Affinity Healthcare

Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident common areas (activity rooms, pub/parlor/dining rooms) were maintained in good repair (without holes, painted) and homelike on units M2 and B2. Findings include: Review of the facility's policy titled Resident Right-Safe/Clean/Comfortable/Homelike Environment, dated as last revised September 2021, indicated but was not limited to the following: -It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior During all days of survey (9/19-9/26/24), the surveyor observed the following: Unit B2: -the unit hallway had multiple areas where hand sanitizer pumps had been removed, revealing unpainted torn drywall -the dining room had a hole in the wall approximately three inches long by one and a half inches…

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 Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were formulated and maintained in the medical record for one Resident (#106), out of a total sample of 25 residents. Specifically, the facility failed to ensure Advanced Directives were reviewed, documented, valid, and maintained in the medical record. Findings include: Review of the facility's policy titled Advanced Directives, dated as last revised 1/2024, indicated but was not limited to the following: -Advanced directives will be respected in accordance with state law and facility policy. -Information about whether or not the resident has executed an advanced directed shall be displayed in the medical record. -The plan of care will be consistent with his or her documented treatment preferences and/or advanced directives. -Advanced…

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 staff interview, the facility failed to ensure for one Resident (#35) with a gastrostomy tube, of a total sample of 25 residents, that medications were administered in accordance with the physician's order and Professional Standards of Practice. Specifically, the facility failed to ensure Nurse #3 followed the physician's order when administering each of the Resident's medications via the gastrostomy tube (GT). Findings include: Review of the [NAME] Skill Checklist for Taylor's Clinical Nursing Skills. A Nursing Process Approach, 5th Edition, Skill 5-2 Administering Medications via a Gastric Tube, the following standard included but was not limited to the following: 10. Prepare medication. Pills: Using a pill crusher, crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup, for future comparison of information.…

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 interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with accepted professional standards of practice prior to administration for 1 of 4 medication carts reviewed. Specifically, the facility failed to: -For Residents #47, #82, and #117, ensure staff did not pre-pour medications and store them in the medication cart; and -Ensure Schedule II-V controlled substance medications were maintained in a separately locked, permanently affixed compartment. Findings include: Review of the facility's policy titled General Guidelines for Medication Administration, dated September 2018, indicated but was not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to administer. -Medications are administered at the time they are prepared. Medications are not prepared either in advance of medication pass or for more than one resident at a time. On 9/25/24 at 10:57 A.M., the surveyor and Nurse #1 observed…

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

Based on observation and interview, the facility failed to ensure that dignity was provided during the dining experience for seven Residents (#9, #33, #27, #37, #51, #76 and #77), out of a total sample of 29 residents. Specifically, the facility failed to ensure that: 1. For Residents #9, #33, #37, #51, #76 and #77, staff did not provide a towel as a clothing protector while eating; 2. For Residents #9, #27, #33, #46, #51, #77, staff delivered meals to all residents seated at the table simultaneously, resulting in residents waiting an extended period of time to receive their meal while watching their tablemates eat; and 3. For Resident #51, did not stand over the Resident while feeding him/her in the dining room. Findings include: 1. On 6/27/23 at 11:50 A.M. and 6/28/23 at 11:44 A.M., the surveyor observed six Residents (#9, #33, #37, #51, #76 and #77) of seven Residents in the B-2 Unit dining room with white towels draped around their necks as clothing protectors. 2. On 6/28/23 at 11:44 A.M., the surveyor observed seven residents in the B-2 Unit dining room: two Residents (#76 and…

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

Based on record review, review of the rehab consultant's contract and policy, review of the American Physical Therapy Association (APTA) guidelines, review of Massachusetts law, and interviews, the facility failed to provide skilled physical therapy services in accordance with professional standards when the physical therapist is supervising the physical therapist assistant from an offsite setting and when providing telehealth physical therapy. In addition, based on observations, record review, interview, and policy review, the facility failed to implement their falls policy after Resident #107 fell. Specifically, the facility failed to: 1. Provide regularly scheduled, documented collaboration between the physical therapist and the physical therapy assistant regarding patient care; 2. For Residents #91, #17, and #117, ensure the the physical therapist performed at least a monthly onsite re-examination of the Residents and failed to include the required information and consent for telehealth visit for the discharge assessment; and 3. For Resident #107, follow their policy and…

