The Center At Advocate

Based on observation and interview the facility failed to maintain confidential resident information (medication administration information) on 2 of 5 resident units (2 [NAME] and 3 West). Findings include: 1. On 6/4/25 at 9:02 A.M., on the 2 [NAME] unit, the surveyor observed an unattended medication cart. The laptop computer on top of the cart was a open and displaying a resident's name and their Medication Administration Record. The laptop screen was visible to residents and staff in the corridor. During an interview on 6/4/25 at 9:04 A.M., Nurse #1 returned to the medication cart. She shut the laptop computer screen, said that it should not be open and should be in a private setting when the cart is unattended. During an interview on 6/5/25 at 10:46 A.M., with the Director of Nursing she said that it is the expectation that the laptop computer screen by covered or in a private setting when it is open to a resident's medical record. 2. On 6/4/25 at 9:47 A.M., during the medication pass in the 3 [NAME] unit corridor, Nurse #9 left the medication cart to find medications in 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 records reviewed and interviews, for three of five sampled resident (Resident #2, #4, and #5), the Facility failed to ensure that the resident and/or his/her family member or legal representative participated in the development and implementation of their person-center care plans, when the residents and/or their legal representatives were not invited to attend an interdisciplinary care plan meeting following the completion of their Comprehensive Minimum Data Set (MDS) Assessment. Findings include: Review of the Facility Policy titled, Comprehensive Care Plans, dated as last revised 11/01/24, indicated that comprehensive care plan will be reviewed and revised by the IDT after each comprehensive and quarterly Minimum Date Set (MDS) Assessment. The Policy further indicated that the IDT includes, however, not limited to; -The Attending Physician; -A Registered Nurse; -A Certified Nurse Aide; -A member of the food and nutrition services staff; -The Resident and the resident's representative, to the extent…

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, for one of five sampled residents (Resident #1) who had requested bed rails be placed on his/her bed for repositioning and safety reasons, the Facility failed to ensure his/her request was adequately addressed when bed rails were not provided and was told he/she did not need them. Findings include: Review of the Facility Policy titled Resident Rights, dated 11/01/24, indicated that each resident has the right to a dignified existence, self-determination, and communication with the access to people and services inside and outside the facility. The Policy further indicated that the resident has the right to be informed of, participate in his or her treatment. Resident #1 was admitted to the Facility in February 2025, diagnoses included but not limited to Peripheral Artery Disease (PAD) with bilateral foot gangrene, diabetic neuropathy, Acute Lymphoblastic Leukemia (ALL) in remission, chronic pain and chronic urinary retention with an indwelling catheter in place. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 02/21/25,…

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.

Based on records reviewed, interviews, and observation for three of five sampled residents (Resident #3, #4 and #5), who had all been assessed as being their own person, the Facility failed to ensure that 1) Resident #3 was assessed for the use of bed rails and that his/her physicians order was for bed rails, and 2) after Resident #4 and #5 underwent a room change, that the bed rails were provided on their new beds, per their physicians orders. Findings include: Review of the Facility Policy titled Proper Use of Bed Rails, dated as last revised 11/01/24, indicated that the facility is to utilize a person-centered approach when determining the use of bed rails. The Policy further indicated that a proper assessment, informed consent, and a physician's order must be obtained prior to utilizing bed rails. 1) Resident #3 was admitted to the Facility in April 2025, diagnoses include status post left total knee replacement, bipolar disorder, Chronic Obstructive Pulmonary Disease (COPD) and obesity. Review of Resident #3's Informed Consent for Use of Bed Rails, dated 04/18/25, indicated…

