Cape Cod Post Acute Care

Based on record reviews and interviews, for one of three sampled residents (Resident #1) who had physician orders for wound dressing changes, the facility failed to ensure they maintained complete and accurate resident Treatment Administration Records (TAR) in the Electronic Medical Record (EMR) when Resident #1's TAR's, related to documentation of dressing changes, were not consistently completed during the months of May 2024 and June 2024. Findings include: Review of the Facility Policy, Charting and Documentation, dated as revised January 2023, indicated that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: - Date and time the procedure/treatment was provided; - Name and title of the individual(s) who provided the care; - The assessment data and/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 records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that after an administrative staff member (Director of Nurses #1) was made aware on 4/08/24 that Resident #1 was found with an injury of unknown origin (facial bruising), that it was reported to the Department of Public Health (DPH) within two hours, as required, when it was not reported to the DPH until 4/09/24, the following day. Findings include: Review of the Facility Policy titled Abuse, with a revision date of October 2022, indicated the Facility prohibits the mistreatment, neglect, and abuse of residents by anyone. The Policy indicated the following: -all alleged violations involving abuse, neglect, exploitation, and/or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law; -the facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved; -an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Resident #58 was admitted to the facility in October 2023 with diagnoses including: Alzheimer's dementia and depression. Review of the most recent BIMS for Resident #58 indicated he/she was severely cognitively impaired with a score of 1 out of 15 and his/her healthcare proxy (HCP) was invoked. Review of the medical record indicated the Resident's last Activity Assessment and documentation was completed on 10/31/23 and indicated but was not limited to the following information: - Religious/Spiritual information: Resident #58 is Catholic and would be interested in attending religious services and receiving religious visits. - Interests/Preferences: gardening, music, Boston sports, movies, newspapers, cats and being with people is number one thing he/she enjoys - Participation Expectations: Family would like the Resident to attend groups, although he/she cannot partake, they believe the stimulation of being near other people would be beneficial. Unable to be independent in any situation but the staff can put on…

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

Based on interview, the facility failed to ensure the activity program was directed by a qualified professional from November 17, 2023, through the survey exit date 3/19/24. Findings include: During the entrance conference on 3/12/23 at 9:30 A.M., the Administrator said the facility did not have an Activity Director. During an interview on 3/13/24 at 3:55 P.M., Activity Assistant #2 said she had started at the facility in January 2024 with no previous experience in activities or long-term care. During an interview on 3/14/24 at 11:35 A.M., Activity Assistant #3 said she had started at the facility in January 2024, with no previous activity experience, and was currently transitioning out of the activity department to the laundry department. During an interview on 3/14/24 at 12:13 P.M., Activity Assistant #1 said she had started at the facility in 2019 and was a part time activity assistant and that she was not responsible for any oversight of the activity department. During an interview on 3/14/24 at 12:15 P.M., Activity Assistant #1, #2 and #3 said they were the only activity staff…

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

Based on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves. Specifically, the facility failed to: 1. Consistently and accurately identify and implement their nursing staffing pattern for optimal resident care; and 2a. Ensure the identification for residents with special treatments and conditions the facility consistently provides services for such as IV medications, isolation and quarantined individuals with infectious disease, those requiring dialysis, and the level of assistance with activities of daily living, and b. Provide a full-time Activities Director to meet the needs of the residents. Findings include: Review of the Facility Assessment, dated as last revised: 3/8/24, indicated but was not limited to the following: Persons involved in completing/updating assessment: Administrator, Director of Nurses (DON), Medical Director, Food Service Director (FSD), Building Services…

