Waterview Lodge Llc, Rehabilitation & Healthcare

Based on interview, and record review, the facility failed to ensure pharmacy recommendations from medication regimen reviews (MRR) were reviewed and addressed timely for two Residents (#8 and #42) out of a total sample of 21 residents. Specifically:1. For Resident #8, the facility failed to ensure that the Pharmacist's recommendation to evaluate the use of Flonase (corticosteroid nasal spray) was addressed in a timely manner by the Physician.2. For Resident #42, the facility failed to ensure that the Pharmacist recommendation for an Abnormal Involuntary Movement Scale (AIMS) assessment (rating scale used to measure involuntary movements of the face, mouth, trunk, or limbs known as tardive dyskinesia (TD) in a resident taking antipsychotic medications) was addressed timely by the Physician. Findings include:Review of the facility policy titled Pharmacy Recommendations and Medication Order Changes Policy, undated, indicated the following: -all medication recommendations and order changes must be reviewed, clarified as soon as possible, documented accurately, and implemented promptly…

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

Based on observation, and interview, the facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal requirements on two nursing units (Unit Four and Unit Three) out of three total nursing units, and that expired medications were removed from use in a shared medication storage room for three (Unit Two, Unit Three and Unit Four) out of three medication storage rooms observed. Specifically, the facility failed to:1. ensure that medication carts on Unit Four and Unit Three were locked when the medication carts were unattended, to prevent unauthorized personnel and residents access to medications on and in the medication carts.2. ensure for Unit Two, Unit Three, and Unit Four medication storage rooms, that expired over-the-counter medications were removed from the medication storage cabinet to mitigate potential administration to the facility residents. Findings include: Review of the facility policy titled Policy and Procedure for Medications Storage, dated 6/23/18, included but was not limited to:*All drugs and biologicals will be stored 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 observations, interviews, and record review, the facility failed to maintain an accurate medical record for one Resident (#69) out of a total sample of 21 residents, relative to Resident behaviors for refusal of care, increasing the Resident's risk for ineffective behavior monitoring, behavior assessment, and the implementation of interventions to address the Resident's behavioral needs.Specifically, facility staff failed to document instances of Resident #69's refusal of care when:-Facility staff identified Resident #69 had frequent refusal of care.-The surveyor observed Resident #69 refuse care from facility staff when care was offered to the Resident. Findings include:Resident #69 was admitted to the facility in April 2011 with diagnoses including Dementia, Depression, and Schizophrenia. Review of Resident #69's Behavior Nursing Note, dated 10/15/25, indicated:- .resistive to care-gets angry when staff approach for hygiene and care- . anger is exhibited by screaming loudly at staff- . no effect on verbal redirection- . sometimes responds to reapproach. Review of 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 interview, record review, and observation, the facility failed to offer each Resident a nourishing snack at bedtime when more than 14 hours elapsed between the substantial evening meal and breakfast the following day. Specifically, the facility failed to offer each Resident items from the basic food groups, either singly or in combination with each other, at bedtime when 15 hours elapsed daily between the scheduled substantial evening meal and breakfast the following day. Findings include: Review of the United States Department of Agriculture (USDA) guidelines titled Food Group Gallery, based on the Dietary Guidelines for Americans 2020-2025 and accessed on 10/29/24 at https://www.myplate.gov/eat-healthy/food-group-gallery indicated the following: - There are five basic food groups (fruits, vegetables, grains, protein foods, and dairy). -The fruit group includes berries, 100% fruit juice, melons, and other whole fruits. -The vegetable group includes dark green vegetables, red and orange vegetables, beans, peas, lentils, starchy vegetables, and other vegetables. -The grains…

