Belmont Manor Nursing Home, In

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide a dignified existence for two Residents (#222 and #23) out of a total sample of 24 residents, and for residents on three of four units. Specifically: 1.) For Resident #222, the facility failed to maintain his/her urinary catheter bag in a privacy bag; 2.) For Resident #23, the facility failed to provide a dignified dining experience; and 3.) The facility failed to provide a dignified dining experience on Station 2 unit for residents dependent on staff for eating. 4.) The facility failed to ensure a dignified dining experience on Station 4 unit, when staff was observed using their cell phone during the lunch meal while assisting residents during the meal. Findings include: The facility policy titled 'Dignity', dated as revised 3/28/19, indicated it is the policy of [NAME] Manor Nursing Center to provide care in a dignified manner and to promote a lifestyle that is dignified and respectful to the resident. The facility policy titled…

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 staff developed and implemented a baseline care plan for four Residents (#103, #41, #25, and #69), out of a total sample of 24 residents. Specifically, the facility failed to develop a baseline care plan within 48 hours of the Resident's admissions, which included the instructions needed to provide effective and person-centered care to the Residents with Dementia which meet professional standards of quality care. Findings include: Review of the facility policy titled 'Baseline Care Plans', dated revised November 2017, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. 1.) Resident #103 was admitted to the facility in January 2024 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #103 had severe cognitive impairment as…

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

Based on interview and record review the facility failed to ensure that residents' individualized dementia care needs are met through the assessment, development, and implementation of care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative for five Residents (#21, #103, #41, #25, and #69), out of a total sample of 24 residents. Specifically, for Residents #21, #103, #41, #25, and #69, the facility failed to develop an interdisciplinary dementia care plan to ensure the Resident received appropriate treatment and services specific to his/her needs for dementia care. Findings include: 483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Review of the document titled 'Dementia Special Care Unit (DSCU) Disclosure Form' indicated on 2/28/2024 the facility disclosed they meet the specific state licensure requirements to provide specialized care 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 observation, record review and interview the facility failed to accurately document in the medical record for four Residents (#77, #57, #53, and #32) out of a total sample of 24 residents. 1.) For Resident #77 and #57, the facility documented padded side rails were in place when the Residents were in bed, when they were not. 2.) For Resident #53, the facility documented that the Resident's oxygen tubing was changed when it was not. 3.) For Resident #32, the facility documented that a palmar guard (a device for contracture management) had been applied when it was not. Findings include: Review of the undated facility policy titled 'Documentation', dated January 2008, indicated the following: - Documentation should be an accurate written account of the resident's current condition, response to events and to medication, care and treatment. - Documentation should be accurate, current, brief, concise and legible. 1a.) Resident #77 was admitted to the facility in April 2022 and had diagnoses that include Alzheimer's dementia and weakness. Review of the most recent Minimum Data Set…

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

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#118) did not self-administer medications out of a total sample of 24 residents. Specifically, Resident #118 was observed with pills left at bedside for self-administration after he/she was assessed to not be able to self-administer medications. Findings include: Review of the facility policy titled 'Medication Administration - Self-Administration by Resident', dated 11/17, indicated: - If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. - The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Review of the facility policy titled 'Medication Administration - General Guidelines', dated 9/18, indicated: - Medications are to be administered at the time they are prepared. - The person who prepares the dose for administration is…

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 investigate bruises of unknown etiology for one Resident (#4) out of a total sample of 24 residents. Findings include: Review of the facility policy titled 'Incident and Accident Investigating and Reporting', dated as revised 5/22/19, indicated that for a bruise of unknown origin, the facility should obtain caregiver statements from the proceeding 24 hours. Resident #4 was admitted to the facility in December 2016 with diagnoses including Alzheimer's dementia, kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #4 is severely cognitively impaired, rarely/never understood and requires maximum assistance with activities of daily living. On 12/3/24 at 9:28 A.M., the surveyor observed Resident #4. The Resident had dark purple areas, consistent with bruises, on both the right and left hands, in between the forefingers and thumbs and covering the dorsal aspect of each hand. Review of the medical record failed to indicate that Resident #4…