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 residents in one of two dining areas experienced a dignified and homelike dining experience. Findings include: On 3/12/24 at 12:05 P.M., the surveyor made the following observations on the North Two Unit dining room: - Fourteen residents were seated at various tables in the dining room. - Staff members were delivering meal trays to the residents off the first lunch truck that had arrived on the unit. - At 12:08 P.M., seven out of the 14 residents in the dining room area were served their lunch meal. One out of four residents seated at the table closest to the television was not served a meal. One out of two residents seated at the table by windows was not served a meal. Two residents seated at table diagonally positioned to the television were not served a meal. Three residents seated at a table closest to the entrance of the dining area were not served a meal. - At 12:14 P.M., the second lunch truck arrived on the unit. - The last resident in the dining room was served their meal at 12:23 P.M., 15 minutes after 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 a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response. Findings include: Review of the facility's policy titled Resident Council, last revised January 2023, indicated the following: -Resident Council meetings should be held monthly -meeting minutes will be recorded by designated staff representative -minutes from the previous month will be reviewed at the start of every meeting before opening up the meeting for new concerns -concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. Concern/response forms must be completed within 7 days of being issued. During the entrance conference on 3/12/24 at 9:40 A.M., the surveyor requested three months of Resident Council minutes, with approval from 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 5. Review of the facility's policy titled Physician - Consultations, dated as last revised 10/2022 indicated but was not limited to the following: -It is the policy of this organization that all residents receive medical care in a timely manner. -Follow up: to be done within the time frame requested by the consultant and approved by attending physician. Resident #108 was admitted to the facility in April 2023 with diagnoses which included urinary retention. Review of the MDS assessment, dated 1/10/24, failed to indicate a BIMS had been completed. Review of the MDS Assessment, dated 10/17/23, indicated Resident #108 had scored a 15 out of 15 on the BIMS, indicating he/she was cognitively intact. Review of the medical record indicated Resident #108 was hospitalized in June 2023. Review of the Discharge summary, dated [DATE], indicated but was not limited to the following: -Resident was treated for a urinary tract infection (UTI) in the setting of self-straight catheterization. -Out-patient follow up with urology.…

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 follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Properly label and date food products, and maintain safe and clean equipment in two of two nourishment kitchenettes; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 3. Properly label and store resident food items in the Southwest Unit medication refrigerator which was unintended for resident food storage use. Findings include: 1. Review of the facility's policy titled Food From Outside, last revised 1/2023, indicated but was not limited to: - Food brought by family/visitors that is left with the resident to consume later will be labeled and…

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

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to: 1a. Implement COVID-19 testing every 48 hours for all staff during a COVID-19 outbreak for 11 out of 11 sampled staff members in accordance with their policy, state, and national standards, when the facility was experiencing an outbreak of COVID-19 infections, and b. Implement COVID-19 testing every 48 hours for all residents during a COVID-19 outbreak in accordance with their policy, state, and national standards, when the facility was experiencing an outbreak of COVID-19 infections; 2. Ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses; and 3. Maintain an accurate…

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 medications were not self-administered without a physician's order and an assessment for self-administration was completed for one Resident (#41), out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised January 2023, indicated but was not limited to the following: - The resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. - Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. - In addition to general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, this can be accomplished on paper or through EHR system. - If residents are determined to be able to self-administer: (a) the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications 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.

Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident (#94), out of a total sample of 24 residents, was assessed for a less restrictive device based on the Resident's medical symptoms. Findings include: Review of the facility's policy titled Restraint Use, dated as revised 1/2023, indicated but was not limited to the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom. - the use of restraints may only be used to ensure the immediate physical safety of the resident and must be discontinued at the earliest possible time - restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the resident or others from harm - the type of restraint must be the least restrictive intervention that will be effective to protect the resident or others from harm - the use of the restraint shall be based on a…

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

Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident and provide the resident and/or their representative with a summary of the baseline care plan for two Residents (#38 and #108), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #38, to provide him/her a written summary of the baseline care plan by completion of the comprehensive care plan and document receipt of the information within the Resident's clinical record; and 2. For Resident #108, to develop and implement a baseline care plan for the Resident's urinary retention, indwelling Foley catheter, and need for straight catheterization (insertion of a catheter into the bladder to drain urine which is then removed once the bladder is empty). Findings include: Review of the facility's policy titled Care Plans - Baseline, revised October 2022, indicated but was not…

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

Based on record review and interviews, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#2), out of a total sample of 24 residents. Specifically, the facility failed to review and revise the fall care plan with the IDT after each Minimum Data Set (MDS) assessment. Findings include: Review of the facility's policy titled Comprehensive Care Plan, revised October 2022, included but was not limited to: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. - The 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 IDT reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been re-admitted to the facility from a hospital stay; and 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 observation, interview, policy review, and record review, the facility failed to provide services, equipment and assistance for one Resident (#26), out of a total sample of 24 residents, to prevent the decline and discomfort of his/her left-hand contracture. Findings include: Review of the facility's policy titled Appliances - Braces/Slings/Splints, dated as revised 10/2022, indicated but was not limited to the following: - in order to protect the safety and well-being of residents, and to promote quality care, this facility uses appropriate techniques and devices for appliances, splints, braces and slings - the facility policy is to assure all splints, braces, slings, etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position - Therapy evaluates splints/device/appliance at a minimum of quarterly for effectiveness and documents continued need Nursing: - ensures proper donning (putting on) and doffing (taking off) appliances is known by…

