St Joseph Rehab & Nursing Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a skin impairment care plan for one Resident (#33) out of a total sample of 31 residents. Findings include: Resident #33 was admitted to the facility in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia. Review of Resident #33's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #33 is dependent on staff for self-care and mobility tasks. Review of the wound physician note dated 1/30/25 indicated Resident #33 had a non-pressure wound on his/her sacrum for over 11 days measuring 1.4 x 1.3 x 0.1 cm (centimeters). Review of Resident #33's care plans failed to indicate a care plan for actual skin impairment was developed when the Resident's wound began. During an interview on 2/5/25 at 6:55 A.M., 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.

Based on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#69) out of a total sample of 31 residents. Specifically for Resident #69 the facility failed to review and revise the care plan related to the use of an air mattress. Findings include: Review of facility policy titled Care Plan- Nursing, dated October 7, 2021, indicated the following: -The care plan is to be reviewed and revised by all staff providing care or services for the resident at least 92 days following the completion of every MDS. The Care plan includes a statement of problem; reasonable, measurable and time limited goals; and specific interventions, along with the discipline responsible. -When there are changes in resident's condition, the comprehensive care plan is updated as needed to change goals, time frames or interventions. Resident #69 was admitted to the facility in October 2020 with diagnoses that include major depressive disorder and weakness. Review of Resident #69's most recent Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for three Residents (#28, #101 and #69) out of a total sample of 31 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #28 was admitted to the facility in January 2024 with diagnoses including diabetes, chronic diabetic ulcer of the left foot, and tachycardia. Review of Resident #28's most recent…

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 interviews, the facility failed to: 1) provide assistance with incontinence care for two Residents (#60 and #33) and 2) provide assistance with meals for two Residents (#25 and #55) out of a total sample of 31 residents. Findings include: Review of the facility policy titled, ADL (Activities of Daily Living) Policy, dated 1/2025, indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent if the resident and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting) and d. toileting (meals and…

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

Based on record review and interview the facility failed to ensure services consistent with professional standards were provided for one Resident (#75) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 31 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located. Findings include: Review of facility policy titled Home Dialysis Program: Hemodialysis Access Site Care, dated November 1,2023, indicated the following: -Care of AVFs (arteriovenous fistula): -h. Do not use the access arm to take blood pressure. Resident #75 was admitted to the facility in October 2022 with diagnoses that include end stage renal disease, dementia and diabetes. Review of the most recent Minimum Data Set (MDS) Assessment, dated 1/1/25, indicated that the Resident was unable to complete the Brief Interview for Mental Status and 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.

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 2 out of 2 eligible sampled CNAs. Findings include: During review of 3 CNA employee records, the Surveyor was unable to locate annual performance reviews for 2 out of 2 eligible CNAs. The third CNA had not yet been at the facility for a year. During an interview on 2/05/25 at 11:33 A.M., the Human Resource Director said the annual reviews were not completed and he was unsure why. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing was unable to say why the annual reviews had not been completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure accurate medical records were completed for three Residents (#28, #101 and #33) out of a total sample of 31 residents. Specifically, 1) for Residents #28 and #101 the facility failed to ensure physician orders were documented accurately and 2) for Resident #33 skin assessments were completed accurately. Findings include: 1a. Resident #28 was admitted to the facility in January 2024 with diagnoses including diabetes, chronic diabetic ulcer of the left foot, and tachycardia. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #28 requires substantial assistance from staff for functional daily tasks. Review of Resident #28's physician orders indicated the following orders: -Bi-lat (bilateral) LE (lower extremity) ACE…

