Twin Oaks Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide Nursing services consistent with professional standards of practice for two Residents #24 and #11 out of a total sample of 21 residents. Specifically; 1. For Resident # 24, the facility failed to include how much oxygen the Resident should be taking via nasal cannula, and how often the oxygen tubing should be changed in the physician's orders. 2. For Resident #11, the facility failed to implement a physician's order to administer tube feeding with correct enteral feeding and correct rate. Findings include: A review of the facility policy titled 'Oxygen Administration' indicated the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#56) out of a total sample of 21 residents. Specifically; the facility failed to change a wound dressing for three days. Findings include: Review of the facility policy titled Dressings, Dry/Clean dated revised September 2013, failed to indicate to follow a physician's order. Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. On 6/16/25 at 8:10 A.M. the surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also…

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 consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility failed to ensure staff implemented Resident #11's, physician ordered, rolled facecloth to contracted [left] hand every shift. Findings include: Review of the facility policy titled 'Resident Mobility and Range of Motion', revised July 2017, indicated: - Residents will not experience an avoidable reduction in range of motion (ROM). - Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. - Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless a reduction in mobility is unavoidable. Resident #11 was admitted to the facility in March 2021 with diagnoses including contracture, unspecified joint. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/25/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#1) out of a total sample of 21 residents. Specifically, for Resident #1 the facility failed to ensure significant weigh loss was assessed and continually monitored. Findings include: Review of the facility policy titled, Weighing and Measuring the Resident, dated as revised March 2011, indicated the following: -The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. -Reporting: 1. Report significant weight loss/weight gain to the nurse supervisor. 2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. a. 1 month- 5% loss is significant;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a trauma informed care plan for two Residents #10 and #1 out of a total sample of 21 residents. Specifically: 1. For Resident #10, the facility failed to develop a post-traumatic stress disorder (PTSD) care plan addressing the needs of trauma by minimizing triggers and re-traumatization. 2. For Resident #1, the facility failed to develop a care plan addressing PTSD with a history of suicide attempt. Findings include: A review of the facility policy titled 'Trauma Informed Care' with no revision date indicated the following: -Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. -The facility will identify…

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 it was free from a medication error rate of greater than 5 percent. Specifically, one of two nurses observed made two errors in 33 opportunities resulting in a medication error rate of 6.06%. These errors impacted one Resident (#18) out of four residents observed. Findings include: Review of the facility policy titled Adverse Consequences and Medication Errors dated as revised April 2014 indicated the following: -A medication error is defined as the preparation or administration of drugs or biological's which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. For Resident #18 the facility failed to administer medications as ordered by the physician. Review of the current doctor's orders indicated an order for the following: 1. Lactose Fast Acting Relief Oral Tablet (Lactase) Give 2 tablets by mouth before meals for lactose intolerance. Start Date 6/13/25. 2. Saline Spray Nasal Solution…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to accurately document in the medical record for one Resident (#56 ) out of a total sample of 21 residents. Specifically, for Resident #56 the facility documented a dressing change was completed for three days when it was not. Findings include: Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. On 6/16/25 at 8:10 A.M. two surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also observed that the dressing was dated 6/12/25. On 6/16/25 at 12:50 P.M. the surveyor and Nurse #1 observed Resident #56 sitting on the edge…

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

Based on record review and interviews, the facility failed to offer the Influenza vaccine during influenza season to one Resident out of a sample of five residents reviewed. Specifically, the facility failed to offer Influenza vaccination on admission to the facility or during their stay at the facility. Findings include: Review of the facility policy, titled 'Influenza Vaccine', undated, indicated the following: -All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. -Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. A review of five resident medical records indicated one out of the five residents had not been vaccinated for Influenza. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building…

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

Based on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one out of five sampled residents. Specifically, the facility failed to offer a COVID-19 vaccination to a resident on admission to the facility or during their stay at the facility. Findings include: Review of the facility policy, titled 'Coronavirus Prevention and Control', dated as revised January 2023, indicated the following: -Facility leadership and clinical staff are responsible to take reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease (COVID-19). A review of five resident medical records indicated one out of the five residents had not been vaccinated for COVID-19. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building but expects the Infection Preventionist to be tracking the vaccinations. During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist said he has only been working in the facility for the…

