Fitchburg Healthcare

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#12) out of a total sample of 27 residents. Specifically, for Resident #12, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of organism transmission to the Resident, staff, and other residents within the facility. Findings include:Review of the facility policy titled Infection Control Guidelines for Nursing Procedures, revised 7/2024, included but was not limited to: *To provide guidelines for general infection control while caring for residents.-Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing resident's infections which may include:>Prevention of the transmission 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.

Based on observation, interviews and records reviewed, for one of three sampled residents (Resident #1), who resides on a secured Dementia unit, has a known behavior that includes physical aggression and has been involved in multiple resident to resident physical and verbal altercations, the Facility failed to ensure that they provided him/her with an adequate level of staff supervision on the unit to maintain residents safety in an effort to prevent resident to resident altercations, therefore placing him/her and other residents on the unit at risk for injury. Findings include: Review of the Facility policy titled, Care Plan, comprehensive Person-centered, revised 01/2024, indicated a comprehensive, person-centered care plan will be developed for each resident. The policy indicated a care plan will include objectives that meet the residents' physical, psychosocial and functional needs. The policy indicated that the resident comprehensive care plan will identify problem areas and their causes as warranted and develop interventions that are targeted and meaningful to each 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 records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when during the provision of care, two staff members overheard Certified Nurse Aide (CNA) #1 interacting with Resident #1, during which CNA #1 used profanities and spoke to him/her in a raised, very loud tone of voice.Findings include:Review of the Facility's Policy titled, Abuse Investigation and Reporting, dated as last revised February 2024, indicated that every resident in the facility will be treated with respect and dignity. Review of the Facility's Policy titled, Resident Rights, dated as last revised January 2024, indicated all residents have a right to a dignified existence and employees shall treat all residents with kindness, respect, and dignity.Resident #1 was admitted to the Facility in May 2025, diagnoses included Lewy Body Dementia (a type of brain disease characterized by the…

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

Based on record review, policy review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for one Resident (#111) out of a total sample of 24 residents. Specifically, for Resident #111 the facility failed to have the Resident evaluated for the capacity to make medical decisions following a decline/change in their cognitive status. Findings include: Review of the facility policy titled Advanced Directives, last revised January 2024, indicated the following: -the interdisciplinary team (IDT) will conduct ongoing review of the resident's decision-making capacity and communicate significant changes as appropriate. -determine the decision-making capacity of the resident and invoke (activate) the decisions of the legal representative as appropriate. 1. Resident #111 was admitted to the facility in December 2023, with diagnoses including vascular Dementia (decline in reasoning, planning, memory, judgement, and other thought…

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, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner [NP]) of a significant change in condition for two Residents (#23 and #111) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. For Resident #23, when the blood sugar reading was greater than 400 mg/dL (milligrams per deciliter). 2. For Resident #111, when the blood sugar reading was less than 70 mg/dL and greater than 401 mg/dL. Findings include: Review of the facility policy for Diabetes- Clinical Protocol, last revised December 2020 indicated: -the Physician will follow-up any acute episodes associated with a change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -the Physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. -the staff will identify and report complications such as .hypoglycemia (low blood sugar).…

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 ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for five Residents (#59, #90, #113, #56, and #111) out of a total sample of 24 residents. Findings include: 1. Resident #59 was admitted to the facility in August 2024, with diagnoses including Unspecified Dementia with behavioral disturbance (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis, usually associated with adverse behaviors). Review of the Resident #59's PASRR Level I, dated 9/3/24, indicated the Level I screen was completed after the Resident's admission to the facility. 2. Resident #90 was admitted to the facility in May 2023, with diagnoses including Unspecified Dementia with behavioral disturbance, Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, 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 interview, and record review, the facility failed to the facility failed to provide care and services consistent with professional standards of practice for two Residents (#113 and #91) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #113, ensure that Physician orders were obtained for a recommended Hemoglobin A1C (HbA1c - test used to identify Diabetes [disease that affects how the body uses blood sugar]) lab to be drawn as recommended by the Behavioral Health Nurse Practitioner (NP) for the Resident on medications for mental health conditions. 2. For Resident #91, maintain and document fluid restrictions and administer dietary supplements as ordered by the Physician for treatment of End Stage Renal Disease (the final stage of kidney disease where the kidneys can no longer function on their own leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#11) out of a total sample of 24 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #11. Findings include: Resident #11 was admitted to the facility in May 2021, with diagnoses including Unspecified Schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior), Unspecified Dementia (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest or pleasure in activities that a person used to enjoy), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere…

