Charlene Manor Extended Care Facility

Based on record review and interview, the facility failed to develop a baseline care plan for one Resident (#73) out of a sample of three closed resident records reviewed. Specifically, the facility failed to develop a baseline care plan for Resident #73 within 48 hours of admission to the facility, when a comprehensive care plan was not developed in place of a baseline care plan, to provide effective and person-centered care of the Resident. Findings include: Resident #73 was admitted to the facility in May 2024, with diagnoses including Unspecified Fall and Displaced (out of alignment or in several pieces) Intertrochanteric (top of the thigh bone, where the hip and thigh meet) Fracture (cracking or breaking) of Right Femur (thigh bone). Review of Resident #73's Baseline admission Care Plan, dated 5/26/24, indicated the following: -The Resident's date of birth . -The Resident's date of admission to the facility. -The Resident's medical history. -The Resident's Physician's name and contact information. Further review of the Baseline Care Plan indicated that no other sections 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT), and included the Resident and/or Resident's Representative for three Residents (#17, #92, and #88) out of a total sample of 25 residents. Specifically, facility failed to provide evidence that: 1. Resident #17 and/or his/her Representative were invited and attended/did not attend two separate care plan meetings held for the Resident. 2. Resident #92's care plan was reviewed and revised by the IDT following one Resident Assessment completed. 3. Resident #88's care plan was reviewed and revised by the IDT following two separate Resident Assessments completed. Findings include: Review of the facility's policy titled Care Planning, dated 10/1/10 and revised 10/28/22, indicated the following: -A letter will be sent to each resident or resident representative inviting them to the care plan meeting. -Each discipline reviews the overall plan and any concerns prior to the 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.

Based on observation, interview and record review, the facility failed to provide assistance with personal hygiene for two Residents (#88 and #43) out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #88 and #43 were offered and/or provided with grooming assistance when both Residents required the assistance of staff for grooming activities. Findings include: 1. Resident #88 was admitted to the facility in August 2022, with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) with Dyskinesia (uncontrolled, involuntary movements of the face, arms or legs). Review of the Activities of Daily Living (ADL: basic skills needed in daily life and include eating, bathing, toileting and grooming/personal hygiene) Care Plan, initiated 8/25/22, indicated Resident #88 had decreased ability to perform ADLs due to decreased cognition and mobility. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure one Resident (#88) out of a total sample of 25 sampled residents, received care and services consistent with professional standards of practice relative to completing a timely assessment and obtaining treatment orders for an identified skin issue. Specifically, the facility identified Resident #88 had a quarter sized fluid filled blister on his/her right lower leg and failed to assess the cause of the blister, notify the Physician and Responsible Party timely and obtain treatment orders to assist in healing, increasing the risk of potential further skin decline and infection. Findings include: Review of the facility policy titled Skin Integrity Management, revised November 2023, indicated based on the comprehensive assessment of the resident, the facility must ensure that the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not develop pressure ulcer 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.

Based on observation, interview, and record review, the facility failed to offer assistance in scheduling an appointment to ensure good foot health was maintained for one Resident (#78) out of a total sample of 25 residents. Specifically, for Resident #78, the facility failed to offer podiatry services to maintain good foot health when the Resident was at risk for decline in his/her foot health related to a history of Peripheral Vascular Disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and below the knee amputation (surgically cutting off a limb). Findings include: Review of the facility policy titled Consulting services, Podiatry/Dental/Optometry/Audiology, approved date 12/22/16, indicated the following: -Resident/Resident Representative are provided information about consulting services upon admission and at any time when need arrives. Resident #78 was admitted to the facility in September 2024, and had diagnoses of PVD, Sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune…

