Poet's Seat Healthcare Center

Based on interviews and record review, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#3), out of a total sample of five residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised March 2022, indicated the following: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessment of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements 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 interviews, observations and policy review, the facility failed to ensure its residents knew how to file a grievance (complaint or concern). Findings include: Review of the facility policy titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2020, indicated the following: -Residents or their family members, guardians, or representative may voice a grievance to the facility staff in person, by telephone, or via written communication -The facility will notify residents, individually or through postings in prominent locations through the facility, of the right to file a grievance On 10/27/22 at 2:00 P.M., the surveyor conducted a resident group meeting with nine residents. When asked if they were aware of how to file a grievance, all nine residents stated they were unaware of where to find the grievance form, who to ask to obtain one or what the process was to file a grievance. During an interview on 10/31/22 at 7:49 A.M., the Administrator said that she was the grievance official. She said that often she will receive a complaint from a staff member…

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 its staff developed baseline care plans within 48 hours of admission and/or that the baseline care plans were provided to four Residents (#3, #29, #32 and #39) or their Representatives (if applicable), out of a total sample of 17 residents. Findings include: Review of the facility policy titled Baseline Care Plans, revised December 2016, indicated a baseline plan of care to meet the resident's immediate needs will be developed within forty eight hours of admission. The Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs . 1. Resident #3 was admitted to the facility in February 2022. Review of the clinical record indicated no documented evidence that a baseline care plan for Resident #3 was developed within 48 hours of admission, as required. Review of the Resident's current interdisciplinary care plans indicated they were initiated in October 2022 (8 months later). Further review of the care plans indicated no…

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 its staff reviewed and revised the plan of care for six Residents (#2, #3, #15, #28, #32, and #48), out of a total of 17 residents sampled. Findings include: 1. Resident #2 was admitted to the facility in April 2020. Review of the medical record indicated that Minimum Data Set (MDS) Assessments were completed for the Resident on the following dates: 3/18/21, 6/10/21, 9/2/21, 11/5/21, 5/5/22, and 7/28/22. Further review of the medical record did not include any evidence that the care plan was reviewed by the interdisciplinary team after each assessment. On 11/02/22 at 2:39 P.M., the Clinical Reimbursement Nurse said there was no evidence there were any interdisciplinary care conferences were held, as required. 2. Resident #28 was admitted to the facility in April 2022. Review of the medical record indicated MDS Assessments were completed on the following dates: 5/2/22, 6/11/22, and 9/8/22. Further review of the medical record did not include any evidence that the care plan was reviewed 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 interview and record review, the facility failed to ensure one Resident (#3) was free from significant medication errors, out of a total of 17 sampled residents. Findings include: Resident #3 was admitted to the facility in February 2022 with diagnoses including Atherosclerotic Heart Disease (build of up plaque in the walls of the arteries causing obstruction of blood flow) and Hypertension (high blood pressure/BP). Review of the 10/2022 Physician's Orders indicated the following: -obtain vital signs every shift -Hydralazine HCL (medication used to treat high blood pressure) 10 milligram (mg) tablet, give orally every 6 hours as needed (PRN) for high BP; systolic (pressure in the arteries when the heart beats) BP greater than (>) 160 and/or diastolic (pressure in the arteries when the heart rests) BP > 100 Review of the 10/2022 Medication Administration Record (MAR) indicated the following dates with elevated BPs levels meeting the criteria to receive the PRN Hydralazine: -10/15/22 on the day shift: 163/80 -10/15/22 on the night shift: 173/80 -10/16/22 on the evening shift:…

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 interview, the facility failed to ensure its staff properly secured and stored prescription medication, as required. Specifically facility staff failed to 1.) keep a box of emergency medication locked up, and 2.) monitor the medication refrigerator temperatures regularly on one of two units inspected. Findings include: Review of the facility policy Storage of Medications, revised April 2019, included the following: - drugs and biologicals used in the facility are to be stored in locked compartments and under proper temperature, light and humidity controls Review of the facility's copy of insulin storage recommendations, provided by the facility's contracted pharmacy service indicated unopened insulin should be refrigerated at temperatures between 36 degrees to 46 degrees Fahrenheit. 1. During an observation and interview on 10/26/22 at 1:48 A.M., the surveyor observed a plastic box under the nursing station counter which was in full view from the left side of the nursing station. The box was secured with a thin plastic zip tie closure with a label 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 and interview the facility failed to ensure that its staff stored food in accordance with professional standards for food service safety. Specifically, the facility staff: 1) did not properly seal and/or label/date food when opened, 2) did not thoroughly clean areas where food and dishware was stored, 3) did not store foods off the floor, and 4) did not dispose of food that had expired. Findings include: Review of the Food Safety and Inspection Service United States (U.S.) Department of Agriculture Sanitation Performance Standards Compliance Guide, revised March 2016, indicated the following: -All food-contact surfaces, including food-contact surfaces of utensils and equipment, must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions or the adulteration (action of making something poorer in quality by the addition of another substances) of the product -Non-food-contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary…

