The Guardian Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to: 1. Ensure staff properly labeled the packaging box and/or its multidose vial of Tubersol (tuberculin) (purified protein derivative, a combination of proteins that are used in the diagnosis of tuberculosis) stored inside two of three medication room storage refrigerators reviewed; and 2. Ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised February 2018, indicated but was not limited to the following: -Certain medications or package types, such as multiple dose injectable vials, certain ophthalmic (per manufacturer specifications), once opened, require an expiration date shorter than the manufacturer's…

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 a reasonable accommodation was made for one Resident (#207), out of a total sample of 22 residents. Specifically, the facility failed to ensure the Resident was provided with a call bell device that was within reach and able to be used if the Resident desired to call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, revised March 2021, indicated but was not limited to the following: -Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. -Ask the resident to return the demonstration. -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check on these residents frequently. Resident #207 was admitted to the facility in April 2024 and had diagnoses including unspecified fracture of left femur, closed fracture with routine healing, aftercare following joint replacement surgery,…

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, policy review, and interviews, for one Resident (#207), of 22 sampled residents, the facility failed to implement an individualized, person-centered care plan. Specifically, the facility failed, for Resident #207, who was status post partial left hip replacement, to implement the intervention for the use of an abductor wedge pillow to maintain anterior hip precautions. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated as revised March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident -The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions…

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 follow professional standards of practice for one Resident (#206), out of a total sample of 22 residents. Specifically, the facility failed to administer medications per physician's orders and manufacturer's instructions for use. Findings include: Review of the facility's policy titled Administering Medications, revised April 2022, indicated but was not limited to the following: -Medications are administered in a timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #206 was admitted to the facility in April 2024 with diagnoses including benign prostatic hypertension (BPH) (enlarged prostate), acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer's disease, 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, policy review, and interview for three Residents (#9, #35, and #75), of 22 sampled residents, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #9, #35, and #75, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, undated, indicated but was not limited to: -Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, every six months, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. 1. Resident #9 was admitted in February 2023 with diagnoses that included unspecified dementia, mood disturbance, anxiety…

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 adhere to infection control practices for hand hygiene while preparing medications. Findings include: Review of the facility's policy titled Administering Medications, revised 2022, indicated but was not limited to the following: -Staff follows established facility infection control procedures (e.g. handwashing) for the administration of medications, as applicable. Review of the facility's policy titled Handwashing/Hand Hygiene, revised March 2023, indicated but was not limited to the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap…

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. Findings include: Review of the Facility Assessment, dated 10/7/22, failed to address the following areas: - COVID-19 management, preparations, staffing needs and supply needs - Potential needs for residents who may require isolation or quarantine for infectious diseases - Average resident acuity for those receiving BiPap/CPaP (non-invasive respiratory ventilation), intravenous medications, and injectable medications, - Behavioral health needs of residents who experience substance use disorders Further review of the Facility Assessment and educational trainings provided to staff indicated the facility did not implement its plan for communication and cultural competencies for residents who are non-English speaking or have cultural needs and specifications uncommon to the facility and surrounding community. Review of the 2022…

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, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, indicated but was not limited to the following: -The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents -The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee -The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program -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 document review, interview, and policy review, the facility failed to develop and implement a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility. Specifically, the facility failed to: 1. Measure the success of performance improvement projects (PIPs), actions taken, track performance, and regularly review, analyze and act on data collected; and 2. Ensure the quality assurance committee identified quality deficient areas identified during the survey period to develop and implement an appropriate corrective action plan to ensure satisfactory outcomes. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, indicated but was not limited to the following: -The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents -The owner and/or governing board (body) of our…