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

Based on record review and interview the facility failed to meet professional standards of quality for four Residents (#55, #48, #63 and #24) out of a total sample of 18 residents. Specifically: 1. For Resident #55, #48 and #63 the facility failed to assess their hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration. 2. For Resident #24 the facility failed to obtain his/her Depakote level as ordered by the Physician. Findings include: 1. For Resident #55, the facility failed to assess his/her hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration. Resident #55 was admitted in 9/2021 with diagnoses including depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/9/24, indicated Resident #55 scored a 7 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated Resident #55 has an activated health care proxy in place. Review of the progress note, dated 5/3/24, indicated the…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who has entrusted the facility to manage his/her Personal Needs Account (PNA), the Facility failed to ensure they maintained a system of accounting that assured Resident #1 monthly PNA checks, that were received and processed by the Facility, were then deposited into the correct account, when two of Resident #1 monthly PNA checks were somehow deposited into the Facility's Operations Account, which resulted in Resident #1's account balance to be inaccurate for several months. Findings include: Review of Resident #1's Resident Statement Landscape (PNA), from 6/03/23 to 8/06/23, indicated the following: - there was no record of deposit to the account in the amount of $72.80 a month in June 2023, July 2023, and August 2023 (totaling $218.40), in PNA funds that were unaccounted for. During an interview on 12/12/23 at 11:10 A.M., Resident #1 said the Facility manages his/her Personal Needs Account (PNA) by receiving and depositing a monthly check of $72.80 into his/her PNA. Resident #1 said on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, the facility failed to ensure the building had a home-like environment on 3 of 3 nursing units evidenced by, gouged walls, various stains on the ceilings and walls, broken tiles, rusted toilet paper holders, and rusty detached baseboard covers on 3 of 3 nursing units. Findings include: During an environmental rounds on 5/2/23, and 5/3/23, the surveyor observed the following: room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]- gouges on the wall behind bed A and B. The baseboard heating cover was detached and protruding out. room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]'s shared bathroom had missing tiles on the wall and floor. room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]- the shared bathroom with a rusted paper towel holder. room [ROOM NUMBER]- the shared bathroom with rusted paper towel holders. The bathroom doors were scuffed with white…

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 complete Comprehensive (Annual and Admission) Minimum Data Set (MDS) Assessments in a timely manner for 2 Residents (#59 and #33) and failed to complete a discharge MDS in a timely manner for 1 Resident (#59) out of a total sample of 34 residents. Findings include: Review of the Resident Assessment Instrument (RAI) Manual 3.0 indicated the following: 1. An admission Data Set (MDS) assessment must be completed no later than the 14th day from admission and must be transmitted to the Centers for Medicare and Medicaid (CMS) no later than 35 days from the Assessment Reference Date (ARD). 2. The Annual and Quarterly MDS must be completed no later than 14 days from the ARD. 3. A discharge MDS must be completed no later than 14 days after discharge and transmitted to CMS no later than 14 days of completion of the MDS. 1. For Resident #59 review of the MDS's indicated the admission MDS had an ARD of 12/27/22, and was transmitted to CMS on 3/6/23, 80 days after…

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

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs. Findings include: Review of the facility policy titled Performance Assessments and dated as last reviewed 12/2020, indicated that the Executive Director and the Director of Nursing Services and location leaders with direct reports in a job that requires annual skills evaluation, are responsible to ensure a Performance assessment related to skills is completed annually. Review of the facility document titled Evaluation Form failed to indicate that the CNA's individual skills required to perform their jobs were evaluated to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for all 5 CNAs. During an interview on 5/01/23, at 3:16 P.M., the DON said that a skills performance review is not…