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 [NAME], [NAME] Based on record review and interview the facility failed to ensure its staff maintained complete, accurate and readily accessible medical records for four Residents (#15, #26, #29 and #39), out of 17 residents sampled. Findings include: 1. For Resident #15 the facility failed to maintain a complete medical record relative to a court ordered treatment plan. Resident #15 was admitted to the facility in [DATE] with diagnoses including Schizophrenia and Depression. A record review indicated an expired court ordered treatment plan dated [DATE], with a review date of [DATE]. During an interview on [DATE] 4:12 P.M., the Administrator said that the social work consultant/department were typically the ones who monitor the legal information for residents. She said the treatment plan in Resident #15's chart was expired and requested more time to research the concern. During a follow-up interview on [DATE] at 8:00 A.M., the Administrator provided an updated and current treatment order. She said the current…

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 1.) ensure staff reviewed their Infection Control Policies and Procedures at least annually to ensure policies and procedures are current, 2.) create written policies related to COVID-19 surveillance and symptom monitoring, 3.) implement their procedures for COVID-19 screening prior to each shift for staff, putting the facility at risk for transmission for COVID-19 within the facility, and 4.) ensure that staff monitored for signs and symptoms of COVID-19 every shift on a unit conducting outbreak testing for two Residents (#26 and #44), out of three total sampled residents, to stop the spread of COVID-19 infection. Findings include: 1. The facility failed to review their written facility wide infection prevention and control program (IPCP) annually. Review of the IPCP packet provided by the Administrator of the facility titled Managing Infections indicated no documentation that the facility staff had reviewed the packet annually. During an interview on 11/2/22 at 12:33 P.M., the Administrator said the IPCP had…

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 policy review, the facility failed to ensure its staff protected the privacy of one Resident (#48), out of a total of 17 sampled residents. Specifically, the facility staff hung a sign containing personal information about the Resident on a wall next to his/her bed in plain view. Findings include: Review of the facility policy titled, Quality of Life - Dignity, revised February 2020, included the following: -Staff protect confidential clinical information, for example: -Signs indicating the resident's clinical status or care needs are not openly posted in the resident rooms unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reason is permissible (e.g., taped inside a closet door). Resident #48 was admitted to the facility in October 2020 and had suffered a Cerebrovascular Accident (also known as a stroke, which occurs when the supply of blood to the brain is reduced or blocked completely, preventing the brain tissue from getting oxygen and nutrients), causing Dysphagia…

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 its staff answered a call bell in a timely manner for one Resident (#54) who required physical assistance from staff, out of 17 total residents sampled. Findings include: Review of the facility policy titled Call Bell, undated, indicated that providing timely response to residents in need of assistance is essential to ensuring high quality resident outcomes. Resident #54 was admitted to the facility in March 2011. Review of the Minimum Data Set (MDS) Assessment, dated 10/6/22, indicated the Resident required a one-person physical assist for transfers, and an extensive assist of one person during toilet use. During a resident group meeting on 10/27/22 at 1:46 P.M., Resident #54 said that the facility staff do not always answer call bells in a reasonable time. Resident #54 further said that he/she has waited for an hour at times. When asked how often wait times can be long, he/she replied, frequently. On 10/31/22 at 9:46 A.M., while the surveyor was seated at the South Unit Nurses' Station, a loud,…