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, document review, and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that included the required members at their meetings. Findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program Governance and Leadership, revised March 2020, indicated but was not limited to: -The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body -The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting -The committee has the full authority to oversee the implementation of the QAPI program, including, but not limited to the following: a. Establishing performance and outcome indicators for quality of care and services delivered in the facility; b. Choosing and implementing tools that best capture 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, policy review, and document review, the facility failed to implement their policy to grant COVID-19 vaccination exemptions for staff. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services guidance titled Revised Guidance for Staff Vaccination Requirements, dated October 26, 2022, indicated but was not limited to the following: - Facilities must have a process by which staff may request exemption from COVID-19 vaccination based on an applicable Federal law. This process should clearly identify how an exemption is requested, and to whom the request must be made. Additionally, facilities must have a process for collecting and evaluating such requests, including the tracking and secure documentation of information provided by those staff who have requested exemption, the facility's determination of the request, and any accommodations that are granted. - Medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and 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 policy review, the facility failed to ensure, as part of its quality assurance and performance improvement (QAPI) program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program was conducted. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership, revised March 2020, indicated but was not limited to the following: -The governing body is responsible for ensuring that the QAPI program is adequately resourced and funded including training and staff coverage sufficient to conduct the activities of the program During the recertification survey, the facility failed to provide the surveyor with QAPI training or sign in sheets on the facility's QAPI program. During an interview on 11/10/22 at 11:31 A.M., Consulting Staff #1 said QAPI training was in the works by corporate. The Administrator and Consulting Staff #1 said they did not have documentation of mandatory QAPI training or sign in sheets on the facility's QAPI program…

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 develop and implement a comprehensive ethics and compliance training program. Findings include: Review of the facility's policy titled Compliance and Ethics Program Components, dated December 2020, indicated but was not limited to the following: - the purpose of the compliance and ethics program is to prevent and detect criminal, civil and administrative violations and to ensure quality of resident care - the facility is committed to integrity, transparency and accountability to promote a culture of ethical and lawful practices - the program includes the following components: 1. a compliance and ethics committee 2. communication and education including ongoing in-service training, risk specific job training, and program orientation During an interview on 11/9/22 at 1:42 P.M., the Staff Development Coordinator said the facility has not provided any trainings to the staff on ethics or compliance, and she is not aware of the existence of a facility Ethics Committee. During an interview on 11/10/22 at 12:36 P.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that dignity was provided during the dining experience for four Residents (#15, #32, #84, and #89), out of a total sample of 27 residents. Specifically, the facility failed to ensure that staff: 1. For Resident #15, did not stand over the Resident while assisting him/her to eat in the Unit dining room; 2. For Residents #32, a. delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching tablemates eat, and b. did not stand over the Resident while feeding him/her in the dining room; 3. For Resident #84, delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching tablemates eat; 4. For Resident #89, a. delivered meals to all residents seated at his/her table simultaneously and did not wait an extended period of time to receive his/her meal while watching…

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, policy and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding a lack of face cloths and towels was acted upon timely. Findings include: Review of the facility's policy titled Nursing Home Resident's Rights: Grievances, undated, included but was not limited to: -The facility must make prompt efforts to resolve grievances the resident may have; the resident has the right to receive the written result of the grievance -Standard grievances must be resolved within 5 - 7 business days Review of the Resident Council Minutes, dated 8/16/22, indicated residents had concerns about difficulty in getting face cloths or towels when they need them. Review of the Resident Council Minutes, dated 9/2/22, indicated residents had concerns about difficulty in getting face cloths and towels when they need them. Review of the Resident Council Minutes, dated 10/10/22, indicated residents had concerns about difficulty in getting face cloths and towels when they need them. During a Resident group…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to develop and implement individual person-centered care plans for seven Residents (#56, #22, #51, #54, #29, #32, and #89), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #56, to develop a person-centered plan of care to monitor suicidal ideation; 2. For Resident #22, to develop and implement an individualized care plan for healthcare proxy activation and language barrier; 3. For Resident #51, to develop a comprehensive care plan for both hearing loss and denture use; 4. For Resident #54, to develop a comprehensive plan of care for an abdominal wound; 5. For Resident #29, to develop and implement an individualized plan of care for communication needs; 6. For Resident #32, to develop and consistently implement a comprehensive care plan for: a. a blood clot in the left basilic vein, anticoagulant therapy and a hematoma to the right hand; b. dietary preferences related to the Resident's…