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

Based on observations, policy review and interviews the facility failed to ensure medication carts were clean, had medications that were stored according to manufacturer's guidelines (refrigerated), and that medications once opened were dated according to manufacturer's guidelines on 3 out of 3 sampled medication carts. Findings include: Review of the facility policy titled, Storage of Medications, undated, indicated the facility shall store all drugs and biological's in a safe, secure, and orderly manner. - drugs and biological's shall be stored in the packaging, containers or the dispensing systems in which they are received. - nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - the facility shall not use discontinued, outdated, or deteriorated drugs or biological's. - medications requiring refrigeration must be stored in the refrigerator. Review of the facility policy titled, Administering Medications, undated, indicated: - the expiration/beyond use date on the medication label must be checked prior 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 observations and interviews, the facility failed to ensure it was administered in a manner that enables it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: During the recertification survey conducted on 4/30/23, through 5/3/23, the survey team observed concerns with a lack of activities programming for all residents, an unclean and non-homelike environment in resident rooms and bathing areas and a lack of sufficient staffing. On 4/30/23, the survey team identified a lack of activities program for all residents living in the facility. On 4/30/23, the surveyors identified the building did not have a home-like environment on 3 of 3 nursing units evidenced by, gouged walls, various stains on the ceilings and walls, broken tiles, rusted toilet paper holders, and rusty detached baseboard covers on 3 or 3 nursing units. During an interview with 2 surveyors, on 5/01/23, at 4:31 P.M., the Director of nursing, when asked if a Certified Nurse's Aide could adequately care for 16 residents 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 record review and interview the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) program. The facility also failed to make a good faith effort to establish a quality assurance and improvement plan to maintain the quality of life and well-being for residents by failing to offer meaningful, person-centered activities and failing to maintain the building in a homelike manner. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program and dated as revised February 2020, indicated that 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. Further review indicated that the QAPI plan includes tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes…

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, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plans, to ensure satisfactory outcomes. Findings Include: Review of the sign-in sheets for the quarterly QAPI meetings indicated 2 sign-in sheets for the quarterly QAPI meeting held on 1/19/23. The sign-in sheets had signatures of some of the same people but in different ink. One of the sheets indicated the signature of the Medical Director while the other sheet indicated that he attended by phone. Further review failed to indicate a scheduled quarterly QAPI review had taken place. During an interview on 5/03/23, at 3:12 P.M. with the Administrator and the the Administrator In Training (AIT), the AIT said that she was not able to locate the sign in sheet for the quarterly QAPI meeting in April 2023. The Administrator acknowledged the 2 sign-in sheets for 1/19/23, but could not account for why there were 2…

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 interviews, the facility failed to implement effective pest control management by not following pest control recommendations as evidenced by mouse activities, droppings on multiple resident rooms, including the kitchen. Findings include: During an environmental tour on the 3rd floor on 5/2/23, at 7:50 A.M., the surveyor observed multiple mouse traps below the radiator base board in room [ROOM NUMBER]. Resident #33 told the surveyor that a pest control service installed those mouse traps after he/she reported mouse sightings. Resident #33 told the surveyor that he/she can still hear mouse activity such as walking/chewing at night every now and then. Resident #33 told the surveyor that all rooms have mouse traps. The surveyor observed mouse traps in resident rooms, dining areas, and family rooms on all three nursing units on 5/3/23. Review of the facility grievance logs indicated residents had reported mouse sightings on 3/28/23, and 4/10/23. Review of the pest control reports and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to implement the plan of care for 2 Residents (#6, #50) and failed to develop a person-centered care plan with individualized interventions for 2 Residents (#67 and #23) out of a total sample of 34 residents. Findings include: Review of the facility policy titled Shower/Tub Bath and not dated, failed to indicate that the resident has the choice of a shower or tub bath. Further review failed to indicate how often a shower is to be offered to a resident. 1. Resident #6 was admitted to the facility in September 2013 with diagnoses including dementia, schizophrenia and bipolar disorder. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #6 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review indicated that Resident #6 is totally dependant for bathing. During an interview on 4/30/23, at 9:52 A.M., Resident #6 said she/he wants a shower twice a week and only gets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to 1.) provide meaningful and person-centered activity programming on one resident care unit out of three resident care units and 2.) failed to provide activities to three Residents (#23, #370, and #67.) out of a total sample of 34 residents. Findings include: Review of the facility's policy entitled, Programming for Residents, dated as revised 4/21/17, indicated the following: Activity programs are relevant and valuable to resident's quality of life. Activities are provided for maintenance and enhancement of each resident' quality of life while promoting physical, cognitive, and psychosocial well being. 1 The focus should be on the resident's abilities, not disabilities. 2 Activity programs are to be meaningful and reflect the resident's interests. and lifestyles and choices a Lifestyle and choices b Help the resident to develop new relationships c Resident to feel independent and helpful d Provide a sense of belonging 3. During the…

