Cape Regency Rehabilitation & Health Care Center

Based on record review and interview, the facility failed to ensure advanced directives for one Resident (#116), out of total sample of 23 residents, were executed in accordance with the Resident's wishes, specifically, their Medical Orders for Life Sustaining Treatment (MOLST medical order form that relays instructions between health professionals about a patient's care based on an individual's right to accept or refuse medical treatment). Findings include: The Facility does not have a policy for Advanced Directive formulation. Resident #116 was admitted to the facility in April 2025 with diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident #116 scored 3 out of 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. On 05/14/25 at 01:54 P.M., the surveyor and Unit Manager #3 reviewed Resident #116's electronic medical record which indicated that the Resident's code status was Full Code. Review of the paper record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Resident's physician and activated Health Care Proxy (HCP) about a significant medication error so as to re-evaluate the potential need to alter the treatment plan for one Resident (#76), from a total sample of 23 residents. Specifically, the facility failed to notify the primary physician and health care proxy of a medication reconciliation error resulting in Resident #76 receiving nine additional doses of Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots). Findings include: Review of the facility's policy titled Medication Error Reporting, dated April 2015, indicated, but was not limited to the following: -A medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional. -A medication error report is to be completed immediately after an error is discovered to ensure proper resident/patient follow-up.…

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

Based on observations and interviews, the facility failed to ensure residents had a homelike environment. Specifically, the facility failed to: 1. Ensure a comfortable and homelike dining experience in one of three dining rooms; and 2. Repair a water damaged wall area around a built-in wall unit air conditioner. Findings include: 1. During dining observations throughout the survey on 5/14/25, 5/15/25, and 5/16/25, surveyors observed the following: On 5/14/25 from 8:15 A.M. through 8:30 A.M., the surveyor observed the third-floor dining room: -Five residents were seated at one round folding table (different than the other five tables), no tablecloth, all breakfast meals were served on trays -Seven out of 13 residents were served from the first meal truck and all meals were served on the meal trays -None of the six tables had tablecloths -At 8:38 A.M., the remaining six residents received their breakfast meal with the plates, bowls and cups remaining on the meal trays. On 5/14/25 at 12:30 P.M., the surveyor observed the third-floor unit dining room. All six tables had maroon…

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 labeled and stored in accordance with acceptable professional standards for three Residents (#64, #24, #23), of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #64, to ensure the Resident's inhaler and allergy nasal spray medications were stored securely; 2. For Resident #24, to ensure the Resident's nasal spray medication was stored securely; and 3. For Resident #23, to ensure the Resident's inhaler medication was stored securely. Findings include: Review of the facility's policy titled Medication Storage in the Facility, undated, indicated but was not limited to the following: - Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. - The manner of storage prevents access by other residents. 1. Resident #64 was…

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 implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Infection Control Prevention Program - Antibiotic Stewardship, revised 3/2024, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's infection prevention and control program. The goal of this program is to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. - The facility will establish an antimicrobial stewardship team (AMS) dedicated to improving antimicrobial use. - The core members of the AMS team will include, but not be limited to the Medical Director, Pharmacy Consultant, Director of Nurses (DON), and Infection Preventionist (IP). - The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure two Residents (#23 and #87), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended pneumococcal vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed: 1. For Resident #23, to ensure the Resident's medical record included documentation that indicated the Resident/Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination and declined vaccination; and 2. For Resident #87, to ensure the Resident's medical record included documentation that indicated the Resident/Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination and either consented to receive or refused…