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 7. Resident #395 was admitted to the facility in October 2022 with medical diagnoses of chronic obstructive pulmonary disease, Parkinson's disease, and adult failure to thrive. Review of the Physician's Orders, dated 10/29/22, included but was not limited to: -Myrbetriq Tablet Extended Release 24-hour, 50 MG (Miregron ER) Give 1 tablet via G-Tube one time a day for urinary antispasmodics, (10/29/22). On 11/3/22 at 09:47 A.M., the surveyor observed Nurse #6 on the Grove Unit administering medications to Resident #395 via Gastrostomy-Tube. Upon reviewing the medication poured, Nurse #6 said Myrbetriq (used to treat overactive bladder) 50 MG tablet was not available. Nurse #6 said this medication is not available in an Emergency Kit/ house stock. Review of the Medication Administration Record, dated 10/29/22 to 10/31/22, failed to indicate that Myrbetriq was administered to the Resident as ordered on 10/30/22 and 10/31/22. Review of the Medication Administration Record, dated November 2022, failed to indicate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed for four Residents (#22, #29, #69, and #89) to provide an ongoing activity program to meet and support the individual preferences of the residents, out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #22, to provide support to pursue their one to one (1:1) preferred activities of choice in his/her room; 2. For Resident #29, to support their choice for independent activities; 3. For Resident #69, to encourage and support their choice of group and independent activities and interaction with his/her peers that met their cultural and cognitive needs; and 4. For Resident #89, to develop and provide a program of ongoing resident-centered activities that takes into account the Resident's interests, needs, and cultural preferences to maintain or improve the resident's physical, mental and psychosocial well-being and independence. Findings include: Review of the facility's policy titled Activity Evaluation, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to provide an environment which would remain free of accidents and hazards including for two Residents (#64, #10), in a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #64, to conduct a fall risk assessment and implement interventions following a fall; 2. For Resident #10, ensure hazardous items were not left at the bedside and accessible to wandering residents on the unit; and 3. Ensure (a.) one housekeeping closet and (b.) one supply closet were locked, and hazardous/toxic items chemicals were not accessible to wandering residents on the [NAME] Unit. Findings include: 1. Review of the facility's policy titled Falls-Clinical Protocol, dated as revised in March 2018, indicated the following: -staff will ask the resident or family about history of falling -staff will assess and document the following: vitals, recent injury, musculoskeletal function, change in cognition, neurological status, pain, frequency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and policy review, the facility failed to a. Ensure an opened Insulin Emergency Kit was returned to the Pharmacy in exchange for a new kit; b. Ensure an expired medication was not administered to a resident; and c. Dispose of an overflow of non-controlled medications in the collection receptacle. Findings include: On [DATE] at 12:20 P.M., the surveyor reviewed the Medication Storage Room on the second floor Meadows Unit with Unit Manager (UM) #1. Upon reviewing the refrigerator, the surveyor observed the following: a. Insulin (regulates blood sugar level) Emergency Kit #Il092, no expiration date, was opened. The kit failed to include documentation on when and why it was opened. Review of the Emergency Kit Exchange Form inside the e-kit was blank. The kit was not returned to pharmacy to be replaced. During an interview, UM #1 said she did not know when and why the e-kit was opened. b. Omeprazole (used to treat certain conditions where there is too much acid in the stomach) 2/ML…

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 staff interviews, the facility failed to ensure medication irregularities identified during the Pharmacist's Drug Regimen Review were reported and acted upon for two Residents (#73 and #63), out of five residents sampled for unnecessary medication reviews. Findings include: Review of the facility's policy titled Medication Regimen Reviews, dated May 2019, indicated the following process: -within 24 hours the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. -if the physician does not provide a timely or adequate response, the consultant identifies no action has been taken, the medical director or the administrator will be contacted. -the attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it. -the consultant pharmacist provides the director of nurses with a written signed and dated copy of all medication regimen reports. 1. Resident #73 was admitted 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 record review, policy review, and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant agent prescribed for five Residents (#10, #32 #72, #401 and #73), from a total sample of 27 residents. Findings include: Review of the facility's policy titled Anticoagulation-Clinical Protocol, last revised 11/2018, included but was not limited to: Assessment and Recognition -As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications b. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulant medication should be assessed for bleeding) -The Physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious…