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

Based on records reviewed and interviews, for one of five sampled residents (Resident #2) whose Physician's Orders included the administration of a narcotic medication for pain, the Facility failed to ensure the resident was free from a significant medication error due to omission, when Resident #2 missed two consecutive doses of scheduled pain medication because nursing staff could not gain access to the facility's Emergency Medication Dispensing System (EMDS, electronic kiosk system that requires a security code to be entered by nursing staff in order to access and dispense stored medications). Finding include: Review of the Facility Policy titled Medication Errors, dated as last revised 11/01/24, indicated that the Facility is to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The Policy further indicated that all medications shall be administered as follows; -According to a Physician's Order, including medication omissions; -Per Manufacturer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of five sampled residents, (Resident #1), the Facility failed to ensure they maintained complete and accurate medical/clinical records, when documentation on his/her Activities of Daily Living (ADL) Flow Sheets that were to be completed daily by Certified Nurse Aides (CNA's), was often left blank. Findings include: Review of the Facility Policy titled Documentation in the Medical Record, dated as last revised 11/01/24, indicated that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The Policy further indicated the following; -Licensed staff and Interdisciplinary Team Members (IDT) shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy; and -Documentation shall be completed 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 reviews and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge (DC) Summary indicated he/she had a scheduled appointment with a Urologist in the community for a consult, the Facility failed to ensure nursing provided care and services that met professional standards of quality, when Resident #1 missed the Urology Consult appointment because nursing overlooked the appointment when reviewing his/her Hospital DC Summary, and transportation was never booked. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse…

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

Based on employee personnel record review and interview, the facility failed to complete annual reviews for five out of five employees reviewed. Findings include: On 6/5/24 at 12:30 P.M., the surveyor reviewed five employee personnel records. All records failed to indicate an annual review was completed for any of the five employees in 2023. During an interview on 6/5/24 at 1:49 P.M., the Director of Nursing said she is responsible for annual reviews being completed for the employees at the facility and said no annual reviews were completed this past year.

Based on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control. Findings include: Review of the Facility Assessment, updated and reviewed with QAPI Committee, dated, March 2024 indicated the following: -Facility resources need to provide competent support and care for our resident population every day and during emergencies. -Infection Control and Preventionist. -Staff training / education and competencies programs are reviewed and revised to ensure we provide the level and types of support and care needed for our resident population. Include staff certification requirements as applicable. -The facility evaluates our infection prevention and control program on a routine basis and as needed. The interdisciplinary team includes but is not limited to SDC (Staff Development…

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 develop and implement the plan of care for 2 Residents (#192 and #62) out of a total sample of 38 residents. Specifically, the facility failed to 1. develop a suicidal ideation care plan and 2. develop a care plan for a behavior of chewing on any items in his/her hands which puts him/her at risk for choking. Findings include: Review of the facility policy titled Comprehensive Care Plans, revised 2/2023, indicated: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. - The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 1.…

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

Based on interviews, record review and policy review, the facility failed to ensure agency nursing staff were provided with an orientation to the facility's day-to-day operations including medication administration procedure. Findings include: Review of the facility policy titled Orientation, revised 2/2023, indicated, but was not limited to: - It is the policy of this facility to develop, implement, and maintain an effective orientation process for all individuals providing services under a contractual arrangement consistent with their expected roles. - General orientation must be completed prior to the employee's formal contact with facility residents. Review of the facility assessment, dated 12/13/22, indicated, but was not limited to: - Are agency staff sufficiently trained to address needs of resident population? Review of the facility assessment, dated 12/13/22, failed to indicate how the facility ensures agency staff are sufficiently trained to address needs of the resident population. On 6/6/24 at 9:05 A.M., the surveyor observed Nurse #14 prepare medication for a 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, policy reviews and interviews, the facility failed to ensure medications with short expiration dates were dated when opened, failed to ensure medication carts, cabinets were securely locked when unattended and medications were securely locked, refrigerated medications were stored correctly. Findings include: Review of the facility policy titled 'Medication Storage' last revised in February 2023, indicated the following but not limited to: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -All drugs and biologicals will be stored in locked compartments, i.e. medication carts, cabinets, drawers, refrigerators, medication rooms, under proper temperature controls. -All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. -Unused medications 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 observations, record review, policy review and interviews, the facility failed to 1.) maintain airborne precautions for one Resident (#94) who was diagnosed with chicken pox, 2.) conduct site-specific infection control surveillance and risk assessments including surveillance data and documentation of follow-up activity in response to active varicella outbreak that required airborne precautions to be implemented, and 3.) failed to report a communicable disease timely to the local and or state health department when a communicable disease was diagnosed on [DATE]. Findings include: Review of the facility policy titled, Transmission Based (Isolation) Precautions, dated May 2024 indicated the following: -it is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. -Airborne precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or 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 observations, record review and interview, the facility failed to maintain one Resident's (#94) dignity by ensuring his/her clothing covered sensitive body parts, out of a total sample of 38 residents. Findings include: Resident #94 was admitted to the facility in September 2021 with diagnoses including major depression and schizophrenia. Review of Resident #94'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. The MDS also indicated Resident #94 required supervision with bathing and dressing tasks. On 6/4/24 from approximately 8:00 A.M., to 8:50 A.M., Resident #94 was observed walking up and down the hallway barefoot. The Resident was wearing black sweatpants, and the right side of the pants were ripped open, exposing the Resident's buttocks. During this time, the Resident walked past a nurse several times and stopped to speak with a Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment, specifically, the facility failed to address a chirping fire alarm. Findings Include: During an observation on 6/4/24 at 11:13 A.M., the surveyor observed a fire alarm in room [ROOM NUMBER] chirping repeatedly. During an observation on 6/5/24 at 6:50 A.M., the surveyor observed a fire alarm in room [ROOM NUMBER] chirping repeatedly. During an observation on 6/6/24 at 7:00 A.M., the surveyor observed a fire alarm in room [ROOM NUMBER] chirping repeatedly. During an interview on 6/6/24 at 9:56 A.M., the Maintenance Director said that he is usually told about any issues in the building via maintenance logbooks that are kept on all nursing units or staff call his direct phone line for any issues. The Maintenance Director said he was not aware or told of the chirping fire alarm in room [ROOM NUMBER].