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), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 had an unwitnessed fall, and was found in the bathroom kneeling on the floor, the Facility failed to ensure the Provider and Family Member #1, were notified. Findings include: Review of the Facility's Policy, titled Condition: Significant Change, dated April 2015, indicated the following: -staff will communicate with the physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management - the physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition -this notification shall be documented in the clinical record Review of the Facility's Policy, titled Falls Management, dated as reviewed/revised April 2024 indicated the following: -anytime a resident is found on the floor, a fall is considered to have occurred -post fall, once 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 was found on the bathroom floor after an unwitnessed fall by nursing staff, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Nurse #1 said she assessed Resident #1 after the incident, she did not document it, did not complete an incident report or write a progress note, and did not report the unwitnessed fall to the oncoming shift nurse, so he/she could be monitored. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility…

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

Based on observation, interview, and policy review, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Ensure staff performed hand hygiene in between each resident during a medication pass and did not touch the medications with their bare hands; 3. Ensure staff performed hand hygiene in between glove changes during a dressing change treatment for Resident #257; and 4. Ensure transmission based precautions (TBP) were implemented according to Centers for Disease Control and Prevention (CDC) guidance for Resident #21. Findings include: 1. Review of the facility's policy titled The Infection Prevention Program, dated as revised October 2022, included but was not limited to the following: -This facility follows the professional standards set forth as recommended by the CDC/OSHA. The goal of the Infection Prevention Program is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. -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 review with the Resident Council. Findings include: Review of the facility's policy titled Resident Council, last revised 10/2015, indicated the following: - It is the policy of this home that the Recreation Department will provide support and assistance in the formation of a Resident Council. - The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home. - Resident Council will meet monthly. - Maintain written minutes including residents in attendance, opening, adjournment times, discussions and/or actions that take place. - Notify Department Heads in writing of concerns that come up during the meeting. - Retain a copy of the resolutions that address each concern. - Retain minutes on file for a minimum of one (1) year. - 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on 1 of 3 resident care units. Findings include: Review of the facility's policy titled Preventative Maintenance, undated, indicated but was not limited to: -The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identified areas/items in need of repair. The Maintenance Director will follow all policies regarding routine periodic maintenance. On 3/22/24 at 10:00 A.M., the surveyor observed the window screens on the first floor at the end of both hallways to be broken and did not fit correctly in the window leaving gaps where the screen was bent between the glass and screen. On 3/27/24 at 1:56 P.M, the surveyor observed the first floor resident sitting area with wall molding separating…

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 follow 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 maintain safe and clean microwaves in three out of three kitchenettes. Findings include: Review of the 2022 Food Code, a model for safeguarding public health and ensuring food is safe for consumption, indicated: 4-201.11 Equipment and Utensils. Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms . Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. On 3/27/24…

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

Based on record review, policy review, and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians. Specifically, the facility failed to: 1. Complete antibiotic usage audit tools, which are used to track, report, and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program; and 2. Ensure antibiotics prescribed are necessary for one Resident #40. Findings include: Review of the facility's policy titled Antibiotic Stewardship, dated as revised October 2022, indicated but was not limited to the following: -It is the policy of this facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. -The facility will establish an antimicrobial stewardship team dedicated to improving antimicrobial use. -When symptoms of an infection are documented, the following measures will be implemented: Symptoms…

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 the kitchen walk-in freezer was maintained in safe operating condition. Findings include: On 3/26/24 at 8:35 A.M., the surveyor observed the walk-in freezer, located in the main kitchen, to have frost accumulation on the bottom of the window on the outside of the door. The surveyor was able to pull open the freezer door without unlatching it. The surveyor observed the inside of the walk-in freezer to have shaved ice on the floor immediately inside the door. In addition, the surveyor observed ice accumulation on the floor below the back wall, on English muffins located below the cooling fan, and on two roasting pans covered with aluminum foil. The surveyor observed a block of ice with a direct dripping from the cooling fan. The door handle for the freezer did not latch and the door did not close all the way. On 3/28/24 at 10:55 A.M., the surveyor inspected the walk-in freezer with the Food Service Director and observed the outside window of the freezer to have an increased accumulation of ice; the inside of the freezer…