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 offer COVID-19 vaccines, in accordance with national standards of practice to five Residents (#31, #8, #55, #68, and #64) of five applicable residents reviewed, out of a total sample of 18 residents. Specifically, the facility failed to offer COVID-19 vaccines to the eligible residents when: -The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended an additional dose of updated (2023-2024 formula) of COVID-19 vaccine be administered for older adults,aged [AGE] years and older. -The COVID-19 vaccine was not medically contraindicated and Resident's #31, #8, #55, #68, and #64 had not already been immunized with the recommended additional COVID-19 vaccine dose. Findings include: Review of the CDC ACIP guidelines titled Use of an Additional Updated 2023/2024 COVID-19 Vaccine Dose for Adults Aged 65 Years: Recommendations of the Advisory Committee on Immunization Practices - United States, 2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that Minimum Data Set (MDS) Assessments were coded accurately for four Residents (#74, #9, #49, and #71) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #74, ensure the most recent MDS was coded accurately relative to a fall event. 2. For Resident #9, ensure the most recent MDS was coded accurately relative to the use of a restraint. 3. For Resident #49, ensure the MDS assessment was coded accurately relative to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD: a chronic lung disease that causes obstructed airflow from the lungs that leads to respiratory problems including difficulty breathing, shortness of breath and wheezing) and Oxygen use. 4. For Resident #71, ensure the MDS assessment was coded accurately relative to Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) services. Findings 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 observation, interview, record review and policy review, the facility failed to adhere to professional standards of practice to ensure that significant medication errors did not occur for four Residents (#33, #81, #21, and #22) out of four applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to ensure that an appropriate process was in place for identifying Residents during the medication pass procedure for Resident's #33, #81, #21, and #22. Findings include: Review of the facility's policy titled Preparation and Guidelines, revised 12/2019, indicated: -Identify resident using two identification methods before administering medication (example: photo plus verbal confirmation of last name, photo and confirmation by family member). [NAME] M., The Five Rights: A Destination Without a Map. P T. 2010 Oct; 35(10):542. PMCID: PMC2957754. Retrieved from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean, safe, comfortable, and homelike environment for one Resident (#23) out of a total sample of 18 residents. Specifically, the facility failed to ensure that Resident #23's wheelchair was maintained in a clean, safe, and homelike condition when the Resident's wheelchair was observed to have a damaged left armrest. Findings include: Resident #23 was admitted to the facility in July 2020, with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Osteoarthritis (a degenerative joint disease caused by an inflammatory reaction in bone and joint tissue, that worsens over time, often resulting in swelling, stiffness, chronic pain and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, and interview, the facility failed to investigate an incident of physical aggression for two Residents (#49 and #54) out of a total sample of 18 residents. Specifically, the facility failed to appropriately investigate a resident-to-resident altercation involving Resident #49 and Resident #54 and/or assess any potential impact resulting for both Residents. Findings include: Review of the facility's policy titled Resident Abuse, undated, indicated: -Residents of the facility will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants volunteer staff and other individuals. -Under the Administrator's direction, the facility will thoroughly investigate any alleged violation involving mistreatment, about or neglect, according to state law. -Immediately investigate the alleged incident during the shift on which the alleged abuse occurred. -Interview the resident and other resident witnesses. Conduct at least three 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, interview, and record review, the facility failed to ensure a comprehensive care plan was initiated for the care and services of three Residents (#72, #64 and #74), out of a total sample of 18 Residents. Specifically, the facility failed to: 1. For Resident #72, develop a comprehensive care plan addressing the care and services needed relative to the Resident's cognitive loss and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). 2. For Resident #64, develop comprehensive care plans when the Minimum Data Set (MDS) Assessment triggered for cognitive loss for the Resident. 3. For Resident #74, assess and revise the Resident's Care Plan to include measurable goals for falls prevention after the Resident sustained a fall with injury. Findings include: Review of the facility policy titled Comprehensive Care Plan, revised 5/1/24, indicated the following: -The Interdisciplinary Team will continue to develop the 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 observation, interview, and record review, the facility failed to provide care and services according to professional standards of practice relative to indwelling suprapubic catheter (Foley/a flexible tube placed through a surgical incision through the abdominal wall into the bladder to drain urine) for one Resident (#30) out of a total sample of 18 residents. Specifically, the facility failed to ensure that the correct size suprapubic urinary catheter had been placed for Resident #30 as ordered, placing the Resident at increased risk for bladder irritation, infection and pain. Findings include: Resident #30 was admitted to the facility in February 2011, with diagnoses including paraplegia (complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord) and Neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly. Depending on the type of neurological disorder causing the problem, the bladder may empty spontaneously…

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, policy and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#49), out of a total sample of 18 residents. Specifically, for Resident #49, the facility failed to notify the Physician and administer Oxygen as ordered when the Oxygen liter flow rate (the rate of supplemental Oxygen delivered through an oxygen delivery device) being set for the Resident was not as ordered by the Physician. Findings include: Review of the facility's policy titled Respiratory Medicaid Coverage Communication Sheet, revised July 2001, indicated: -Once it has been determined that a resident require oxygen support secondary to an acute or chronic respiratory of cardiac condition, the PCP should be notified by licensed personnel. Review of the facility's policy titled Change in a Resident's condition or Status, undated, indicated: -Nursing services will notify the Resident's Attending Physician when there is 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 observation, interview, and record review, the facility failed to ensure that medications were stored in a secure and safe manner, according to professional standards of practice for one Resident (#30), out of a total sample of 18 residents. Specifically, the facility failed to adhere to safe medication storage practices when wound care medications were left in an unlocked drawer in Resident #30's room. Findings include: Resident #30 was admitted to the facility in February 2011, with diagnoses including Paraplegia (chronic condition that involves the partial or complete loss of muscle function and feeling in the lower half of the body, including both legs) and a pressure ulcer of the sacrum (sacrum: a triangular bone in the lower back). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #30 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a total possible score of 15. Review of the facility policy titled Policy and…

