Blueberry Hill Rehabilitation And Healthcare Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement personalized care plans for four Residents (#91, #106, #117, and #323), out of a total sample of 39 residents. Specifically: 1. For Resident #91, the facility failed to develop a care plan for suicide ideation, 2. For Resident #106, the facility failed to develop a skin at risk care plan, 3. For Resident #117, the facility failed to implement a care plan for a pacemaker. 4. For Resident #323, the facility failed to implement a plan of care for skin checks. Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered, dated 2001, indicated the following: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive…

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 meet professional standards of practice for 12 Residents (#40, #47, #41, #92, #108, #4, #55, #12, #19, #106, #2 and #75) out of a total of 39 sampled residents. Specifically: 1. For Resident #40, the facility failed to a.) obtain a physicians order for the treatment of a skin tear and b.) failed to complete weekly skin checks as ordered. 2. For Resident #47, the facility failed to complete weekly skin checks as ordered. 3. For Resident #41, the facility failed to complete weekly skin checks as ordered. 4. For Resident #92, the facility failed to complete weekly skin checks as ordered. 5. For Resident #108, the facility failed to complete weekly skin checks as ordered. 6. For Resident #4, the facility failed to to complete weekly skin checks as ordered. 7. For Resident #55, the facility failed to a.) to complete weekly skin checks as ordered and b.) obtain weights as ordered. 8. For Resident #12, the facility failed to obtain weights 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide a person-centered activity program for four Residents (#25, #103, #87, and #28) out of a total sample of 39 residents. Finding include: 1. Resident #25 was admitted in June 2023 with diagnoses including bipolar disorder and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #25 scored a 12 out of a possible 15 on the Brief Interview of Mental Status (BIMS), indicating moderate cognitive impairment. Review of the MDS indicated that Resident #25 scored a 10 out of a possible 27 points on the Patient Health Questionnaire (PH-Q9), indicating moderate depression. During observations throughout survey, Resident #25 did not get out of bed and was in his/her room in bed. Resident #25 did not have any entertainment materials provided, outside of the television, which was on one time during observation. Review of Resident #25's care plan indicated the following: Focus: I am independent 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 observation, record review and interviews, the facility failed to ensure sufficient staffing to assure that residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for Fiscal Year Quarter 3 2024 (April 1 - June 30) Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D Fiscal Year Quarter 3 2024 (April 1 - June 30), indicated the following: - This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). - Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low. Review of the facility's 'Facility Assessment Tool' dated as reviewed 7/24/24, indicated the following: The following grid represents a typical staffing pattern based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors,…