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 ensure one Resident (#108), was not catheterized unless required by his/her clinical condition to manage urinary continence/incontinence and prevent urinary tract infections (UTI), out of a total sample of 24 residents. Specifically, the facility failed for Resident #108 to ensure staff provided training and education on self-catheterization technique, provided education on symptoms and complications, evaluated, and re-evaluated the Resident's ability to self-catheterize, developed, and implemented a care plan timely, and to make a follow up appointment with a urologist as recommended. Findings include: Review of the facility's policy titled Incontinence-Urine-Assessment and Management, dated as last revised 1/2023, indicated but was not limited to the following: -The staff and practitioner will appropriately screen for and manage individuals with urinary incontinence. -Identification and management of UTI will follow relevant clinical guidelines. -Functional and/or cognitive capabilities or limitations…

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

Based on observation, interview, and record review, the facility failed for one Resident (#49), out of a total sample of 24 residents, to ensure staff provided the necessary care and services in accordance with professional standards of practice. Specifically, the facility failed to maintain sanitary conditions of oxygen (O2) tubing and equipment to help decrease the risk of potential contamination and infection and administer the O2 flow rate per physician's orders. Findings include: Review of the facility's policy titled Oxygen Therapy, revised October 2022, indicated but was not limited to the following: -Failure to administer Oxygen appropriately can result in serious harm to the patient. -Oxygen is administered according to physician's order. -Review the resident's care plan to evaluate for any special needs the residents may have. -Flow rate must be adjusted by a Licensed Nurse. -Tubing Change - Oxygen cannula tubing, without humidification, is changed weekly and as needed. -Concentrator filters should be washed at least weekly or as needed. Resident #49 was admitted to 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, record review, and policy review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#226), out of one total Resident receiving dialysis, by a. providing ongoing communication between the nursing facility and dialysis facility, and b. consistently documenting assessments of the Resident's condition and left Arteriovenous (AV) fistula (surgically created for hemodialysis treatment) site. Findings include: Review of the facility's policy titled Dialysis Management, revised October 2022, indicated but was not limited to the following: -Residents receiving hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. -On admission the resident will be assessed to determine access type. The site will be observed for function and signs and symptoms of infection. -The nurse will obtain orders for monitoring of site, and interventions as appropriate. Orders to include are to observe shunt for thrills and bruits every shift; report any abnormal…

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 monthly medication regimen reviews were maintained as part of the permanent medical record and failed to ensure recommendations made by the pharmacy consultant were addressed timely for 1 Resident (#69), out of 5 residents selected for an unnecessary medication review. Findings include: Review of the facility's policy titled Pharmacy Consultant Med (medication) Review, last revised January 2023, indicated the following: -The Pharmacy Consultant should report irregularities to the attending physician, medical director, and DON (Director of Nurses) with the resident's medication regimen -The Pharmacy Consultant will document his/her findings and recommendation on the monthly drug regimen review report -The unit manager/designee will make sure all recommendations are acted upon Review of the facility's policy titled Abnormal Involuntary Movement (AIMS), last revised October 2022 indicated an AIMS test would be completed by a licensed nurse every six months for residents on antipsychotic therapy.…

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

Based on observation, interview, and policy review, the facility failed to ensure staff stored and properly labeled all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure staff properly labeled, once opened, all drugs and biologicals stored in one of three medication carts reviewed; and 2. Ensure one (North 1 Unit) of three medication storage rooms reviewed was locked and secured. Findings include: 1. Review of the facility's policy titled Storage of Medications, dated 2017, indicated but was not limited to the following: -Certain medications or package types such as ophthalmics, once opened, require an expiration date shorter than the manufacturer's expiration date 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 enter the date opened and the new date of expiration. The expiration date of the vial 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 interview, the facility failed to provide one Resident (#26), out of a total sample of 24 residents with a meal consistent with his/her allergies. Findings include: Resident #26 was admitted in December 2020 with diagnoses including: Hemiplegia and hemiparesis (one-sided muscle weakness or paralysis) affecting the left non-dominant hand and polyneuropathy (the damage of multiple peripheral nerves resulting in problems with sensation, coordination and or function). Review of the most recent Brief Interview for Mental Status (BIMS), dated 12/6/2023, indicated Resident #26 was cognitively intact with a score of 15 out of 15 and made his/her own decisions. During an interview on 3/12/24 at 8:59 A.M., Resident #26 said he/she has a consistent issue of being delivered strawberry jam on his/her breakfast tray and that he/she has an allergy to strawberries. Review of the medical record for Resident #26 indicated Allergies: strawberries was documented on: - the current physician's orders, dated…