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, observation, and policy review, the facility failed to store medications and biologicals in a safe manner. Specifically, the facility failed: 1. For Resident #10, to ensure wound treatment supplies were not left out and unsecured in the Resident's room; 2. For Resident #32, to ensure treatment supplies were not left out and unsecured in the Resident's room; and 3. To label refrigerated medications appropriately, store and label Tuberculin (used in a test by hypodermic injection for infection with or immunity to tuberculosis) vials appropriately and ensure medications in the active medication cart were not expired. Findings include: Review of the facility's policy titled Storage of Medications, revised November 2020, indicated but was not limited to the following: -With the exception of Emergency Drug Kits, drugs and biological used in the facility are stored in a locked compartment under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - the nursing staff 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 staff interview, the facility failed to ensure the resident and/or the resident representative had information in advance to exercise the resident's rights for one Resident (#22), out of a total sample of 27 residents. Specifically, the facility failed to ensure the Resident's Health Care Proxy (HCP) and Resident #22 were given information necessary to make health care decisions, including the risks and benefits of psychotropic medications and provide consent for its use, prior to administration. Findings include: Review of the facility's policy titled Resident Representative, dated February 2021, indicated the facility treats the decisions of the resident representative as the decisions of the resident in accordance with applicable law. It further indicated but was not limited to: - the resident representative is an individual chosen by the resident to act on behalf of the resident in order to support the resident's decision-making capability - the facility staff respects the delegated resident representative's decisions regarding 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, interview, and policy review, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the purpose for psychotropic medications as well as the risks and benefits, prior to their use for three Residents (#19, #24, and #71), out of a total sample of 27 residents. Findings include: Review of the facility's policies titled Antipsychotic Medication Use, dated December 2016, and Behavioral Assessment, Intervention, and Monitoring, revised March 2019, included but was not limited to the following: -The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated -The resident and family/representative will be informed of the resident's condition as well as the potential risks and benefits -When medications are prescribed for behavioral symptoms, documentation will include 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, interview, and policy review, the facility failed to accurately reflect the updated Medical Orders for Life-Sustaining Treatment (MOLST)/Advanced Directive in the medical record for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Advanced Directives, revised December 2016, indicated but was not limited to the following: -The interdisciplinary team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. Resident #51 was admitted to the facility with diagnoses including congestive heart failure (chronic condition where heart does not pump blood as well as it should), anxiety disorder, obstructive sleep apnea (intermittent airflow blockage during sleep), depression, atherosclerotic heart disease (build- up of fats, cholesterol, and other substances in and on the artery walls), and chronic obstructive pulmonary disease (lung disease 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 observations, record reviews, and interviews, the facility failed to notify the Physician of seizure activity for one Resident (#64), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, last revised February 2021, included, but was not limited to: -Our facility promptly notifies the resident, his or her attending Physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). -The nurse will notify the resident's attending Physician or Physician on call when there has been a: -accident or incident involving the resident; -discovery of injuries of an unknown source; -significant change in the resident's physical/emotional/mental condition; -need to alter the resident's medical treatment significantly; -specific instruction to notify the Physician of changes in the resident's condition -The nurse will record in the resident's medical record information relative 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 and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#32), from a total sample of 27 residents. Specifically, the facility failed to ensure staff did not communicate Resident #32's private health information and images of his/her body with his/her Physician via text messaging utilizing an unsecured mobile phone platform. Findings include: Resident #32 was admitted to the facility in September 2022 with diagnoses including dementia. During an interview on 11/9/22 at 11:05 A.M., Physician #1 said that he was on vacation from 11/3/22 to 11/6/22 and had text message communication with Unit Manager #2 on 11/4/22 and 11/7/22 regarding a change in condition for Resident #32. The Physician opened his mobile phone and reviewed the text message exchanges with the surveyor. The text messages included, but was not limited to: -Resident's first and last name -Resident's date of birth -Resident's admission date -Resident's gender -Resident's race -the name of the facility 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 policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#15), out of a total sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed: 1. For Resident #15, to follow their policy for investigating and reporting a bruise of unknown origin; and 2. To follow their policy for reporting and investigating an allegation of neglect that was documented in Resident Council Minutes. Findings include: 1. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated as revised April 2021, included, but was not limited to the following: -The program consists of a facility-wide commitment and resource allocation to support the following objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; - Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents b. neglect of residents; and/or c. theft,…

