Regalcare At Holyoke

Based observations, interviews, policy and record review the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on three (Unit Two, Unit Three and Unit Four) out of three observed units. Specifically, the facility failed to: 1)Ensure sufficient staff as determined by the Facility Assessment 2)Ensure call bells were responded to timely for Residents #83 & Resident #22 Findings include: Review of the facility policy titled Emergency Staffing Strategies, dated September 2020, indicated but was no limited to the following: -In the event that sufficient staff is not available from the individual SNF's (Skilled Nursing Facility) workforce, the facilities incident commander shall coordinate other available corporate resources to obtain additional employees from other facilities to staff the stricken facilities during emergencies and disasters. -Assign ancillary staff who possess Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nurse Aide (CNA)…

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 establish and implement policies, in accordance with applicable Federal, State and local laws and regulations regarding smoking for two Residents (#82 and #244) out of four applicable residents out of a total sample of 21 residents. Specifically, the facility failed to: 1. Ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials. Finding include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11 included but was not limited to: - Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. - The facility is obligated to ensure the safety 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 observations, interviews, and record review, the facility failed to ensure precautions are taken for the resident's individual safety relative to smoking. Specifically, the facility failed to: 1. Ensure fire prevention equipment was readily available in the smoking area to ensure a safe smoking environment. 2. Ensure the smoking plan of care was implemented for two Residents (#82 and #244) out of four applicable residents out of a total of 21 sampled residents relative to resident possession of smoking materials (Resident #82 and #244) and providing a safety intervention (smoking apron) (Resident #244 and #245) assessed to require one. 3. Ensure staff, who accompanied residents outside to smoke, were educated as to what safety interventions to implement in the event of an emergency relative to resident smoking. Findings include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11…

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 test tray results, the facility failed to serve palatable food at an appetizing temperature, to all residents, on three Units (Unit Two, Unit Three, and Unit Four) of three units observed as well as in the Main Dining Room. Findings include: On 5/22/24, the surveyor conducted a Resident Council Meeting with 11 residents. Of the 11 residents who were present, 10 actively participated in the meeting and resided Units Three and Four. The following concerns were identified by the participating residents: -Two residents said the food was always cold -One resident said the food was bland but otherwise is good -One resident said the food was either too bland or had too much salt -One resident agreed the food was salty, specifically that the gravy was salty During the initial walkthrough on 5/21/24 at 10:15 A.M., the surveyor received the following comments from two residents on Unit Two: -The food is cold and is never hot enough. -The food is always cold. I don't think they cook it right or they need heat boxes. 1. On 5/23/24 from 11:43 A.M. to 12:06…

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 two Unit (Unit #3 and Unit #4) kitchenettes were maintained in a clean and sanitary manner out of three Unit kitchenettes observed. Findings include: Review of the facility policy titled Food Brought Into Facility, revised 5/22, indicated the following: -Perishable foods must be stored and identified with the resident ' s name, food item, and use by date. These can be stored in the nursing unit kitchen nourishment refrigerator. Review of the Daily Checklist for Dietary Cleanliness, undated, provided by the Food Service Director (FSD), indicated the following: -Make sure Unit Kitchens are stocked, cleaned, and rotated all shifts. This includes Microwave, Refrigerators, Toaster, etc. Unit Three During an observation on 5/21/24 at 8:47 A.M., in the Unit Three Kitchenette the following was observed: -Toaster crumb drawer laden with crumbs and toaster had burnt on material inside. -Frozen item in kitchenette freezer dated 6/1/24 with no name. During an observation on 5/22/24 at 12:38 P.M., in the Unit Three kitchenette the…

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

Based on observations and interviews, the facility failed to ensure Administration and/or the Governing Body provided residents in the facility with appropriate care and services in order to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to identify and implement plans to address numerous facility wide concerns, failed to fully assess the facility staffing needs in order to meet resident needs, and failed to ensure supplies for resident care were available and accessible. Findings include: During the re-certification survey conducted by the survey team from 5/21/24 through 5/24/24, the following concerns were identified by residents/resident representatives and staff: -resident supplies including incontinence briefs, washcloths or towels, and clothes were not always available 1. Review of the Facility Assessment, dated 4/17/24, indicated the facility accepts residents with a broad range of diseases and disabilities primarily including common diseases of the elderly for its long-term care unit. These conditions, physical 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 record review and interviews the facility failed to implement their grievance policy and assist one Resident (#56) to file a grievance out of a total sample of 21 residents. Specifically, the facility staff failed to follow up and investigate a report of a missing electric razor. Findings include: Review of the facility policy titled Grievances, dated 8/2019 indicated the following: -Staff members are encouraged to assist residents in filing a grievance and/or complaint when the resident believes that his/her rights have been violated. -Upon receipt of a grievance, complaint report or the missing items form, the Director of Social services will begin an investigation into the allegation. Resident #56 was admitted to the facility in August 2023 with diagnoses that include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the Minimum Date Set (MDS) Assessment, dated 3/29/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10…