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

Based on interview and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision for one Resident (#62), out of a total sample of 29 residents. Specifically, the facility failed to ensure Resident #61's eye examination recommendations, to be seen and evaluated by a glaucoma specialist, were implemented. Findings include: Resident #62 was admitted to the facility in November 2016 with diagnoses which included diabetes and stroke with right-sided paralysis. Review of the Minimum Data Set (MDS) assessment, dated 4/15/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the Resident was cognitively intact. In addition, section B1200 indicated the Resident wears corrective lenses. During an interview on 6/29/23 at 5:15 P.M., Resident #62 said he/she has been seen by the eye doctor and is supposed to see an eye specialist for the right eye evaluation of his/her cataract and glaucoma and they have never made an appointment. The Resident said the same thing happened last…

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, interviews, and policy review, the facility failed for one Resident (#51), out of a total sample of 29 residents, to ensure effective interventions were implemented to prevent three unwitnessed falls. Findings include: Review of the facility's policies titled Accidents and Incidents-Investigating and Reporting, last revised 11/2017, and Assessing Falls and Their Causes, last revised 11/2018, included but was not limited to: -The following data, as applicable, shall be included on the Report of Incident/Accident form: k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; After a fall: -Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. Resident #51 was admitted to the facility in April 2021 with diagnoses including Huntington's disease (progressive neurological disease). Review of the Minimum Data Set (MDS) assessment,…

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

Based on record review, policy review, and interviews, the facility failed to ensure the consultant pharmacist identified and reported irregularities (use of a medication that is inconsistent with accepted standards of practice) and/or recommendations were addressed by the physician or physician extender for three Residents (#13, #37, and #70), out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #13, ensure the consultant pharmacist's recommendations were addressed to ensure there was a stop date for an as needed (prn) Klonopin (anticonvulsant used as adjunct therapy for psychosis) as required, and an appropriate indication for antipsychotic therapy was identified on the physician's order; 2. For Resident #37, ensure the consultant pharmacist identified and reported an irregularity regarding inappropriate diagnoses to justify the use of antipsychotic medication; and 3. For Resident #70, ensure the consultant pharmacist's recommendations to change an order for analgesic medication to avoid exceeding the maximum recommended daily dose were…

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: 1. Failed to ensure 1 of 4 kitchenettes was maintained in a sanitary manner to prevent potential illness or contamination of food; and 2. Failed to ensure the snack cart on the M2 Unit was maintained in a sanitary manner to prevent potential illness or contamination of food while serving snacks to residents. Findings include: Review of the 2013 Food Code, a model for safeguarding public health and ensuring food is safe for consumption, for Massachusetts indicated: 6-501.111 Controlling Pests: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. 4-903.11 Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: Clean equipment and multiuse utensils which have been cleaned and sanitized, laundered linens, and single-service and single-use articles can become contaminated before their intended use in a variety of ways such as through water leakage, pest infestation, or other…

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

Based on record review and interview, the facility failed to ensure the arbitration agreement presented to residents in the admission packet included the required information for two Residents (#31 and #96), out of a sample of three records reviewed. Findings include: Review of the facility's admission packet, Attachment M Arbitration Agreement, dated 9/2017, did not contain the following required information: 1. The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. 2. The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. Review of the facility's admission folder for three sampled residents indicated the arbitration agreement they signed did not have the required information (listed above) as follows: -Resident #31 signed the arbitration agreement on 11/4/20. -Resident #60 signed the arbitration…

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

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to ensure that laundry room personnel performed hand hygiene after handling soiled linens and wore appropriate personal protective equipment when handling soiled linens. Findings include: According to the Centers for Disease Control and Prevention (CDC), Appendix D, Best Practices for Personal Protective Equipment (PPE) for Laundry Staff: -Practice hand hygiene before application and after removal of PPE. -Wear tear-resistant reusable rubber gloves when handling and laundering soiled linens. On 6/30/23 at 11:00 A.M., the surveyor observed Employee #2 in the laundry room wearing thick, black, reusable gloves, a reusable gown, and a face mask, loading linen soiled with feces into the middle washing machine. After loading the soiled linen into the machine, Employee #2 was observed pushing the soiled laundry bin…