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff followed their abuse/neglect policy related to resident to resident abuse for one Resident (#37) out of a total of 38 sampled residents. Findings include: Review of the facility's Abuse, Neglect and Exploitation policy dated February 2023 indicated: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse means the use of oral, written or gestured communications or sounds that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability. Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff reported a resident to resident altercations for one Resident (#37) out of a total of 38 sampled residents. Findings include: Review of the facility's Abuse, Neglect and Exploitation policy dated February 2023 indicated: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse means the use of oral, written or gestured communications or sounds that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability. Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur. Reporting/Response:…

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 an updated Pre-admission Screening and Resident Review (PASARR) for one Resident (#192) out of a total sample of 38 residents. Findings include: Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the clinical record indicated Resident #192 received a PASARR Level II (a screening for individuals with serious mental illness, intellectual disability, developmental disability, or other related condition requiring specialized services). The PASRR indicated the following: - Your PASARR level II has been completed. It has been determined that you are appropriate for a Provisional Emergency admission to a Nursing Facility that cannon exceed…

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 the behavioral health care plan for one Resident (#192) after a comprehensive assessment and suicidal ideation. Findings include: 1. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the hospital discharge paperwork indicated Resident #192 reported suicidal ideation (SI) during his/her hospital stay, stating if I did have access to firearms, I would kill myself and I have nothing to live for. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new…

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 specifically provide required assistance with activity of daily living for one Resident (#287) out of a total sample of 38 residents. Findings include: Review of facility policy titled 'Activities of Daily Living (ADLs), reviewed February 2023 indicated the following but not limited to: -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #287 was admitted to the facility in May 2024 with diagnoses including, bipolar disorder and depression. Review of Resident #287's Minimum Data Set assessment dated [DATE] indicated he/she did not participate in a Brief Interview of Mental Status Exam. On 6/4/24 at 9:19 A.M., Resident #287 was observed sitting in his/her room, the Resident was observed with long thick bushy chin hairs. The Resident said he/she would like assistance with removing the facial hair. On 6/5/24 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 ensure the environment was free of hazards for one Resident (#37) out of a total of 38 sampled residents. Specifically, the facility failed to develop and implement interventions addressing Resident #37's behaviors of hoarding hazardous items, such as razors. Findings include: Resident #37 was admitted to the facility in September 2023 with diagnoses including traumatic brain injury, schizophrenia and traumatic hemorrhage of the cerebrum. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #37 scored 6 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating he/she is severely cognitively impaired. Review of Resident #37's clinical nurse progress notes indicated: On 1/22/2024 at 1:04 P.M., Pt (patient] sent out 911, section 12 (an emergent hospital transfer to keep a Resident safe from self-harm or harm to others). Made homicidal comments, social worker & psych NP (Nurse Practitioner) made aware.…

