Sachem Center For Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper size mattress was on the bed for one Resident (#323), out of a sample of 18 residents. Specifically, the facility failed to ensure the Mattress Bolster/Extender (an object used to fill gaps between the mattress and footboard of a bed) was put on the bariatric (obesity) bed, leaving a gap of approximately 10 inches between the end of the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury. Findings include: Review of the facility's policy titled Bed Safety, undated, indicated but was not limited to the following: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. -To try and prevent death/injuries from beds and related equipment.…

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 document review and interview, the facility failed to provide their staff training on facility ethic standards, policies, and procedures. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. The Facility Assessment failed to indicate ethics and compliance training were required in accordance with the regulations. Review of annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were mandatory for staff, included but were not limited to 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 review of Resident Council Minutes, resident and staff interviews, and policy review, the facility failed to ensure staff documented, addressed, and promptly resolved concerns brought forward during Resident Council Meetings held from 8/7/23 through 1/12/24. Findings include: Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following: - the purpose of Resident Council is to provide a forum for: discussions of concerns and suggestions for improvement, consensus building and communication between the residents and facility - a Resident Council response form will be utilized to track issues and their resolutions, the facility department related to any issues will be responsible for addressing items of concern Review of the Resident Council Meeting Minutes, dated 8/7/23, indicated but were not limited to the following: Nursing: - Nursing staff are often talking on their phones in their native language during care with residents. - Certified Nurse Assistants (CNAs) chatting very loudly in the halls with each other throughout…

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

Based on document review, policy review, and interviews, the facility failed to maintain a grievance process that supported the resident's right to formulate grievances anonymously and consistently document a resolution with acknowledgement. The total sample was 21 residents. Specifically, the facility failed to: 1. Have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns; and 2. Document evidence of a concern of missing items being resolved with an acknowledged by the complainant for Resident #14. Findings include: Review of the facility's policy titled Administration, Grievance Policy, undated, indicated but was not limited to the following: - The facility will support the resident/responsible party to voice grievances/concerns regarding treatment, care, management of funds, lost articles and any violation of resident rights. - The resident/responsible party can bring forward their concerns verbally or by the written grievance process -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #9 was admitted to the facility in July 2019 with diagnoses including: multiple sclerosis (MS), dementia, and cognitive communication deficit. On 1/30/24 at 9:02 A.M., the surveyor observed Resident #9 sitting in a Broda chair (positioning chair) in his/her room with a closed left hand. The surveyor did not observe a brace or assistive device in the room or on the Resident. During an interview on 1/31/24 at 8:09 A.M., Nurse #9 said the Resident's left hand is contracted closed and is not usable. Review of the medical record for Resident #9 indicated but was not limited to the following: - Two licensed monthly summaries, completed on 1/8/23 and 3/3/23 respectively, indicated functional limitation related to contractures and limited range of motion (ROM) - Two Nurse Practitioner's (NP) notes, dated 2/6/23 and 4/3/23, respectively, indicated Resident had muscle rigidity, extremity stiffness, and contractures Review of the Resident's current care plans as of 1/31/24 failed to indicate the Resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #73 was admitted to the facility in December 2023 with diagnoses including Stage 3 pressure injury of the left buttock, weakness, and rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury). Review of the MDS assessment, dated 12/23/23, indicated Resident #73 had a BIMS score of 14 of 15, indicating he/she was cognitively intact. Review of Section M: Skin Conditions of the MDS assessment indicated the Resident had two stage 3 pressure ulcers/injuries on admission. The assessment also indicated Resident #73 was receiving pressure ulcer/injury care including the application of non-surgical dressings and ointments. Review of Resident #73's December 2023 Physician's Orders indicated the following: - Start Date 12/18/23: Left Buttock - Normal Saline Wash (NSW) + Calcium Alginate + Cover with Border Gauze Dressing every day shift and as needed (PRN). Review of the consultant Wound Physician's documentation, dated 12/26/23, indicated the following: - Stage 3 pressure ulcer 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 observation, interview, and policy review, the facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened to prevent potential use of an expired medication in one medication cart out of five medication carts in use by the facility. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: - The expiration/beyond use date on the medication label is checked prior to administering. - When opening a multi-dose container, the date opened is recorded on the container. On [DATE] at 11:45 A.M., the surveyor inspected the medication cart side A on the Joppa unit and made the following observations: -Four tubes of Erythromycin (antibiotic) eye ointment opened, and in use, for different residents with no opened date. During an interview on [DATE] at 11:47 A.M., Nurse #9 said the eye drops are only good for 30 days once opened and has no way of knowing if the medication has…