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 a baseline care plan was developed for two Residents (#257 and #259) for their history of substance abuse, out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Care plan - Baseline, dated as revised in November 2017, indicated but was not limited to the following: - a baseline care plan is developed within 48 hours of admission based on information obtained during the admission process as a guide for care until the comprehensive care plan is developed. 1. Resident #257 was admitted to the facility in March 2024 with a diagnosis of alcohol abuse. Review of the most recent Brief Interview for Mental Status (BIMS), dated 3/12/24, indicated Resident #257 was cognitively intact with a score of 15 out of 15. Review of the baseline care plans and current comprehensive care plans as of 3/27/24 failed to indicate a baseline care plan was developed to assist the Resident in managing his/her substance use disorder. 2. Resident #259 was admitted to the facility in March…

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 develop individualized, person-centered care plans regarding pain management for two Residents (#257 and #259), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled: Comprehensive Care Plans, dated as revised November 2017, indicated but was not limited to the following: - the facility is committed to providing residents with all necessary care and services to enable them to achieve their highest quality of life - recognizing each resident as an individual, the facility will identify and meet those needs in a resident-centered environment - care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of function and reflect resident preferences - care plans are a combination of data from the hospital discharge record, physician data, evaluations performed by professionals, resident goals of treatment and acute/chronic events, behaviors and/or illnesses. - comprehensive care plans are developed by the…

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

Based on observation, policy review and interview, the facility failed to ensure one Resident (#41) was administered their medications in accordance with professional standards and the facility policy. The total sample was 21 residents. Findings include: Review of the facility's policy titled Medication Administration - Oral, dated June 2015, indicated but was not limited to the following: - drugs for oral administration are available in tablets, capsules, syrups, elixirs, oils, liquids, suspensions, and powders. - the nurse is to stay with the resident until he/she has swallowed the medication. Resident #41 was admitted to the facility in July 2023 with diagnoses including stroke, hypertension, and diabetes mellitus. On 3/27/24 at 7:56 A.M., the surveyor observed Nurse #1 pour liquid protein 30 milliliters (mls) into a cup for Resident #41 as part of his/her morning medications. The nurse then left the cup of medication with the Resident after informing him/her what the medication was. She did not observe the Resident ingest the medication to ensure it was consumed by the Resident.…

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

Based on observation, interview, and record review, the facility failed for two Residents (#33 and #65), out of a total sample of 21 residents, to ensure staff provided the necessary respiratory care and services in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #33, to ensure continuous positive airway pressure (CPAP) mask and tubing were stored properly in a sanitary manner to prevent potential contamination from germs and environmental debris; and 2. For Resident #65, to ensure CPAP mask and tubing were stored in a sanitary manner to decrease the risk of potential contamination. Findings include: Review of Lippincott's Manual of Nursing Procedures 9th edition, dated 2023, indicated but was not limited to the following: -When the CPAP therapy has been completed, follow these steps: -Clean and disinfect the equipment using a facility-approved disinfectant according to the manufacturer's instructions -Store it properly 1. Resident #33 was admitted to the facility in September 2022 with diagnoses including acute and chronic…

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 maintain an effective resident-centered pain management program to assist one Resident (#257) in meeting their individual pain goals, out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Pain Management, dated April 2015, indicated but was not limited to the following: - the facility is committed to assisting each resident attain or maintain their highest practicable well-being, by evaluating pain and using interventions to prevent pain from interfering with overall quality of life - in the evaluation the resident's perception of pain is always considered reality and the resident's goal of pain for pain management will be honored - the resident's acceptable level of pain will be determined by resident interview and evaluation - the facility will: assess potential for pain, recognize the onset or presence of pain, assess using a standardized scale, develop and implement interventions to pain management both pharmacological and non-pharmacological, use pain…