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, policy review, and interview, the facility failed maintain professional standards in the managing and care for urinary catheter devices for one Resident (#27), out of a total sample of 38 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag and tubing were not placed directly on the floor. Findings include: Resident #27 was admitted to the facility in January 2024 with diagnoses including obstructive uropathy and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/24/24, indicated Resident #27 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. This MDS also indicated Resident #27 was dependent on staff for assistance with toileting hygiene and had an indwelling urinary catheter. Review of Resident #27's physician's order, dated 5/16/24, indicated: - Indwelling Three way Foley Catheter 22 Fr (french units) with a 10cc (cubic centimeters) balloon to CD (catheter drainage) bag or leg bag in place check patency.…

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

Based on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#55) 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 38 residents. Specifically, the facility failed to ensure that clamps exchanging blood between a patient and a hemodialysis machine were at the bedside. Findings include: Review of the facility policy titled 'Hemodialysis' reviewed February 2023, indicated the following but not limited to: -This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical nursing, mental, and psychosocial needs of residents receiving hemodialysis. 1. Resident #287 was admitted to the facility in May 2024 with diagnoses including acute kidney failure, type 2 diabetes mellitus…

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 a plan of care was developed for trauma-informed care for one Resident (#101), who was admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD), out of a total sample of 38 residents. Findings include: Review of the facility policy titled 'Trauma Informed Care' reviewed February 2023, indicated the following, but not limited to: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and /or re-traumatization. -Collaboration - an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. -Trauma-specific care plan interventions will recognize the interrelation between…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 4 errors out of 28 opportunities, resulting in a medication error rate of 14.29%. Those errors impacted two Residents (#87 and #91), out of four residents observed. Findings include: Review of the facility policy titled 'Medication Administration', revised 2/2023, indicated, but was not limited to: Policy: Medication are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. 10. Ensure that the six rights of medication administration are followed: b. Right drug c. Right dosage 1.) For Resident #87, the nurse attempted to administer the incorrect dosage of a medication and the incorrect medication. Resident #87 was admitted to the facility in September 2021 with diagnoses including hypertension and venous ulcers. Review of Resident #87's physician's orders indicated: - Metoprolol (a medication used to treat high…

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 that one Resident (#87), was free from significant medication errors, out of a total sample of 38 residents. Specifically, the nurse prepared to administer double the prescribed dose of the medication metorolol (which is a medication that lowers blood pressure and heart rate). Findings include: Review of the facility policy titled 'Medication Administration', revised 2/2023, indicated, but was not limited to: Policy: Medication are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. 10. Ensure that the six rights of medication administration are followed: c. Right dosage. Resident #87 was admitted to the facility in September 2021 with diagnoses including hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/13/24, indicated that Resident #87 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #87's active physician's orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide the correct ordered therapeutic diet for two Residents (#40 and #45) out of a total sample of 38 residents. Findings include: Review of the facility policy titled Therapeutic Diets, dated Reviewed / Revised 2/2023, indicated the following: -Therapeutic Diets including mechanically altered diets where appropriate will be based on the residents' individual needs as determined by the resident assessment. -All diet orders are to be communicated to the dietary department in accordance with facility procedures-dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and or the appropriate nutritive content as prescribed. -Therapeutic diet is a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition. -Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples…

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

Based on interviews and review of the facility assessment, the facility failed to accurately evaluate their resident population and identify the resources needed to provide the necessary care and services of the resident population related to behavioral health services. Findings include: Review of the facility assessment, revised 3/19/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs. It was determined during survey that out of a total universe of 68 residents identified with depression disorder, 6 residents were not provided the behavioral health services after an identification of decreased mood through the PHQ-9 (personal health…

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 maintain an accurate medical record for one Resident (#16), out of a total sample of 38 residents. Specifically, the nurses documented in the Treatment Administration Record (TAR) that they had applied a resting hand splint to Resident #16's left hand when they had not. Findings include: Resident #16 was admitted to the facility in March 2014 with diagnoses including with a left hand contracture and a history of traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/24/2024, indicated Resident #16 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated Resident #16 was dependent on staff for dressing, transfers, and mobility. Review of the physician's order, dated 10/30/23, indicated: - Patient to wear resting hand splint on left hand in am and removed at bed, every day and evening shift *-* kept in bedside drawer Review of the plan of care related to need for assistance with ADLS…