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, policy review, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Implement COVID-19 testing every 48 hours for all staff during a COVID-19 outbreak for 1 out of 5 sampled staff members; 2. Follow infection control standards during a medication pass, for Resident #66 and Resident #75; 3. Follow infection control practices during a wound dressing change for Resident #73; and 4. Appropriately utilize personal protective equipment (PPE) for residents on enhanced barrier precautions and transmission-based precautions for Resident #33. Findings include: 1. Review of the facility's policy titled Coronavirus Prevention and Control, dated as revised in January 2023, indicated if the facility identifies that the resident or staff member's first exposure occurred less than 2 days ago, then they should wait to test until 24 hours after any exposure and then test residents and staff at least every 48 hours on the affected unit until the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interview, the facility failed to maintain an effective training program, as indicated in their facility assessment. Findings include: Review of the Facility Assessment, dated as updated in May 2023, indicated but was not limited to the following: -Throughout the year all employees receive training and education on topics related to patient care and services. -Some training provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality Assurance Performance Improvement (QAPI) initiatives, ensuring regulatory compliance, best practices, clinical competencies, program development, etc. Review of annual mandatory training content titled: Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were provided during the 9/21/23 mandatory in-service: -Abuse and Neglect; Resident Rights; Advance directives; Health Insurance Portability and Accountability Act (HIPAA) -ADL Training; Assisting with 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 documentation review and interview, the facility failed to provide their staff training in effective communication, as indicated by the Facility Assessment. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: -Throughout the year employees receive training and education on topics related to patient care and services. -Some trainings provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training, and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs) and other: Communication - effective communications for direct care staff Review of annual mandatory training content titled: Round [NAME] Annual Education, dated 9/21/23, indicated but was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interview, the facility failed to ensure staff attended and received education on the facility Quality Assurance and Performance Improvement (QAPI) program, as indicated in the Facility Assessment. Findings include: Review of the Facility Assessment, dated as updated in May 2023, indicated but was not limited to the following: -Throughout the year all employees receive training and education on related topics to patient care and services. -Some training provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality Assurance Performance Improvement (QAPI) initiatives, ensuring regulatory compliance, best practices, clinical competencies, program development, etc. -List of staff training and competencies needed by staff type: -Nurses and Certified Nurse Assistants (CNAs), and Others: Quality Assurance Performance Improvement (QAPI). Staff educator or designee will educate facility staff on QAPI on hire Review of annual…

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 documentation review and interview, the facility failed to ensure their staff were educated on infection control and prevention which included, training on standards, policies, and procedures for the facility's infection prevention and control program. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training, and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs), and other: -Infection control - a facility must include as part of its infection prevention 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 document review and interview the facility failed to provide behavioral health trainings as required in accordance with their facility assessment. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs): Behavioral Health, including: Aggressive behaviors, Intrusive wandering, Self-destructive/self-injurious behaviors, coping mechanisms for unhealthy behaviors Nurses, CNAs, Activities and Social services:…

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 notify the physician and the Resident's responsible party about a change in condition, specifically a significant weight loss of 10.95% in one month, and to re-evaluate the potential need to alter the treatment plan for one Resident (#71), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Weight Measurement, dated as revised February 2022, included but was not limited to: - Residents with a weight variance of 5% more or less than the previous month will be re-weighed. - The charge nurse will notify the physician, responsible party and dietician when a 5% more or less variance is noted. Review of the facility's policy titled Change in a Resident's Condition or Status, undated, indicated but was not limited to the following: - Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition - The nurse will notify the resident's attending physician or physician 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, policy review and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to implement their policy for reporting and investigating an allegation of neglect for Resident #33 who was in pain and not administered pain medications for over an hour. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law Enforcement. -Facility investigation will be completed within 72 hours 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, policy review, and interview, the facility failed to ensure an allegation of neglect was reported for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to report an allegation of neglect to the State Survey Agency (Department of Public Health) for Resident #33, who was experiencing pain of a 9 (on a scale of 1-10 with 10 being the worst pain), and who was not administered pain medications for over an hour. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law…

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

Based on observation, policy review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to follow their policy for investigating an allegation of neglect for Resident #33 who was experiencing pain of a 9 (on a pain scale of 1-10 with 10 being the worst pain), and who waited over an hour for pain medication. Findings include: Review of the facility's policy titled Abuse indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law Enforcement) -Facility investigation will be completed…