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, records review and policy review, the facility failed to implement their abuse policies and procedures. Specifically; 1) The facility failed to investigate an allegation of abuse according to policy and procedure for one Resident (#30), out of a total of 21 sampled residents resulting in potential for psychological harm. 2) The facility failed to implement their employee screening procedures to ensure new employees have no previous abuse, neglect or mistreatment findings for one staff member (CNA #4) out of 5 staff members reviewed. Findings include: Review of facility policy titled Abuse: Investigation, dated March 2022, indicated but was not limited to the following: -The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individual who may have knowledge of the event should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. -Documentation 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, interviews, records review and policy review, the facility failed to prevent the potential for further abuse for one Resident (#30) out of a total of 21 sampled residents. Specifically, the facility failed to follow their policy and take steps to protect the Resident and prevent him/her from the potential of further abuse during an investigation of an allegation of abuse. Findings include: Review of the facility policy titled Abuse: Identification & Reporting dated March 2022 indicated but was not limited to the following: -All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process Review of the facility policy titled Abuse: Investigation dated March 2022 indicated but was not limited to the following: -The nursing supervisor will take appropriate steps to protect the resident, if applicable, from further mistreatment and to ensure appropriate care is provided. Separate accused/suspected employee or resident from alleged victim and other residents. Suspension of employee pending…

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 provide recommended specialized services from the Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities (ID/DD) in all individuals (regardless of source of payment) seeking admission to Medicaid- or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services), for one Resident (#21) out of 21 total residents sampled. Specifically, the facility failed to provide Resident #21 with individual psychotherapy as recommended by the Department of Mental Health (DMH) based on the PASRR Level II Evaluation. Findings include: Resident #21 was admitted to the facility in January 2024 with multiple diagnoses that included Bipolar Disorder (a SMI that causes extreme mood swings, from high to low, that affect your energy, thinking, 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 an intervention was implemented as recommended by the Wound Physician's Assistant (PA) for one Resident (#48) out of a total sample of 21 residents. Specifically, the facility failed to ensure a protective boot was obtained for Resident #48 as recommended by the Wound PA to protect the Resident's foot where he/she had a transmetatarsal amputation (TMA-surgical removal of part of the foot). Findings include: Resident #48 was admitted to the facility in January 2023 with diagnoses including Type 2 Diabetes Mellitus, right TMA, and osteomyelitis (a bone infection). During an observation on 5/21/24 at 8:54 A.M., the surveyor observed Resident #48 seated in his/her wheelchair. He/She had a bandage to his/her right foot area, was dangling, and he/she was not wearing a protective boot. During an observation on 5/22/24 from 8:34 A.M. to 9:12 A.M., the surveyor observed Resident #48 to be seated in his/her wheelchair. He/She had a bandage to his/her right foot area and was not wearing a protective boot. 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.

Based on record review an interview the facility failed to ensure one Resident (#12) out of a total of 21 residents sampled received proper treatment and assistive devices to maintain vision abilities. Specifically, for Resident #12 the facility failed to coordinate follow-up services relative to vision, after communicating his/her vision concerns. Findings include: Resident #12 was admitted to the facility in February 2022. Review of the 2/22/24 Minimum Data Set (MDS) Assessment indicated the Resident was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Review of the Request for Services signed by the Resident on 2/28/22, indicated Eye Care as one of the requested services provided by the mobile contracted agency. During an observation and interview on 5/21/24 at 12:07 P.M., Resident #12 said that he/she had been seen by the eye doctor sometime last July and has not been seen again since. He said that during this visit he/she understood that he/she would be obtaining new glasses to help with his/her worsening vision. The Resident…