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 its staff provided the required transfer documentation to a receiving provider for one Resident (#28), out of a total of 17 sampled residents, putting the Resident at risk for complications and adverse events upon transfer to the receiving facility. Findings include: Resident #28 was admitted to the facility in April 2022 with a diagnosis of Adult Failure to Thrive (a syndrome of weight loss, decreased appetite and poor nutrition, often accompanied by dehydration). Review of the medical record included a Nursing Progress Note, dated 5/21/22, indicating the following: - Resident was alert with conversation, but very sleepy in between interactions. Received all current lab results during morning report with further elevated and critical sodium level of 169 (normal sodium levels range from 135-145 milliequivalent per liter (mEq/L), a condition called hypernatremia which can led to confusion, muscle twitching, seizures, coma, and death). All labs were called to the attending physician with a new order to send 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 interview and record review, the facility failed to ensure its staff provided the required notices of transfer or discharge to the Resident, his/her Representative (if applicable) and the State Long-Term Care Ombudsman for two Residents (#23 and #28), out of a total of 17 sampled residents, as required. Findings include: 1. Resident #28 was admitted to the facility in April 2022. Review of the medical record indicated the Resident was transferred and subsequently admitted to the hospital on [DATE]. Further review of the medical record did not indicate any evidence that the required notice of intent to transfer or discharge the Resident was provided to the Resident and/or his/her representative and the Ombudsman, as required. During an interview on 11/1/22 at 1:15 P.M., Social Worker (SW) #1 said whenever a resident goes out to the hospital, they or their responsible party should receive an intent to transfer/discharge notice as well as a bed hold notice. She further said the only time she completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure its staff provided the required notices of bed-hold policy and return to the Resident and/or their Representative (if applicable) for two Residents (#23 and #28), out of a total of 17 sampled residents, as required. Findings include: 1. Resident #28 was admitted to the facility in April 2022. Review of the medical record indicated that Resident #28 was transferred and subsequently admitted to the hospital on [DATE]. Further review of the medical record did not indicate any evidence that the required notice of bed hold policy and return was provided to the Resident and/or his/her representative, as required. During an interview on 11/1/22 at 1:15 P.M., Social Worker (SW) #1 said whenever a resident goes out to the hospital, the resident and/or his/her responsible party should receive a notice of bed hold policy and return. She further said it is the Receptionist's responsibility to issue these notices. During an interview on 11/1/22 at 1:20 P.M.,…

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 its staff completed Comprehensive Minimum Data Set (MDS) Assessments timely, as required, for two Residents (#1 and #3), out of a total of 17 sampled residents. Findings include: 1. Resident #3 was admitted to the facility in February 2022. Review of the clinical record indicated Resident #3 was hospitalized on [DATE] and returned to the facility on [DATE]. Further review of the clinical record indicated a Comprehensive MDS Assessment, with an Assessment Reference Date (ARD) of 10/20/22, was in progress. Sections C (Cognitive Patterns), D (Mood) , E (Behavior), Q (Participation in Assessment and Goal Setting), S (Massachusetts State Specific) and V (Care Area Assessment Summary) were not completed. During an interview on 11/02/22 at 10:56 A.M., the Clinical Reimbursement Nurse said that once a resident was admitted to the facility, the facility staff have 14 days to complete and lock the Comprehensive MDS Assessment. He said that Resident #3 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, interview and record review, the facility failed to ensure its staff accurately coded the Minimum Data Set (MDS) Assessments for two Residents (#34 and #44), out of a total sample of 17 residents. Findings include: 1. For Resident #34, the facility staff failed to accurately code the Comprehensive MDS Assessment relative to 1.) antipsychotic medication (used to treat psychosis and other psychotic disorders) administered, 2.) a Gradual Dose Reduction (GDR- stepwise tapering of medications), and 3.) his/her dental status during the assessment period. Resident #34 was admitted to the facility in June 2019. Review of the Dental Care Plan, initiated on 4/17/22, indicated Resident #34 had no natural teeth or dentures and was edentulous (without teeth). Review of the Physician's Orders indicated that the Resident was prescribed Olanzepine (antipsychotic medication) 2.5 milligrams (mg) daily at bedtime from 3/31/22 until 8/9/22 when it was discontinued. Review of the 9/2022 Medication Administration Record (MAR) indicated there were no prescribed antipyschotic…

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 the staff developed and/or implemented the plan of care for three Residents (#2, #28 and #48), out of a total sample of 17 residents. Findings include: 1. For Resident #2, the facility failed to ensure the staff implemented the plan of care relative to obtaining weekly weights as per the Physician's Orders. Resident #2 was admitted to the facility in April 2020. Review of the Minimum Data Set (MDS) Assessment, dated 5/5/22, indicated the Resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 6 out of 15 and required extensive assistance of two staff with transfers. Review of the Dietitian's Note, dated 6/13/22, indicated Resident #2 had a 14 pound (lb.) weight loss over a two month period. Review of the Physician's Orders, dated 6/14/22, indicated an order to weigh the Resident weekly for health monitoring. Review of the Medication Administration Record (MAR) from 6/2022 through 10/2022 indicated the Resident's weight was not obtained weekly as…

