Mission Care At Holyoke

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to safely provide feeding assistance for two Residents (#14 and #5), out of a total sample of 24 residents, when both Residents required assistance for eating, putting both residents at risk for aspiration. Specifically, 1. For Resident #14, the facility failed to ensure that safe swallow strategies recommended by the Speech Therapist (ST) were implemented and that liquids provided to the Resident were the ordered consistency. 2. For Resident #5, the facility failed to ensure the Resident was provided with nectar (mildly) thick beverages during the breakfast meal. Findings include: Review of the facility's Fluid Consistencies Chart, undated, indicated Honey consistency was described as a liquid that coats a fork and slowly sinks through the prongs (e.g. Yogurt, Honey). Review of the facility's Feeding (Dependent Feeding) Policy, revised 6/19/23, indicated the following: -Residents will be fed by staff that have appropriate training in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide nutrition and hydration services as required for one Resident (#75) out of a total sample of 24 residents. Specifically, for Resident #75, the facility failed to provide health shakes as ordered at the breakfast meal, putting the Resident at risk for compromised nutritional status. Findings include: Review of the facility policy titled Nourishments and Supplements, effective May 1995 and revised in January 2024, indicated but was not limited to the following: -Policy statement: High calorie food options .may be offered when a resident requires additional calories or nutrients. -Dining services will prepare nourishments as ordered. -Nursing staff will deliver nourishments/supplements to residents as ordered . Resident #75 was admitted to the facility in August 2021, with diagnoses including dysphagia, acquired absence of other specified parts of digestive tract, Dementia, and history of traumatic brain injury (TBI). 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 assist one Resident (#89), out of a total sample of 24 residents, in obtaining routine dental services. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #89 received routine dental services as requested. Findings include: Resident #89 was admitted to the facility in April 2023 with diagnoses including Alzheimer's Disease. Review of the Request for Service Form, dated and signed 5/15/23, by the Resident Representative requested Dental Services. Review of a Physician's order dated 7/26/24, indicated: -May have Vision, Auditory, Dental, Podiatry, Wound Consult. Review of Resident #89's Dental Care Plan initiated 10/17/24, indicated: -the Resident has broken natural teeth and cavities noted on admission to the facility. -coordinate arrangements for dental care. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #89: -was severely cognitively…

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, and interviews, the facility failed to adhere to infection control standards of practice while serving meals to residents on one Unit (3rd Floor) out of three Units observed. Specifically, the facility failed to ensure that staff distributing food during the lunch meal service on the 3rd Floor Unit performed appropriate hand hygiene to prevent contamination and the spread of foodborne illnesses. Findings include: Review of the facility policy titled Hand Hygiene, last revised 6/19/24, indicated: -Hand hygiene will be performed in accordance with national standards from the Centers for Disease and Prevention and the World Health Organization (WHO). >Hand hygiene should be performed: -When coming on duty. -Before entering a resident's room and upon exiting a resident's room. -Before and after handling peripheral vascular catheters and other invasive devices. -After removing gloves or aprons. -After completing duty. >Alcohol-based hand rub may be used for all other hand hygiene opportunities (for example [e.g.] when soap and water is not indicated). -After caring…

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 uphold Resident Rights for one Resident (#70), out of a total sample of 24 residents, relative to rights exercised by the Resident's Representative. Specifically, for Resident #70, the facility failed to implement an effective discharge planning process including documentation of referrals made and response from referrals that focused on the Resident Representative's goals of discharging the Resident to a skilled nursing facility closer to involved family members, putting the Resident at risk of decreased family visits. Findings include: Review of the Resident's [NAME] of Rights, revised in October 2024, indicated the following: -you have the right to exercise your rights as a resident and as a citizen. The facility must protect and promote your rights and support, encourage and assist you in exercising them. -you have the right to make choices about aspects of your life that are significant to you. Review of the facility Policy 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.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 12/09/24 during the day shift, Maintenance Assistant #1 hugged Resident #1 and kissed him/her on the mouth, without his/her consent, which made him/her feel uncomfortable. Findings include: Review of the Facility Policy titled Resident Rights and Responsibilities, dated as revised July 2017, indicated the Facility will protect and promote the rights of each resident as set forth in the Resident [NAME] of Rights, which includes the right to be treated with respect and dignity. Resident #1 was admitted to the Facility in March 2021, diagnoses included Chronic Obstructive Pulmonary Disorder (COPD), anxiety disorder, Post-Traumatic Stress Disorder (PTSD), major depressive disorder with psychotic symptoms, and schizoaffective disorder. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/03/24, indicated Resident #1 was cognitively intact with a score of 15 out…