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

Based on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 3 nurses observed made 7 errors out of 28 opportunities resulting in a medication error rate of 25%. Those errors impacted 4 Residents (#15, #30, #57, and #272) out of 5 residents observed. Findings include: Review of the facility policy titled, Administering Medications, undated, indicated: - medications must be administered in accordance with the orders, including any required time frame. - the individual administering the medication must check 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. 1. For Resident #15, Nurse #2 crushed medications that were not crushable and failed to prime an insulin pen prior to use resulting in the incorrect dose of insulin being administered. During the medication pass observation on the 1st Floor on 5/1/23, at 8:20 A.M., Nurse #2 administered the following to Resident #15: -…

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 test trays, the facility failed to ensure food was served at safe and appetizing temperatures. Findings include: During the initial screening process on 4/30/23, at approximately 8:00 A.M., multiple residents interviewed on the 3rd floor unit complained of poor food quality. On 5/3/23 at 8:17 A.M., the third-floor food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:38 A.M., the following was recorded: -Scrambled eggs, 100 degrees Fahrenheit, tasted warm but not hot -Breakfast Pastry, 90 degrees Fahrenheit, palatable -Hot cereal, 120 degrees Fahrenheit, watery and without flavor -Orange Juice, 60 degrees Fahrenheit, slightly cool, not cold -Milk, 58 degrees Fahrenheit, slightly cool, not cold On 5/3/23 at 8:27 A.M., the first-floor food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:48 A.M., and the following was recorded: -Scrambled eggs registered at 90 degrees Fahrenheit, were warm to taste and had 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 observations and interview the facility failed to maintain proper sanitation practices related to food storage, food labeling, and food handling. Findings include: Review of the undated facility policy, titled Preventing Food borne Illness - Food Handling, indicated the following: *Food will be stored, prepared, handled and served so that the risk of food borne illness is minimized. During the initial kitchen walk through on 4/30/23, at 7:09 A.M., the following produce was observed with significant visible signs of decomposition: *Tomatoes *Celery *Potatoes *Cabbages During an observation on 4/30/23, at approximately 7:45 A.M., the following was observed: *4 unlabeled and undated sandwiches in the refrigerator on the 1st floor kitchenette. *An unlabeled and undated container of food in the refrigerator of the 2nd floor kitchenette. During a tray line observation on 4/30/23, at 12:27 P.M., the surveyor observed the cook contaminating his gloves by touching the handles of serving utensils, a knife, and the microwave door. The cook then used the same contaminated gloves 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.

3. For Resident #23 the facility failed to accurately document Resident #23's skin assessment and progress notes related to his/her skin status. Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia. Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. Further, the MDS did not indicate Resident #23 displayed behaviors and did not indicate under section M skin, that Resident #23 had any open skin areas, that were not pressure areas. The surveyor made the following observations: -On 4/30/23, at 8:23 A.M., Resident #23 was observed with multiple reddened, circular scabbed areas on both his/her upper right and left arms. -On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain informed consent for the administration a psychotropic medication (Depacote Sprinkles) prior to administration for one Resident (#27) out of a total sample of 34 residents. Resident #27 was admitted in October, 2022 with diagnoses including anxiety and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #27 scored a 99 on the Brief Interview for Mental Status (BIMS), indicating he/she could not participate. The MDS indicated Resident #27 is severely cognitively impaired. Review of the physician orders for Resident #27 indicated the following: - Depakote Sprinkles (a psychotropic medication used to treat seizures and bipolar disorder) Capsule Delayed Release 125 milligrams (mg); give 2 capsule by mouth at bedtime and 1 capsule by mouth two times a day. During an interview on 5/01/23, at 8:23 A.M., the Director of Nursing said that there should be a consent for Depakote in the chart. The Director of Nursing said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to file a grievance for missing personal property for 1 Resident (#21) out of a total of 34 residents. Findings include: Review of the facility policy titled Grievances and dated 3/2021, indicated the following: *Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of the other residents, staff members, missing items, theft of property, etc., without fear of reprisal in any form. *Grievances and/or complaints may be submitted orally or in writing. *Staff members are encouraged to assist residents in filing a grievance and/or complaint when the resident believes that his/her rights have been violated. *The grievance will be investigated and communicated to the filer within 72 hours. *Upon receipt of a grievance, complaint report or the missing items form, the Director of Social Services will begin an investigation into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to report in the required timeframe 1. an injury of unknown source for one Resident (#370) and 2. a resident-to-resident (Resident #67 and Resident #31) verbal altercation resulting in a fall with an injury for one Resident (#31) out of a total sample of 34 residents. Findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, dated March 2017 indicated the following: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall Be Promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the…