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 maintain an effective pest control program on one (M2 Unit) of four units reviewed. Findings include: During an interview on 6/27/23 at 11:19 A.M., Resident #31 said there is still a pest control problem with cockroaches in the kitchenette and mice running around at night. He/she said you can even hear them in the ceilings at night. The surveyor observed mice droppings behind the dressers, along the walls and in the closet behind the piles of plastic bags. In the bathroom, the surveyor observed a hole at the base of the door jamb stuffed with paper towels. Resident #31 said his/her roommate stuffs the mouse holes with paper towels to try to stop the mice from coming into their room. Review of the Pest Control provider's logbook for the M2 Unit indicated continued pest sightings including cockroaches and mice on the following dates: -undated sheet of paper indicated night shift Monday-Wednesday-Friday, M 2 kitchen and nurses' station, mice sightings 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 interview and observation, the facility failed to ensure one Resident (#11) had running hot and cold water in their bathroom, out of a total sample of 29 residents. Findings include: Resident #11 was admitted to the facility in November 2011 with diagnoses which included seizure disorder, traumatic brain injury, and depression. During an interview on 6/29/23 at 12:08 P.M., Resident #11 said he/she has not had running water in his/her bathroom for months. Resident #11 said he/she has asked the nurses and the certified nursing assistants (CNA) if they could get his/her sink fixed for months. The Resident said it is driving him/her nuts; he/she can't wash his/her hands after going to the bathroom. On 6/29/23 at 12:09 P.M., the surveyor observed Resident #11's bathroom sink in his/her room, and found the sink had no handles on the hot or cold water stems. The surveyor attempted to turn on the hot and cold water by turning the stem controls and was unable to. The surveyor did not observe any hand sanitizer in the bathroom. During an interview on 6/29/23 at 12:12 P.M.,…

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 for one Resident (#51), out of four residents with restraints, from a total sample of 29 residents, to ensure a pelvic restraint was used for the least amount of time as required. Findings include: Resident #51 was admitted to the facility in April 2021 with diagnoses including Huntington's disease (condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions). Review of the 5/25/23 Minimum Data Set assessment indicated Resident #51 had impairment in both short and long-term memory, had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living, and had bed rails that were identified as a restraint. Review of a Physical Restraint Initial Evaluation, signed as completed on 5/18/23, indicated the Resident's safety is impacted by his/her uncontrolled movements and needs the pelvic restraint or constant supervision or will end up on the floor. Rehab to evaluate and treat as indicated.…

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

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#58), of a total sample of 29 residents. Specifically, the facility failed to ensure an allegation of mistreatment by a Certified Nursing Assistant (CNA) was reported, thoroughly investigated, and action was taken to protect the Resident pending the outcome of the investigation. Findings include: Review of the facility's policies titled Abuse Identification and Reporting, dated 11/2017 and Abuse: Investigation, dated 12/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. -The…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse by one Resident (#58) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 29 residents. Findings include: Resident #58 was admitted to the facility in August 2022 with diagnoses including a seizure disorder. Review of the most recent Minimum Data Set (MDS) assessment indicated Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the grievance log and grievance investigations from January 2023 to July 2023 indicated the following grievance was logged onto the monthly log reports: A 2/17/23 grievance form indicated Resident #58's [family member] left a voicemail for the Administrator reporting improper treatment of the Resident by staff and it needs to stop. The investigation indicated Resident #58 was interviewed and reported that staff are meanies and Certified Nursing Assistant (CNA) #5 intentionally kicks…

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, record review, and policy review, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one Resident (#58), of a total sample of 29 residents. Specifically, the facility failed to ensure an allegation of abuse by a Certified Nursing Assistant (CNA) on 2/17/23, was thoroughly investigated and protected the Resident pending the outcome of the investigation. Findings include: Review of the facility's policy titled Abuse Identification and Reporting, dated 11/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - Any suspected allegation of abuse shall be immediately reported to the Executive Director or his/her designee. - All alleged violations are…

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

Based on record review, policy review, and interview, the facility failed to ensure that the Risk for Falls care plan was individualized with appropriate interventions after a fall for one Resident (#84), out of a total sample of 29 residents. Findings include: Resident #84 was admitted to the facility in December 2018 with diagnoses which included seizures, traumatic brain injury, and dementia. Review of the medical record indicated Resident #84 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The Resident had three falls from April 2023 to June 2023. Review of the facility's policy titled Assessing Falls and Their Causes, revised January 2018, included but was not limited to: -Review the resident's care plan to assess for any special needs of the resident -When a resident falls, the following information should be recorded in the resident's medical record: Appropriate interventions to prevent future falls Review of a Nursing Note, dated 6/18/23, indicated Resident #84 was lying on the floor at bedside. Review of the…