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

Based on observation, interview, record and policy review, the facility failed to ensure that staff adhered to infection control standards for transmission-based precautions for two Residents #61 and #79, and on two Units (Unit One and Unit Three) out of three units observed to stop the spread of infection in the facility. Specifically, the facility failed to ensure: 1. On Unit One, for Residents #61 and #79, that staff wore the required personal protective equipment (PPE) when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility. 2. On Unit Three, that staff performed hand hygiene after caring for a COVID positive resident, between contact with multiple residents to prevent contamination and mitigate the spread of infection during a COVID-19 outbreak in the facility. Findings include: Review of the facility policy titled Isolation Policy and Procedures dated 10/22/21, indicated the following: *Droplet Precautions: -In addition to standard precautions, use droplet precautions for residents known or suspected to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#44) out of a total sample of 24 residents. Specifically, the facility staff failed to: -Implement a schedule for cleaning and storage of Resident #44's BiPAP mask (a mask used in conjunction with a BiPAP device [non-invasive ventilation machine that is capable of generating two adjustable pressure levels ), placing the Resident at risk for nosocomial (healthcare associated) infections. -Clean and maintain the Resident's oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated) filter in accordance with professional standards and placing the Resident at risk for impaired oxygen delivery and equipment malfunction. Findings include: Review of the facility policy titled Concentrator Maintenance, undated, indicated the following: It is the facility policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards of practice for one Resident (#94) out of a total sample of 24 residents. Specifically, the facility failed to: -consistently communicate the facility Nurse's assessment of the Resident prior to him/her going to dialysis. -collaborate with applying EMLA (Lidocaine) cream to the dialysis access site prior to the Resident leaving the facility to prevent pain when the dialysis site is accessed in the dialysis facility. -implement recommendations made by the dialysis center to remove pressure dressings within 24 hours of dialysis treatments to prevent clotting of the dialysis access site. Findings include: Resident #94 was admitted to the facility in February 2022, with a diagnosis of End Stage Renal Disease (ESRD: when the kidneys no longer work as they should to meet the body's needs) and was dependent on dialysis treatments (a treatment that does the work of the kidneys 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 record review and interview, the facility failed to ensure that one Resident (#96) out of a total sample of 24 residents was free from a significant medication error. Specifically, the facility staff failed to: -discontinue an order for an antipsychotic medication (medication used to treat certain types of mental health problems whose symptoms include psychotic experiences) dosage of 20 milligrams (mg) of Abilify, before administering the newly ordered dosage of 25 mg of Abilify resulting in the Resident receiving an excessive dosage (45 mg) of the medication, which was greater than the recommended maximum dosage of 30 mg daily. Findings include: Resident #96 was admitted to the facility in February 2023 with a diagnosis of Schizophrenia (a chronic brain disorder with symptoms such as delusions, hallucinations, disorganized speech, trouble speaking, and lack of motivation). According to the Nursing Drug Handbook (2022), page 144, Aripiprazole (brand name Abilify, an antipsychotic medication) Indications and Dosage indicated but was not limited to: -for Schizophrenia:…

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

Based on record review and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made, if you become unable to speak for yourself) for two Residents (#30 and #79) out of a total sample of 24 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) decisions were made by: 1. Resident #30, who had not been deemed as lacking capacity for informed decision making by the facility's Physician instead of their Health Care Proxy (HCP-a legally designated person who can make medical decisions for a person deemed by a medical professional to be unable to make their own medical decisions). 2. Resident #79, who was not determined by the Physician/ Nurse Practitioner (NP) as being unable to make their own medical decisions, instead of the HCP. Findings include: Review of the facility policy titled MOLST, last revised 2/19/21, indicated: -that if a resident (or if the resident lacks…

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, policy and record review, the facility failed to implement the facility smoking policy one Resident (#22) out of a total sample of 24 residents. Specifically, for Resident #22 the facility failed to ensure that staff completed re-admission smoking evaluations after the Resident was hospitalized on two occasions. Findings include: Review of the facility policy titled Resident Smoking-MA, reviewed 2/14/23, indicated the following: -Smoking evaluations: Smoking evaluations should be done upon admission/re-admission and after significant change in resident status. Resident #22 was admitted to the facility in June 2021, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) with severe mood disturbance and a history of a traumatic brain injury (TBI - a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain). Review of list titled Smoking Group provided to the…

