Catholic Memorial Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required on five of seven units in the facility. Specifically, the facility failed to ensure all medication and treatment carts were locked when unattended and unsupervised. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated 3/2021, indicated but was not limited to: -Policy: Medications and biologics are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Procedures: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not in use or in…

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 records reviewed for two Residents (#74 and #103), of 38 sampled residents, the facility failed to maintain professional standards of practice. Specifically, the facility failed to ensure: 1. For Resident #74, heel protection lifts/boots were in place, as ordered by the physician; and 2. For Resident #103, heel protection boots and bilateral hand carrots (orthotic positioning device) were in place, as ordered by the physician. Findings include: 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 and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They…

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, policy review, and record review, for one Resident (#3), of 38 sampled residents, the facility failed to ensure he/she received care and treatment to promote healing of a pressure injury. Specifically, for Resident #3, the facility failed to assess his/her pressure injury weekly and designate a multidisciplinary skin care team to review the plan of care weekly from 10/25/23 through 1/30/24 resulting in a wound infection requiring hospitalization and intravenous (IV, through a catheter directly into a blood vessel) antibiotics. Findings include: Review of the facility's policy titled Wound & Skin Care Protocol, dated as revised 1/24, indicated but was not limited to: -The facility will designate and support a multidisciplinary skin care team whose purpose is to review the plan of care for all residents with wounds on a weekly basis and make recommendations to the plan of care Resident #3 was admitted to the facility in July 2021 with the following diagnoses: multiple sclerosis…

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

Based on observation, interview, and policy review, the facility failed to ensure all medications used in the facility were safely and securely stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly store controlled drugs in separately locked compartments in three of eight medication carts reviewed; 2. Properly label all medications stored in one of six medication refrigerators and two of eight medication carts; 3. Lock one of seven medication storage cabinets and one of six-unit medication refrigerators when not attended by persons with authorized access; and 4. Store medications at proper temperatures to preserve their integrity for three out of six-unit medication refrigerators and maintain consistent documentation of medication refrigerator temperatures for six out of seven medication refrigerators reviewed. Findings include: 1. Review of the facility's policy titled Controlled Substances, dated February 2019, indicated, but was not limited to the following: -All controlled substances, CII-V are stored…

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 staff interviews, the facility failed to ensure that for six Residents (#84, #99, #139, #197, #198, and #65), out of a total sample of 35 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed a. For Residents #84, #99, #139, and #197 to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy; b. For Resident #198, to ensure the PRN (as needed) psychotropic drugs were limited to 14 days; and c. For Resident #65, to re-evaluate for a gradual dose reduction of psychotropic medications as recommended by the psychiatric Nurse Practitioner. Findings include: Review of the facility's policy titled Psychopharmacologic Drugs (undated), included, but was not limited to: -Diocesan Health Facilities…

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 document review, the facility failed to ensure that three out of six unit medication refrigerators were maintained in safe operating condition to help preserve the integrity of the medications stored. Findings include: Review of the facility's policy titled, Storage of Medications, dated February 2019, indicated, but was not limited to the following: -All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC) Temperature -The facility should maintain a temperature log in the storage area to record temperatures at least once a day -The facility should check the refrigerator or freezer temperature and maintain a log in which medications (but not vaccines) are stored, at least once a day, per USP/NF Guidelines. The USP (Unites States Pharmacopoeia and National Formulary) guidance from April 28, 2017, indicated the refrigerator temperature for medication storage should be controlled between 36 degrees and 46 degrees Fahrenheit (F). On 6/23/22 the surveyor…

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, interviews, record review, and policy review, the facility failed for one Resident (#100), to ensure the Resident was assessed by the Interdisciplinary Team (IDT) for the self-administration of medications, out of a total sample of 35 residents. Findings include: Review of the facility's policy titled Self-Administration of Medications, dated February 2019, indicated but was not limited to the following: - In order to maintain the residents' highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's IDT has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. - If the resident desires to self-administer medications and an assessment by the IDT indicates it is appropriate, this is documented in the appropriate place in the resident's record; - For those residents assessed, the IDT determines the resident has the ability to self-administer and the skills to self-administer medications. Such as, removal…