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 ensure recommendations from behavioral health services were relayed to the physician and implemented for two Residents (#91, #4) out of a total sample of 39 residents. Findings include: Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, dated 2001, indicated the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 1. Resident #91 was admitted to the facility in May 2023 with diagnoses including bipolar disorder, major depression, anxiety, and suicidal ideations. Review of Resident #91's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she had a Brief Interview for Mental Status score of 12 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide dental services for four Residents (#28, #103, #18 and #111), out of a total sample of 39 residents. Specifically, 1. For Resident #111, the facility failed to follow-up with a recommendation from the dentist to have teeth extracted. 2. For Resident #18, the facility failed to make a dental appointment to ensure his/her dentures fit appropriately, 3. For Resident #28, the facility failed to have the Resident seen by the contracted dentist for over two years after the consulting dentist made the recommendation for new dentures, and 4. For Resident #103, the facility failed to have the Resident seen by the dentist since admit to the facility, Findings include: Review of the facility policy titled, Dental Services, undated, indicated the following: - Routine and emergency dental services are available to meet the resident's of oral health services in accordance with the resident's assessment and plan of care. - Social services or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and test trays, the facility failed to provide food at a safe and palatable temperature for 2 out of 3 test trays. Findings include: According to the current U.S. Department of Agriculture (USDA) website: * Hot food should be held at 140 °F (Fahrenheit) or warmer. * Cold food should be held at 40 °F or colder. On 11/4/24 at 7:44 A.M., on the [NAME] Unit, a test tray resulted in the following temperatures: - Ham- 93 degrees Fahrenheit - French Toast- 94 degrees Fahrenheit - Milk- 50 degrees Fahrenheit The food on the test tray on the [NAME] unit tasted cold and bland. On 11/5/24 at 8:22 A.M., on the Hale Unit, a test tray resulted in the following temperatures: - French toast- 119.7 degrees Fahrenheit - Ham- 119 degrees Fahrenheit - Milk- 50 degrees Fahrenheit The food on the test tray on the Hale unit tasted luke warm and bland.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure nursing staff documented accurately in the medical record for two Residents (#37 and #65) out of a total sample of 39 Residents. Specifically, 1. For Resident #37, the facility failed to ensure nursing staff accurately documented an orthotic device was worn as ordered. 2. For Resident #65, the facility failed to ensure nursing staff accurately documented which arm a blood pressure was taken. Findings include: 1. Resident #37 was admitted in October 2014 with diagnoses including stroke with left sided hemiplegia. Review of Resident #37's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she was cognitively intact. Section GG of the MDS also indicated Resident #37 had an impairment in range of motion of one upper extremity. On 11/3/24 at 8:46 A.M. and 11:35 A.M., Resident #37 was observed lying in bed 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 3. On 11/5/24 at 7:33 A.M. and 7:40 A.M., the surveyor observed the Wound Physician and Nurse #5 enter a resident's room with a posted Enhanced Barrier Precaution (EBP) sign and provided wound care with out PPE on. During an interview on 11/5/24 at 7:44 A.M., the Wound Physician and Nurse #5 said they did wound rounds on each of the Resident's but did not apply Personal Protective Equipment (PPE) as they thought it was only for bigger wounds. During an interview on 11/7/24 at 8:00 A.M., the Regional Nurse said PPE should be applied during all wound care. Based on observation, interview, record review, and policy review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1. The facility failed to ensure staff performed hand hygiene, used sterile equipment and followed enhanced barrier precautions during a dressing…

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 1a. assess decision-making capacity and 1b. obtain consent for a psychotropic medication for one Resident (#323), out of a total sample of 39 residents. Findings include: Review of the facility policy titled Advance Directives, dated 2001, indicated the following: - Upon admission the interdisciplinary team assesses the residents decision-making capacity and identifies the primary decision-maker if the resident is determined not to have a decision-making capacity. - The interdisciplinary team conducts ongoing review of the residents decision-making capacity and invokes the resident representative or health care agent if he resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief…

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 reviews and interviews, the facility failed to ensure one Resident (#111) was allowed to participate in the care planning process, out of a total sample of 39 residents. Findings include: Review of the policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, indicated the following: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The resident is informed of his or her right to participate in his or her treatment, and provided advanced notice of care planning conferences. - If participation of the resident and his/her representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. - Each resident's comprehensive person-centered care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide one Resident (#18) with the right to alternate the position of his/her bed independently, out of a total sample of 39 residents. Findings include: Resident #18 was admitted to the facility in May 2021 with diagnoses including dysphagia (difficulty swallowing), bipolar disorder and anxiety. Review of Resident #18's most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #18 had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, which indicated he/she had severe cognitive impairment. On 11/3/24 at 8:30 A.M., Resident #18 was observed eating breakfast in his/her room while lying in bed and the Resident's bed was reclined to a 45-degree angle. The Resident did not have a bed remote allowing him/her to incline the bed if desired. The Resident was observed coughing while eating. On 11/3/24 at approximately 12:15 P.M., Resident #18 was observed eating lunch alone in his/her room while lying in bed.…

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 a clean, homelike environment on one out of three resident care units. Specifically, the Hale Unit had lingering, stale urine odors in the hallway. Findings include: Review of the facility's policy titled 'Homelike Environment, dated as revised February 2021, included the following: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation 2. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; f. pleasant, neutral scents; 3. The facility staff and management minimizes, to the extent possible, the characteristic of the facility that reflect a depersonalized, institutional setting. The characteristics include: b. institutional odors: The surveyors…