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 policy review, and interview, the facility failed to 1). maintain a homelike environment on 3 of 3 resident units and 2) failed to provide a clean, sanitary, and homelike environment for one Resident (#91) out of a total sample of 33 residents. Specifically, for Resident #91, there was a brown liquid on multiple surface areas of the Resident's room that failed to be cleaned for three days. Findings include: 1. Review of the facility policy titled Maintenance Department Policy and Procedures, undated, indicated the following: Environmental Concerns: Maintain set of state and local quality standards and company compliance requirements. Identify and record equipment monitored and breakdowns; monitoring devices; reporting, and alarms; equipment maintenance, repairs, replacement and reporting; and monitoring device maintenance, repairs, replacement, and reporting. Review of the facility policy titled 'Home Like Environment Guideline', dated 7/7/17, indicated, but was not limited to: 2. 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 investigate six allegations of possible abuse, neglect and possible misappropriation evidenced by staff completing grievance forms instead of completing a full investigation. Findings include: Review of the facility's Abuse Policy, dated as revised 10/24/22 indicated: *Upon notification of the allegation of abuse, the Supervisor will take steps to protect the resident in question as well as other residents that may be affected. *The licensed nurse will notify the Administrator and/or Director of Nursing services immediately. *An investigation by the Administrator or Director of Nursing MUST be initiated within 24 hours of their knowledge of the alleged incident. The investigation includes interviewing all staff involved (directly or indirectly) any family involved, all residents involved and any visitors involved. The Administrator will document a summary of interviews. Review of the facility's Grievance Book included the following: Grievance A: 2/7/23: A resident reported that he/she asked to be changed at 5:00 A.M. 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 observations, record review and interview, the facility failed to provide the necessary activities of daily living (ADLs) for dependent residents for four Residents (#9, #92, #66, #413) out of a total sample of 33 residents. Specifically, 1). the facility failed to provide the proper assistance with meals for three Residents (#9, #92, #66) and 2). the facility failed to provide nail care for Resident #413. Review of the facility policy titled ADL Support Guideline, dated 8/10/17, indicated the following: *Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care an services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe environment for four Residents (#103, #43 #36, and #8) out of a total sample of 33 residents. Specifically: 1) For Resident #103 the facility failed to implement the physician's order for the use of fall mats. 2) For Resident #43 the facility failed to ensure nursing staff implemented the falls plan of care of having fall mats in place. 3) For Resident #36, a Resident who is at risk of elopement, the facility failed to provide the Resident with a wander guard (a device that would alarm if a resident were to leave the unit) as ordered. 4)For Resident #8, the facility failed to implement the physician's order for the use of bilateral bed siderail padding for a Resident with a history of epilepsy (a disorder of the brain characterized by repeated seizures). Findings include: Review of the facility policy titled Accident & Incidents Guideline, dated 2/8/18 indicated the following: *The intent of this policy is that the center…

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, observation and interview, the facility failed to provide care and services consistent with professional standards for four Residents (#51, #96, #69, #86) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 33 Residents. Specifically: 1) For Resident #51 the facility failed to ensure that nursing staff obtained a physician's order for dialysis and failed to ensure a care plan was developed for dialysis. 2) For Resident #96, the facility failed to implement recommendations from the dialysis center to hold his/her scheduled medications due to low phosphate. 3) For Resident #69, the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) at the appropriate time. 4) For Resident #86 the facility failed to ensure ongoing communication and collaboration with the dialysis facility…

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, record review, and interviews for two Residents (#9 and #59) out of three Residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of two nurses observed made three errors out of 26 opportunities resulting in a medication error rate of 11.54%. Specifically, 1.) For Resident #9, Nurse #3 administered a medication ordered to be given with meals, without a meal. 2.) For Resident #59, Nurse #4 failed to administer scheduled eye drops as ordered and documented a medication (vitamin d) as administered when it was not. Findings include: Review of the facility policy titled 'General Dose Preparation and Medication Administration', revised 1/1/22, indicated, but was not limited to: 5.8 Follow manufacturer medication administration guidelines (e.g., providing medication with fluids or food). 6. Document necessary medication administration/treatment information (e.g., when medications are given) on appropriate forms. 1.) Resident #9 was admitted to the facility in August 2018 with diagnoses…

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 properly store food items and properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Findings include: During the initial walkthrough of the kitchen on 2/6/24 at 7:08 A.M., the surveyor made the following observations in the walk-in refrigerator: *A container labeled as meal containing an assortment of cooked mixed foods. *A container with an ineligible food item name with the date written as 1/6/24. The container had multiple food items inside. During the follow-up visit to the kitchen on 2/7/24 at 11:33 A.M., the surveyor made the following observations: In the walk-in refrigerator: *A container labeled applesauce with a use by date written as 2/6. *A container labeled as Reg Jello with a use by date written as 2/6. *A container labeled as Diet Jello with a use by date written as 2/6. In the walk-in freezer: *Boxes containing food were observed directly on the floor. During an observation of the lunch tray line…

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 maintain accurate medical records for two Residents (#8, #91) out of a total sample of 33 residents. Specifically: 1. For Resident #8, the facility documented that the Resident's bed side rails were padded when they were not, 2. For Resident #91, the facility incorrectly entered a physicians order for tube feeding, and 3. For Resident #91, the facility incorrectly documented a medication that was administered by a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) was administered by mouth. 1. Resident #8 was admitted to the facility in June 2020 with diagnoses including history of epilepsy and anxiety disorder. Review of Resident #8's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 14 out of a possible 15 indicating that the Resident is cognitively…