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

Based on observation and staff interview, the facility failed to ensure that the right to personal privacy was maintained for one Resident (#154). Findings include: On 06/24/22 from 1:00 P.M. through 1:20 P.M., Surveyors #1 and #2 observed the facility's consultant Psychologist interviewing Resident #154 in his/her room. The consultant Psychologist was seated at the end of the Resident's bed and directly in front of the open doorway. The Psychologist asked Resident #154 questions specific to memory, in a voice easily heard by the two surveyors. The surveyors could hear the Resident answering the Psychologist's questions. The Resident's voice was hesitant, shaky and he/she stuttered. The Resident could be heard asking for reassurance that he/she was answering the questions correctly. During the observation from 1:00 P.M. through 1:20 P.M. on 6/24/22, the surveyors observed Nurse #18 (seated at the nurses' station), a dietary aide, and a certified nursing assistant outside the Resident's room, as well as Unit Manager #1 walking by the Resident's room twice, while the consulting…

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, record review, and policy review, the facility failed to ensure two Residents (#189 and #203), out of 35 sampled residents, were free from Velcro seat belt restraints. Findings include: Review of the Physical Restraints Policy, dated April 2022, indicated the following restraint procedures: -identify specific medical symptoms that require the use of restraints -obtain a physician order -restraints will be removed for 10 minutes every two hours to allow for activities of daily living 1. Resident #189 was admitted to the facility in August 2020 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/31/22, indicated Resident #189 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a severe cognitive impairment. Review of the current Physician's Orders included an order dated 4/21/22 indicating Resident #189 had a Velcro alarm belt on the wheelchair and to monitor the times the Resident intentionally removed the alarm belt when out of bed; with special instructions indicating this 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.

Based on policy review, record review, and interviews, the facility failed to ensure that staff implemented written policies and procedures for allegations of abuse for one Resident (#197), out of 35 sampled residents. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect, undated, indicated but was not limited to: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. -Employees are obligated to report immediately to their supervisors or their administrator, any observed or suspected incidents of abuse. This reporting is necessary in order that the nursing home can inform the alleged violations to DPH prior to preliminary investigation as required. -Upon reporting of any alleged abuse, the administrator must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of 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 policy review, record review, and interview, the facility failed to ensure staff reported two allegations of verbal abuse within two hours to the Department of Public Health (DPH) for two Residents (#197 and #65), out of a total sample of 35 residents. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect, undated, indicated but was not limited to: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. -Employees are obligated to report immediately to their supervisors or their administrator, any observed or suspected incidents of abuse. This reporting is necessary in order that the nursing home can inform the alleged violations to DPH prior to preliminary investigation as required. -Upon reporting of any alleged abuse, the administrator must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment,…

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

Based on policy review, record review, and interview, the facility failed to ensure staff thoroughly investigated and reported the results of an allegation of abuse for two Residents (#197 and #65), out of a total sample of 35 residents. Specifically, the facility failed to: 1. For Resident #197, investigate an allegation of verbal abuse; and 2. For Resident #65, report the results of a completed investigation of resident-to-resident abuse to the Department of Public Health within five days. Findings include: Review of the facility's Abuse Prohibition Policy & Procedure, undated, and Incident Reporting Policy and Procedure, undated, included but was not limited to: It is the policy of the Diocesan Health Facilities that abuse prohibition is comprehensively enforced, as defined Freedom from Abuse, Neglect, and Exploitation (42 Code of Federal Regulations 483.12) -All Resident allegations of abuse must be investigated according to DPH policy. 1. Resident #197 was admitted to the facility in September 2019 with diagnoses including chronic obstructive pulmonary disease and anxiety.…