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 investigate an allegation of potential neglect for one Resident (#25) out of a total sample of 39 residents. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 2021, indicated the following: - Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Resident #25 was admitted in June 2023 with diagnoses including bipolar disorder and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #25 scored a 12 out of a possible 15 on the Brief Interview of Mental Status (BIMS), indicating moderate cognitive impairment. Review of the MDS indicated that Resident #25 scored a 10 out of a possible 27 points on the Patient Health Questionnaire (PH-Q9), indicating moderate depression. During an observation and interview on 11/3/24 at 7:48 A.M., Resident #25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide supervision during meals for two Residents (#92 and #18) out of a total of 39 sampled residents. Findings include: 1. Resident #92 was admitted to the facility in October 2022 with diagnoses including schizophrenia and repeated falls. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #92 is severely cognitively impaired and requires assistance with transfers and bathing. On 11/3/24 at 8:00 A.M., the surveyor observed Resident #92 eating his/her meal in the dining room. Review of Resident #92's activities of daily living care plan included the following intervention: Eating: I require Supervision with all meals r/t (related to) significant risk of aspiration and I require cues for pacing my oral consumption as I sometimes eat too rapidly and I aspirate/choke on food. Encourage to get out of bed to consume meals in unit dining room, initiated 8/22/2024 On 11/5/24 at 8:07 A.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 observations, record review and interviews, the facility failed to ensure an orthotic device was worn as ordered for one Resident (#37) out of a total sample of 39 residents. Findings include: Resident #37 was admitted in October 2014 with diagnoses including stroke with left sided hemiplegia (paralysis on one side of the body). Review of Resident #37's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she is cognitively intact. Section GG of the MDS also indicated Resident #37 had an impairment in range of motion of one upper extremity. On 11/03/24 at 8:46 A.M. and 11:35 A.M., Resident #37 was observed lying in bed with his/her left hand in a closed, fisted position. The Resident was not wearing a splint and there was no splint observed in his/her room. Using the Resident's dry erase board to communicate, Resident #18 said he/she used to wear a splint on his/her left wrist but has…

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 provide respiratory care services in accordance with professional standards of practice for one Resident (#19) out of a total sample of 39 residents. Specifically, for Resident #19, the facility failed to ensure his/her oxygen concentrator air filter was in place. Findings Include: Resident #19 was admitted to the facility September 2024 with diagnoses that include acute respiratory failure with hypoxia and aspiration. Review of Resident #19's most recent Minimum Data Set (MDS) Assessment, dated as 10/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated the use of oxygen. The surveyor made the following observations: -On 11/3/24 at 7:38 A.M. and 11:44 A.M., the surveyor observed the resident receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed no filter in the concentrator. -On 11/4/24 at 7:57 A.M., the surveyor observed the resident receiving oxygen via nasal cannula. Observation…

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 pain management was provided to residents who require such services, consistent with professional standards of practice for one Resident (#39) out of a total sample of 39 residents. Specifically, for Resident #39 the facility failed to administer scheduled pain medications timely in accordance with physician's orders. Findings Include: Review of facility policy titled Pain Assessment and Management, dated as revised October 2022, indicated the following: - The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. - Pain management is defined as the process for alleviating the resident's pain based on his or her clinical condition and established treatment goals. Resident #39 was admitted to the facility in January 2024 with diagnoses that include arthropathies (surgical procedures to replace some or all of a joint) of right shoulder and contusions…

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 person-centered plan of care was developed for Trauma-Informed Care for one Resident (#4), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 39 residents. Findings include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care, dated August 2022, indicated to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Nursing staff are trained on trauma screening and assessment tools. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Resident #4 was admitted to the facility in…

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

Based on observation, record review and interviews, the facility failed to ensure that the nursing staff demonstrated appropriate competencies, and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure that 3 licensed nurses (#5, #6, and #9), two who were on the schedule during the survey, and one recently on the schedule on 11/2/24, out of a total of six nursing employee records reviewed, had nursing competency evaluations. Findings include: During the survey process the survey team through observation, record review and interview identified concerns impacting resident care specifically, pressure ulcer care, change in condition, insulin administration, infection control, and implementing the medical plan of care. Review of the Facility assessment dated as reviewed 1/29/24 indicated the following: -Services that may be required by our resident population, included but was not limited to: -Activities of Daily Living -Bowel and Bladder Programming -Chronic Illness Support -Dementia and Memory Care -Hypodermoclysis (subcutaneous…