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 and policy review, and interview, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#23) out of a total sample of 24 residents. Specifically, for Resident #23, the facility staff failed to: 1. verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size urinary catheter was in place. 2. to obtain an appointment with a Urologist as requested by the Nurse Practitioner (NP) to prevent catheter related complications. Findings include: Review of the facility policy for Indwelling Foley Catheter Insertion, last revised December 2020, indicated: -to verify that there is a Physician's order for this procedure. -review the resident's care plan to assess for any special needs of the resident. -the following information should be recorded in the resident's medical record: the…

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

Based on observation, interview, and record review, the facility failed to maintain proper nutrition and hydration care and services for one Resident (#64) out of a total sample of 24 residents. Specifically, for Resident #64, the facility failed to appropriately monitor daily fluid intake and follow the care plan to ensure that the Resident maintained fluid restriction amounts as ordered by the Physician. Findings include: Resident #64 was admitted to the facility in December 2022, with diagnoses including Chronic Kidney Disease Stage 4 (CKD - a condition where the kidneys have become severely damaged and have a decreased ability to filter toxins and excess fluid from the blood), and Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs). Review of Resident #64's Minimum Data Set (MDS) Assessment, dated 9/3/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15. Review of Resident #64's September 2024…

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, record and policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for one Resident (#64) out of a total sample of 24 residents. Specifically, for Resident #64, the facility failed to: -ensure that the Resident who had a chronic pulmonary diagnosis was administered the appropriate liter per minute (LPM - flow rate) of supplemental Oxygen [O2] as ordered by the Physician. -routinely assess and monitor that the Resident's oxygen delivery device was set at the prescribed liter flow rate. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. - Oxygen therapy should be administered in accordance…

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 and policy review, and interview, the facility failed to complete ongoing communication with the contracted dialysis center related to dialysis care and services for one Resident (#91) out of one applicable resident, out of a total sample of 24 residents. Specifically, for Resident #91, the facility failed to: -ensure that dialysis communication forms included updated information on the Resident's dialysis care and services. -maintain communication with the dialysis center related to an elevated laboratory result for the Resident. Findings include: Review of the facility's End Stage Renal Disease and Dialysis Policy, initiated 11/2017 and revised 9/2023, indicated: -Agreements between this facility and the ESRD (End Stage Renal Disease) facility include aspects of how the residents care will be managed. -Ongoing communication and collaborations with the dialysis facility regarding dialysis care and services. Resident #91 was admitted to the facility in August 2024, with diagnoses including End Stage Renal Disease (ESRD - a medical condition where the kidneys cease…

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 ensure that Physician orders were in place for lab work for one Resident (#120) out of a total of two residents reviewed for infection control. Specifically, for Resident #120, the facility failed to obtain Physician orders prior to completing Vancomycin (an antibiotic) trough laboratory (labs that measure the amount of Vancomycin in the blood stream to ensure it is at a therapeutic level) draws. Findings include: Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, last revised 2/2020, indicated the following: -The Physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Resident #120 was admitted to the facility in September 2024, with a diagnosis of left kidney contusion (bruising to the left kidney) and Methicillin Resistant Staphylococcus Aureus (MRSA-strain of gram-positive bacteria resistant to several antibiotics, making it difficult to treat, which…

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 and policy review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to one Resident (#21) out of a total sample of 24 residents. Specifically, for Resident #21, the facility failed to ensure that a speech and language therapy evaluation was completed timely, when it was identified the Resident was having difficulty swallowing. Findings include: Review of the facility policy titled Evaluations, updated 9/5/17, indicated the following: -Evaluations will be initiated within a reasonable amount of time of receipt of Physician's order or authorization, or according to facility policy. Resident #21 was admitted to the facility in February 2015, with a diagnosis of dysphagia (difficulty swallowing). Review of the Nursing Progress Note dated 9/6/24 at 10:57 A.M., indicated: -the Resident was having trouble with his/her mechanical soft meals (meal provided is chopped into small pieces and of soft texture). -meal texture was down graded to puree (smooth consistency with uniform texture). -the Nurse Practitioner was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to ensure that administration of Pneumococcal Vaccination was provided timely to one Resident (#113) out of a total sample of five residents. Specifically, for Resident #113, the facility failed to ensure a Pneumococcal Vaccination was administered timely after the Resident and/or Resident Representative consented to receive the Pneumococcal Vaccination. Findings include: Review of the Centers for Disease Control and Prevention (CDC) information sheet titled Pneumococcal Timing Vaccine Timing for Adults, dated 9/12/24, indicated the following recommendation: -If a patient has had the Pneumococcal Conjugate Vaccine-13 (PCV-13 at type of pneumococcal vaccination) at any age and Pneumococcal Polysaccharide Vaccine-23 (PPSV23 a type of pneumococcal vaccination) at or after the age of 65 after 5 years PCV-20 or PCV-21 should be offered. -Together, with the patient, vaccine providers may choose to administer PCV-20 or PCV-21 to adults = [AGE] years old…