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

Based on policy review, record review, and interview, the facility failed to ensure a Physician's order for admission was obtained according to facility policy for two Residents (#211 and #212), out of three closed records reviewed, from a total sample of 35 residents. Findings include: Review of the facility's admission Procedure policy, last reviewed in March 2022, included but was not limited to: -Residents shall be admitted on ly on the written order of a Physician, Physician Assistant or Nurse Practitioner. 1. Resident #211 was admitted to the facility in May 2022 with diagnoses including diabetes mellitus, hypertension, and cerebral infarction. On 6/3/22, the Resident was discharged home with services. Review of the medical record failed to indicate an order to admit Resident #211 to the facility. 2. Resident #212 was admitted to the facility in May 2022 for a five-day respite stay and received Hospice services. The Resident had diagnoses including cerebrovascular disease. The Resident was transferred to the hospital on 5/12/22 and did not return to the facility. 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 observations, record reviews, and interviews, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#74 and #71), out of a total of 35 sampled residents. Specifically, the facility failed 1. For Resident #74, to develop and implement the care plan for weekly weights and record percentage of meals consumed, per the physician's orders; and 2. For Resident #71, to implement the care plan and provide mealtime assistance and cueing. 1. Resident #74 was admitted to the facility in October 2021 with diagnoses including Parkinson's disease, dementia with Lewy bodies, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 4/14/22, indicated Resident #74 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The MDS indicated the Resident was not on a physician-prescribed weight loss plan. Review of the June 2022 Physician's Orders included the following orders initiated 10/24/21: - CNA [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, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for two Residents (#112 and #84), out of a total sample of 35 residents. Specifically, the facility failed 1. For Resident #112, to revise the care plan for the use and monitoring of psychotropic medications; and 2. For Resident #84, to revise the care plan for skin to reflect the Resident's intermittent behavior of removing booties prescribed by the physician as an intervention to prevent to development of pressure injuries to his/heels. Findings include: 1. Resident #112 was admitted to the facility in January 2022 and diagnosed with dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #112 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 03 out of 15, the MDS indicated the Resident received psychotropic medications. Review of the Comprehensive Care Plans included but was not limited to:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure professional standards of practice were followed for two Residents (#100 and #99), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #100, to ensure nursing staff did not leave medications at the bedside; and 2. For Resident #99, to complete ongoing comprehensive skin assessments. Findings include: 1. Review of the facility's policy titled, Storage of Medications, dated February 2019, indicated but was not limited to the following: -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Resident #100 was admitted to the facility in November 2019 with diagnoses including a primary admission diagnoses of treated lung cancer and irritable bowel syndrome. Review of the Minimum Data Set (MDS) assessment, dated 4/28/22, indicated Resident #100 was alert and oriented. On 6/21/22 at 11:00 A.M. and at 2:00 P.M., 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 interview and record review, the facility failed to assist one Resident (#85), out of a total sample of 35 residents, in obtaining an alternative or replacement hearing device in a timely manner upon discovering the Resident's hearing aids were lost. Findings include: Resident #85 was admitted to the facility in January 2022. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/20/22, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS further indicated in Section B the Resident had moderate difficulty with hearing and hearing aids were used. During an interview on 6/21/22 at 9:36 A.M., Resident #85 said he/she is hard of hearing (HOH) and does not have hearing aids. Review of the Communication Care Plan indicated, but was not limited to, the following under approaches to be used with Resident #85: - I am HOH and may miss part of what you are saying to me especially in a noisy busy environment - I am HOH and wear bilateral hearing aids. Please insert them daily so that I can…