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 Reviews (MMRs) conducted by the consultant pharmacist were addressed by the facility in a timely manner for two Residents (#55 and #117), out of a total sample of 39 Residents. Findings include: 1. Resident #55 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes, cellulitis of right and left lower limb, protein-calorie malnutrition, anxiety and major depressive disorder. Review of Resident #55's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. Review of Resident #55's consultant pharmacist recommendations, dated 10/21/24, indicated This resident has two different orders PRN (as needed) Pain: Tylenol Oral Tablet 325 mg (milligrams) (acetaminophen) give 3 tablet by mouth every 6 hours as needed for pain. Oxycodone HCL oral…

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 one Resident's (#75) medication regime was free from unnecessary medications, out of a total sample of 39 residents. Specifically, the facility failed to adhere to the physician's ordered parameters and administered insulin when Resident #75's blood sugar was below 100. Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, not dated, included but was not limited to the following: Treatment/Management 1. Based on preceding assessment, including causes and complications, the Physician will order appropriate interventions, which may include: d Insulin. Monitoring and Follow-Up 4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. Resident #75 was admitted to the facility in September 2020 with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the 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 observations and interviews, the facility failed to ensure all medications used in the facility were stored in accordance with accepted professional principles of practice on two out of three units. Specifically, 1. The facility failed to ensure nursing staff secured medications while not present at his/her medication cart, 2. The facility failed to ensure nursing staff secured the treatment cart during wound rounds, 3. The facility failed to secure antifugnal cream which was left in Resident #2's room. Findings include: Review of the facility policy titled Medication Labeling and Storage, dated February 2023, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing mediations and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise…

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 the appropriate diet texture for one Resident (#323) out of a total sample of 39 residents. Specifically, Resident #323 was given a soft cookie while being prescribed a puree diet. Findings include: Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicates Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of the Speech Therapy Treatment Encounter note, dated 9/5/24, indicated the following: - Patient seen for dysphagia follow up session in the context of dinner meal. At time of encounter, patient was found with mech (mechanical) soft cookie and incomplete bolus in mouth.…

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 three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to include, in writing, the reason for the transfer/discharge to the hospital, on the Notice of Intent to Transfer/Discharge, that was sent to the residents representatives, as required. Findings include: 1) Review of Resident #1's Progress Note written by the Social Worker, dated 09/06/23, indicated he/she was admitted to the hospital on [DATE], and the Notice of Intent to Transfer was forwarded (to his/her representative). Review of Resident #1's Notice of Intent to Transfer/Discharge Resident with less than 30 day notice, dated 09/06/23, copy within the medical record, omitted the reason for the transfer/discharge to the hospital on [DATE]. 2) Review of Resident #2's Progress Note written by the Social Worker, dated 12/11/23, indicated he/she was transferred to the hospital on [DATE], was admitted , and the Notice of Intent to Transfer was sent to his/her…

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

Based on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Findings Include: Review of the facility assessment, undated, indicated the following: Staffing Guidelines *Our facility has created a staffing pattern to ensure that our residents's needs are met on a consistent basis. Our staffing patterns provide a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of Massachusetts' regulatory requirements for minimum number of hours of care per resident day (PPD) of 3.58 hours (of which at least 0.508 hours must be care provided by a registered nurse into our staffing baseline. We further develop our staffing to provide sufficient nursing care based on the residents' acuity, needs, and census to ensure that we meet the needs of each of our residents, which may result in staffing that exceeds the minimum required PPD. *Staffing assignments are determined by looking at both census…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for five out of five certified nursing assistants (CNAs), and three out of three licensed nurses whose education records were reviewed. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or…

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

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for five of five sampled Certified Nurses Assistants (CNAs). Findings include: During the review of 5 CNA employee records on 10/26/23 at 10:38 A.M., the Surveyor noted that 5 of 5 sampled CNAs did not receive annual performance reviews. During an interview with the Director of Nursing on 10/26/23 at 1:18 P.M., the above concerns were reviewed. The Director of Nursing said she has only been at the facility since last week and staff performance reviews were on her list of things to do.

