10/24 at 7:23 A.M., the surveyor observed two boxes of cabbages placed on top of the milk refrigerator. The cabbages appeared wilted, with yellow leaves, some of the cabbages appeared rotten, the leaves appeared decayed and slimy. The boxes had a receiving date of 5/29/24, there was no use by date on the boxes. On 6/11/24 at 11:23…

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 complete Comprehensive (Annual and Admission) Minimum Data Set (MDS) Assessments in a timely manner for 5 Residents (#65, #321, #2, #64, and #8) out of a total sample of 27 residents. Findings include: Review of the undated facility policy, titled Electronic Transmission of the MDS (Minimum Data Set), indicated the following: *MDS electronic submissions shall be conducted in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations governing the transmission of such data. Review of the Omnibus Budget Reconciliation Act (OBRA) regulations indicate that a comprehensive (Annual or Admission) Assessment should be completed within a year of the previous Comprehensive Assessment. 1. Resident #65 was admitted to the facility in March 2022 with diagnoses including hemiplegia. Review of Resident #65's Minimum Data Set (MDS) assessments indicated the following: An Annual Assessment with an Assessment Reference Date (ARD) of 3/17/23, was completed 4/6/2023, 20 days after the ARD and over a year after the admission…

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 complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 4 residents (#65, #20, #64, and #8) out of a total sample of 27 residents. Findings include: Review of the undated facility policy, titled Electronic Transmission of the MDS (Minimum Data Set), indicated the following: *MDS electronic submissions shall be conducted in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations governing the transmission of such data. Review of the Omnibus Budget Reconciliation Act (OBRA) regulations indicate that a Quarterly Assessment must be completed within 92 days of the previous Quarterly Assessment. 1. Resident #65 was admitted to the facility in March 2022 with diagnoses including hemiplegia. Review of Resident #65's Minimum Data Set (MDS) assessments indicated the following: A Quarterly Assessment with an Assessment Reference Date (ARD) of 9/22/22, was completed 12/1/22, 70 days after the ARD and 156 days after the previous Quarterly Assessment. 2. Resident #20 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review an interview the facility failed to implement the plan of care for three Residents (#7, #21 and #23), failed to develop a dental care plan for one Resident (#23), and failed to develop a comprehensive trauma informed care plan for 2 Residents (#9 and #52) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Care Plans- Comprehensive and dated as revised 12/7/21, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident. Further review indicated that assessments of residents are ongoing and care plans are revised as information about the resident's condition changes. 1. Resident #7 was admitted to the facility in October 2019 with diagnoses including dysphagia (difficulty swallowing), dementia and Schizoaffective disorder. Review of the care plan dated as revised 2/27/23, indicated…

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 schedule review and interview, the Facility failed to ensure a Registered Nurse (RN) provided services for 8 hours a day, 7 days a week at the facility, as required. Findings include: Review of the staffing schedule from 4/11/23 through 4/25/23 failed to indicate that a Registered Nurse (RN) was present in the facility for 4 of the 15 days reviewed. During an interview on 4/25/23 at 11:46 A.M., the Director of Nursing acknowledged that there was no Registered Nurse present on 4 of 15 days, when there should have been.

Based on observation and interview the facility failed to ensure 1. a dignified dining experience for one Resident (#57) and 2. a dignified existence for one Resident (#56) out of a total 27 sampled residents. Findings include: Review of the facility's policy titled Quality of Life Dignity, dated 3/21, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident #57 was admitted to the facility in July 2020 and had diagnoses that included fronototemporal neurocognitive disorder and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/2/23, indicated that he/she was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #57 was dependent on staff for eating. During an observation on 4/23/23 at 8:05 A.M., Resident #57 was observed in bed. There was a staff person sitting on the bed beside him/her, feeding Resident #57 breakfast. During an observation on 4/23/23 at 12:20 P.M., Resident #57 was observed in bed. There was a staff person…

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

Based on observation, interview, record review and policy review the facility failed to ensure one Resident (#57) was assessed for the use of a restraint out of a total 27 sampled residents. Findings include: Review of the facility policy titled Use of Restraints, dated March 2017, indicated the following: * Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. * Physical Restraints are defined as any manual methods or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove, which restricts freedom of movement or restricts normal access to ones body. * Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). * Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include…