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 services were coordinated with the hospice provider to implement the resident's plan of care as required in the provider contract agreement for two Residents (#12 and #70), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #12, to provide ongoing documentation, and maintain a complete medical record of services to ensure prompt and effective communication and continuity of care for the Resident. 2. For Resident #70, to provide ongoing documentation, and maintain a complete medical record of services to ensure prompt and effective communication and continuity of care for the Resident. Findings include: Review of the facility's policy titled Hospice Services, last revised January 2023, indicated but was not limited to the following: - Our facility contracts for hospice services for residents who wish to participate in such programs. - When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to implement policy and procedures to ensure residents/resident representatives were educated on benefits and potential side effects of immunizations, documented consent, or refusal of the immunization, and offered and administered the influenza and pneumococcal immunization in a timely manner for one out of five residents sampled. Specifically, the facility failed for Resident #32, to educate on benefits and potential side effects, offer the immunizations, and document in the medical record consent/refusal for the influenza and pneumococcal vaccines. Findings include: Review of the facility's policy titled Influenza Vaccination/Control, dated as last revised 2/2023, indicated but was not limited to the following: -The facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. -The Infection Preventionist (IP)/designee will educate, promote, and oversee the administration program 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 policies and procedures to ensure residents/resident representatives were educated on benefits and potential side effects, documented consent or refusal of the immunization and offered and administered the COVID-19 immunization and/or booster in a timely manner for 1 out of 5 residents sampled. Specifically, the facility failed for Resident #61 to educate, offer, and administer the immunization, and document in the medical record consent/refusal. Findings include: Review of the facility's COVID-19 Vaccination policy, undated, indicated but was not limited to the following: -It is the policy of this facility to offer and encourage all residents to receive the COVID-19 vaccine per the Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Department of Public Health (DPH) guidelines and recommendations. -The residents will be offered the vaccine upon admission and at intervals decided by their physician (MD) in accordance with the CDC, CMS, and DPH…

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

Based on records reviewed and interviews, for five of eight sampled residents (Resident #2, #7, #8, #5 and #6), the Facility failed to ensure medications were administered in accordance with the acceptable standards of nursing practice, when scheduled medications were administered late. Findings include: Review of the Facility's Policy, titled, Medication Administration, dated as revised 10/2022, indicated: -Medications must be administered in accordance with the orders, including any required time frame. -Medications must be administered within one hour of their prescribed time. Review of the Facility's Policy titled, Medication Pass - Liberalized, dated January 2023, indicated: -medication will be given within the time code for which it is carried; -medications ordered to be given at a specific time will be administered within one hour of that time; Review of the Northeast Two Low Unit's 9/19/23 Census Report, indicated that there were 20 residents residing on that side of the Unit. During an interview on 9/19/23 at 10:41 A.M., Minimum Data Set (MDS) Nurse #2 said that she came 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of eight sampled residents (Resident #8), who was alert, oriented and whose preference include being able to receive a shower, the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of receiving a weekly shower. Findings include: Review of the Facility's Policy titled, Activities of Daily Living (ADL) Support, dated as last revised October 2022, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good personal hygiene including bathing. Review of the Facility Policy's titled, ADL - Bath/Shower, dated as last revised October 2022, indicated that it is the policy of the facility to shower residents to cleanse and refresh the resident, observe the skin, and to provide increased circulation. Review of the Facility's Policy titled, Resident Rights, dated as last revised October 2022, indicated that residents have 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 records reviewed and interviews, the facility which maintained an average daily occupancy of greater than 60 residents (averaging 113 residents per day), failed to ensure the Director of Nurses (DON) did not serve as a charge nurse on a unit. Findings include: Review of the Facility's Job Description for The Director of Nurses (DON), indicated the Director of Nurses reported to the Administrator, and was responsible for assuming the total responsibility for deliverance of quality resident care through the development and management of nursing personnel, fiscal resources, and maintenance of a safe environment. The DON was responsible for frequent rounds on all nursing units to evaluate resident care and provide support to nursing personnel. The DON manages nursing personnel including recruitment, selection, position assignment, orientation, in-service education, supervision, evaluation and termination. The Policy further indicated that the DON develops and revises departmental policies and procedures to assure compliance with Federal, State, Department of Public Health 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 records reviewed and interviews, the facility failed to ensure narcotic reconciliation was completed and documented for four of four medication carts. Findings include: Review of the Facility's Policy titled, Narcotic Count, dated as revised October 2022, indicated the following: -the on-coming and the off-going nurses assigned to the medication cart will be responsible for ensuring the accuracy of the controlled drug count; -proper count procedure should be completed by both nurses standing at the cart and validating the number of narcotics matches the amount on the page and that every page not signed out in the index is reviewed; -verify that the number of individual controlled drugs matches the number on the declining inventory on each identified page; -continue the process until the full index has been checked and the controlled medications have been viewed and accounted for by the on-coming nurse; -once the nurse has accepted the count, signed off on the controlled medication count acknowledgment page in the back of the book and accepts the keys, it is then that…