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 allegations of abuse were reported to the State Agency, for one Resident (#15), out of a total sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed to report: 1. a bruise of unknown origin for Resident #15; and 2. an allegation of neglect that was documented in Resident Council Minutes. Findings include: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated as revised in April 2021, included but was not limited to the following: -Investigate and report any allegations within timeframes required by federal requirements (no later than 2 hours) Resident #15 was admitted to the facility in August 2016 with diagnoses including Alzheimer's disease and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment, dated 8/11/22, indicated Resident #15 had both long- and short-term memory problems, severely impaired cognitive skills for daily…

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 allegations of abuse were investigated and residents protected from further harm for two Residents (#15 and #32), out of a sample of 27 residents, and for one allegation brought forward during a Resident Council Meeting. Specifically, the facility failed to investigate and protect: 1. Resident #15, for a bruise of unknown origin; 2. Resident #32, for an allegation of abuse; and 3. A Resident identified in the August 2022 Resident Council Minutes that alleged neglect. Findings include: Review of the facility's policy titled Investigations- How to Conduct, dated as revised November 2019, indicated the following: -the supervising nurse begins the investigation immediately and completes the incident report -conducts interviews, with written statements of potential witnesses -identify who was involved -identify what occurred -summarize analysis of facts gathered 1. Resident #15 was admitted to the facility in August 2016 with diagnoses including Alzheimer's disease and cognitive communication disorder.…

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 ensure that its staff issued transfer notices to two Residents (#32 and #543) or Resident Representatives, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Transfer or Discharge (last revised March 2021) included but was not limited to: -The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: 1. name, address, email and telephone number of the entity which receives appeal hearing requests; 2. information about how to obtain, complete and submit an appeal request; and 3. how to get assistance completing the appeal process e. The facility bed-hold policy; and f. the name, address,…

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 ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for two Residents (#32 and #543), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Transfer or Discharge (last revised March 2021) included but was not limited to: -The resident and representative are notified in writing of the following information: -The facility bed-hold policy 1. Resident #32 was admitted to the facility in September 2022 and had an activated Health Care Proxy. Review of the medical record indicated Resident #32 was transferred to the hospital on [DATE] and 11/4/22. Further review of the medical record indicated no evidence that a facility bed-hold notice for the above dates was issued to the Resident or Resident Representative as required. During an interview on 11/10/22 at 9:19 A.M., the surveyor reviewed Resident #32's medical record with Nurse…

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 that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care and provide the resident and his or her representative, if applicable, with a written summary of the baseline care plan for one Resident (#243), in a total sample of 27 residents. Specifically, the facility failed to develop a baseline care plan for anticoagulation therapy. Findings include: Resident #243 was admitted to the facility in November 2022 with diagnoses including cerebral vascular accident. Review of the medical record indicated a Physician's Order for the following: -Heparin (anticoagulant) 5000 units/milliliter. Inject 5000 units subcutaneously three times a day (start date 11/4/22) Further record review indicated that there was no documentation in the medical record that a 48-hour care plan with initial goals, services and treatments to be administered…

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 review and revise the care plan for one Resident (#54)'s nephrostomy tube (thin plastic tube that is passed from the back, through the skin and then through the kidney where the urine collects) based on their changing needs/status, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated but was not limited to the following: -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change -The interdisciplinary team reviews and updates the care plan when the desired outcome is not met -The comprehensive, person-centered care plan describes services that would otherwise be provided but are not provided due to the resident exercising his or her rights, including the right to refuse treatment Resident #54 was admitted to the facility with diagnoses including openings of urinary tract, malignant neoplasm of right…