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, record review and policy review, the facility failed to ensure that one Resident (#53) out of a total sample of 25 residents, was free from potential accidental hazards when the Resident was allowed to store an Albuterol Sulfate inhaler (aerosolized bronchodilator medication) on his/her bedside table and use the inhaler without assessment or supervision. Specifically, for Resident #53, the facility failed to ensure: -that a prescribed Albuterol Sulfate inhaler was kept in a secured medication cart and not at the Resident's bedside. -the Resident was assessed to self-administer the medication, and was aware of precautions like an increased heart rate and/or difficulty breathing that could result from the medication use or overuse. -that the inhaler was not easily accessible to the Resident and potentially other residents when it was left on Resident #53's bedside table to be administered without Physician approval and without Licensed Staff supervision. Findings include: Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter, for one Resident (#2) out of a total sample of 25 residents, which increased the Resident's risk for indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). complications and resulted in a delay in treatment. Specifically, facility staff failed to: -Follow hospital discharge instructions for Resident #2 to attend a scheduled appointment with the Urologist. -Consult the Physician when Resident #2 experienced urinary leakage (complication that can occur when a urinary catheter becomes dislodged or obstructed) outside of his/her indwelling urinary catheter system when the Resident's plan of care did not contain specific instructions to manage indwelling urinary catheter leakage. -Provide timely treatment to correct indwelling urinary catheter complications when the Resident's indwelling urinary…

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 recommendations made by the facility Dietitian were followed for one Resident (#104), out of a total sample of 25 residents, who experienced a significant weight loss and was at risk for further decline. Specifically, for Resident #104, the facility failed to ensure that weekly weights were obtained when recommended by the Dietitian after the Resident experienced a significant weight loss of 13.44% in five months. Findings include: Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated the following: -Review dietitian's recommendations. -Obtain orders per recommendations. -If Medical Doctor (MD) does not want to follow recommendations, document explanation in nursing note. Resident #104 was admitted to the facility in January 2024, with diagnoses of Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Dementia (a group of conditions characterized by impairment of at least two brain functions, such…

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 ensure correct use of bed rails (side rails: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths) for one Resident (#2) out of a total sample 25 residents. Specifically, facility failed to provide quarter size bed rails for Resident #2, as ordered by the Physician, when facility staff positioned bed rails for Resident #2 in the upward half-rail position at the middle of the bed bilaterally, increasing the Resident's risk for limited mobility and injury. Findings include: Review of the facility's policy titled Side Rails - Assessment and Use of, dated 8/2005 and revised 10/17/17, indicated the following: -The facility provides an optimum safe sleeping environment for the resident. -Individual resident needs for side rails were considered. -Side rails may be an enabler, a restraint, or both. -Use of side rails requires an assessment of the resident's mobility and cognitive functioning to determine the category of use 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 observation, interview, and record review, the facility failed to ensure all Licensed Nurses had appropriate competencies relative to indwelling urinary catheter care and services for one Resident (#2) out of a total sample of 25 residents. Specifically, facility failed to ensure that Nurse #5 was assessed for competency to care for residents with indwelling urinary catheters when: -The Facility Assessment indicated facility staff had been determined to be clinically competent in caring for residents with genitourinary conditions requiring indwelling catheters. -Resident #2 had an indwelling urinary catheter, experienced an indwelling urinary catheter complication of urinary leakage, and required intervention to correct the urinary catheter leakage. -Nurse #5 was responsible for providing care for Resident #2, assessed that the Resident had urinary catheter leakage, was unfamiliar with the urinary catheter placement and did not obtain Physician orders to address the urinary leakage resulting in delayed treatment and increasing the Resident's risk for further indwelling…

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

Based on observation, record review and interview, the facility failed to ensure that one Resident (#419) was free from unnecessary drug administration. Specifically, facility failed to administer Oxycodone (highly addictive opioid medication used to treat moderate to severe pain) dosage and pain scale parameters as ordered by the Physician, in accordance with Resident #419's reported pain level, which resulted in the Resident receiving one excessive dose of Oxycodone and increased the Resident's risk for health complications. Findings include: Review of the facility's policy titled Administration Procedures for All Medications, dated 9/20/13, indicated the following: -The purpose was to administer all medications in a safe and effective manner. -Check the Medication Administration Record (MAR) for order. -Read the medication label three times . compare the label to the MAR. -Refer to the MAR for instruction details. Review of the Department of Justice/Drug Enforcement Administration Oxycodone Drug Fact Sheet reviewed at…