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

Based on observation, interview, and record review, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents' needs. Specifically, the facility failed 1) For Resident #78, to ensure that he/she was out of bed for all meals per physician's orders; 2) For Resident #63, to ensure that a urinalysis was obtained timely, resulting in a delay of 11 days; 3) For Resident #40, to ensure that the staff provided supervision to a scheduled urology appointment, resulting in a delay of care; 4) For 27 out of 27 sampled residents, to ensure scheduled assessments were completed timely; 5) For Resident #32, to ensure showers were provided as scheduled; and 6) For Residents #87 and #46, to ensure morning ADL (activities of daily living) care was provided timely and at the Residents' preferred time. Findings include: 1. Resident #78 was admitted to the facility in March 2022 with diagnoses which included Type 2 Diabetes and hemiplegia and hemiparesis following Cerebral Infarction. Review of Resident #78's Physician's Orders,…

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 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 2 out of 2 certified nursing assistants (CNAs) and 2 out of 2 licensed nurses. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, 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 occupational functions successfully. 1) Throughout the Recertification Survey (8/16/22 through 8/24/22), the surveyors identified concerns across multiple care areas including but not…

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 staff interview, the facility failed to ensure that food is stored, prepared, and distributed in accordance with professional standards. Specifically, the facility failed to: 1.) Ensure that food was stored, prepared, and distributed under sanitary conditions; 2.) Ensure that the dish machine was chemically sanitizing dishware at the proper concentration, to reduce/destroy bacteria that may potentially cause food borne illness to individuals that were a high-risk population; and 3.) Ensure three unit kitchenette/refrigerators were maintained in a sanitary manner to store food and fluid. Findings include: 1. During the initial kitchen tour on 8/16/22 at 8:50 A.M., the surveyor, accompanied by the Food Manager (FM), observed the following sanitation concerns: -The two ice scoops, located in the scoop holder, were observed to have debris on the surface and the interior of the scoop holder was dirty. The FM said the scoops and holder are cleaned monthly when the ice machine is cleaned. -The interior of the ice machine had specks of black dots,…

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 Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to: 1) Fully document the acuity of the patient population, including assistance with activities of daily living and number of residents requiring specialized treatments; 2) Address the use of agency and traveler staff and the education and resources needed for the continued use of agency and traveler staff needed to fill licensed nurses and Certified Nursing Assistant (CNA) staff positions; 3) Address the use of Resident Care Assistants for the care and treatment of residents and the required oversight and education required during the COVID-19 pandemic; 4) Implement the identified education resources including a computerized educational program and annual competencies with licensed and CNA staff members; and 5) Implement the identified Safety Committee Meetings to include the inspection of 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.