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 1. thoroughly Investigate a bruise of unknown source for one Resident (#370) and 2. failed to investigate a resident-to-resident verbal abuse (Resident #31 and Resident #67) out of a total sample of 34 residents. Review of the facility's policy titled, Abuse Investigation and Reporting, dated March 2017 indicated the following: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall Be Promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies. A. The…

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

Based on record review and interview the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 3 Residents (#30, #56, and #9) out of a total sample of 34 residents. Findings include: Review of the Resident Assessment Instrument (RAI) manual 3.0 indicated the following: The Quarterly MDS must be completed no later than 14 days from the assessment reference date (ARD). 1. For Resident #30 review of the MDS's indicated a Quarterly assessment with an ARD of 9/22/22, with a completion date of 11/15/22, 40 days late. Further review indicated a Quarterly assessment with an ARD 12/20/22, and a completion date of 1/10/23, 7 days late. 2. For Resident #56 review of the MDS's indicated a Quarterly assessment with an ARD of 11/8/23, and a completion date of 1/10/23, 49 days late. Further review indicated a Quarterly assessment with an ARD of 1/24/23, and a completion date of 4/11/23, 63 days late. 3. For Resident # 9 review of the MDS's indicated a Quarterly assessment with an ARD of 9/22/22, and a Completion date of 11/15/22, 38 days late. A Quarterly…

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 accurately complete the Minimum Data Set (MDS) assessment for 3 Residents (#50, #22 and #67) out of a total sample of 34 residents. Findings include: 1. Resident #50 was admitted to the facility in July 2022 with diagnoses including Alzheimer's, heart disease and chronic obstructive pulmonary disease. Review of the medical record indicated the following weights: Date Time Weight 4/2/2023 15:07 113.8 Lbs (pounds) 3/29/2023 11:55 113.8 Lbs 3/22/2023 15:00 113.8 Lbs 3/15/2023 15:45 113.4 Lbs 3/1/2023 14:23 112.8 Lbs 2/22/2023 14:48 112.4 Lbs 2/8/2023 14:21 111.0 Lbs 2/1/2023 13:59 117.5 Lbs 1/25/2023 13:25 118.4 Lbs 1/18/2023 14:17 118.4 Lbs 1/11/2023 09:24 117.0 Lbs 1/4/2023 13:34 117.0 Lbs 12/21/2022 14:05 117.3 Lbs 12/21/2022 14:04 117.3 Lbs 12/17/2022 07:53 117.0 Lbs 11/16/2022 15:47 146.9 Lbs 10/26/2022 13:40 148.5 Lbs 10/19/2022 12:56 149.5 Lbs Review of the medical record indicated that Resident #50 a history of significant weight loss in the past 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, policy review and interview the facility failed to 1. ensure that nursing administered medications that met professional standards of quality for 1 Resident (#22) and 2. failed to ensure professional standards of care for one Resident's (#23) skin, out of 34 sampled Residents. Findings include: Review of the facility policy titled, Administering Medications, undated, indicated: - Medications must be administered in accordance with the orders. - The following information must be checked/verify for each resident prior to administering medications. a. vital signs 1. Resident #22 was admitted to the facility in January 2023 with diagnoses including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 is able to be understood and he/she had the ability to understand others. The MDS further indicated Resident #22 does not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide feeding assistance to 1 Resident (#27), resulting in the Resident not eating a meal, out of a total sample of 34 residents. Findings include: Resident #27 was admitted in October, 2022 with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #27 is severely cognitively impaired. Further review of the MDS indicated that Resident #27 requires extensive assist of one person with eating. Review of the activities of daily living care plan indicated the following: *Requires 1 ASSIST with eating r/t DX (diagnosis) of Dysphagia , Behaviors and confusion, will not complete meals without staff assist, eats in DR (dining room). On 4/30/23, at 12:36 P.M., the surveyor observed Resident #27 at a table in the dining room with food in front of him/her. A certified nursing aide (CNA) came over and put a spoon in Resident #27's ice cream and then walked away. At 12:41 P.M., 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, record review and interview the facility failed to ensure care was provided for one Resident (#23), who required extensive assistance. Specifically, Resident #23 was not provided nail care, resulting unclean fingernails out of a total sample of 34 residents. Findings include: Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia. Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. During the survey, the surveyor observed the following: *On 4/30/23, at 8:23 A.M. Resident #23, was resting in bed. Both his/her right and left hands had uneven fingernails, with debris under nail beds. *On 4/30/23, at…