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 accurately complete the Minimum Data Set (MDS) assessment for one Resident (#23) out of a total sample of 27 residents. Findings include: Resident #23 was admitted to the facility in April 2020 with diagnoses including traumatic brain injury, psychotic disorder with delusions and dementia. During an observation on 4/23/23 at 9:51 A.M., the surveyor observed Resident #23 to have carious and missing teeth. Review of the facility document titled Dental Group, dated 7/29/22, indicated that resident #23 has only 8 remaining teeth and those teeth require extraction secondary to decay. Review of the MDS dated [DATE], indicated that Resident #23 did not have any broken or carious teeth. During an interview on 4/24/23 at 12:00 P.M., the Assistant Director of Nursing (ADON) said that the MDS should accurately reflect the condition of the residents teeth.

Based on observation, record review and interview the facility failed to notify the physician of increasing carbon dioxide (CO2) levels in the blood (a potentially life threatening condition) for one Resident (#26) out of a total sample of 27 residents. Findings include: Resident #26 was admitted to the facility in February 2023 with diagnoses including chronic obstructive pulmonary disease, diabetes and heart disease. Review of the nurse's admission summary note dated 1/28/23, indicated that Resident #26 was admitted to the facility on oxygen (O2) at 1 liter/minute via nasal cannula. Review of the doctor's orders indicated an order dated 3/28/23, for O2 continuous to maintain a sat (a measure of O2 in the blood) greater than 90%. Review of the discontinued doctor's orders failed to indicate a discontinuation order for O2 on admission. Review of the facility document titled Laboratory: 2/15/2023 14:55 Basic Metabolic Panel/NT-ProBNP/Complete Blood Count (CBC) w/Auto Differential/PT/INR / CALL BACK RESULTS indicated that the CO2 (carbon dioxide level in the blood) was 38 mmol/L…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide assistance with Activities of Daily Living (ADL's) for one Resident (#21) out of a total sample of 27 residents. Findings include: Resident #21 was admitted to the facility in October 2022 with diagnoses including dementia, need for assistance with personal care and cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #21 requires an extensive assist with grooming. Further review indicated that Resident #21 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment, indicating Resident #21 is severely cognitively impaired. During an observation on 4/23/23 at 10:36 A.M., the surveyor observed Resident #21's upper lip, chin and cheeks to have significant amounts of long dark hair. During an interview on 4/23/23 at 8:05 A.M., Resident #21 said that he/she does not like facial hair and wants it removed. During an observation on 4/23/23 at 12:49 P.M., the surveyor observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff provided care consistent with professional standards, related to replacing, dating oxygen tubing for two Residents (#26 and #18) and failed to ensure staff cleaned and maintained a Bi-level Positive Airway Pressure (BiPAP) machine for 1 Resident (#36). Findings include: 1. Resident #26 was admitted to the facility in February 2023 with diagnoses including chronic obstructive pulmonary disease, diabetes and heart disease. During an observation on 4/23/23 at 7:51 A.M., the surveyor observed Resident #26 receiving oxygen at 2 liters/minute via nasal cannula. The oxygen tubing was labeled and dated 3/19/23. Review of the doctor's orders failed to indicate an order to change the oxygen tubing. Review of the care plan, dated 3/6/23, indicated to change oxygen tubing per policy. Review of the policy titled Oxygen administration and dated revised 3/2021, failed to indicate how often oxygen tubing is to be changed. During an interview…

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, record reviews and interviews, the facility failed to provide dental services to one Resident (#23) out of a total sample of 27 residents. Findings include: Resident #23 was admitted to the facility in April 2020 with diagnoses including traumatic brain injury and dementia. During an observation on 4/23/23 at 9:51 A.M., the surveyor observed Resident #23 to have carious and missing teeth. During an interview on on 4/23/23 at 9:51 A.M., Resident #23 said that his/her teeth need to come out. Review of the dentist note dated 7/29/22, indicated that Resident #23 has multiple missing, broken and carious teeth. Review of the dentist note dated 2/13/23, indicated that Resident #23 has rampant tooth decay and needed to have all of teeth extracted and a set of full dentures fabricated. Review of the nurse's note dated 2/13/23, indicated that Resident #23 was seen that day by the dentist. Further review indicated that the dentist reported that Resident #23's teeth require extraction and would have to have procedure out of facility, but would fit him/her for dentures, 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.