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

Based on interview, and record review, the facility failed to ensure that one Resident (#99) out of a total sample of 25 residents, was free from a significant medication error when a dose of Vitamin K medication was administered to the Resident and resulted in sub-therapeutic (dose or concentration of a drug lower than that usually prescribed to treat a disease effectively) laboratory levels. Specifically, for Resident #99, the facility failed to ensure that Vitamin K medication was not administered to the Resident when there was no Physician orders for the medication to be administered after a one time dose order was given. Findings include: Review of the facility policy titled Administration Procedures for All Medications, dated 9/20/13, indicated the purpose of the policy was to administer mediations in a safe and effective manner. Review of the facility policy titled Anticoagulant Therapy, revised 7/17/19, indicated anticoagulant therapy is the administration of medications (for example Coumadin or Warfarin) that reduce the tendency of blood to coagulate (become thicker so it…

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 ensure that dental services were provided for two Residents (#88 and #43), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #88, provide regular bi-annual dental visits as requested by the Resident Representative. 2. For Resident #43, ensure dental services were offered to the Resident's Representative when the Resident had complaints of mouth and dental pain and required antibiotic treatments. Findings include: Review of the facility policy titled Consulting Services, Podiatry/Dental/Optometry/Audiology, dated 12/22/16, indicated the facility has a contract with credentialed providers for in house services of podiatry, dental, optometry, and audiology. The policy also included: -Services will be offered to all residents as a means of providing highest practicable level of functioning and care. -Resident/Resident Representative are provided information about consulting services upon admission and at any time when the need arrives. -Resident/Resident Representative…

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 adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for two Residents (#108 and #2) out of a total sample of 25 Residents. Specifically, the facility failed to: 1) ensure Resident #108's over-bed table was cleaned and disinfected before used to eat and drink off after a used urinal was set on the table. 2) ensure Resident #2's indwelling urinary catheter (a device inserted into the bladder to drain urine) was maintained off the floor. Findings include: 1) Review of the facility policy titled Nutrition and Meals, Assisting Residents with, dated May 2005, indicated the following: -If the resident eats in his/her room: >clean the over-bed table . Resident #108 was admitted to the facility in June 2024, with diagnoses including Cerebral Infarction due to Thrombosis (a condition where a blood clot caused loss of blood flow and damage to the brain). On 11/4/24 at 8:40 A.M., the surveyor observed CNA #2 enter Resident #108's room. The surveyor observed…

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 provide evidence that updated COVID-19 vaccines were offered to three Residents (#5, #92, and #61) out of five applicable sampled residents, in a total sample of 25 residents, which increased the Residents' risks for illness. Specifically, the facility failed to provide evidence that a second dose of 2023-2024 COVID-19 vaccine was offered to Resident's #5, #92, and #61, according to National Standards, when: -Each Resident received one dose of the 2023-2024 COVID-19 vaccine. -the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended an additional dose of updated (2023-2024 formula) of COVID-19 vaccine be administered for older adults,aged [AGE] years and older. -Each Resident met criteria for a second dose of the 2023-2024 COVID-19 vaccine. -The COVID-19 vaccine was not medically contraindicated and the residents had not already been immunized with the recommended additional dose. Findings…

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 (which included taking photographs) interviews and records reviewed, for three out of three resident units, the facility failed to ensure it provided a safe, clean, comfortable and homelike environment for it's residents, when during the course of the survey observations conducted in common areas, resident rooms and resident care areas, the surveyors observed obvious signs of various stages of disrepair, aging and unclean conditions, in carpets, flooring, walls and moldings, and furniture, all of which were in areas accessed and utilized by residents in their daily lives, and were either unclean, unsafe, in need of immediate repair and/or created potentially hazardous conditions, none of which supported that a homelike environment was being provided for facility residents. Findings include: Review of the Facility Policy titled Housekeeping and Maintenance Department Responsibilities, dated September 2011, indicated it is important to maintain a clean, safe, and sanitary environment for our…