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

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#51), out of a total sample of 27 residents, received the proper treatment to maintain hearing abilities. Findings include: Review of the facility's policy titled Hearing-Impaired Resident, Care Of, revised February 2018, indicated but was not limited to the following: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors -Staff will assist the resident with locating available resources, scheduling appointments and arranging transportation to obtain needed services -When interacting with the hearing- impaired resident, staff will implement the following: a. Evaluate the resident's preferred method of communication (lip reading, tablet, etc.) with staff and other residents b. Determine the resident's awareness of and adaptation to hearing loss d. Regularly engage the resident in conversation using whatever communication method he or she prefers g. When speaking, enunciate clearly, slowly, and in 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 observation, interview, and record review, the facility failed to provide treatment and services for one Resident (#54), out of 27 sampled residents, with a nephrostomy tube (thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where urine collects). Specifically, the facility failed to securely anchor the nephrostomy tube to help prevent inadvertent dislodgment, provide ongoing assessment, and educate the Resident on self-care to help prevent catheter-related urinary tract infections. Findings include: Review of the facility's policy titled Catheter Care, Urinary, revised September 2014, indicated but was not limited to the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections Maintaining Unobstructed Urine Flow -Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing 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 ensure the cleaning of respiratory care equipment for one Resident #78, in a total sample of 27 residents. Findings include: Review of the facility's policy titled Respiratory Therapy Prevention of Infection, dated November 2011, indicated for oxygen administration to wash the filters from the oxygen concentrators every seven days with soap and water; rinse and squeeze dry. Resident #78 was admitted to the facility in March 2022 with a diagnosis of chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of the Physician's Orders for Resident #78 indicated the Resident was receiving 3 liters of Oxygen, continuously through a nasal cannula. Review of the orders included an order to change and date the tubing once per week. On 11/03/22 at 7:35 A.M., the surveyor observed the oxygen concentrator for Resident #78 to be in use by the Resident. On the side of the concentrator was a filter (normally black in color) which was tan in color due to the dust. 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 observation, interview, and policy review, the facility failed to ensure for one Resident (#543) of one resident receiving hemodialysis treatment, care and services were consistent with professional standards of practice. Specifically, the facility failed to ensure ongoing communication and collaboration with the dialysis center regarding care and services was maintained. Findings include: Review of the facility's policy titled Dialysis Management, dated as revised on 5/2019, indicated but was not limited to the following: -Facility will establish open communication with the Resident's dialysis center utilizing a dialysis communication book completing the dialysis communication form -The nurse will establish pre-dialysis vital signs (blood pressure, temperature, pulse and respirations), advanced directives and any pertinent resident information -On return from the dialysis center the nurse will review the communication returning from the dialysis center Resident #543 was admitted to the facility in March 2015 with diagnoses including chronic kidney disease. 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 interviews and record reviews, the facility failed to ensure the physician reviewed the total program of care for two Residents (#64 and #69), out of a total sample of 27 residents. Specifically, the physician failed to review the following total programs of care for: 1. Resident #64 with a diagnosis of epilepsy and use of an anticonvulsant medication; and 2. Resident #69 with a pacemaker. Findings include: 1. Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy. Review of the Physician's Orders indicated Resident #64 received Depakote (an anticonvulsant) sprinkles capsule 125 milligrams (mg), give 4 capsules twice per day for seizures. Review of the medical record indicated the last therapeutic levels for Depakote (Valproic Acid) were collected on 11/11/21. Review of the Physician's Progress note, dated 3/2/22, failed to indicate Resident #64 had a seizure disorder and was taking an anticonvulsant medication. Review of the History and Physical, dated 7/14/22, failed to indicate any history of seizure disorder. Review of the Nurse…