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 its staff provided resident treatment and care in accordance with professional standards of practice for one Resident (#44), out of a total of 17 sampled residents. Specifically, the facility failed to ensure its staff provided a daily dressing change as ordered by the Physician. Finding include: Resident #44 was admitted to the facility July 2021. Review of the facility policy titled, Dressings, Dry/Clean, dated September 2013, indicated the following: -verify that there is a physician's order for this procedure -review the resident's care plan, current orders, and diagnosis to determine if there are special resident needs. -check the treatment record Review of the Order Summary Report, dated 11/2/22, indicated the Resident had a skin tear to his/her left outer aspect of the calf with a Physician's Order to cover the Steri-strips (a wound closure tape put across a wound to keep the edges together) with a non-stick dressing daily and as needed (PRN) until resolved. Review of the care plan, initiated on…

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

Based on observation, interview and record review, the facility failed to ensure its staff provided necessary foot care and treatment for one Resident (#36), out of a total of 17 sampled residents. Specifically, the facility failed to offer podiatry (a branch of medicine devoted to the study, diagnosis and treatment of foot problems and conditions related to the lower legs) services resulting in overgrown toenails and pain when wearing footwear. Review of the facility policy titled, Foot Care, revised March 2018, indicated the following: - Residents will receive appropriate care and treatment in order to maintain mobility and foot health. - Residents will be provided with foot care and treatment in accordance with professional standards of practice. Resident #36 was admitted to the facility in March 2022. Review of the current Physician's Orders included the following: - May see podiatrist, dentist, audiologist and ophthalmologist, initiated 3/25/22 - Monitor second toenail left foot every shift, initiated 10/23/22 Review of the medical record did not include evidence that 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 ensure its staff provided services relative to limited range of motion for one Resident (#28), out of a total of 17 sampled residents. Specifically, the facility failed to assess and treat a contracture (a shortening and hardening of muscles, tendons, or other her tissue, often leading to deformity and rigidity of joints), to his/her right hand and wrist, putting him/her at risk for increased contractures and pain. Resident #28 was admitted to the facility in April 2022 with a diagnosis of Cerebral Palsy (a group of disorders that affect movement and muscle tone and can cause stiff muscles with exaggerated reflexes (spasticity), stiff muscles normal reflexes (rigidity) and variations in muscle tone, such as being too stiff or too floppy (mayoclinic.org)). Review of the Resident's Care Plan did not include evidence a plan of care was developed relative to the limitations in his/her range of motion or contracture. Review of the Nursing Evaluations, dated 4/25/22, 6/7/22, and 9/7/22, did not include evidence 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 staff failed to ensure the environment remained free of accident hazards relative to smoking for one Resident (#23), out of a total of 17 sampled residents. Findings include: Review of the facility policy titled Resident Smoking Policy and Procedure, dated 2020, indicated that the residents were not permitted to have any smoking paraphernalia in their room or on their person and that all smoking paraphernalia should be given to the nursing staff for safe keeping Review of the Resident Smoking List provided by the facility indicated that Resident #23 was an independent smoker. Review of the Minimum Data Set (MDS) Assessment, dated 6/26/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. During an interview on 10/26/22 at 9:52 A.M., Resident #23 said that he/she holds onto his/her lighter and cigarettes because cigarettes are expensive, and the facility had lost them before. Review of the Smoking Care Plan, initiated on 7/18/22,…