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, interviews, and observations, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility. Findings include: Review of the Facility's undated policy titled QAPI Plan, indicated the following: -Purpose: To take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to create exceptional experiences causing those we serve to always prefer us. To do this, all employees will participate in ongoing QAPI efforts to support our mission by ensuring we fulfill the needs of the population we serve. -QAPI includes all employees, all departments and all services provided. -QAPI focuses on systems and processes, rather than…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was severely cognitively impaired, the Facility failed to ensure staff implemented and followed their Abuse Prohibition Policy, when on 10/30/23 Certified Nurse Aide (CNA) #1 witnessed an alleged incident of physical abuse involving Nurse #1 and Resident #2 but did not immediately report the incident to his or her supervisor per facility policy, therefore placing Resident #2 and other residents at risk for abuse. Findings Include: Review of the Facility's Policy, dated as revised 02/27/17, titled Resident Abuse Prevention, Investigation and Reporting indicated that all staff who suspect abuse, neglect, mistreatment and or misappropriation must immediately make an oral report to his or her supervisor. The Policy indicated the following: -All employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation of abuse they are told about by residents, families, visitors, or other staff. -When an employee believes that he or she 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 records reviewed and interviews, for one of four sampled residents (Resident #1), who sustained a fall that resulted in a right hip fracture, and several weeks later sustained a large hematoma (a collection or pooling of blood outside of the blood vessel) to his/her left lower leg the Facility failed to 1) ensure nursing assessed Resident #1 after the fall and before transferring him/her up off of the floor, placing him/her at an increased risk for injury, 2) ensure nursing monitored Resident #1's left lower leg hematoma for any changes or deterioration and 3) ensure nursing completed an incident/injury report when staff identified Resident #1's new left lower leg hematoma. Findings include: Review of the Facility policy, Accidents and Incidents-Investigating and Reporting, dated 12/29/11, indicated the following: -Regardless of how minor an accident or incident may be, including injuries of an unknown source, report the accident/incident to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned.…

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

Based on records reviewed and interviews, for one of two sampled employee personnel files (Certified Nurse Aide, CNA #1), the Facility staff failed to ensure CNA #1 received training on the facility procedures for reporting suspected abuse, neglect, exploitation, and misappropriation of resident property as required by Federal Regulations, and in accordance with Facility Policy. Findings include: Review of the Facility's Training Policy, dated as reviewed 10/27/22, indicated it is the policy of the Facility to support a training program throughout the organization which includes education and competencies for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles. The Policy indicated that required training will include Abuse, Neglect and Exploitation Prevention & Reporting. The Policy indicated that when considering individuals providing services under a contractual arrangement, training conducted by parent organization-affiliate should obtain necessary details regarding this training. Review…

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 the resident designated smoking area complied with the Centers for Medicare and Medicaid Services (CMS) guidance for a safe smoking area. Specifically, the facility failed to provide readily available safety equipment including access to a fire extinguisher and a safe, designated smoking area for all smoking residents. Findings include: Review of the CMS circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from secondhand smoke. -The facility is also required to provide portable fire extinguishers in all facilities (NFPA101, 2000 ed., 18/19.3.5.6). Review of the facility's policy titled Resident Smoking Policy dated 7/15/22, indicated but was not limited to the following: -Smoking is never allowed inside the facility and is allowed only in designated…

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 policy review, the facility failed to ensure over that over the counter medications (OTC-medications that can be purchased without a prescription) and medical supplies that included needles were secured and accessible to authorized personnel only. Specifically, the facility failed to ensure that the first floor medical supply room was safe and secure and did not provide an accidental and safety hazard to residents. Findings include: Review of the facility policy titled Storage of Medications, revised on 6/10/22 indicated the following in part: - .medication supplies are locked or attended by persons with authorized access. On 9/13/23 at 4:50 P.M., two surveyors observed the medical supply room door (located on the first floor, in the center of the building where the three hallways merged) to be opened and unattended. The supply room was easily accessible to residents, staff, and visitors. The surveyors noted the room had many medical supplies including boxes of needles and an unlocked metal cabinet containing a supply of OTC medications. During…