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 implement the plan of care for two Residents (#67 and #47) out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. For Resident #67, develop a person-centered care plan that included measurable objectives related to bilateral hand contractures (when muscles, tendons, joints or other tissues tighten or shorten causing loss of movement). 2. For Resident #47, implement a Physician's order to weigh weekly when the Resident had been identified as having failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). Findings include: Review of the facility's policy for Resident Mobility and Range of Motion (ROM), dated April 2018, indicated the following: -The care plan will be developed by the interdisciplinary team (IDT) based on the comprehensive assessment, and will be revised as needed. -The care plan will include specific interventions, exercises and…

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

Based on observations, interview and record review, the facility failed to provide Activities of Daily Living (ADLs - bathing, dressing, grooming) care for two Residents (#110 and #53), out of a total sample of 26 Residents. Specifically, the facility staff failed to ensure that Resident #110 and Resident #53 were provided grooming to remove facial hair per their preference/comfort. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL's) Supporting, dated 4/2018 and revised 9/2019, included: -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, -including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 1. Resident #110 was admitted to the facility in March 2022 with a diagnosis of Major Depression Disorder with psychotic symptoms (a distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations, or both). Review of the ADL…

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 provide care and treatment in accordance with professional standards of practice for one Resident (#34) out of a total sample of 26 residents. Specifically, the facility staff failed to: -notify the Physician and implement the facility policy when the Resident had a weight gain of 14.76% in one month. -apply ace wraps (bandages used to help reduce swelling) to edematous (abnormally swollen with fluid) lower extremities (legs) as ordered when the Resident presented with 3+ edema (depression mark of 5 to 6 millimeters left in the edematous area when pressed with the finger tips that rebounds in 60 seconds) in both lower extremities. Findings include: Review of the facility policy titled Weight Management, dated 5/23/18, indicated: -All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight change (suggested parameters for evaluating significance of unplanned and undesired…

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

Based on observations, record review, and interviews, the facility failed to ensure its staff provided foot care for one Resident (#34), out of a total sample of 26 residents. Specifically, the facility staff failed to ensure Diabetic foot care was provided to maintain good foot health per facility policy and professional standards. Findings include: Resident #34 was admitted to the facility in August 2022 with a diagnosis of Type 2 Diabetes Mellitus without complications (a chronic condition that affects the way the body processes blood sugar). Review of the facility policy titled Diabetes-Clinical Protocol, revised 12/2020, included: -Licensed staff will conduct Diabetic foot care on all Diabetic residents Per Physician order -Diabetic Foot Care consists of the following: a. Visual inspection for impaired skin integrity. b. Cleansing feet appropriately and thoroughly drying feet, especially between toes. c. Apply lotion to dry feet as needed unless contraindicated. d. Apply appropriate footwear. Review of the Centers for Disease Control and Prevention (CDC) article titled…

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 its staff provided an environment as free of accident hazards as possible for two Residents (#26 and #106) out of 26 total sampled residents. Specifically, the facility staff failed to: 1. Provide continual supervision for Resident #26 which resulted in the Resident obtaining metal silverware, walking into an unoccupied third floor resident room, forcing the window fully open using the silverware, and removing the screen when the Resident had a recent history of exit seeking and attempted elopement through his/her own third floor bedroom window at the facility, increasing the Resident's risk for injury. 2. Assess and obtain a Physician order for Resident #106 to store and self-administer Unisom (sleep aid medication) at the bedside, increasing the Resident's risk for improper self-medication administration and potential drug reactions. Findings include: Review of the facility's policy, titled Accidents and Incidents_investigating and Reporting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide indwelling Foley catheter (also known as urinary catheter - a tube placed through the urethra into the bladder to drain urine) care, per professional standards for two Residents (#24 and #105) out of 6 applicable residents from a total sample of 26 residents. Specifically, the facility staff failed to ensure that the indwelling urinary catheter tubing for Residents #24 and #105 was securely placed as required to prevent possible dislodgement and trauma. Findings include: Review of the Centers for Disease Control's Guidelines for Proper Techniques for Urinary Catheter Insertion, reviewed 11/5/2015, indicated to Properly secure indwelling catheters after insertion to prevent movement and urethral retraction. Review of the facility policy titled Catheter Care of Indwelling Catheter, dated 4/2018, indicated that the catheter tubing should be secured to the thigh with a leg strap. 1. Resident #24 was admitted to the facility in February…