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

Based on interviews and record review, the facility failed to ensure one Resident (#64), in a sample of 27 residents, had been seen by a physician every sixty days and that required visits alternated between the Physician and the Nurse Practitioner. Findings include: Resident #64 was admitted to the facility in June 2021 with a diagnosis of epilepsy, dementia, and diabetes. Review of the medical record for Resident #64 indicated the Resident had been seen by the Physician on 3/3/22. The following visits were conducted by the Nurse Practitioner: 7/14/22, 8/27/22, and 9/29/22. The electronic and paper medical record failed to include any other progress notes from the Physician or the Nurse Practitioner. During an interview on 11/3/22 at 3:40 P.M., the Medical Record staff said there were no additional Physician or NP progress notes available for Resident #64. During an interview on 11/8/22 at 1:15 P.M., the Assistant Director of Nurses said Resident #64 was last seen by the Physician on 3/3/22 (8 months prior) and the required visits should have alternated between the Physician 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 one Residents #63 was free from unnecessary psychotropic medications, in a sample of five residents reviewed for unnecessary medication. Specifically, for Resident #63, the facility failed to ensure a.) an antipsychotic was given to treat a specific condition and was given in the lowest possible dosage for the shortest period of time, and b.) an as needed (PRN) psychotropic medication was limited to 14 days. Resident #63 was admitted to the facility in July 2022 with a diagnosis dementia, major depressive disorder, recurrent severe without psychotic features, and anxiety. a. Review of the Physician's Orders indicated an order initiated on 7/12/22 for Olanzapine (antipsychotic) 5 milligrams (mg) three times per day for mood disorder. Review of the Psychiatric Nurse Practitioner's (NP) progress notes indicated the following: 7/15/22: check mark indicated psychosis was absent (no indication of audio or visual hallucinations or delusions); 7/29/22: check mark indicated psychosis was absent, noted as no delusions 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 observation, interview, record review, and policy review, the facility failed to provide routine dental services to meets the needs for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Dental Examination/Assessment, revised December 2013, indicated but was not limited to the following: -Resident shall be offered dental services as needed -Dental examinations will be made by the resident's personal dentist or by the facility's consultant dentist -Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist Resident #51 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), dyskinesia (uncontrolled, involuntary muscle movement) of the esophagus, and gastro-esophageal reflux disease (GERD). Review of the Minimum Data Set (MDS) assessment, dated 9/16/22, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and did not have loosely fitting full or partial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide skilled rehabilitative services following an appeal decision for one Resident (#22), out of a total sample of 27 residents. Findings include: Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, reduced mobility, and abnormalities of gait and mobility. Review of the current Physician's Orders indicated the following rehabilitative (rehab) order: - (8/1/22) Occupational Therapy (OT), Physical Therapy (PT), and/or Speech Therapy (ST) to evaluate and treat as needed Review of skilled rehab documentation indicated Resident #22 was on OT services from 8/2/22 - 9/29/22 and PT services from 8/30/22 - 9/30/22; was hospitalized a short time on 9/30/22 and received skilled OT a second time from 10/4/22 - 10/17/22 and PT services a second time from 10/6/22 - 10/20/22. Review of the OT Discharge summary, dated [DATE], indicated but was not limited to the following: -…

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

Based on interviews and record review, the facility failed to ensure its staff maintained accurate documentation for two Residents (#72, #1B), out of a total of 24 residents. Specifically, the facility failed to: 1. For Resident #72, ensure the Resident's comprehensive care plan did not include a cardiac monitoring device when the Resident did not have one; and 2. For Resident #1B, accurately identify the rationale/diagnosis for the use of the medication Valproic Acid. Findings include: 1. Resident #72 was admitted to the facility in October 2020. Review of the Resident's Comprehensive Care Plans included but was not limited to: -Focus: The Resident has a zio patch external monitor (single-use monitor designed to improve patient compliance while maximizing diagnostic yield) to left upper chest related to recent hospitalization related to myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs) and for post hospitalization cardiac monitoring (12/22/22) -Interventions: Ensure the monitor…

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 that 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 (#10 and #72), of a total sample of 27 residents. Specifically, the facility failed to ensure: 1. For Resident #10: a. an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the medical record; and 2. For Resident #72: a. to ensure an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the medical record. Findings include: Review of the Hospice Care Services Agreement, signed June 23, 2021, included but was not limited to: -The Hospice provider shall coordinate with the facility in the admission process…

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 document the administration and results of a COVID-19 test for one Resident (#51), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Coronavirus Disease - Testing Residents, dated September 2021, indicated but was not limited to the following: - all COVID-19 tests conducted for residents, including results are documented - documentation includes the date and time the test was conducted and results obtained Review of the facility's Resident Testing Logs indicated Resident #51 was COVID-19 positive on 9/1/22. Review of the medical record for Resident #51 failed to indicate a COVID-19 test had been conducted on 9/1/22. During an interview on 11/9/22 at 7:43 A.M., the Infection Preventionist (IP) reviewed the facility testing logs and said Resident #51 was positive for COVID-19 on 9/1/22. Upon reviewing the medical record, she said the staff did not document on the Treatment Administration Record or in the progress notes that a COVID-19 test was conducted on 9/1/22.…

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.