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 and policy review, the facility failed to maintain a safe, functional, sanitary and comfortable environment for residents, staff, and the public. Specifically, the facility failed to ensure that: 1) the main dining room provided a homelike environment for the residents and their visitors. 2) the kitchenettes on two out of the three Units (Meadows Rehab and [NAME]) remained sanitary. Findings include: Review of the facility policy titled Clinical Services Resident Rights Policy, revised on 9/19/22, indicated the following: .The resident has the right to a safe, clean, and comfortable and homelike environment . Review of the facility policy titled Environmental Services Guidelines, dated 9/2011 indicated the following: -All horizontal surfaces such as .counters, sinks, floors etc . will be cleaned daily . -Horizontal surfaces will also be cleaned as needed when spills or soiling occur. 1) During an interview on 9/12/23 (prior to the start of survey) the Ombudsman noted that there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessments were accurately coded for the use of an anticoagulant (medication that help prevent blood clots), for two Residents (#8 and #95), out of five applicable resident records. Findings include: 1. Resident #8 was admitted to the facility in August 2022 with diagnoses including Coronary Artery Disease (CAD-damage or disease in the heart's major blood vessels) and Heart Failure (HF-a chronic condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood). Review of the Minimum Data Set (MDS) Assessment, dated 8/14/22, indicated in Section N that the Resident received an anticoagulant in the last seven days. Review of the MDS assessment dated [DATE], indicated in Section N that the Resident received an anticoagulant in the last seven days. Review of the MDS assessment dated [DATE], indicated in Section N that the Resident received an anticoagulant in the last seven days. Review of…

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

Based on observation, interview, and records reviewed for one Resident (#58) out of a total sample of 24 residents, the facility failed to ensure that services provided met professional standards of quality. Specifically, the facility failed to ensure a medication was given on an empty stomach per manufacturer guidance. Findings include: Review of the United States Food and Drug Administration (FDA) website titled Prilosec (OTC-over the counter also known as Omeprazole) a medication used to treat Gastroesophageal Reflux Disease (GERD- a condition in which stomach contents such as acid back up into the esophagus [a muscular tube that brings food from the mouth into the stomach] which can cause heart burn/indigestion) Information, content current as of 11/27/15, indicated the following: -Swallow one tablet with a glass of water before eating in the morning. Resident #58 was admitted to the facility in March 2023 with a diagnosis of GERD. During an observation and interview on 9/13/23 at 9:53 A.M., the surveyor observed the Resident in his/her room with his/her breakfast tray in front…

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 Hospice services were ordered and provided for one Resident (#122), out of two applicable closed records. Specifically, the facility staff failed to enroll Resident #122 for Hospice Care and ensure the provision of appropriate end-of-life services. Findings include: Review of the facility policy titled, Hospice Program, revised 3/28/22, included, but not limited to: -When clinically appropriate, a Medical Doctor (MD) order is requested for Hospice evaluation. A visit/interview with the resident/family may be conducted to determine the resident's wishes relative to participation in the hospice program. -When a resident participates in the Hospice program, a coordinated Care Plan between the facility, Hospice agency and the resident/family will be developed and shall include directives for managing pain and other comfort measures. The Care Plan shall be revised and updated as necessary to reflect the resident's current status. Resident #122 was…