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

Based on observations, record review and interview, the facility failed to ensure quality care was provided to one Resident (#18), out of a total sample of 34 residents. Specifically when on 4/22/23, Resident #18 sustained a laceration to his/her left leg and was transferred to the hospital. Resident #18 returned from the hospital with sutures to his/her left leg and nursing obtained a telehealth visit which resulted in recommendations for antibiotic use and a suture removal date. The facility failed to ensure nursing implemented orders for an antibiotic and a plan for on-going monitoring and assessment of the wound. Findings include: Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination. Review of the Minimum Data Set (MDS) assessment, 3/28/23, indicated Resident #18 could make themselves understood and he/she has the ability to understand others. The MDS indicated his/her vision was severely impaired and required…

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 for one Resident (#63) foot care was provided to maintain good foot health, out of a total sample of 34 residents. Specifically, for Resident #63 the facility failed to provide podiatry services for elongated toenails and failed to provide treatment for scaly, dry areas of the foot. Findings include: Review of the facility policy, entitled Diabetic Foot Care dated 9/16/16, indicated the following: The purpose of this procedure is to ensure that all residents are provided appropriate foot care and are monitored routinely for alterations in skin integrity to their feet. It is the intention of this facility to monitor, identify, and resolve any issues with skin integrity timely. Diabetic foot care will be provided by a licensed nurse. Inspect all aspects of the feet, including the sole and heal (sic) Inspect for discolored areas, cracks or splits, calluses, peeling skin, swelling, blisters and ulcers. Apply lotion to feet, avoiding between toes. Resident #63 was admitted to the facility in May 2022 with…

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

Based on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#8) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled Residents. Specifically, the facility failed to have and accurate flow rate for feedings and accurate flush settings. Findings included: Review of the facility policy titled Enteral Nutrition dated 3/22/21, adequate nutritional support support through enteral feeding will be provided to residents as ordered. - The dietician, with the input from the physician and the nurse, will calculate fluids to be provided (beyond free fluids in the formula) - Enteral feedings will be scheduled to try to optimize resident independence whenever possible. The schedule will not be altered. Resident #8 was admitted to the facility in April 2021 with diagnoses including respiratory failure, gastronomy tube placement, dysphagia, epilepsy, contracture, tracheostomy,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain respiratory equipment according to professional standards of practice for 2 Residents (#22 and #8) out of a total sample of 34 Residents. Findings include: Review of the facility policy titled oxygen administration, dated 3/2021, indicated the purpose of the procedure is to provide guidelines for safe oxygen administration. - verify there is a physician's order for oxygen administration. - review the resident's care plan to assess for any special needs of the resident. - document the oxygen flow rate, route, and rational. 1. For Resident #22 the facility failed to ensure that his/her oxygen flow rate was set according to the physician's order and failed to ensure that an oxygen tubing bag was not used for multiple residents. Resident #22 was admitted to the facility in January 2023 with diagnosis including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide care and services consistent with professional standards for one Resident (#22), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of one applicable sampled resident, in a total sample of 34 residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for the Resident's dialysis appointments. Findings include: Review of the facility policy titled, Dialysis Patients, dated 3/21, indicated a dialysis communication binder will be sent with the patient in case of documentation with the facility and the dialysis center. Resident #22 was admitted to the facility in January 2023 with diagnosis including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness. Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs on 1 of 3 units. Findings included: 1. Review of the facility assessment dated reviewed 1/16/23, indicated the following during a typical month: 1. The average daily census of the 3rd floor unit is 36. 2. The number of clinically complex residents in the facility is 10-15. 3. The number of residents with behavioral symptoms and cognitive performance issues is 40-70. Further review indicated that the number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 15-20. Further review failed to indicate how the CNA's were to be distributed through out the facility and shifts during the 24 hour period. Review of the CNA daily assignment sheets and daily staffing schedules, indicated that on 4/13/23, 4/16/23, 4/18/23, 4/20/23, 4/25/23, 4/29/23, 4/30/23 and 5/1/23, 5/2/23, 2 CNA's were assigned to…