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

Based on observation, interview, and policy review, the facility failed to maintain a clean and sanitary environment in the facility main kitchen where food items were prepared and stored for resident consumption. Specifically, the facility failed to ensure all staff wore hair restraints while in the facility kitchen and in the vicinity of food preparation areas to prevent contamination and the spread of infections. Findings include: Review of the facility policy titled Dietary Services, undated, indicated the following: -Hairnets, covering all hair, will be worn by all dietary employees at all times. -Any hair length over collar length must wear a hair net. On 10/23/24 at 12:04 P.M., the surveyor observed Additional Staff #2 in the facility kitchen near the stove speaking with a dietary staff member. The surveyor observed several pots containing food covered with clear plastic wrap on the stove. The surveyor also observed that Additional Staff #2 did not have a hair restraint in place. Additional staff #2 said that she had come into the kitchen for just a moment, without a hair…

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 adhere to infection prevention and control program standards for two Residents (#292, and #287) out of a total sample of 18 residents, to help prevent the development and transmission of infections. Specifically, the facility failed to: 1. Implement Contact Precautions for Resident #292, when the Resident was re-admitted to the facility with Methicillin-Resistant Staphylococcus Epidermidis (MRSE: form of Methicillin-Resistant Staphylococcus Aureus [MRSA: type of bacteria that is contagious, resistant to several antibiotics, and if left untreated, can cause sepsis or death] drug-resistant form of staph bacteria that may be difficult to treat due to their resistance to methicillin and other common antibiotics) which increased the risk for transmission of MRSE infection in the facility. 2. Ensure Resident #287's indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) tubing was positioned…

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, record and policy reviews, the facility failed to implement an infection prevention and control program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to develop policies and procedures and implement a water a management program to minimize the risk of Legionella and other opportunistic waterborne pathogens. Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) QSO-17-30 memo titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionaire's Disease (LD), last revised 7/6/18 indicated the following: -Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. >Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. >Outbreaks…

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, documentation review and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for all residents on one unit and failed to provide one Resident (#45) out of a total sample of 18 residents, an activity program that engaged the Resident and supported their physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. To provide resident-centered, meaningful, and engaging activities to residents on the fourth floor. 2. To ensure facility sponsored group activities were offered to support the psychosocial well-being of the residents, including Resident #45. Findings include: 1. Review of the Activity Calendar, dated August 2023, indicated that there were no activities scheduled after 3:30 P.M., for the entire month of August. On 8/8/23 the activity calendar included the following: 9:30 A.M., rise and shine visits 10:00 A.M., coffee social 11:00 A.M., fitness fun 12:00 P.M., helping hands 12:30 P.M., soda club 1:30…

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

Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#68, #27, and #86) out of a total sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended 20-Valent Pneumococcal Conjugate Vaccine (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings Include: Review of the facility policy titled Pneumococcal Vaccine, revised 2/13/23, indicated the following: -The facility will incorporate guidelines and standards as recommended by the Centers for Disease Control for Pneumococcal Vaccinations. -Offer Vaccine to residents who are eligible to receive it, unless they decline. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated the following: -For adults 65 and over who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that its staff honored the rights of one Resident (#40) to formulate advanced directives (an individual's wishes regarding medical treatment), out of a total sample of 18 residents. Specifically, the facility staff executed a Medical Order for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form with the Resident's Representative when the Resident continued to be capable of making their own health care decisions. Findings include: Review of the Massachusetts Health Care Proxy (HCP) form, revised 1/2015, indicated that the appointed Health Care Agent's (Proxy's) authority becomes effective if my (the) attending Physician determines in writing that I (the Resident) lacks the capacity to make or to communicate health care decisions. Resident #40 was admitted to the facility in January 2020 with diagnoses including anxiety, major Depression, and…