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, that food was not cooked below a possible contaminate, and that ready to eat food was not contaminated by the handle of serving tongs. Findings include: Review of the undated facility policy titled Food Storage, indicated the following: -Food requiring refrigeration shall be stored at or below 40 degrees Fahrenheit. -Food shall be stored in closed, sealed containers -The Director of Culinary Services or designee will ensure that food is properly labeled and dated. Outdated food is promptly removed along with dented cans. Review of the facility policy titled Food Preparation and Service, revised November 2022, indicated the following: -Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby reduce the risk of…

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

Based on interviews and policy review, the Facility failed to have the Medical Director actively involved in the antibiotic stewardship program. Findings include: The facility policy titled Medical Director, undated, indicated 2. The medical director is a licensed physician in this state is responsible for: overseeing and helping develop and implement care-related policies and practices; participating in efforts to improve quality of care and services; serving as a source of education, training, and information. 3. Medical director functions also include, but are not limited to: acting as a consultant to the director of nursing services in matters relating to resident care services; participating in staff meetings concerning infection prevention and control, quality assurance and performance improvement, antibiotic stewardship, pharmaceutical services, resident care policies, etc. During an interview on 10/26/23 at 8:47 A.M., Regional Nurse #2 said the facility does not have a real antibiotic stewardship program in place. The Regional Nurse said there have been many Director of…

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

Based on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action…

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

Based on record review policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for five of five Certified Nurse Aides (CNAs). Findings include: Review of the policy titled, In-service Training, Nurse Aide, last revised August 2022, indicated the following: Policy statement: *All nurse aide personnel participate in regular in-service education. Policy Interpretation and Implementation: *4. Annual in-services: a. ensure the continuing competence of nurse aides. b. are no less than 12 hours per employment year. During the review of employee education files on 10/25/23 at 4:15 P.M., the Surveyor noted 5 out of 5 Certified Nursing Aides sampled did not receive 12 hours of required in-service education within 12 months. During an interview on 10/26/23 at 1:18 P.M., The Director of Nursing said she has only been at the facility since last week and the nurse aide training was on her list of things to do to ensure all yearly education are completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a home-like environment on two of three resident units. Findings include: Review of the facility policy titled, Homelike Environment, undated, indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; pleasant, neutral scents. On 10/22/23, the surveyors noted the Hale Unit and the [NAME] Unit had a strong odor of stale urine and feces throughout the hallways, and dining area at various times during the day (7:00 A.M. - 3:00 P.M.) On 10/23/23, 10/24/23, 10/25/23, the surveyors noted the Hale Unit and the [NAME] Unit had a strong odor of stale urine and feces throughout the hallways, and dining area at various times during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to implement and develop care plans for 7 Residents, # 37, #222, #52, #75, #272 #19 and #65 out of a sample of 31 residents. Specifically, 1. For Resident #37, the facility failed to develop a mood and behavior care plan, 2. For Resident #222, the facility failed to develop a behavior care plan, 3. For Resident #52, the facility failed to develop a mood and behavior care plan. 4.For Resident #75, the facility failed to implement fall interventions as indicated in his/her care plan. Specifically, the facility failed to: (a) administer a helmet at all times as indicated in the physician's orders, (b) implement two floor mats and maintain the bed in a low position as indicated in the care plan. 5. For Resident #272, the facility failed to obtain weights as ordered, 6(a) For Resident #19 the facility failed to implement a falls care plan, (b). For Resident #19 the facility failed to develop a care plan regarding the Resident's behavior 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 3. Resident #16 was admitted to the facility in September 2019 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 indicating severe impairment. During observations on 10/22/23 at 8:40 A.M., 10/24/23 at 7:58 A.M., and 10/5/23 at 8:03 A.M., Resident #16 was observed eating breakfast alone in bed. A review of the Resident's October 2023 physician's orders indicated the following: *I require staff assistance with eating meals A review of the ADL care plan initiated 5/10/23 indicated the following: *Eating: I require hands on assistance for eating and drinking During an interview with the Speech Therapist #1 on 10/26/23, she said Resident #16 should not be eating or drinking alone in the room, there should always be a staff member in the room to cue or assist during all meals. Based on observations, record review, policy review and interviews, the facility failed to provide assistance…