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 the resident and their representative with a summary of the baseline care plan for two Residents (#65 and #74), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Care plans - Baseline, dated as revised July 2023, indicated but was not limited to the following: - a baseline care plan will be developed and implemented to assure a resident's immediate care needs are met and maintained - a baseline care plan will be developed within 48 hours of the resident's admission The facility policy does not indicate that a summary of the baseline care plan is provided to the resident or their representative as required. 1. Resident #65 was admitted to the facility in December 2023 with diagnoses including: neurocognitive disorder with Lewy bodies, metabolic encephalopathy, anxiety disorder, unspecified psychosis, and type 2 diabetes mellitus. Review of the medical record included the most recent Brief Interview for Mental Status (BIMS) which indicated a score of 2 out…

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 one Resident (#60), out of a total sample of 21 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed, for Resident #60, to administer scheduled pain medication as ordered. Findings include: Review of the facility's policy titled Administering Medications, undated, included but was not limited to the following: - Medications are administered in accordance with prescriber orders, including any required time frame. - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. - If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interview, the facility failed to provide an activities program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for two Residents (#56 and #65), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #56, to provide an activities program that would meet his/her individual interests to enhance his/her quality of life; and 2. For Resident #65, to plan for or provide an activities program that would meet his/her individual interests to enhance his/her quality of life. Findings include: Review of the facility's policy titled Activity Program, undated, indicated but was not limited to the following: -Activity programs designed to meet the needs of each resident are available on a daily basis. -Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. -Our activity programs consist 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 observation, interview, and record review, the facility failed to provide appropriate treatment and services to manage a contracture and prevent further potential complications in one Resident (#9) with muscular sclerosis, out of a total resident sample of 21 residents. Findings include: Resident #9 was admitted to the facility in July 2019 with diagnoses which included: multiple sclerosis (MS), dementia, and cognitive communication deficit. On 1/30/24 at 9:02 A.M., the surveyor observed Resident #9 sitting in a Broda chair (positioning chair) in his/her room with a closed left hand. The surveyor did not observe any brace or assistive device in the room or on the Resident. During an interview with observation on 1/31/24 at 8:09 A.M., the surveyor observed Nurse #9 assisting the Resident with his/her breakfast meal. The Resident's left hand was observed to be tightly closed with the arm lying across his/her upper abdomen. Nurse #9 said the Resident's left hand is contracted closed and is not usable. She…

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, interviews, record review, and policy review, the facility failed to identify a significant weight loss of over 10% in one month and provide treatment and interventions to prevent further unprescribed, unplanned weight loss for one Resident (#71), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Weight Measurement, dated as revised February 2022, included but was not limited to: - All residents will be weighed at a minimum monthly - Residents with a weight variance of 5% or more or less than the previous month will be re-weighed. - The charge nurse will notify the physician, responsible party and dietician when a 5% more or less variance is noted. - The dietician will review the resident weight and make recommendations accordingly. - When a significant weight fluctuation of 5% more or less is noted, the resident will be weighed based on determination of the Interdisciplinary Team (IDT). - The resident plan of care will be updated accordingly.…

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 ensure enteral nutrition and fluids provided via a percutaneous endoscopic gastrostomy tube (PEG, an opening into the stomach for delivery of nutrition and hydration) or gastrostomy tube (G-tube, a tube inserted into the stomach through which nutrition is provided) were provided in accordance with professional standards of practice and facility policy for two Residents (#74 and #48), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #74, to ensure enteral feedings were provided via PEG tube in accordance with physician orders; and 2. For Resident #48, to ensure enteral formula containers and water flush bags were labeled with the Resident's name, date and time hung, and initialed by staff members. Findings include: Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, undated, included but was not limited to: - The purpose of this procedure is to provide a guideline for…

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 to ensure staff provided respiratory care in accordance with professional standards for one Resident (#16), out of a total sample of 21 residents. Specifically, the facility failed to ensure nebulizer equipment was changed weekly and stored in a sanitary manner. Findings include: Review of the facility's policy titled Administering Medications through a small volume (Handheld) Nebulizer, undated, indicated but was not limited to the following: -The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. -When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. -Change equipment and tubing every seven days. Resident #16 was admitted to the facility in August 2022 with diagnoses which included chronic respiratory failure with hypoxia, pleural effusion, and chronic obstructive pulmonary disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/23,…

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.