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 care for one Resident (#1), out of two applicable residents sampled, in a total sample of 26 residents, related to a peripheral venous catheter (a small flexible tube placed into a peripheral vein to administer intravenous (in the vein) therapy. Specifically, the facility staff failed to: - obtain a Physician's order to insert and change a peripheral venous catheter. - obtain Physician approval to leave a peripheral venous catheter in place for longer than 7 days. Findings include: Review of the facility policy titled Standard Care of Peripheral Venous Catheter last revised in February 2019 indicated the following: - Nurse will obtain Physician's order for infusion therapy - The Physician must approve peripheral venous catheter indwelling times greater than 7 days Resident #1 was admitted to the facility in May 2023 with diagnoses including Chronic Kidney Failure and Acute Kidney Failure. Review of the Minimum Data…

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 care for one Resident (#122), who required hemodialysis (a process for purifying the blood of a person whose kidneys are not working normally) out of one applicable sampled resident, in a total sample of 26 residents. Specifically, the facility staff failed to provide care according to professional standards for the Resident's Arteriovenous Fistula (AV Fistula-a surgically created passageway between an artery and a vein, usually located in the arm and used as an access to administer hemodialysis treatments). Findings include: Review of the facility policy titled Hemodialysis Access Care, last revised in November 2017, indicated the following to prevent infection and/or clotting: - keep access site clean and dry - do not use access site arm to take blood samples, administer intravenous fluids or give injections - check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing…

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 identify triggers that may cause re-traumatization for one Resident (#106) with a diagnosis of Post-Traumatic Stress Disorder (PTSD), out of one applicable sampled residents. Findings include: Review of the facility's policy for Trauma Informed Care, dated August 2019, indicated the following: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -General Guidelines: Trauma-informed care is culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Resident #106 was admitted to the facility in December 2021 with diagnoses including Anxiety Disorder, Major Depressive Disorder and PTSD. Review of a Psychosocial Evaluation, dated 4/6/23, indicated a Comprehensive Trauma Screening was completed and the following questions (included but not limited to) were answered: -History of trauma?- yes -Mental…

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 the facility's Licensed Nurse staff schedule and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, facility staff failed to provide at least eight consecutive hours of RN services in the facility over one 24-hour period, when no Nurse staffing waivers were in place. Findings include: Review of the as worked Nursing Staff Schedule provided by the facility, dated 6/18/23, included no evidence that a RN was scheduled or had worked at the facility on 6/18/23. During an interview on 7/5/23 at 10:14 A.M., the Director of Nursing (DON) said the facility had no Nurse staffing waivers in place. During an interview on 7/6/23 at 1:53 P.M., the Director of Nursing (DON) reviewed the Nursing Staff Schedule dated 6/18/23, with the surveyor and said no RNs were on the schedule for that day. The DON then said there was always a RN on-call and she would look back to see which RN was on-call that day and whether they worked in the facility. During a follow-up interview 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 policy review, record review and interview, the facility failed to obtain Physician ordered laboratory specimens for Hemoglobin A1C (Hgb A1C-a blood test that measures the average sugar level over the past three months) for two Residents (#106 and #34) with diagnoses of Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar), out of a sample of 26 residents. Findings include: Review of the facility policy titled Diabetes - Clinical Protocol, revised 12/2020, included: -For residents who meet the criteria for Diabetes testing, the Physician will order pertinent screening; for example A1C - For the resident on oral (by mouth) medication(s) who is well controlled: >monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages) >monitor A1C on admission (if no results from a previous test are available) or when diabetes is diagnosed and every three to six months thereafter 1. Resident #106 was admitted to the facility in December 2021 with a diagnosis including Diabetes Mellitus. Review of the July…

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 adhere to food safety requirements in preventing hair contamination of food being prepared for facility residents. Specifically, the facility failed to ensure that three staff members working in the food preparation area of the kitchen, wore hair restraints to contain their hair during meal preparation. Findings include: Review of the facility's policy, titled Personal Hygiene for Food Handlers, dated June 2018, included that hair restraints such as hats, hair coverings or nets are worn at all times when in the kitchen. On 7/5/23 at 7:12 A.M., during the initial tour of the kitchen, the surveyor observed three Dietary Staff who had no hair restraints, in the food preparation area handling food. During an interview on 7/5/23 at 7:15 A.M., Dietary Staff #1 said that staff were all expected to wear hair restraints. During an observation on 7/6/23 at 11:40 A.M., the surveyor observed Dietary Staff #1 wearing a cap on the top of his/her head with hair on the back and sides of his/her head unrestrained and exposed…

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.