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

Based on observation, record review and interview, the facility failed to ensure Nurse #2 was competent and had the required skill set to prepare and administer medications for one Resident (#15), that met professional standards of quality, out of a total sample of 34 Residents. -Nurse #2 crushed medications that should not have been crushed and Nurse #2 did not clean the rubber seal of an insulin pen and she did not prime the insulin pen prior to administering the injection. (removing the air from the needle and the cartridge that may collect during normal use. It is important to prime the pen before each injection so that the injection will work correctly. If a nurse does not prime before each injection, a nurse may give too much or too little insulin, resulting in the incorrect dose being administered.) Finding include: Review of the Humalog (short acting insulin) pen (insulin pen) manufacture's instructions, dated as reviewed 2023, indicated: - Wipe the rubber seal with an alcohol swab. - Push the capped needle straight onto the pen (rubber seal) and twist the needle on. - Prime…

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

Based on observations, record review and interviews, the facility failed to provide dental services to one Resident (#34) out of a total sample of 34 residents. Findings include: Review of the facility policy titled Dental Services and dated last revised 11/2017 indicated that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Further review indicated that all dental services provided are recorded in the resident's medical record. Resident #34 was admitted to the facility in July 2021 with diagnoses including diabetes, heart disease and kidney disease. During an interview on 4/30/23, at 10:07 A.M., Resident #34 said she/he has had a tooth ache for 3 weeks. Resident #34 then said that the pain is at an 8 out of 10, with 10 being the worst ever. Resident #34 then said that she/he had been telling the nurses about the pain for weeks. During an interview on 5/1/23, at 11:39 A.M. Resident #34 said the tooth pain was a 3 out of 10. Resident #34 then said that the pain was not as bad…

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

Based on record review and interviews the facility failed to implement an effective antibiotic stewardship program for one Resident (#18) out of a total sample of 34 Residents. Findings include: Review of the facility policy, titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated as revised 12/19, indicated: - antibiotic usage and outcome will be collected and documented using a facility- approved antibiotic surveillance tracking form. - the infection preventionist will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. - at the conclusion of the review, the provider will be notified of the review findings and recommendations. The provider will documented if he/she agrees to make the change. Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination. Review of Resident #18's telemedicine…

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 review of personnel files and training documentation, the facility failed to ensure 2 of 2 certified nurse aides (CNA) and 1 of 1 nurses' were provided with training on dementia management in accordance with State and Federal requirements. Findings include: Review of the 4 hour Hand-in Hand dementia care training certificate indicated that CNA #1 and #13 and Nurse #2 successfully completed the 4 hour Hand-in Hand dementia care training on 2/27/23. Review of the facility documents titled Dementia Care Education Test For 4 hr Training, indicated that CNA #1 and #13 and Nurse #2 took the test on 4/22/23, nearly 2 months later. Further review indicated that the dementia training test was not signed by any of the employees whose name was on the test. The surveyor requested to see the time card punches for the dates of 2/27/23 and 4/22/23 for CNA #1, #13 and nurse #2. The surveyor was presented with time card punches for 2/22/23. During an interview on 5/1/23, at 2:42 P.M., the Director of Nursing (DON) was unable to explain why the date of the dementia training…

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.