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 consistently provide substance use disorder counselling and services for two Residents (#257 and #259), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Treatment Options for Residents with Substance Use Disorder, dated March 2024, included but was limited to: - the facility will offer appropriate individualized treatment for all residents living with the disease of addiction or with a history of substance use disorder - newly admitted residents with substance use disorder will be assessed by licensed substance use clinicians, or designee, and offered appropriate referrals as indicated, warranted, feasible and agreed upon - substance use clinicians, or designee, will provide resources to residents who request and/or accept referral to substance use treatment and will support/assist with initiating treatment - residents with substance use disorder and actively being treated as well as residents with a history of substance use disorder, will be offered behavioral…

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 safely store medications on one out of three units observed. Specifically, the facility failed to ensure medication carts were secure when not in view of the licensed nurse. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart, dated February 2018, indicated but was not limited to the following: -The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel On 03/26/24 at 9:05 A.M., the surveyor observed the medication cart on first floor south side, in the hallway outside of room [ROOM NUMBER], the cart was unlocked, the medications were unsecured, and there was no licensed nurse in the area. On 3/26/24 at 9:07 A.M.,…

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

Based on interview and record review, the facility failed to ensure laboratory (lab) services were obtained for one Resident (#89), out of a total sample of 21 residents. Specifically, the facility failed to follow the physician's plan to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), HgbA1c (hemoglobin A1C), lipid panel, and TSH (thyroid-stimulating hormone). Findings include: Resident #89 was admitted to the facility in October 2023 with diagnoses of diabetes and a history of a stroke with left sided hemi-paresis. Review of the medical record indicated Resident #89 was seen by the physician on 1/18/24 for generalized weakness and slow progressive decline. The Physician's Progress Note included a plan to check the CBC, CMP, HgbA1c, lipid panel and TSH. Review of the Physician Interim Orders indicated orders for the following labs were written: 1/18/24: Keppra level 2/12/24: Digoxin level, CBC, CMP, EKG Review of the medical record failed to indicate the CBC, CMP, HgbA1C, lipid panel or TSH were completed. During an interview on 3/28/24 at 10:17 A.M.,…

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

Based on observation, record review, and 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; and 2.) Ensure three unit kitchenette refrigerators were maintained in a sanitary manner to store food and fluid. Findings include: 1. On 9/19/22 at 8:15 A.M., the surveyor observed the following sanitation concerns in the kitchen: *Walk-in freezer had two large containers of frozen vegetables left open and exposed to the air *Diet aide serving breakfast was not wearing a hairnet On 9/21/22 at 8:00 A.M., the surveyor entered the main kitchen and observed breakfast meal service. [NAME] #2 was observed serving breakfast. [NAME] #2 was observed leaving the tray line, turn to the stove and open the oven door with her gloved hand. [NAME] #2 picked up 4 pieces of French toast directly out of the oven, returned to the tray line and began serving again without changing her gloves or washing her…

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

Based on observation, record review, and interviews, the facility failed to develop a comprehensive person-centered care plan for four Residents (#10, #214, #68, and #112) and implement a care plan for one Resident (#6), out of a total sample size of 25 residents. Specifically, the facility failed 1.) For Resident #10, to ensure staff developed a comprehensive care plan for the care and treatment of a pressure area to the left lateral foot; 2.) For Resident #214, to ensure staff developed a comprehensive care plan following a fall at the facility resulting in a facial laceration; 3.) For Residents #68 and #112, to ensure staff developed a comprehensive care plan for the use of psychotropic medications; and 4.) For Resident #6, to ensure staff implemented a care plan for fall interventions. Findings include: 1.) Resident #10 was admitted to the facility in August 2015 with diagnoses that included cerebrovascular accident (stroke) and peripheral vascular disease. Review of the Wound Care notes, dated 8/1/22, indicated the Resident had presented with a new wound to the left foot. 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, staff and resident interviews, and review of food temperature logs, the facility failed to ensure that food and drink are palatable, attractive, and served at a safe and appetizing temperature. Findings include: During an interview on 9/19/22 at 10:11 A.M., Resident #165 said the food is cold, especially the eggs. During an interview on 9/19/22 at 10:58 A.M., Resident #87 said the food is terrible, sometimes I don't know what it is. The Resident said sometimes he/she was hungry after meals because sometimes he/she did not eat. The Resident said the other day the meat had a lot of gristle and he/she could not eat it. During an interview on 9/19/22 at 11:34 A.M., Resident #70 said the food is horrible. The Resident said that he/she chokes a lot, so they give him/her peanut butter and jelly sandwich with all my meals because he/she can't eat certain foods. During an interview on 9/19/22 at 11:58 A.M., Resident #13 said the food is 50%. During an interview on 9/19/22 at 12:14 P.M., Resident #17…