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 the call light was accessible for one Resident (#79) out of a total of 38 sampled residents. Findings include: Review of the facility's Call lights: Accessibility and Timely Response policy, dated February 2023 indicated: Staff will ensure the call light is within reach of resident and secured as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #79 was admitted to the facility in December 2021 with diagnoses including dementia, cerebrovascular accident (stroke) and depression. Review of Resident #79's Minimum Data Set assessment dated [DATE] indicated he/she scored 15 out of 15 on the Brief Interview of Mental Status Exam indicating intact cognition. The MDS also indicated that Resident #79 requires assistance with bathing, dressing and transfers. On 6/4/24 at 8:52 A.M., the surveyor observed Resident #79 laying in bed with his/her call…

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 its abuse policies and procedures as evidenced by 1.) failing to report allegations of abuse to the state agency as required and 2.) failing to investigate allegations of abuse for 4 Residents (#17, #79, #101, discharged Resident (#1) out of a total of 28 Sampled Residents. Findings include: Review of the Facility's Abuse Mistreatment and Neglect policy, undated, indicated: *Any incident affecting the health or safety of the resident is reported to the Director of Nursing Services, the Administrator, the attending physician and next-of-kin or legal representative. *If the Director of Nursing Services and/or the Administrator have reasonable cause to believe that any resident may have been abused, mistreated, exploited or neglected, then an immediate report of the incident will be sent to the Department of Health with a completed report to follow. The report is sent no later than 2 hours after the allegation is made. *The Director of Nursing…

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 report abuse allegations as required for 4 Residents (#17, #79, #101) and discharged Resident (#1) out of 28 sampled Residents. Findings include: Review of the facility's Abuse, Mistreatment and Neglect policy undated, indicated: *Any incident affecting the health or safety of the resident is reported to the Director of Nursing Services, the Administrator, the attending physician and next-of-kin or legal representative. *If the Director of Nursing Services and/or the Administrator have reasonable cause to believe that any resident may have been abused, mistreated, exploited or neglected, then an immediate report of the incident will be sent to the Department of Health with a completed report to follow. The report is sent no later than 2 hours after the allegation is made. 1.) The facility failed to report Resident to Resident abuse between a.) Resident #101 and Resident #17 on 2/8/23 within 2 hours and b.) failed to report potential abuse between…

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 facility policy review, the facility failed to 1.) ensure that food items were accurately labeled and dated to determine an expiration/use by date and 2.) failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: 1. Review of the facility policy titled, Food Storage, dated 9/13/16, indicated the following: *Purpose: to service safe food and demonstrate safe food handling at all times in compliance with local, state, and federal guidelines. *Refrigerated, ready to eat, potentially hazardous food opened or prepared shall be clearly marked at the time of preparation to indicate the date of preparation. Ready to eat food items shall not be consumed after 72 hours. *Ready prepared leftovers shall be discarded within 72 hours of the date originally prepared. On 4/23/23 at 7:13 A.M., the following was observed in the kitchen refrigerator: *1 container of pureed food not labeled or dated. *2 containers of pasta and meat not dated. *1 package of turkey…

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 obtain consent for the use of psychotropic medications for 1 Resident (#66), out of a total sample of 28 residents. Findings include: Resident #66 was admitted to the facility in October 2021 with diagnoses including dementia with behavioral disturbance and depression. Review of Resident #66's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #66 requires extensive assistance from staff for functional daily tasks. Review of Resident #66's physician orders indicated the following orders: *Ativan (an anti-anxiety medication), .5 mg (milligrams), once a day, written 10/29/21 *Buspirone (an anti-anxiety medication), 15 mg twice a day written 1/19/21. *Buspirone, 10 mg, once a day, written 1/19/21. *Fluoxetine (an anti-depressant medication) 40 mg once a day, written 10/29/21. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the physician of a change of status for 1 Resident (#66), out of a total sample of 28 residents. Findings include: Resident #66 was admitted to the facility in October 2021 with diagnoses including dementia with behavioral disturbance and depression. Review of Resident #66's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #66 requires extensive assistance from staff for functional daily tasks. Review of a nursing note written on 12/29/22 indicated the following: *this writer spoke with resident about finding a lump in breast (the Resident) stated (the Resident) never had a mammogram and is concerned, I told her I would reach out to NP (nurse practitioner), for consult to breast center or family gynecologist for referral to have a mammogram. Further review of the medical…