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 reviews, policy review, and interviews, the facility failed to assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#20, #58 and #71) out of a total of 5 sampled Residents. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated but was not limited to the following: - For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview the facility 1) failed to allow one Resident (#36) the right to participate in his/her own treatment by having the Resident's Health Care Proxy (HCP) make the decision without the HCP being invoked by the physician and 2) failed to ensure informed consent for the administration of psychotropic medications, including the risk/benefits of the medication and potential side effects, was obtained from the resident and/or representative for one Resident (#19) out of a total sample of 33 residents. Findings include: 1. Review of the facility policy titled, Resident Representative Guideline, dated July 2021, indicated the following: *The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with the law. *A resident who has not been found to be incompetent by the state court has the right to appoint a resident representative who may…

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 reviews, observations and interviews the facility 1) failed to develop a care plan for suicidal and homicidal ideation for one Resident (#36) when he/she returned from an involuntary hospitalization, and 2) failed to develop a plan of care addressing a primary diagnosis of fluid overload and a fluid restriction for one Resident (#86), out of a total sample of 33 residents. Findings include: Review of the facility policy titled Care Plan Guideline, revised 8/18/2017, indicated that the interdisciplinary team should develop a comprehensive care plan for each resident which includes objectives to meet the resident's medical and nursing needs. The facility policy further indicated that the interdisciplinary team is responsible for the implementation of the care plan and that the interdisciplinary team reviews each care plan on a quarterly interval at a minimum and update the plan of care as necessary with any changes as they occur. 1. Resident #36 was admitted to the facility in December 2021 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to revise care plans for two Residents (#77, #86), out of a total sample of 33 residents. Specifically, 1. the facility failed to revise Resident #77's care plan related to skin impairment and 2. the facility failed to revise the hemodialysis (process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care plan for Resident #86 to accurately depict his/her dialysis access site. Findings include: Review of the facility's policy, entitled Care Plan Guideline, dated as revised 8/18/2017 indicated the following: *Policy Statement. It is the policy of each nursing center to develop an individualized plan of care for each resident utilizing the information that is gathered from each assessment performed. A baseline care plan shall be developed within 24 hours of admission that addresses the immediate care needs of the resident. A comprehensive care plan…

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 interviews, the facility failed to provide an activities program to meet the needs of one Resident (#9) out of a total sample of 33 residents. Findings include: Resident #9 was admitted to the facility in 2018 with diagnoses including dementia, stroke, muscle weakness and dysphagia. Review of Resident #9's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, which indicated he/she had severe cognitive impairment. Section F of the MDS indicated it was very important for Resident #9 to have the newspaper, listen to music, keep up with news, be around animals, and do his/her favorite activities. The activities listed on the activity calendar on 2/6/23 were coffee lover, relaxing music, cooking group, and move to the music. Resident #9 was not observed participating in any of the listed activities on 2/6/23 and was not observed to leave his/her room or have a one-on-one visit.…

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, policy review, interviews, and records reviewed for two Residents (#104 and #20), out of 33 total sampled residents, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to 1.) obtain a physician order to treat a wound for Resident #104 and 2.) follow physician's orders to ensure safe positioning during meals for Resident #20. Findings include: Review of the facility policy titled 'Wound Care Guidelines', dated 7/17/22, indicated, but was not limited to: 1. Verify that there is a physician's order for this procedure. 1.) Resident #104 was admitted to the facility in January 2024 with diagnoses including dementia and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/24, indicated that Resident #104 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of 15. On 2/6/24 at 7:55 A.M. and 2/7/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement treatment recommendations related to pressure ulcers for one Resident (#9) out of a total of 33 sampled Residents. Findings include: Review of the facility's Wound Care Guidelines, dated 8/17/22, did not indicate a methods or means for staff to implement treatment recommendations made by the Wound Physician. Resident #9 was admitted to the facility in August 2018 with diagnoses including vascular dementia and peripheral vascular disease. Review of his/her most Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with activities of daily living. Review of Resident #9's clinical record indicated he/she developed a stage III sacral pressure ulcer while hospitalized in December 2023 which was being monitored by the Wound Physician. Review of the Wound Physician's notes dated 1/4/24, 1/11/24, 1/25/24, 2/1/24 indicated the following treatment recommendation: Silver sulfadiazine, apply…