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

Based on observation, record review, and interviews, the facility failed for one Resident (#16) to provide an ongoing activity program to meet and support the individual preferences of the Resident, out of a total sample of 29 residents. Specifically, the facility failed to ensure the Resident's television (TV) was functioning so the Resident could watch their preferred show. Findings include: Resident #16 was admitted to the facility in October 2022 with diagnoses including schizophrenia and depression. Review of the Minimum Data Set (MDS) assessment, dated 11/01/22, indicated Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #16 was able to independently turn the television to the program of his/her choice. Review of the Activities Care Plan indicated but was not limited to the following: Focus: Attend activities of interest/choice and engages in self-initiated leisure activities Goals: Will initiate leisure activities one to two times a day such as visiting with family/friends, talks 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, record review, and interview, the facility failed to ensure the care and treatment of residents with catheters was provided per standards of practice. Specifically, the facility failed to position catheter bags off the floor to prevent the risk for infection for one Resident (#29), out of 29 sampled residents. Findings include: Review of the Agency for Healthcare Research and Quality (AHRQ) website indicated drainage bags should be always kept below the level of the bladder and off the floor to avoid the risk of infection (March 2017). Resident #29 was readmitted to the facility in May 2023 with diagnoses including retention of urine, unspecified. Review of the Minimum Data Set (MDS) assessment, dated 2/1/23, indicated that the Resident is cognitively competent and requires extensive assistance with personal hygiene. Review of Resident #29's Clinical Record indicated the use of an indwelling urinary catheter (a sterile tube inserted to the bladder to drain urine). Review of the Physician's Orders, dated June 2023, included an order to change CD [catheter…

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 staff interview, the facility failed to ensure appropriate care and maintenance of oxygen administration equipment was provided for one Resident (#33), out of a total sample of 29 residents. Findings include: World Health Organization: Care, cleaning and disinfection of oxygen concentrators Checklist (2022) -Inspect and clean air intake filter (1-2 times per week) 1. Pull the filter gently out and replace with spare one. 2. Put the filter in cool, soapy water and swirl gently to remove debris. 3. Remove from soapy water and place it in [NAME] area until completely dry. 4. Store the spare filter until next cleaning is needed. Resident #33 was admitted to the facility in October 2012 with diagnoses including chronic obstructive pulmonary disease (lung disease which blocks airflow and makes it difficult to breathe). Review of the medical record indicated the following current Physician's Order: -Change oxygen tubing every week on Thursday 11:00 P.M. - 7:00 A.M. shift…

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 one Resident's (#13) medication regime was free from unnecessary psychotropic medications, in a sample of 29 residents. Specifically, the facility failed to ensure an as needed (prn) medication order for Klonopin (anticonvulsant used as adjunct therapy for psychosis) was limited to 14 days, then evaluated by the physician as required. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised 11/2017, included but was not limited to: -Residents will not receive prn doses of psychotropic medications unless that medication is necessary to treat specific conditions that is documented in the clinical record -The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. Resident #13 was admitted to the facility in September 2022 with diagnoses including delusional disorder. Review of the 6/10/23 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, policy review, and interview, the facility failed to ensure that medications were properly stored and labeled in accordance with current accepted professional standards in 1 of 4 medication carts reviewed. Findings include: Review of the facility's policy titled Storage of Medications, revised August 2020, indicated but was not limited to the following: Expiration Dating (Beyond-Use Date): -Certain medications or package types, such as Intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solution strips require an expiration date once opened to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. -The Nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. -The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. -If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to include and identify the Home Health Aide (HHA) role of care between the facility and the hospice provider, in the person-centered hospice care plan for one Resident (#22), out of a total sample of 29 residents. Findings include: Review of the contract agreement between the facility and the consultant Hospice provider, signed as effective 3/3/23, indicated but was not limited to: Responsibilities of the Nursing Facility: -In accordance with applicable laws and regulations, including without limitation, Hospice and Facility shall comply with the General Terms and Conditions as part of this Agreement. Nursing Facility shall consult with Hospice regarding the development and/or modification of a Plan of Care for each eligible resident. -The Plan of Care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included 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.