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 prevent Resident abuse when physical intimate touch occurred between Resident #101 and Resident #17 out of a total of 28 sampled Residents. Resident #101 lacks capacity to consent. Findings include: Review of the facility's Abuse Mistreatment and Neglect policy, undated, indicated: *Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Resident #101 was admitted to the facility in May 2022 with diagnoses including Alzheimer's disease, and depression. Review of his/her most recent Minimum Data Set (MDS) dated [DATE] indicated he/she scored 3 out of possible 15 on the Brief Interview for Mental Status Exam indicating severe cognitive impairment and requires assistance with bathing, dressing and grooming. Review of Resident #101's clinical record indicated his/her Health Care Proxy was activated on 5/19/22 indicating Resident #101 is not his/her own decision maker. Review of Resident #101's behavioral care…

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 investigate allegations of abuse for 2 Residents (#97, #101) and discharged Resident (#1) out of 28 Sampled Residents Review of the Facility's Abuse, Mistreatment and Neglect policy, undated, indicated: *The Director of Nursing coordinates the investigation of alleged violations. *Nursing or Social Service personnel will conduct interviews with subject (if possible) the accused, potential witnesses and supervisory personnel as needed. *The completed standardized incident form is reviewed for additional data. 1. Resident #101 was admitted to the facility in May 2022 with diagnoses including Alzheimer's disease, and depression. Review of his/her most recent Minimum Data Set (MDS) dated [DATE] indicated he/she scored 3 out of possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment and requires assistance with bathing, dressing and grooming. Review of Resident #101's clinical record indicated his/her Health…

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 3. For Resident #98 the facility failed to develop and implement a care plan for the risk for aspiration. Resident #98 was admitted to the facility in March 2022 and has diagnoses that includes cognitive communication deficit, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, and dysphagia (difficulty in swallowing). Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 1/25/23 indicated Resident #98 had a Brief Interview for Mental Status Score of 15 out of 15 indicating he/she was cognitively intact. Further review of the MDS, indicated Resident #98 required extensive assistance with bed mobility, transfers, independent with eating with set up, and required a mechanically altered diet. Review of the medical record indicated in a nursing progress note dated 4/15/23 that Resident #98 returned from an acute care hospital, with diagnosis of aspiration (aspiration occurs when food, or drink are breathed into the airway) and (is) on a ground diet…

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 provide assistance during meals for 3 Residents (#41, #63 and #82) out of a total sample of 28 residents. Findings include: 1. Resident #41 was admitted to the facility in November 2021 with diagnoses including stroke and dysphagia. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE] indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating he/she has moderate cognitive impairment. On 4/23/23 at 8:31 A.M., Resident was observed lying in bed eating breakfast. The privacy curtain was drawn, and the Resident was not visible from the hallway. There were no staff present to provide supervision, cueing or assistance if needed. On 4/24/23 at 8:33 A.M., Resident was observed lying in bed eating breakfast. The privacy curtain was drawn, and the Resident was not visible from the hallway. There were no staff present to provide supervision, cueing or assistance if needed.…

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 obtain physician orders for treatment of a skin tear for 1 Resident #76 out of a total sample of 28 residents. Findings include: Review of facility policy titled 'Skin Management Program' updated 4/18 indicated the following: Policy and Procedure: *3. Skin will be monitored routinely. Certified Nursing Assistant (C.N.A) observe skin daily and are to report any redness or other concerns to the Nursing Manager. The licensed staff is to assess the area and implement either preventative or actual treatment approaches as per house protocol and MD order. New skin areas/wounds are reported to DON (Director of Nursing) RD (Registered Dietician) MDS coordinator, SDC (Staff Development Coordinator) and Unit Manager. Resident #76 was admitted to the facility in May 2021 with diagnoses including schizoaffective disorder, bipolar, pseudobulbar affect, and dementia. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide services to maintain adequate hearing for 1 Resident (#66) out of a total sample of 28 residents. Findings include: Resident #66 was admitted to the facility in October 2021 with diagnoses including dementia with behavioral disturbance and depression. Review of Resident #66's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #66 requires extensive assistance from staff for functional daily tasks. During an interview on 4/23/23 at 8:07 A.M., Resident #66 said his/her hearing aides have been broken for along time and he/she has been trying to get staff to help him/her get them fixed. The Resident said he/she is very upset that no one has helped him/her with this yet. Review of Resident #66's clinical record indicated the following: *Resident #66 requested audiology services on…