Based on interview and document review, the facility failed to designate an individual who had specialized training in infection prevention and control to be responsible for the facility's Infection Prevention and Control Program (IPCP). Findings include: During the entrance conference on 8/16/22 at 9:40 A.M., the Director of Nurses (DON) said the Infection Preventionist has been out on leave. She said the facility does not have a back-up Infection Preventionist within the facility who meets the qualifications to oversee the program, therefore she has been overseeing the IPCP program at the facility. The Director of Nurses further said, there is one nurse within the facility who has begun the training, but it has not been completed at this time. During an interview on 8/17/22 at 2:46 P.M., the Director of Nurses said the Infection Preventionist has been out and last worked in the facility on 7/12/22. She said since that time she has been responsible for the IPCP at the facility. The Director of Nurses said she did not have any specialized training in infection prevention and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to evaluate the effectiveness and revise the comprehensive care plan for seven Residents (#56, #82, #81, #65, #63, #26, and #301), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Residents #56, #82, #81, #65, #63, and #26, to review and revise the Residents' care plan after each fall; and 2. For Resident #301, to review and revise the care plan for the resident's skin condition and treatments provided. Findings include: 1. a) Resident #56 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's disease and hypertension. The Resident was hospitalized for a repair of a fractured hip in March 2022. Review of the medical record indicated a new care plan was developed on 3/3/22 for an actual fall with surgical intervention (ORIF right femoral shaft), poor balance, and unsteady gait. -The interventions included: *1:1 attention and supervision when possible *floor mat on both sides of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to ensure that services provided met professional standards of quality for 16 Residents (#79, #26, #99, #60, #100, #353, #351, #49, #56, #82, #301, #81, #63, #65, #37, and #71), out of a total sample of 27 residents. Specifically, the facility failed 1.) For Residents #79 and #26, to complete an assessment for wandering/elopement risk and provide a rationale for the intervention of a wander bracelet prior to its implementation; 2.) Resident #99, to complete a Restraint and Elopement Assessment as indicated; 3.) For Residents #60, #100, #353, and #351 to obtain resident weights per the facility policy; 4.) For Resident #49, to follow a physician's order to complete a Physical Therapy evaluation; 5.) For Residents #56, #82, #301, #81, #63, #79, #65, #37, and #71, to ensure staff monitored the Residents following a fall for signs and symptoms of neurological complications, per the facility's policy; and 6.) For Residents #100, #49, #81,…

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, interview, and policy review, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to 14 days, unless documented by the attending physician or prescribing practitioner that it is appropriate to extend beyond 14 days for four Residents (#79, #82, #8, and #38), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, last reviewed 2/18/22 included but was not limited to the following: - PRN orders for psychotropic drugs are limited to 14 days. - Except if the attending physician or prescribing practitioners believes that it is appropriate for the PRN order to be extended beyond 14 days based on an evaluation of the resident for the appropriateness of that medication. - The physician shall document the rationale in the resident's medical record and indicate the duration for the PRN order. 1.) Resident #79 was admitted to the facility in April 2022 with diagnoses that included dementia with behavioral disturbance and anxiety. Review of the Minimum…

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, staff and resident interviews, and record review, the facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Findings include: During an interview on 8/16/22 at 8:00 A.M., Resident #44 said the food is terrible and the soup is bad and not hot. During an interview on 8/16/22 at 11:21 A.M., Resident #100 said, The food is pretty bad. During an interview on 8/16/22 at 1:50 P.M., Resident #41 said, I've had better food. During a group meeting with the surveyors on 8/18/22 at 1:00 P.M., there were 17 residents in attendance, and some of them had comments about the food including: -Resident #19 said the coffee is not hot. -Resident #32 said the hot chocolate is barely tepid, and there is no ice or cold drinks. -Resident #23 said the food is cold. On 8/23/22 at 7:45 A.M., the surveyor requested a test tray to be sent to the 2 North unit. The test tray was placed on the food cart at 7:57 A.M, the food cart left the kitchen at 7:59 A.M. and arrived on the unit at 8:00 A.M. After the last tray was passed…

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

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1. Ensure rapid antigen testing was conducted in a manner that is consistent with current standards of practice established by State and Federal agencies to maintain proper infection control and follow universal precautions for biohazard material; 2. Ensure staff applied and maintained Personal Protective Equipment (PPE) while caring for a resident with Clostridioides difficile (CDIFF) (a bacterial infection of the intestinal tract. It is highly contagious as infecting spores are easily spread and can last on surfaces for extended periods), for one Resident (#65) out of a total sample of 27 residents; and 3. Ensure the appropriate signage was placed outside a resident's room who was not up to date with COVID-19 vaccinations, 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 record review, document review, and interviews, the facility failed 1. To ensure rapid antigen testing was conducted in a manner that is consistent with current standards of practice established by State and Federal agencies to maintain proper infection control and ensure the validity of the test results; and 2. To document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test during a COVID-19 outbreak for five out of five residents on the identified outbreak unit. Findings include: 1. Review of Binaxnow Covid-19 AG Card (PN 195-000) - Instruction for use, as indicated in the Department of Public Health Memorandum, dated 10/28/21 indicated the following: - Treat all specimens as potentially infectious. Follow universal precautions when handling samples, this kit and its contents. - Proper sample collection, storage, and transport are essential for correct results. - Inadequate or inappropriate sample collection,…