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

Based on interview and record review, the facility failed to ensure its staff managed and monitored the psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication regimen to promote and maintain the highest practicable mental, physical, and psychosocial well-being of four Residents (#36, #113, #272, and #41) out of 24 sampled residents. Specifically, facility staff failed to: 1) ensure residents (#36, #113, #272) were consistently monitored for medication side effects and that, 2) ensure an as needed (PRN) psychotropic medication was time limited and reevaluated as required (Resident #41). Findings include: Review of the facility policy titled, Use of Psychoactive Medications and Gradual Dose Reductions (GDR), undated, indicated: -Psychoactive medications will be used in accordance with federal laws and the State Operations manual -The prescriber shall monitor and assess for efficacy, tolerability, and side effects and adjust dose as necessary Review of the facility policy titled use of PRN (as needed) Psychotropics, undated,…

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 promoted care for residents in a manner and environment that maintained and enhanced each resident's dignity and respect, by neglecting to sit with residents while providing dining assistance on one unit (Unit Three) out of three units observed. Findings Include: Review of the facility policy Feeding (Dependent Feeding), revised 6/5/19, indicated the following: -Give resident your complete attention, sit so you are at the same level of the resident. During an observation on 12/27/22 at 9:55 A.M., during the breakfast meal on Unit Three, the surveyor observed Nurse #1 standing while assisting a resident with the breakfast meal. The surveyor noted there were multiple empty chairs throughout the dining area available for the Nurse to use. During an observation on 12/28/22 from 9:23 A.M. 9:30 A.M., during the breakfast meal on Unit Three, the surveyor observed Certified Nurses Aide (CNA) #1 standing while assisting a resident with the breakfast meal. The surveyor also observed that CNA #1 made no attempt to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to provide reasonable and needed accomodations for one Resident (#19), out of a sample of 24 residents. Specifically, the facility staff failed to place a call bell within reach, making it impossible for the Resident to summon help when needed and placing him/her at increased risk for falls. Findings include: Resident #19 was admitted to the facility in December 2021. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident's cognition was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, required extensive assistance with transfers in and out of bed, and had previously fallen two or more times. During an observation and interview on 12/27/22 at 10:34 A.M., the surveyor observed the Resident, lying in his/her bed which was pushed up against the wall on the right side of his/her room. The surveyor also observed the Resident's call bell hanging off of the control panel in 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 one Resident's (#40) personal care choices were honored, out of a total sample of 24 residents. Specifically, the facility failed to provide showers for the Resident per his/her request. Findings include: Resident #40 was admitted to the facility in July 2021. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Further review of the MDS Assessment indicated the Resident was totally dependent with the assistance of two persons for dressing, toileting, bathing, personal hygiene and transfers in and out of bed. During an interview on 12/27/22 at 2:15 P.M., Resident #40 said he/she would love to have a shower and was supposed to receive showers twice weekly. The Resident further said the staff did not shower him/her or wash his/her hair because the facility did not have a shower chair large enough to accommodate…

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 its staff provided Physician notification when insulin (a medication that controls the amount of sugar in the bloodstream) was not available to be administered as ordered for one Resident (#111), out of 24 sampled Residents. Findings include: 1. Resident #111 was admitted to the facility in April 2022 with a diagnosis of Diabetes Mellitus Type 2 (DM II). Review of the facility policy titled General Guidelines for Medication Administration, dated 8/2020, indicated the following: -If a dose of regularly scheduled medication is not available, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. -An explanatory note is entered on the reverse side of the record. -If three consecutive doses, or in accordance with facility policy, of a vital medication are not available, the physician is notified. -Nursing documents the notification and the physician response. Review of the Physician's Orders, dated December 2022, indicated 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 and interview, the facility failed to ensure its staff provided a clean home-like environment for two Residents (#21 and #36), out of a sample of 24 Residents. Specifically, the facility housekeeping staff failed to adequately clean wheelchairs so there was not a build up of food and other debris, that could potentially become a sanitary and safety concern. Findings Include: 1. Resident #21 was admitted to the facility in March 2021. During an observation on 12/28/22 at 8:23 A.M., the surveyor observed Resident #21 seated in his/her wheelchair. The surveyor observed the wheelchair to be filthy and appeared to not have been cleaned. The wheelchair had areas covered in a crusty white dried material, as well as a thick pink gummy substance. Upon further observation the surveyor observed areas on the wheelchair with a sticky substance that had accumulated hair and other debris. During an observation and interview on 12/28/22 at 10:47 A.M., the Housekeeping Director said housekeeping was the department that maintained wheelchair cleanliness. The Housekeeping Director…