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

Based on observation, record review and interview the facility, failed to ensure professional standards of practice were adhered to for the care, and prevention of infection for 1 Resident (#321), with a urinary catheter, out of total sample of 28 residents. Findings include: Review of the facility policy, titled Catheter Care, dated as revised February 2022 indicated the following: * Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. * Preparation: Review the resident's care plan to assess for any special needs of the resident. * Maintaining Unobstructed Urine Flow. 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. * Infection Control b. Be sure catheter tubing and drainage bag are kept off 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 observations, record review and interview the facility failed to provide correct setting for oxygen administration for 1 Resident (#170) out of a total sample of 28 residents. Findings Include: Review of facility policy titled 'Oxygen Administration -Simple Mask' undated indicated the following: Policy: To deliver moderate flow oxygen through nose and mouth, per the physician's order (generally 5-10 LPM (liters per minute and 40%- 60% concentration) via simple face mask. Procedure: *Set the oxygen liter flow to the prescribed liter flow per minute Resident #170 was admitted to the facility in April 2023 with diagnoses including asthma, chronic respiratory failure with hypoxia. Review of Resident #170 most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #170 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she had moderately impaired cognition. The MDS further indicated Resident #71 did not have behaviors and did not reject care. On 4/23/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate pain management for approximately 4 months, which resulted in the increased use of PRN (as needed) pain medication for 1 Resident (#103) out of a total sample of 28 residents. Findings include: Resident #103 was admitted to the facility in June 2022, with diagnoses including cerebral infractions, hemiplegia, and chronic pain syndrome. Review of Resident #103's Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of possible 15, indicating moderately impaired cognition. The MDS also indicated Resident #103 reported occasional pain and received PRN pain medications in the past 5 days. On 4/25/23 at 10:00 A.M., the surveyor observed Resident #103 in bed. Resident #103 told the surveyor that he/she always has pain on his/her bilateral lower legs, but the pain felt worse within the last month. Resident #103 told the surveyor that for pain management he/she is on scheduled Tylenol 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 ensure that 1 Resident (#98) was free of unnecessary medication, out of a total sample of 28 residents. Specifically, Resident #98 continued to be administered Aspirin 325 milligrams QD (once a day), after the physician reviewed and agreed with the pharmacist recommendation to change the order to Aspirin to 81 mgs PO (by mouth) daily. Findings include: Resident #98 was admitted in March 2022 and has diagnoses that includes cognitive communication deficit, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #98 had a Brief Interview for Mental Status Score of 15 out of 15 indicating he/she was cognitively intact. Review of a document entitled Consultant Pharmacist Recommendation to Physician, dated as printed 10/5/23, in Resident #98's medical record indicated the following: Dear (Named) physician, this resident (#98) 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 observations, record review and interviews, the facility failed to provide dental services as needed for 1 Resident (#89) out of a total sample of 28 residents. Findings include: Resident #89 was admitted to the facility in November 2021 with diagnoses including dementia. Review of Resident #89's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, indicating he/she has severe cognitive impairment. During an interview on 4/23/23 at 12:05 P.M., Resident #89 said he/she needed to see the dentist. Resident #89 said he/she has been missing his/her upper teeth for a long time and would really like to have dentures so I can eat like I should. The surveyor observed Resident #89 to have several missing bottom teeth and no upper teeth. Review of Resident #89's dental care plan last revised 1/31/23, indicated the Resident is at risk for altered dentition due to his/her natural teeth are missing. Review of the…

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

Based on observation, record review and interview the facility failed to provide a therapeutic diet as ordered by the physician for 1 Resident (#98) out of a total sample of 28 residents. Findings include: Resident #98 was admitted to the facility in March 2022 and has diagnoses that includes cognitive communication deficit, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, and dysphagia. Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 1/25/23 indicated Resident #98 had a Brief Interview for Mental Status Score of 15 out of 15 indicating he/she was cognitively intact. Further review of the MDS, indicated Resident #98 required extensive assistance with bed mobility, transfers, independent with eating with set up, and required a mechanically altered diet. Review of the medical record indicated in a nursing progress note dated 4/15/23 that Resident #98 returned from an acute care hospital, with diagnosis of aspiration (aspiration occurs when food, or drink are breathed into the airway) and (is) on a ground…

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.