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 and interview the facility failed to ensure 1.) the medication carts and treatment carts were secured on 1 of 3 nursing units, 2.) inhalers and insulin were dated when opened in 3 of 3 medication carts observed and 3.) poured medications were disposed of properly after a resident refused the medications. Findings include: Review of the facility policy titled Medication Labeling and Storage, dated 2/23, indicated The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose vials that have been opened are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility policy titled 'Administering Medications', dated 4/19, indicated The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. During administration of medications, 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 observation, record review and interview the facility failed to provide the prescribed therapeutic diet for 3 Residents (#19, #81, and #37) out of a total of 31 residents. Findings include: Review of the facility policy, titled Therapeutic Diets, indicated the following: -Therapeutic diets are prescribed by the attending physicians to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Resident #19 was admitted to the facility in May 2021 with diagnoses including unsteadiness on feet, adult failure to thrive, dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #19 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Further review of the MDS indicated Resident #19 requires supervision or touching assistance with eating. Review of the facility diet manual (a document which outlines, and is used as a reference for, the facilities available…

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 interview, the facility failed to provide education regarding vaccine refusals, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#48 and #76) out of a total of 5 sampled residents. Findings include: Review of the facility policy titled Infection Control Program, dated June 2023, indicated The facility shall document evidence of annual vaccination against influenza for each resident unless such vaccination is medically contraindicated, or the resident has refused the vaccine. The facility shall document evidence of vaccination against pneumococcal disease for all residents who are [AGE] years of age or older unless such vaccination is medically contraindicated, or the resident has refused offer of the vaccine. The facility shall provide or arrange for pneumococcal vaccination of residents who have not received this immunization, prior to or 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 obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#25) out of a sample of 31 residents. Findings include: A review of the facility's policy titled 'Informed Consent for Psychotropic Medications' with no revision date indicated the following: *Prior to administering psychotropic medications, informed written consent will be obtained from the resident, the resident's health care proxy or the resident's guardian. Resident #25 was admitted to the facility in February 2022 with diagnoses including bipolar disorder manic severe with psychotic features. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating moderate impairment. A review of Resident #25's October Medication Administration Record (MAR) indicated the following: *Seroquel Tablet 300…