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 interviews, the facility failed to maintain acceptable parameters of nutritional status for 1 Resident (#86) out of a total sample of 33 residents. Specifically, the facility failed to maintain a 1,000 milliliter (ml) fluid restriction per the physician's orders for Resident #86. Findings include: Review of the facility policy, titled Fluid Restriction Guideline, revised 2/16/18, indicated a fluid restriction is ordered by a physician or nurse practitioner for residents who have fluid intake concerns related to congestive heart failure, acute/ chronic renal failure, edema or ascites. Further review of the policy indicated that the physician should be made aware of fluid restriction non- compliance. The facility policy further indicated that the dietary department should be notified when a resident is placed on a fluid restriction and the licensed nurse will total all fluids at the end of each 8-hour shift. The 3-11 shift nurse will total all fluid intake and record 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, interview, policy review, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#91) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 33 sampled residents. Specifically, the facility failed to follow physician orders for accurate rate of administration of tube feeding for Resident #91. Findings include: Review of the facility policy titled 'Enteral Feeding Guideline', dated January 2020, indicated, but was not limited to: -Preventing errors in administration 5. Check the enteral nutrition label against the order before administration. Check the following information: rate of administration (ml/hour) (milliliters/hour). Resident #91 was admitted to the facility in November 2023 with diagnoses including atrial fibrillation (an irregular heart rhythm) and a stroke with left-sided hemiplegia (paralysis on the left side of the body). Review of the most recent Minimum Data Set (MDS)…

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, interviews, and records reviewed the facility failed to provide respiratory care services in accordance with professional standards of practice for two Residents (#88 and #86), out of a total of 33 sampled residents. Specifically, the facility failed to 1. follow physician's orders for oxygen management and change oxygen tubing that was left on floor for one Resident (#88) and 2. Ensure that oxygen was administered per physician's orders for one Resident (#86). Findings include: Review of the facility policy titled 'Oxygen Administration', revised 6/8/21, indicated, but was not limited to: -Preparation 1. Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. -Steps in the Procedure 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 1. Resident #88 was admitted to the facility in January 2024 with diagnoses including respiratory failure and chronic obstructive pulmonary disease (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure that the bed rail was implemented in accordance with the bed rail assessment, and that a physician's order was obtained for the use of the bed rail, for one Resident (#77)out of a total sample of 33 residents. Findings include: Review of the facility's policy, titled Bed Rail Use Guideline, with a revision date of April 7, 2021, indicated the following: Policy Statement: It is the policy of this center to ensure residents attain and maintain the highest practical level of well-being and are free from restraints. Each resident is evaluated for functional status on admission, readmission, with significant change, annually and as needed. Bed rails may be used by a resident to assist with their bed mobility in accordance with individual facility interdisciplinary recommendation after less restrictive alternatives have been documented as being trialed and failed on the residence plan of care. Bed rails will only be provided when there is…

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 reviews and interviews, the facility failed to provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being for one Resident (#36) out of a total sample of 33 residents. Specifically, the facility social workers failed to provide support and non-pharmacological interventions to Resident #36 as he/she had increasing behaviors and psychological distress leading to two involuntary hospitalizations for psychiatric concerns. Findings include: Resident #36 was admitted to the facility in December 2021 with diagnoses including major depression and dementia. Review of Resident #36's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she had moderate cognitive impairment. During an interview on 2/09/24 at 8:51 A.M., Resident #36 said he/she has been feeling frustrated for a long time and is sad that he/she cannot leave 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 that recommendations made by the consulting pharmacist during the monthly medication review were acted on by the physician for one Resident (#103), out a total sample of 33 residents. Findings include: Resident #103 was admitted to the facility in September 2023 and has diagnoses that include but not limited to unspecified dementia, ataxic gait, and repeated falls. Review of Resident #103's Minimum Data Set assessment dated [DATE] indicated Resident #103 scored a 9 out of 15 on the Brief Interview for Mental Status exam. Review of Resident #103's medical record indicated the consulting pharmacist entered a note in the medical record dated 10/30/23 that an irregularity was identified during the medication regimen review. Further review of both Resident #103's electronic medical record (EMR) and hard paper medical record failed to indicate the documented response from the physician or prescriber for the consulting pharmacist recommendation dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication was re-evaluated and included a duration of use for one Resident (#19) out of a total sample of 33 residents. Findings include: Review of the facility policy titled, Use and Management of Psychotropic Medications Guideline, dated February 22, 2018, indicated the following: *Physicians and mid-level practitioners will use and prescribe psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. The facility complies with guidelines developed by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions. *The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular…

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, policy review, and interviews the facility failed to 1.) ensure medication carts were locked when unattended on one out of three nursing units, 2.) ensure medications carts were kept clean and orderly in one of four medication carts observed 3.) ensure that medications were properly labeled after opening on 3 of 5 medication carts observed 4.) ensure medications were not stored at bedside for a resident who is not assessed to self- administer medications. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications, dated 8/7/23, indicated Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened…

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.