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

Based on observation, record review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#109), out of one applicable resident, out of a total sample of 24 residents. Specifically, the facility failed to coordinate delivery of medications with Resident #109's dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment schedule to ensure the Resident received all medications as ordered by the Physician. Findings include: Review of the facility's policy, Dialysis Resident, Coordination of Care, dated 12/22/16 indicated the following: -Care plan will include medication management before, during or after dialysis per physician orders. Resident #109 was admitted to the facility in June 2023 with a diagnosis of End Stage Renal Disease (ESRD-when the kidneys are no longer able to work at the level needed for day-to-day life). Review of the medical record indicated the Resident received Dialysis treatments every Tuesday, Thursday, and Saturday at an off-site…

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 and policy reviewed for two Residents (#3 and #8) out of a total sample of 24 residents, the facility failed to ensure residents who are trauma survivors received trauma informed care in accordance with professional standards. Specifically, the facility failed to conduct a trauma-informed assessment per facility policy for Resident #3 and Resident #8, who were both diagnosed with Post Traumatic Stress Disorder (PTSD). Findings include: Review of the facility policy titled Trauma Informed Care dated 11/28/19, indicated the following: -Trauma-informed care assessment will be conducted by Social Services upon admission, quarterly, annually and with significant status change only when known PTSD diagnosis or manifestation or verbalization of trauma. -Interdisciplinary team (IDT) to provide ongoing assessment, evaluation, and revision of care plan . 1. Resident #3 was admitted to the facility in November 2019 with the following diagnoses: anxiety, Major Depressive Disorder and PTSD. Review of Resident #3's medical records indicated no documented evidence that…

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

Based on observation, record review and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#119), out of a total sample of 24 sampled residents. Specifically, the facility failed to administer daily regimen medications as ordered by the Physician putting the Resident at risk for pain, elevated blood pressure, blood clots and alteration in mood. Findings include: Resident #119 was admitted to the facility in August 2023 with diagnoses including displaced fracture of the head of right radius (a bone in the right forearm) and unspecified fracture of left radius (bone in the left forearm). Review of the Physician's orders dated 9/1/23 through 9/31/23 indicated the following: -Allopurinol 200 milligrams (mg) one tablet oral once daily for Gout. -Amlodipine 10mg one tablet oral daily for hypertension (HTN - high blood pressure). -Atorvastatin Calcium 20mg one tablet oral once daily for hyperlipidemia (high cholesterol). -Enoxaparin sodium 40mg solution subcutaneous injection (beneath the skin into the fatty tissue) once daily…

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

Based on observation, record review and interview, the facility failed to ensure accurate medical records were kept for two Residents (#99 and #95), out of a total sample of 24 residents. Specifically, 1. For Resident #99, the facility staff failed to correctly transcribe a medication dose into the Narcotic Log Book. 2. For Resident #95, the facility staff failed to ensure the Resident's care plan matched the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST-a medical form that relays instructions about life sustaining treatment). Findings include: 1. Resident #99 was admitted into the facility in October 2021. During an observation on 9/14/23 at 3:45 P.M. of a medication administration pass for Resident #99, Nurse #5 administered Marinol (used to treat severe nausea, vomiting and loss of appetite), five milligrams (mg), one capsule by mouth. After administering the 5 mg Marinol, Nurse #5 signed out the Marinol dose on a Narcotic Log Book page that indicated the Marinol blister card (pre-formed packaging used for medications) contained 2.5 mg tablets. Review of the…

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

Based on observation, record review and interview, the facility failed to maintain appropriate infection control measures related to the maintenance of respiratory equipment for one Resident (#32), out of a total sample of 24 residents. Specifically, the facility staff did not ensure that Resident #32's nebulizer equipment was maintained in a sanitary manner, to decrease the risk of contamination and infection. Findings include: Review of the facility policy titled, Oxygen and Respiratory Equipment, dated 2/27/23, indicated the following: -It is the policy of this facility to maintain respiratory therapy equipment according to manufacturer recommendations and accepted standards of practice. -Respiratory equipment used on an as needed (PRN) basis should be contained when not in use to prevent accidental contamination, for example being dropped on the floor. Resident #32 was admitted to the facility in June 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD-a type of progressive long-term lung disease that makes it hard to breathe). Review of Physician's orders…

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