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 record review, the facility failed to ensure that its staff assessed, monitored and evaluated the use of a physical restraint for one Resident (#79), out of a sample of 24 residents. Findings include: Review of the facility policy titled, Restraint-Physical, revised 3/11/21, indicated the following: - Physical Restraint, defined: any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. - All residents will be assessed by the interdisciplinary team on admission or when the implementation of a restraint is considered for medical necessity to utilize a restraint. - If a restraint is determined to be medically necessary, the competent resident and/or responsible party and/or legal representative will be informed of the risks and benefits, possible negative outcomes, alternatives to restraint use and a written consent for the use of the restraint will be obtained. - A written…

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 that its staff developed and implemented the plan of care for three Residents (#17, #21 and #52), out of a sample of 24 residents. Specifically, the facility staff: 1) failed to complete weekly skin checks for three Residents (#17, #21 and # 52), and 2) failed to provide an intervention intended to prevent a pressure injury for one Resident (#21), placing them at increased risk for acquired pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Findings include: 1. Resident #17 was admitted to the facility in March 2018 with diagnoses of Dementia and Peripheral Vascular Disease (PVD- a circulation disorder in which narrowed blood vessels reduce blood flow to the limbs). Review of the Minimum Data Set (MDS) Assessment, dated 11/20/22, indicated the Resident had one, unhealed, Stage Three Pressure Ulcer (a wound that has gone through all layers of skin into the fat tissue, caused by pressure). Review of the policy, Pressure Ulcer Prevention, dated 3/18/19,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice, to promote healing of existing pressure ulcers (wounds caused by prolonged pressure on the skin) for one of four applicable residents (Resident #14), out of a total sample of 24 residents. Specifically, the facility failed to ensure that ordered wound care treatments and skin checks to identify new areas of concern were completed as ordered. Findings include: Resident #14 was admitted to the facility in September 2022. During an observation on 12/27/22 at 9:26 A.M., the surveyor observed Resident #14 lying in bed on a pressure relief mattress set at 15 alternating with medium firmness. The surveyor also observed dressing supplies on the windowsill in the Resident's room. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 had severe cognitive impairment as evidenced by a score of zero out of 15 on the Brief…

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 and its staff failed to ensure that the appropriate equipment and assistance to maintain and improve mobility were provided for two Residents (#1 and #41), out of 24 sampled residents with limited mobility. Specifically, the facility staff failed to ensure devices were applied as ordered to prevent and limit contractures (deformity and rigidity of joints resulting in decreased function). Findings include: 1. Resident #1 was admitted to the facility in July 2022 with diagnoses including Traumatic Brain Injury (TBI) and Hemiplegia (muscle weakness or partial paralysis on one side of the body). Review of an Occupational Therapy (OT) note dated 8/10/22, indicated Resident #1 had a left hand contracture and included the following treatment goal: -the Resident would safely wear a hand roll on the left hand (used as a splint) for up to 8 hours with minimal redness, swelling, discomfort or pain. Review of the nursing care plan titled Left-Hand Roll,…

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, interviews, and record review, the facility failed to ensure that its staff provided appropriate care and services for three Residents (#14, #112, and #75), out of three applicable residents, with urinary catheters (tubes that drain urine from the bladder to a collection device outside the body) out of a total sample of 24 residents. Specifically, the facility staff failed to indicate: A) catheter care had been performed, B) evidence of drainage bag changes and urinary output recording, C) that dignity was provided relative to catheter drainage bags, and D) follow infection control practices to prevent contamination and infection. Findings include: 1. For Resident #14, the facility failed to ensure its staff documented catheter care and services as ordered by the Physician. Resident #14 was admitted to the facility in September 2022, with a diagnosis of Obstructive Uropathy (a condition in which urine cannot drain through the urinary tract). On 12/27/22 at 4:10 P.M., 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 observation, interview, and record review, the facility failed to ensure that its staff provided respiratory care consistent with professional standards of practice for one Resident (#1) with a tracheostomy tube (trach: a surgically created opening (stoma) from the neck to the trachea to create an airway for those unable to breathe through the nose or mouth), out of one applicable residents with tracheostomies, out of a total sample of 24 residents. Specifically, facility staff failed to keep a spare tracheostomy tube (trach tube: a tube inserted into the tracheostomy to maintain an open airway) at the bedside in the event of an emergency, and document trach tie changes as ordered. Findings include: Review of an on-line article titled: Tracheostomy Care, published in Nursing Critical Care 2020, indicated: -emergency supplies should be immediately available at the bedside to protect the patient from complications of tracheostomy tube dislodgement -emergency supplies should include spare trach tubes .…