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 appropriate care and services for an indwelling urinary catheter (a device placed into the bladder to allow urine to drain) for one Resident (#32) out of 17 sampled residents. Specifically, the facility staff failed to 1) ensure the Resident had a urology consultation as scheduled and 2) obtain appropriate Physician's Orders for urinary catheter care. Findings include: Resident #32 was admitted to the facility September 2022 with a diagnosis of Benign Prostatic Hypertrophy (enlargement of the prostate gland that can cause urinary difficulty). 1. Review of the Progress Notes indicated Resident #32 was transferred to the hospital on [DATE] and returned to the facility on [DATE] with a new diagnosis of a bladder mass. Review of the hospital discharge instructions, dated [DATE], indicated the Resident was to follow-up with the Urologist (a doctor who specializes in treatment of the urinary system) on 10/25/22. 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 interview and record review, the facility failed to ensure the Physician and/or Nursing staff addressed pharmacy recommendations timely for two Residents (#3 and #48), out of a total sample of 17 residents. Findings include: Review of the facility policy titled Medication Regimen Review (MRR), dated 8/2020, indicated that the consultant pharmacist performed a comprehensive review of each resident's medication regimen and clinical record at least monthly and all findings were reported to the Director of Nursing (DON), the Attending Physician, the Medical Director, and the Administrator or in accordance with facility policy. The policy also included the following: -recommendations were acted upon and documented by the facility staff and/or prescriber -the prescriber accepts and acts upon recommendations or rejects and provides an explanation for disagreeing. -the DON or designated licensed nurse address and document recommendations that do not require a physician intervention 1. Resident #3 was admitted to the facility in February 2022. Review of the clinical record indicated…

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

Based on interview and record review, the facility failed to obtain lab work as ordered by the Physician for one Resident (#34), out of a total sample of 17 residents. Findings include: Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised 11/2018, indicated the following: - the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs -the facility staff will process test requisitions and arrange for tests -the laboratory, diagnostic radiology provider, or other testing source will report the testing results to the facility Resident #34 was admitted to the facility in June 2019. Review of the clinical record indicated a Physician's Order dated 3/22/22 to obtain the following lab work for Resident #34: -Thyroid Stimulating Hormone (TSH), -Complete Blood Count (CBC), -Vitamin B12 level, -Liver Function Tests (LFTs), -Basic Metabolic Panel (BMP), and -Depakote Level Review of the Resident's clinical record indicated no documented evidence that the lab work was completed as ordered by…

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 the staff assisted one Resident (#34) with the process for obtaining dentures, out of a total sample of 17 residents. Findings include: Review of the facility policy titled Dental Services, revised December 2016, indicated that routine and emergency dental services were available to meet the resident's oral health service in accordance with the resident's assessment and plan of care. Resident #34 was admitted to the facility in June 2019. On 11/01/22 at 12:27 P.M., the surveyor observed Resident #34 seated in the Dining Room with other residents during the lunch meal. The Resident was feeding him/herself lunch which consisted of cut up meat, mashed potatoes and diced carrots. The surveyor observed that the Resident was edentulous. Review of the 10/2022 Physician's Orders indicated an order initiated on 3/24/22 for the Resident to have dental services as needed (PRN). Review of the Dental Care Plan, initiated 4/17/22, indicated Resident #34 was at risk for difficulty chewing related to his/her edentulous…

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 staff maintained a medical record that included documentation that residents were offered and received the pneumococcal immunization (a vaccine used to prevent possible life-threatening pneumonia) and/or did not receive the pneumococcal immunization for two Residents (#21 and #26), out of a total of five sampled residents. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised October 2019, indicated the following: -Assessment of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education shall be documented in the resident's medical record. -Residents/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical…

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

Based on interview and record review the facility failed to: 1.) Develop a COVID-19 vaccination policy for its residents, and 2.) Maintain a medical record that included documentation that residents were offered and received and/or did not receive or refused recommended COVID-19 vaccinations for two Residents (#21 and #31) out of a total of five sampled residents. Findings include: 1. The facility failed to create written policies to address COVID-19 vaccination for residents. During the survey entrance conference on 10/26/22 and on multiple occasions on 11/1/22 and 11/2/22 the Administrator, Director of Nursing (DON), and Respiratory Therapist (the staff at the facility who were over seeing COVID-19 within the facility) were asked to provide a COVID-19 resident vaccination policy and no policy was ever provided to the surveyor. On 11/2/22 at 12:33 P.M., the Administrator said the facility had not developed any policies related to COVID-19 vaccinations for residents. 2. For Residents #21 and #31 the facility failed to document in the Resident's medical records whether the Residents…

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 the facility failed to ensure staff developed written policies related to COVID-19 vaccination for its staff. Findings include: During the survey at the entrance conference on 10/26/22 and on multiple occasions on 11/1/22 and 11/2/22 the Administrator, Director of Nursing (DON), and Respiratory Therapist (the staff at the facility who were over seeing COVID-19 within the facility) were asked to provide a COVID-19 staff vaccination policy and no policy was ever provided to the surveyor. On 11/2/22 at 12:33 P.M., the Administrator said the facility had not developed any policies for COVID-19 staff vaccination.