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 report bruises of unknown origin to the state agency as required for one Resident (#4) out of a total of 24 sampled residents. Findings include: Review of the facility policy titled 'Incident and Accident Investigating and Reporting', dated as revised 5/22/19, failed to indicate that injuries of unknown origin are to be reported to the state agency within the required two hour time frame. Resident #4 was admitted to the facility in December 2016 with diagnoses including Alzheimer's dementia, kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #4 is severely cognitively impaired, is rarely/never understood and requires maximum assistance with activities of daily living. On 12/3/24 at 9:28 A.M., the surveyor observed Resident #4. The Resident had dark purple areas, consistent with bruises, on both the right and left hands, in between the forefingers and thumbs and covering the dorsal aspect of each hand. Review of the medical record failed 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 record review and interview, the facility failed to ensure person-centered care plans with measurable goals and individualized interventions were developed and implemented for one Resident (#103), out of 24 sampled residents. Specifically, for Resident #103, the facility failed to develop a plan of care related to activities of daily living (ADL's) and the use of psychotropic medication. Findings include: Review of Facility policy titled 'Care Plans Comprehensive, Resident', dated March 2010, comprehensive care plans are developed by the members of the Interdisciplinary Team (IDT)/healthcare proxy/resident and the comprehensive assessment form (MDS), ancillary assessments, MD orders/progress notes, hospital documentation and resident/family/other interviews are used to develop the individual comprehensive care plan(s) for the resident. According to the Resident Assessment Instrument (RAI), which is a comprehensive assessment tool used in Long-Term Care to identify resident's needs, preferences, 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, record review, and interviews, the facility failed to ensure for one Resident (#32), out of a total sample of 24 residents, that the interdisciplinary team reviewed and revised the plan of care after the quarterly review assessment. Specifically, for Resident #32, the facility failed to review and resolve a care plan for a stage 3 left heel pressure ulcer. Findings include: Resident #32 was admitted to the facility in October 2020 and had diagnoses that include type 2 diabetes mellitus and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated Resident #32 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition, displays physical and other behaviors, and does not display behaviors of rejecting care. Further the MDS indicated that Resident #32 did not have any unhealed pressure ulcers/injuries. Review of the physician's orders did not indicate a treatment order for a pressure…

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 an intervention for contracture management was implemented in accordance with the medical plan of care for one Resident (#32), out of a total of 24 residents. Findings include: Review of the facility's policy titled 'Positioning Devices', not dated, indicated: It is the policy of the facility to attain and maintain good body alignment. The addition of positioning devices to attain and maintain good body alignment will be based on the rehab department recommendation and approved by the MD/NP (medical doctor/nurse practitioner). Examples of positioning devices could include but are not limited to: - Hand roll or hand grips - Splints Procedure: 1. Rehab screen, 2. Implementation of appropriate positioning device is recommended to MD/NP, 3. Education provided for staff, 4. Monitoring of device for appropriate applications and resident acceptance. Resident #32 was admitted to the facility in October 2020 and had diagnoses that 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.

Based on observation, record review and interview the facility failed to implement physician ordered interventions to prevent accidents for two Residents (#77 and #57) out of a total sample of 24 residents. Specifically, for Resident #77 and Resident #57, the facility failed to ensure padded side rails were in place when the residents were in bed. Findings include: 1.) Resident #77 was admitted to the facility in April 2022 and has diagnoses that include Alzheimer's dementia and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/27/24, indicated that on the Brief Interview for Mental Status exam Resident #77 scored a 5 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #77 had no behaviors. Review of the current physician's orders indicated an order for padded side rails when in bed due to agitation, with a start date of 1/30/24. Review of the record failed to indicate Resident #77 refused the padded side rails or removed the padded side rails. On 12/3/24 at 8:23 A.M., Resident #77 was observed in bed asleep.…