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

Based on observation, interview, record review, and policy review, the facility failed to ensure that residents maintained the right to a dignified existence. Specifically, the facility failed to ensure that for one Resident (#40), out of two residents who required the use of a urinary foley catheter, a privacy cover was used to cover their drainage bag. Findings include: Resident #40 was admitted to the facility in May 2022 with a diagnosis of urinary retention. Review of the facility's policy titled Catheter Drainage Bag, dated 11/2019, indicated the following: - When out of bed, utilize a privacy bag to cover the drainage bag Throughout the recertification survey (8/16/22 through 8/24/22), the surveyor made the following observations: - 08/16/22 at 02:49 P.M., Resident #40 was sitting in a wheelchair in the doorway of his/her room. A urinary catheter bag was clipped to the front of the wheelchair with urine visible. There was no privacy bag being used. - 08/17/22 at 09:02 A.M., Resident #40 was sitting in a wheelchair in the doorway of his/her room following breakfast. A urinary…

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 staff interview, the facility failed to ensure that a [NAME] Treatment Order (court approved treatment plan for the administration of antipsychotic medications) was obtained for one Resident (#99) who had a legal guardian and was prescribed and received an antipsychotic medication, out of a total sample of 27 residents. Findings include: Resident #99 was admitted to the facility in May 2021 with diagnoses of early onset dementia with behavioral disturbances, major depressive disorder, and mood disorder. Review of the Minimum Data Set (MDS) assessment, dated 08/2/22, indicated the Resident received an antipsychotic medication daily and on a routine basis. Review of the medical record indicated that a guardian was appointed through the court for Resident #99 prior to admission to the facility. Review of the Physician's Orders indicated the following: -Risperdal tablet 0.25 milligrams (MG), give one tablet by mouth one time per day at 9:00 A.M., initiated 9/2021. -Risperdal tablet 0.5 MG,…

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, interview, and policy review, the facility failed to ensure residents and/or their representatives were fully informed in advance and given information necessary to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#38), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Psychotropic Med Consent, dated 11/19, indicated the following: - Prior to administering psychotropic medications, consent should be obtained for their use. - The written consent form shall be kept in the resident's medical record. Resident #38 was admitted to the facility in December 2021 with a diagnosis of bipolar disorder. Review of the current Physician's Orders for Resident #38 indicated the following: -Fluoxetine (antidepressant) 40 milligrams: Give one capsule by mouth one time per day. Review of Resident #38's Medication Administration Record (MAR) indicated he/she was receiving Fluoxetine daily per physician's orders. Review of the medical record failed to indicate…

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

Based on observation, interview, and record review, the facility failed to ensure staff developed and implemented a comprehensive care plan for three Residents (#79, #301, and #58), out of a total sample of 27 residents. Specifically, the facility failed: 1.) For Resident #79, to ensure staff developed a comprehensive care plan for the care and treatment of a laceration with sutures; 2.) For Resident #301, to ensure staff developed a comprehensive care plan for the care and treatment of a pressure area to the left heel; and 3.) For Resident #58, to ensure staff developed a comprehensive care plan for a left hemiparesis hand contracture present upon admission. Findings include: 1.) Resident #79 was admitted to the facility in April 2022. Review of the medical record indicated that in July 2022 the Resident fell and sustained a laceration to his/her left temple. The Resident was transferred to the hospital for treatment and received two sutures to his/her left temple. The Physician ordered for Bactroban 2% (a skin ointment that prevents bacteria from growing on the skin) daily. Review…