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 resident and staff interview, the facility failed to maintain personal equipment (wheelchair armrests) in good condition for five Residents (#87, #73, #55, #75, and #167), from a total sample of 25 Residents. Findings include: On 9/19/22 and 9/20/22 and throughout all days of survey (9/19/22 through 9/22/22), the following observations were made of residents' wheelchair armrests: On 9/19/22 at 10:30 A.M., the surveyor observed Resident #75's wheelchair armrests covered in silver duct tape. Resident #75 said the armrests have been like this for a while. On 9/20/22 from 10:35 A.M. to 10:40 A.M., the surveyor observed: * Resident #73's left outer armrest with two open areas exposing padding. * Resident #167's right armrest had several cracked, rough areas and the back rest had a tear on the top. * Resident #55's wheelchair armrests had several cracked and rough surfaces. On 9/21/22 at 11:30 A.M., the surveyor observed that Resident #87's wheelchair armrests were badly cracked and rough to the touch. During an interview on 9/21/22 at 11:35 A.M., Resident #87…

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 review and revise the plan of care for one Resident (#16) following a hospitalization for aggressive behavior and a Resident to Staff altercation, out of a total sample of 25 residents. Findings include: Resident #16 was admitted to the facility in December 2021 with diagnoses that included Alzheimer's disease, restlessness, agitation, and dementia with behavioral disturbances. Review of the Minimum Data Set (MDS) assessment, dated June 2022, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating the Resident has moderate cognitive impairment. Further review of the MDS indicated the Resident experienced delusions and physical and verbal behavioral symptoms towards others. Review of the medical record indicated the Resident had a physical altercation with a staff member in July 2022 that resulted in injury to the staff member and the Resident being sent to the hospital for a psychiatric evaluation. Review of the facility Incident Report, dated 7/20/22, indicated in July 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 record review, staff interview, and policy review, the facility failed to ensure that Nurse #9 documented the required information in the medical record for the removal of a PICC (peripherally inserted central catheter) line in accordance with professional standards of practice and the facility's policy for one Resident (#61) of one Residents with a PICC line, from a total sample of 25 residents. Findings include: Review of the facility's policy titled Peripherally Inserted Central Catheter Removal, dated January 2022, indicated was but not limited to the following: POLICY: *The licensed nurse will have documented education and competency in the management and removal of vascular access devices and will practice according to state regulations. PROCEDURE: 19. Documentation at a minimum: *Date/time *Reason for removal *Removed catheter length and condition of the catheter tip *Type of dressing applied *Resident's response to the removal *Comprehensive site assessment *Any complications encountered and interventions *Resident/caregiver education Resident #61 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 policy review, record review, and staff interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards, through ongoing communication and collaboration with the dialysis facility for one Resident (#67), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Hemodialysis, dated 4/2015, indicated the following but was not limited to: - communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: - vital signs - copy of the MAR (Medication Administration Record) - Any change of condition from last hemodialysis treatment - Documentation will be completed prior to dialysis treatment - The communication book/sheet will be reviewed upon return from dialysis Resident #67 was admitted to the facility in January 2022 with diagnoses that include end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 9/2022, indicated the Resident was receiving dialysis services. 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 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 one Resident (#61), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated 4/2015, indicated but was not limited to the following: POLICY: *Each resident's drug regimen will be free from necessary drugs. Administration of psychoactive medications will focus on the individual needs of the resident, and will be prescribed only when necessary and clinically indicated to treat specific conditions and symptoms as diagnoses and documented. Psychoactive medication management will include implementation of behavioral interventions, gradual dose reduction attempts, and adequate monitoring that complies with Federal and State guidelines. PROCEDURE: *Obtain physician's order for each psychoactive medication. Ensure 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 policy review, the facility failed to: 1.) Label medications and biologicals and properly store them, in accordance with currently accepted professional principles; and 2.) Ensure medications were stored at the proper temperature to ensure their efficacy. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated 2/2018, indicated but was not limited to the following: -The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations. -Drugs requiring refrigeration are stored separately in a refrigerator that is used exclusively for medication and medication adjuncts. -Licensed personnel will be responsible to check expiration dates on ordered medications, house stock medications, and supplies. 1.) On 9/22/22 at 9:50 A.M., the Surveyor and Nurse #6 inspected the Second-floor medication cart. The surveyor opened the top drawer of 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 policy review, record review, and staff interview, the facility failed to ensure the physician/physician's assistant (PA) were notified promptly of the critical results of laboratory tests, which fell outside of the clinical reference range, for one Resident (#61), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Physician Notification, dated 11/2016, indicated but was not limited to the following: *Promptly notify physician, physician assistant, or nurse practitioner of laboratory, radiology and other diagnostic services that fall outside of clinical reference ranges. Resident #61 was admitted to the facility in July 2022 with diagnoses that included diabetes. On 9/19/22 at approximately 3:15 P.M., the surveyor observed Nurse #5 answer the telephone and respond that Resident #61's blood glucose level was 35 milligrams/deciliter (mg/dl), (normal range 70-120 mg/dl). Review of the medical record indicated the Resident had blood work obtained on 9/19/22 at 8:15 A.M. that included a Comprehensive Metabolic Panel (CMP) and Complete…