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 maintain acceptable parameters of nutrition status for one Resident (#25) out of a total sample of 24 residents. Specifically, the facility failed to provide interventions to prevent significant weight loss in a timely manner for Resident #25. Findings include: Review of the facility policy titled 'Weight Policy', revised March 2017, indicated: - To provide adequate nutrition and hydration to the residents and prevent weight loss whenever possible. To accomplish this each resident is assessed and monitored to determine if he/she is at risk. For each resident determined to be at risk, treatment and/or preventative measures are instituted. - A Nutrition Alert is to be initiated if a resident has had a 5% weight loss in one month or a 2.5% weight loss in one week and if this occurs, nursing will notify the physician and dietitian. - Weights will be reviewed in a weekly weight meeting that is attended by but limited to Director of Nursing, Registered Dietitian, and Clinical Nurse Manager or charge nurse. - During the weight…

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 respiratory care services in accordance with professional standards of practice for two Residents (#223 and #53) out of a total sample of 24 Residents. Specifically: 1.) For Resident #223 and Resident #53, the facility failed to ensure the oxygen filters were clean and that there was a process was in place for the cleaning/maintenance of the concentrators; and 2.) For Resident #53, the facility failed to ensure the oxygen tubing changed as ordered. Findings include: Review of the facility policy titled 'Oxygen Administration', undated, failed to indicate when to change/clean the oxygen concentrator filters. Further review failed to indicate how often to change oxygen tubing. 1.) Resident #223 was admitted to the facility in September 2024 with diagnoses including pneumonia, chronic obstructive pulmonary disease and dependence on supplemental oxygen. On 12/3/24 at 10:28 A.M., the surveyor observed Resident #223 lying in bed, receiving oxygen at 2 liters per minute (lpm) via nasal cannula. The surveyor…

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 staff interviews, the facility failed to follow infection control standards of practice for the cleaning of shared resident equipment. Findings include: Review of the facility policy titled 'Cleaning/Disinfection of Resident Care Equipment', dated 6/2019, indicated supplies and equipment will be cleaned immediately after use and/or when indicated. Specifically, For cleaning of resident equipment-vital sign machine. - Clean the machine with disinfectant wipe after each use on resident. On 12/4/24 at 9:29 A.M., the surveyor observed Nurse #2 enter the room of a resident on enhanced barrier precautions (EBP) and utilized the portable vital sign caddy (a device that measures vital signs including blood pressure, pulse, temperature, and oxygen saturation) to measure vital signs of the resident thus contaminating the caddy. The surveyor then observed Nurse #2 enter a different room of a resident that was also on EBP without disinfecting the contaminated caddy to measure a different resident's vital signs. During an interview on 12/4/24 at 9:29 A.M., Nurse #2 said…

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 policy review, the facility failed to ensure resident Protected Health Information (PHI) was secure on 3 of 4 units. Specifically, nurses on Station 1, Station 2 and Station 3 failed to ensure PHI on the medication administration computers was not visible and accessible on the nursing units. Findings include: Review of the facility policy titled Medication Administration General Guidelines, dated 12/12, indicated Resident's health information needs to remain private. The pages of the medication administration record must remain closed or covered when not in direct use. Review of the facility policy titled Notice of Privacy Practices, dated 8/17/09, indicated We are required to maintain the privacy of your protected health information. On 12/27/23 at 7:50 A.M., the surveyor observed unattended medication carts with the medication administration computer screens open on top of the carts on Station 1 in the hallway. The screens were open to a Resident screen that included the Residents picture, names and medications listed. No nurse was present at…