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 and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on 2 of 3 nursing units. Findings include: Review of the facility policy titled Protected Health Information (PHI), undated, indicated It is the responsibility of all personnel who access resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. On 10/23/23 at 6:55 A.M., the surveyor observed the high side [NAME] unit medication cart's medication administration tablet open to a resident medication profile page with the resident picture visible, medications and other resident information open and visible in the hallway. No nurse was present at the medication cart. During an interview on 10/23/23 at 6:57 A.M., Nurse #1 said she left the medication administration tablet's screen unlocked and said the screen should be locked when the nurse walks away from the medication cart. On 10/25/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report a bruise of unknown origin for 1 Resident (#81) out of a total sample of 31 residents. Findings include: Review of the facility policy, titled Abuse Investigation and Reporting, revised July 2017, indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. -Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State Licensing/certification agency responsible for surveying/licensing the facility; b. 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 record review and interview, the facility failed to investigate a bruise of unknown origin for 1 Resident (#81) out of a total sample of 31 residents. Findings include: Review of the facility policy, titled Abuse Investigation and Reporting, revised July 2017, indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. -If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. -Role of the investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise and update an Activities of Daily Living (ADL) care plan after a change in status for 1 Resident (#19) out of a total sample of 31 residents. Findings include: Review of the facility policy, titled Care Plans Comprehensive Person-Centered, revised October 2022, indicated the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident ' s condition; b. when the desired outcome is met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #19 was admitted to the facility in May 2021 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 observations, interviews and record review, the facility failed to implement a language communication care plan for one Resident (#16) out of a sample of 31 residents. Findings include: A review of the facility policy titled 'Translation and/or Interpretation of Facility Services' with a revision date of November 2020 indicated the following: *This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. *When encountering LEP individuals, staff members will conduct the initial language assessment and notify the staff person in charge of the language access program. Resident #16 was admitted to the facility in September 2019 with diagnoses including major depressive disorder. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 indicating severe impairment. During an observation 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 observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) was provided in accordance of professional standards of practice and his/her physician's orders for two Residents (#89, and #39), out of a total sample of 31 residents. Specifically, 1(a) For Resident #89, the facility failed to cap the gastronomy tube (G-tube), (b) For Resident #89, the facility failed to follow the G-tube feeding orders, 2. For Resident #39, the facility failed to implement G-tube flushing per the physician's orders. Findings include: Review of the facility policy titled Enteral Feedings, not dated, indicated the following: -All personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities.Maintain strict adherence to storage conditions and timeframes: a. refrigerate prepared or opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to change and clean the oxygen filters for one Resident (#89) out of a total sample 31 residents. Findings include: Review of the facility policy titled Respiratory Therapy - Prevention of infection, dated 11/11, indicated Wash filters from oxygen concentrators monthly with soap and water. Rinse and squeeze dry. Resident #89 was admitted to the facility in April 2021 with diagnoses including anoxic brain damage, tracheostomy, dysphagia and chronic kidney disease. Review of Resident #89's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. On 10/22/23 at 7:33 A.M. and 9:33 A.M., the surveyor observed Resident #89 in bed receiving oxygen via tracheostomy, the 02 (oxygen) concentrator's filter had thick gray fuzz covering the entire 02 filter. 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 interview and record review, the facility failed to review pharmacist recommendations for two Residents (#66 and #81) out of a total sample of 31 residents. Findings include: Review of the undated facility policy, titled 'Medication Regimen Review', indicated the following: -The pharmacist's recommendations as a result of the review will be sent to the appropriate authorized prescriber and the community manager/designee. 1. Resident #66 was admitted to the facility in December 2021 with diagnoses including dementia, cataracts, and psychotic disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #66 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Review of Resident #66's progress notes indicated a pharmacy medication review completed in May 2023 and June of 2023 and that recommendations were made by the pharmacist to the provider on both occasions. During an interview on 10/26/23 at 11:18 A.M., the Director…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of three nurses observed made two errors out of 30 opportunities, resulting in a medication error rate of 6.67 %. Those errors impacted one Resident (#3), out of seven residents observed. Findings include: Review of the facility policy titled, Administering Medications, dated April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 10/25/23 at 8:11 A.M., the surveyor observed Nurse #13 during medication administration pass. Nurse #13 was observed to prepare Resident #3's medications, the surveyor observed Nurse #13 prepare Acetaminophen 325 mg two…

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 facilitate dental services for 1 Resident (#19) out of a total of 31 residents. Findings include: Resident #19 was admitted to the facility in May 2021 with diagnoses including unsteadiness on feet, adult failure to thrive, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #19 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Further review of the MDS indicated resident #19 requires supervision or touching assistance with eating, oral hygiene and transferring. During an interview on 10/22/23 at 9:30 A.M., Resident #19 said he/she was supposed to receive new bottom dentures as his bottom teeth were taken out months ago. The Resident says he/she has asked multiple staff about his/her bottom dentures as he/she would like to have them. During an interview on 10/25/23 at 11:38 A.M., Speech Language Pathologist (SLP) #2 said Resident #19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#75, #222 and #89) out of a total sample of 31 residents. Specifically, for Residents #75, and #89 nursing failed to accurately document in the Medication Administration Record. For Resident #222, nursing failed to document accurately in the physician's orders. Findings Include: 1. Resident #75 was admitted to the facility in August 2020 with diagnoses including seizure disorder related to a head injury. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 9 out of a possible 15 indicating moderate impairment. A review of Resident #75's October 2023 physicians orders indicated the following: *Always ensure resident wears helmet every shift. During an observation on 10/23/23 at 7:52 A.M., Resident #75 was observed in his/her room, lying in the bed without a helmet on. The helmet was observed on top of the dresser.…

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 policy reviews, the facility failed to ensure nursing staff maintained infection control practices during medication administration pass on 2 of 3 units. Findings include: Review of the facility policy titled Administering Medications, dated 4/19, indicated Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy titled Handwashing/Hand Hygiene, dated 4/19, indicated 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; c. before preparing or handling medications; f. before donning sterile gloves;…

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.