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 interviews and record review, the facility failed to ensure its staff provided care consistent with professional standards of practice for one Resident (#91), out of 4 residents receiving dialysis in a total sample of 24 residents. Specifically, the facility staff failed to communicate effectively with the dialysis center by sending the Resident with incomplete, pertinent clinical information. Findings include: Resident #91 was admitted to the facility in September 2022 with a diagnosis of End Stage Renal Disease (ESRD-when kidneys no longer function well enough to meet a body's needs) and required dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) on a Tuesday, Thursday and Saturday schedule. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff: 1) acquired and dispensed medication as ordered for one Resident (#111), out of 24 sampled residents, and 2) replaced an Insulin Emergency Kit (E-Kit) on one out of one unit where the Insulin Emergency kits were stored. Findings include: 1. Resident #111 was admitted to the facility April 2022 with a diagnosis of Diabetes Mellitus Type 2 (DM II). Review of the MDS Assessment, dated 11/13/22, indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. Review of the Physician's Orders dated December 2022, indicated the Resident had an order for Humulin-N insulin, inject 80 units subcutaneously (beneath the skin) twice daily, initiated 5/5/22. Review of the policy titled, Ordering and Receiving Non-Controlled Medication, dated 8/2020, indicated the following: -Repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab…

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 responded to medication regime reviews (MRRs-pharmacy recommendations) timely and documented within the clinical record for two Residents (#113 and #41), out of a total sample of 24 residents. Findings Include: 1. Resident #113 was admitted to the facility in June 2022 with diagnoses including Bullous Pemphigoid (skin condition that can cause large blisters which can result in pain and itching), Vascular Dementia, antisocial personality disorder, and delusional disorder. Review of the Resident's medical record indicated MRRs were done by the Pharmacist on 7/20/22, 9/21/22, and 10/20/22 and recommendations had been made on each date. Further review of the Resident's medical record indicated no documentation the MRRs from 7/20/22, 9/21/22, or 10/20/22 had been reviewed, addressed, and signed by the attending Physician. During an interview on 12/28/22 at 1:24 P.M., Unit Manager (UM) #1 said the MRRs on the dates in question had not been reviewed, addressed, or signed by the attending Physician. She further…

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 its staff stored drugs and biologicals in accordance with currently accepted professional principles on two of three units. Specifically, the facility failed to ensure: A) an unattended medication cart was locked, B) expired patient specific medications were removed from the medication cart and medication storage room, and C) that medication refrigerator temperatures were monitored to ensure vaccines was kept under appropriate temperature controls. Findings include: Review of a facility pharmacy policy titled, Storage of Medications, effective September 2018, indicated the following: -Medications and biologicals are stored safely, securely, and properly and is accessible only to licensed nursing personnel, pharmacy personnel and staff members lawfully authorized to administer medications. -Outdated medications are removed from inventory and disposed of according to procedures for medication disposal. -The facility should check the refrigerator or freezer in which vaccines are stored at least two…

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 staff obtained Physician's orders for COVID-19 testing prior to testing being conducted on two Residents (#12 and #88), out of a total sample of three residents. Findings Include: Review of the Centers for Medicare and Medicaid (CMS) Memo QSO-20-38-NH titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised 9/23/22, indicated the following: -Conducting Testing- In accordance with 42 CFR § 483.50(a)(2)(i), the facility must obtain an order from a Physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist in accordance with state law, including scope of practice laws to provide or obtain laboratory services for a resident, which includes COVID-19 testing (see F773). This may be accomplished through the use of Physician approved policies (e.g., standing orders), or other…

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 and record review, the facility failed to ensure that its staff accurately documented the use of a Continuous Positive Airway Pressure (CPAP) device (a machine that uses positive pressure to keep breathing airways open during sleep). Specifically, the facility staff failed to document the Resident's refusal of wearing the device. Findings include: Resident #79 was admitted to the facility in November 2021 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a condition involving constriction of the airways and difficulty/ discomfort breathing) and Sleep Apnea (a sleep disorder in which breathing repeatedly stops and starts). Review of the December 2022 Physician's Orders included the following: - CPAP settings: 5-12 centimeters of water (cmH2O- unit that measures the pressure). Apply at bedtime, off in the morning, initiated 11/11/21. -Check skin before applying and after removing CPAP after every shift. Review of the November and December 2022 Treatment Administration Records (TARs) indicated no documentation of CPAP use on the following dates:…

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.