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

Based on interview, observation, and policy review, the facility failed to ensure existing interventions to promote healing and/or prevent worsening of a pressure ulcer and prevent skin breakdown on the heels (air mattress; and bilateral heel off booties and a pillow to offload heels, respectively) were followed for one Resident (#84), out of a total sample of 35 residents. Findings include: Review of the facility's policies for Wound & Skin Care Protocol Policy (undated) and Low Air Loss Mattress (undated), included, but were not limited to: Purpose: Identify outcomes-based approaches for the care of residents identified at-risk and those with existing wounds. Treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. Procedure: -Interventions must be care planned and implemented during the admission process and revised as needed; -Check the resident's weight and adjust the low air loss mattress accordingly. This should be done weekly with the weekly weights and documented. Resident #84 was admitted to the facility in July 2021…

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 the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#99), out of a total sample of 35 residents. Findings include: Review of [NAME] NURSING PROCEDURES, 8th edition -oxygen .all oxygen delivery systems should be checked at least once each day -verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed -monitor the patient's O2 saturation level by pulse oximetry to assess response to O2 therapy -assess the patient frequently for signs and symptoms of hypoxia, such as restlessness, decreased level consciousness, increased heart rate, arrhythmias, perspiration, dyspnea, use of accessory muscles, yawning or flared nostrils, cyanosis, and cool, clammy skin, obtain vital signs, as needed. DOCUMENTATION record the date and time of oxygen administration, the type of delivery device, 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 effectively manage one Resident's (#170) pain, out of a total sample of 35 residents. Findings include: Resident #170 was admitted to the facility in May 2021 with medical diagnoses including displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounter for orthopedic aftercare, unspecified fall subsequent encounter, difficulty in walking and other lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 5/23/22, indicated Resident #170 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 99; the MDS indicated the Resident required extensive assistance for all activities of daily living. Review of the Comprehensive Care Plans included but was not limited to: -Focus: Resident does not have a history of complaints of pain. Monitor the Resident for any behaviors that indicate the Resident had pain such as moaning, increased restlessness, grimacing or guarding and report to his/her…

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

Based on document review, record review, and staff interview, the facility failed to ensure that for two Residents (#139 and #197), out of a sample of 35 residents, the facility's psychiatric consultant, who provided one to one (1:1) psychotherapy, developed a treatment plan which identified individualized, person-centered, and measurable goals of treatment. Findings include: Review of the Behavioral Health Service Agreement, signed on 3/18/19, included, but was not limited to: -Meet with medical and professional personnel of the facility to assist in treatment planning and behavioral management 1. Resident #139 was admitted to the facility in February 2020 with diagnoses including dementia and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 5/11/22, indicated Resident #139 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Physician's Orders included, but was not limited to: -May have psychiatric evaluation and treat (initiated on 9/28/21) Review of the medical record indicated Resident #139…

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

Based on observations, record reviews, and interviews, the facility failed to provide the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one Resident (#112) with dementia, out of a total sample of 35 residents. Resident #112 was admitted to the facility in January 2022. Review of a Psychiatric Evaluation, 2/23/22, indicated Resident #112 had cognitive impairment and dementia. Review of the clinical record indicated the facility did not address the Resident's diagnosis of dementia until 3/11/22 (2.5 weeks later). Review of Resident #112's Care Plan for Mood/Behaviors, Episodes of: yelling, screaming, swearing, crying, or hitting staff or my peers, included the following interventions: -Administer medications as ordered, monitor and record effectiveness. Report adverse side effects. Review of the MDS assessment, dated 4/28/22, indicated Resident #112 had severe cognitive impairment as evidenced by a BIMS score of 03 out of 15. The MDS indicated no non-pharmacological resident centered care techniques…

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

Based on record review and staff interviews, the facility failed to ensure medication irregularities identified during the Pharmacist's Drug Regimen Review were reported and acted upon for one Resident (#198), out of a total sample of 35 residents. Findings include: Resident #198 was admitted to the facility in May 2022 with diagnoses which included anxiety. Review of the Pharmacy Drug Regimen Review, dated 6/8/22, indicated two irregularities as noted below: 1. Nsg (nursing) rec (recommend) Cipro Tx (treatment) requires stop-date or clarification. 2. Nsg (nursing) rec (recommend) PRN (as needed) Ativan orders require 14-day limit. During an interview on 6/29/22 at 11:45 A.M., the Director of Nursing (DON) said she was not sure if the recommendations had been addressed, or acted upon, by the facility. The DON explained that the facility process for pharmacist recommendations is, the pharmacy recommendations are e-mailed to her, she gives them to the secretary who places them in each of the nursing unit managers' mailboxes. And, then it is the Unit Managers' (UM) responsibility to…