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

Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure hairnets were worn in the food preparation area, food was labeled, and staff food was not stored with resident food and ingredients. Findings include: Review of the undated facility policy titled Dining Services Food Preparation and Service indicated, but is not limited to, the following: - Food service employees shall prepare and serve food in a manner that complies with safe food handling practices outlined in accordance with the Food Code. -All foods are labeled with a name of product and the date received and use by date once opened. -Prepared foods are labeled and dated with name of product, date opened, and use by date. Review of the Massachusetts food code indicated the following: -FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their 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 ensure one Resident (#46), who was deemed incapable of self-administering medication, did not self-administer torsemide (a diuretic medication), out of a total sample of 25 residents. Findings Include: Review of the facility policy, titled Section 7.1, Medication Administration, dated 2007, indicated, but is not limited to, the following: -Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dinning room unless specifically ordered with meal. -Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide assistance with meals as needed for two Residents (#84 & #40) out of a total of 25 sampled residents. Findings include: Review of the facility policy titled Activity of Daily Living (ADL), dated 4/28/09, indicated It is the policy of the facility to provide ADL care to the residents in a respectful and dignified manner. ADL include but not limited to: bathing, grooming, dressing, elimination and eating. 1. Resident #84 was admitted to the facility in July 2022 with diagnoses including major depressive disorder, severe protein-calorie malnutrition, and abnormal weight loss. Review of Resident #84's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 9 out of a possible score of 15 indicating the Resident had moderate cognitive impairment. The MDS further indicated he/she was dependent on staff for eating. On 12/27/23 at 8:54 A.M., Resident #84 was observed in bed with their breakfast tray, not initiating self…

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 implement a physician's order for the use of an air mattress for one Resident (#88) out of a total sample of 25 residents. Specifically, the facility failed to provide the air pump to the air mattress resulting in no air entering the mattress. Findings include: Review of the facility policy titled Air Mattresses, dated and revised 1/28/19, indicated the following: *Policy: Air Mattress are checked for proper placement, function and firmness control every shift. Checking for placement, function and firmness control will be indicated on the plan of care and documented every shift. Nursing should adjust the firmness control on the air mattress as needed. Maintenance department should be notified if the air mattress is not functioning properly. Resident #88 was admitted to the facility in March 2022 with diagnoses including Parkinson's Disease, heart failure and muscle weakness. Review of Resident #88's most recent Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#108), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 25 sampled residents. Findings include: Resident #108 was admitted to the facility in November 2022 with diagnoses including PTSD and secondary malignant neoplasm of bone (bone cancer). Review of Resident #108's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that that the Resident had a Brief Interview for Mental Status score of 9 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS along with the admission MDS indicated that Resident #108 has a diagnosis of PTSD. Review of Resident #108's care plan for alteration in mood and/or behavior dated 10/6/23 indicated the following problem: *I require psychotropic meds (medication) d/t (due to) my dx (disease) of: PTSD. Review of the care plan failed 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.

Based on observation, interview, and policy review, the facility failed to 1. properly label medication in accordance with currently accepted professional principles in one of four medication carts observed, and 2. failed to ensure medications were stored in locked compartments with access limited to only authorized users, in two of the four facility stations observed. Findings include: Review of the facility policy titled, Section 4.1, Medication Storage, Storage of Medication, dated September 2010, indicated but was not limited to the following: - The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. - In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Review of 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.

Based on observations, record review, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to ensure nursing and housekeeping staff performed hand hygiene appropriately on Station 1, which had multiple residents with Respiratory Syncytial Virus (RSV) and are on isolation precautions. Findings include: Review of the facility policy titled Infection Control, reviewed date 9/20/23, indicated The single most important principle of infection control for all employees is handwashing. Remember you must wash your hands before and after every contact with a resident or any vehicle that could carry bacteria. 1. On 12/27/23 at 8:45 A.M., the surveyor observed a nurse and Certified Nurse Aide (CNA) on Station 1 enter a resident room with a posted sign for isolation precautions and then observed both staff members exit the resident room without performing hand hygiene. The surveyor then observed the same CNA enter an enhanced barrier precaution room with out…

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.