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

Based on record review and interview, the facility failed to implement the plan of care for one Resident (#86) out of a total sample of 18 residents. Specifically, the facility failed to ensure that its staff implemented a comprehensive plan of care relative to routine behavior monitoring for Resident #86. Findings include: Review of the facility's Behavior/Side Effect Monitoring policy, dated September 2005, indicated the following: -Antipsychotic Monitoring: If the resident is being treated for Organic Mental Syndromes (including dementia and delirium with associated psychotic and/or agitated behaviors), it will be necessary to monitor each behavior that is being controlled by the medication. The behavior monitoring is required each shift and is achieved by documenting the number of episodes that each behavioral episodes are noted, a notation of such must be documented. Resident #86 was admitted to the facility in June 2023 with a diagnosis of Dementia with agitation and psychosis. Review of a Physician's order dated 6/23/23, indicated: Seroquel (antipsychotic medication) 12.5…

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 policy review, record review and interview, the facility failed to provide care and treatment in accordance with professional standards of practice for two Residents (#4 and #33) out of a total sample of 18 residents. Specifically, 1. For Resident #4, the facility staff failed to ensure that its staff scheduled a Gastroenterologist (GI) appointment as ordered, for evaluation and management. 2. For Resident #33, the facility failed to monitor regular bowel patterns and implement a bowel regimen (a plan to prevent or treat constipation by following certain habits and using medications if needed) based on those patterns. Findings include: 1. Resident #4 was admitted to the facility in August 2015 with the following diagnoses: Gastroesophageal Reflux Disease (GERD- when stomach acid or bile flows into the food pipe[esophagus] and irritates it), and hematemesis (vomiting blood from your upper digestive tract). Review of hospital Discharge summary dated [DATE], indicated the following: -please call to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide an adequate level of assistance to prevent an accident for one Resident (#21) out of a total sample of 18 residents. Specifically, the facility staff failed to ensure that Resident #21's breakfast meal was reheated in a safe manner and the food temperature was checked before providing the meal to the Resident. Findings include: Resident #21 was admitted to the facility in July 2020 with a diagnosis of Dementia (a general term for loss of memory, language, problem solving and other thinking abilities). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #21 was severely impaired cognitively, as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of a total possible score of 15. Review of the facility's Dietary Policy, undated, indicated the following: -Staff will monitor proper temperature by using a thermometer to ensure that the food is at a safe temperature (not too hot)…

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 individualized care plan interventions to meet the behavioral health needs of one Resident (#45) out of a total sample of 18 residents. Specifically, for Resident #45 the facility staff failed to implement non-pharmacological interventions and provide care plan interventions when the resident was having increased behavioral needs. Findings include: Resident #45 was admitted to the facility in March of 2012 with the following diagnoses: Chronic Paranoid Schizophrenia (severe mental health condition that can involve delusions and paranoia), Dementia, and Psychosis with Hallucinations (is the experience of sensing something that isn't really present in the environment). Review of Resident #45's Behavior/Mood Care Plan, revised on 4/11/23, indicated the following interventions: -Encourage activities that will decrease boredom and provide structure -Respond to verbal expression of sadness calmly- provide support, distract, and involve resident in benign activities of interest -Staff will monitor unsafe…

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 monitor for side effects and adverse reactions of a medication for one Resident (#27), out of a total sample of 18 Residents. Specifically, the facility staff failed to monitor for side effects and adverse events related to the use of an anti-platelet medication (used to thin blood to prevent a stroke or heart attack). Findings include: Resident #27 was admitted to the facility in January 2021 with diagnoses including chronic bilateral lower extremity wounds, and Peripheral Vascular Disease (PVD: a circulatory condition in which narrowed blood vessels reduce blood flow in the limbs). During an interview on 8/8/23 at 8:33 A.M., Resident #27 said he/she took a blood thinner every day. Resident #27 said he/she had some issues with his/her skin. Resident #27 said his/her eyesight was bad and he/she could not see what his/her skin looked like. Review of a Physician's order dated 4/7/23, indicated: Plavix (anti-platelet medication), 75 milligrams (mg) once daily by mouth. Review of the Nursing 2022 Drug Handbook…

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 documentation review and interview, the facility failed to maintain appropriate standards for safe and sanitary food storage, and sanitary hand hygiene during meal service. Findings include: Review of the facility's Food Storage policy, undated, indicated the following: -Intent: Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. -Safe food handling for the prevention of food borne illnesses begins when the food is received from the vendor and continues throughout the facility's food handling process. Review of the facility's Dietary Policy, undated, indicated the following: -Sanitary conditions shall be maintained in the storage, preparation, and distribution of food at all times. -Safe and sanitary microwave oven and food thermometer will be available where food might be heated or reheated. -Staff will monitor proper temperature by using a thermometer to ensure that the food is at a safe temperature (not too hot) prior to serving it to the residents.…

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