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

Based on record review, policy review, and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant agent prescribed for four Residents (#59, #99 #139, and #173), out of a total sample of 35 residents. Findings include: Review of the facility's policy titled Anticoagulation Therapy Policy and Procedure, undated, included, but was not limited to: -Anticoagulation therapy is the administration of certain drugs that reduce the tendency of the blood to coagulate, thus reducing the risk of thrombosis (clotting of the blood). Anticoagulation is indicated for a variety of conditions, including prophylaxis of venous thromboembolism (blood clot) and the prevention of systemic embolism. -Observe for signs of bleeding: Blood in urine or stool Bleeding of gums, nose Small purplish, hemorrhagic spots on the skin Excessive and easy bruising Confusion, changes in mental status 1. Resident #59 was admitted to the facility in December 2021 with diagnoses including a pulmonary embolism. Review of the June 2022…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop an integrated, person-centered hospice care plan identifying coordination of care between the facility and the hospice provider for one Resident (#185), out of a total sample of 35 residents. Findings include: The facility did not have a separate Hospice policy available for review by the surveyor. Review of the contract agreement between the facility and the consultant Hospice provider, signed as effective 3/19/14, indicated but was not limited to: Responsibilities of the Nursing Facility: -In accordance with applicable laws and regulations, including without limitation, all applicable Centers for Medicare and Medicaid Services (CMS) condition of participation. Nursing Facility shall consult with Hospice regarding the development and/or modification of a Plan of Care for each eligible resident. -The Plan of Care must identify the care and services that are needed and specifically identify which provider is responsible for performing 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 policy review, observation, and interview, the facility failed to ensure standards of infection prevention practices were maintained during a dressing change for one Resident (#74), out of a total sample of 35 residents. Findings include: 1. Review of the facility's policy titled Dressing Changes and Changing a Clean Dressing, dated 11/2021, indicated but was not limited to the following: It is the policy of the facility to promote wound healing. Procedure: -Perform hand hygiene. -Apply disposable gloves. -Provide counter traction on skin, loosen tape, and pull ends toward the wound removing the dressing. Discard in plastic bag. -Cleanse and rinse wound as ordered. If wound appears abnormal or infected, always notify Nurse Manager or Supervisor. -Remove gloves and discard in plastic bag. -Washing hands. -Set up dressing supplies and open packages on clean surface. -Apply clean exam gloves. -Pick up dressing holding it by corners. -Center dressing over wound/cover with secondary dressing if ordered. -Tape dressing securely in place, date and initial. -Discard gloves and all…

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

Based on policy review, record review, and interview, the facility failed to implement their Antibiotic Stewardship Program policy to ensure that a stop date or a clinical rationale for continued use was included in the order for one Resident (#198), out of a total sample of 35 residents, being prescribed an antibiotic. Findings include: Review of the facility's Antibiotic Stewardship Program (ASP) Policy, the Antibiotic Stewardship Program Team will be established to be accountable for stewardship activities. The ASP Team consists of a Medical Director, Administrator, Director of Nursing, Infection Preventionist (IP), pharmacy consultant, and laboratory representative. Their duties, as a team included: -Review infections and monitor antibiotic usage patterns on a regular basis. Resident #198 was admitted to the facility in May 2022 with diagnoses which included hepatic cancer and anxiety. Review of the Pharmacy Drug Regimen Review, dated 6/8/22, indicated the consultant pharmacist identified the following irregularity: -6/8/22, Nsg (nursing) rec (recommend) Cipro Tx (treatment)…

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.