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 medical records that are complete, accurate, and systemically organized within accepted professional standards and practice for 2 out of 3 closed Resident records (#114 and #116) and one Resident (#22) record, out of a total sample of 25 residents. Specifically, the facility failed 1.) For Resident #114 and Resident #116, to ensure they had a physician's order to discharge home with services; and 2.) For Resident #22, to ensure he/she had a physician's order to discontinue hospice services. Findings include: 1a.) Resident #114 was admitted in March 2022 with diagnoses including hypertension, atrial fibrillation, cerebral vascular disease, and dementia. Review of a Nursing Progress note, dated 6/28/22, indicated Resident #114 was discharged home with services. Review of the June 2022 Physician's Orders failed to indicate an order to discharge home. 1b.) Resident #116 was admitted in August 2022 with diagnoses including acute cholecystitis and calculus of gallbladder. Review of the Social Service's progress…

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 documentation 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. Specifically, the facility failed to implement transmission-based precautions to prevent the potential spread of suspected Clostridioides difficile (C-diff; a bacterium which causes serious diarrheal infections) per the facility's policy for one Resident (#4), out of a total sample of 25 residents. Findings include: Review of the facility's Infection Prevention Program, last updated 4/2022, included but was not limited to the following: - The program will promote the use of standard precautions for all resident care unless a resident has a known or suspected infectious agent (infected or colonized) including certain epidemiologically important pathogens, which may require additional control measures to effectively prevent transmission. - The program will prevent and control outbreaks and cross…

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, document review, and interview, the facility failed 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. Findings include: 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, storage, and transport may yield false test results. - Solutions used to make the positive control swab are non-infectious. However, patient samples, controls, and test cards should be handled as though they could transmit disease. Observe established precautions against microbial hazards during use and disposal. -Test results 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.