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 perform a rehabilitative (rehab) screen upon admission, resulting in an eight week delay in receiving skilled rehab services for a contracted left hand for one Resident (#58), out of 27 sampled residents. Finding include: Resident #58 was admitted to the facility in June 2022 with diagnoses including a stroke with left sided paralysis. Review of Resident #58's Nursing Evaluation-V7, dated 6/10/22, indicated but was not limited to the following: Musculosketal: -Paralysis checked with left side noted -Contractures was not checked, no contractures noted History of Pain: -Frequency of indicator of pain: Less than daily, more than weekly. -Location of pain: left hand and left foot. -Pain interferes with: sleep -What causes pain to worsen? Moving around -Current pain medication regime: Tylenol and narcotics -Current non-pharmacological interventions: Repositioning Review of the Physician's Orders indicated the following: -6/10/22-Physical therapy, occupational therapy, and speech therapy 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 observation, record review, and interviews, the facility failed to ensure one Resident (#99), out of a sample size of 27 residents, was provided with individualized and meaningful activities to address the resident's customary routines, preferences, and choices to enhance the resident's well-being. Findings include: Resident #99 was admitted to the facility in May 2021 with diagnoses which included early onset dementia with behavioral disturbances, major depressive disorder, mood disorder, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 08/02/22, indicated the Resident received an antipsychotic medication daily and on a routine basis. Review of the medical record indicated that a guardian was appointed through the court for Resident #99 prior to admission to the facility. Review of the Physician's Orders indicated the following: -Risperdal tablet 0.25 milligrams (MG), give one tablet by mouth one time per day at 9:00 A.M. initiated 9/2021. -Risperdal tablet 0.5 MG, give one tablet by mouth two times daily at 2:00 P.M. and 7:30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and policy review the facility failed to: 1.) Label medications and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and 2.) Store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 2 out of 6 medication carts. Findings include: 1.) Review of the policy titled, Medication Storage, with a review date of [DATE], indicated but was not limited to the following: -Medications and biologicals be labeled in accordance with currently accepted professional principles and include - appropriate accessory and cautionary instructions - expiration date when applicable On [DATE] at 2:55 P.M., the surveyor and Nurse #7 inspected the Southwest first floor Med cart 2 medication cart. The medication cart was observed to have one over-the-counter medication bottle that had no expiration date located in the medication…

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 obtain laboratory services as ordered by the physician for two Residents (#63, #38), out of 27 sampled residents. Findings include: 1.) Resident #63 was admitted to the facility in July 2022 with diagnoses of cerebrovascular accident with right sided weakness and diabetes. Review of the medical record indicated Resident #63 presented with a decline in function, so the Nurse Practitioner (NP) ordered a urinalysis, culture and sensitivity (UA C&S) on 8/12/22. Review of a Nurse's Note, dated 8/12/22, indicated that a UA C&S was ordered and needed to be obtained. Further review of the medical record indicated a Nurse's Note, dated 8/22/22, indicated the UA C&S had not been obtained. (This is 11 days after the initial physician's order was written.) Review of the Physician's Orders, dated 8/11/22 and 8/15/22, indicated that orders for a UA C&S to be obtained were written on both these days. Review of the NP's Progress Note, dated 8/22/22, indicated the urine had still not been collected. During an interview on 8/23/22 at 9:58…

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

Based on observation, interview, record review, and review of facility grievances, the facility failed to accommodate one Resident's (#32) allergy to strawberries, out of a total sample of 27 residents. Findings include: Review of Resident #32's most current Physician's Orders, Care Plan, and Nutrition Assessment, all indicated the Resident had an allergy to strawberries. Review of a Resident Council Resolution form, dated 5/18/22, indicated Resident #32 completed a grievance during the Resident Council meeting that he/she was allergic to strawberries and had been getting strawberry yogurt on his/her breakfast tray. On 5/31/22, the Activity Director had documented that the Resident's concern had been resolved. During an interview on 8/18/22 at 5:30 P.M., Resident #32 came out of his/her room and said, I have strawberries on my tray and I'm allergic to strawberries. Resident #32 said he/she had previously submitted a complaint, on 5/18/22, to the dietary department of his/her concern. During an interview on 8/24/22 at 11:30 A.M., the Food Manager and Dietitian were made aware 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 record review and staff interview, the facility failed to maintain documentation in the medical record of blood sugar results, for one Resident (#78), out of a total sample of 27 residents. Findings include: Resident #78 was admitted to the facility in March 2022 with a diagnosis of Type 2 Diabetes Mellitus. Review of the Physician's Orders for Resident #78 indicated the following: - Fingerstick in the morning related to Type II Diabetes Mellitus with diabetic neuropathy (7/21/2022). (A fingerstick is the blood glucose monitoring for diabetics using a glucometer) - If the FSBG (Fasting blood glucose) is less than or equal to 70 and the resident is responsive and able and willing to swallow, treat with 15-20 grams of carbohydrates and assess response, recheck the FSBG in 15 minutes (4-6 oz of orange juice). Every 15 minutes as needed if the FSBG is still less than or equal to 70, retreat with 15-20 grams of carbohydrates by mouth (4-6 oz of orange juice). Then is FSBG is greater than 70, monitor the resident and offer a snack within 30 minutes. Notify provider. (9/19/21) -…

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.