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

Based on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#1) out of one applicable resident, out of a total sample of 21 residents. Specifically, the facility staff failed to coordinate delivery of medications with Resident #1'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 medication as ordered by the Physician. Findings include: Review of the facility's policy titled Care of a Resident with End Stage Renal Disease (ESRD-a permanent stage of chronic kidney disease that occurs when the kidneys can no longer function on their own requiring dialysis or a kidney transplant), dated 4/2022 indicated the following: -Staff caring for residents with End Stage Renal Disease, including residents receiving dialysis outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes, specifically: Timing 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 interviews, record review and review of the Facility Assessment (an assessment completed by the facility to identify what resources are necessary for competent care of residents on a day-to-day or emergency basis), the facility failed to ensure annual performance appraisals for Certified Nurse Aides (CNAs) were completed every 12 months. Specifically, the facility failed to ensure that two CNAs (#4 and #5) out of 2 applicable CNAs reviewed had an annual performance appraisal completed and ensured regular in-service education was completed based on the result of the performance appraisals. Findings include: Review of the Facility Assessment, dated 4/17/24, indicated no documented evidence the facility addressed the need for annual performance appraisals of CNAs. CNA #4 was hired to the facility on 3/15/23. A review of CNA #4's Human Resource (HR) record indicated no documented evidence that performance appraisal(s) had occurred. CNA #5 was hired to the facility on 1/21/20. A review of CNA #5's HR record indicated no documented evidence that performance appraisal(s) 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 record review and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#56), out of a total sample of 21 residents. Specifically, the facility staff failed to provide Behavioral Health Services for Resident #56 when he/she displayed symptoms of Depression (a common and serious mood disorder that may include symptoms of fatigue, sleep and appetite disturbances, agitation, and expressions of guilt, difficulty concentrating, apathy, withdrawal, and suicidal ideation). Findings include: Resident #56 was admitted to the facility in August 2023 with diagnoses that include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and Depression. Review of the Minimum Data Set (MDS) Assessment, dated 3/29/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10 out of a possible 15, and took antidepressant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide specialized rehabilitation services for one Resident (#78) out of 21 total residents sampled. Specifically, for Resident #78 the facility failed to obtain specialized services relative to speech-language pathology for a Resident experiencing ongoing difficulty swallowing putting him/her at an increased risk of experiencing an adverse effect such as aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) or choking. Findings include: Review of the Facility assessment dated [DATE] indicated the facility will provide Speech/language services based on the Resident's needs. Resident #78 was admitted to the facility in June 2023 and had the following diagnoses: of GERD (gastro-esophageal reflux disease, a condition that causes heartburn or acid indigestion) and Dysphagia (difficulty in swallowing food or liquid). Review of the 3/13/24 Minimum Data Set (MDS)…

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 records reviewed, for two of three sampled residents (Resident #3 and #1), the facility failed to ensure they maintained a completed and accurate medical record (1) for Resident #3, Nursing documentation in his/her Treatment Administration Record (TAR) related to the application of Optifoam Dressing was inaccurate and the Certified Nurse Aide Activity of Daily Living (ADL) Flow sheet during the month of October 2023, was incomplete, (2) for Resident #1 his/her weekly skin observation tools were not completed by Nursing, as ordered by the Physician during the months of May 2023 and June 2023. Findings Include: Review of the Facility's policy, Pressure Ulcer/Injury Risk Assessment, dated 03/2022, indicated the type of skin care provided and the condition of the resident's skin (i.e. the size and location of any red or tender areas), should be recorded in the resident's medical record. Review of the Facility's policy, Preventative Pressure Ulcer, dated 04/2022, indicated to reposition residents who are dependent on staff for repositioning, at least every 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 records reviewed and interviews, the facility failed to ensure two Residents (#4 and #2) in a total sample of five residents were up to date with their Pneumococcal (name for any infection caused by bacteria called Streptococcus pneumoniae) Vaccinations, according to National standards for Pneumococcal Vaccination and the facility's policy. Specifically, the facility failed to: 1. Offer a Pneumococcal Vaccination to Resident #4 when the Resident had previously received one dose of the vaccine, but was not up to date with the Pneumococcal Vaccination series. 2. Determine whether Resident #2 was eligible to receive an additional dose of Pneumococcal Vaccine when staff failed to obtain the date Resident #2 received his/her first dose. Findings include: Review of the facility's policy, titled Pneumonia Vaccination, dated April 2017 and revised April 2022, indicated: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. - Upon admission, residents will…

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 its staff implemented the plan of care for two Residents (#44, and #174) out of 18 sampled residents. Specifically, failure to implement: 1. a) monitoring meal intake while transitioning from NPO (does not receive fluid or solids by mouth) to PO (does receive fluid or solids by mouth), b) monitoring weights, and c) fall safety interventions for Resident #44, 2. initiated the bowel regimen protocol as care planned for Resident #174, and 3. ensure Oxygen (O2) was delivered at the ordered flow rate for Resident #15. Findings include: 1. Resident #44 was admitted to the facility in January 2019 with diagnoses including Parkinson's Disease, Epilepsy, significant weight loss in the last six months, and legal blindness. a) Review of the current Physician's orders indicated to document breakfast, lunch, and dinner percentages while the Resident transitions from NPO to PO starting on 1/10/23. Review of the medical record indicated no evidence that the Resident's meal intake percentage was documented after…

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 its staff stored and prepared food in accordance with professional standards for food service and safety. Specifically, they failed to ensure a sanitary environment in the facility main kitchen, as well as in three out of three unit kitchens. Findings include: Review of a facility memo to all kitchen staff, dated 8/10/16 indicated: - All personal belongings brought into the kitchen may be stored in the storeroom. - No food or drink is allowed in the main kitchen work area. This means no eating or drinking in the kitchen. -All personal food and beverage is to be stored in the staff refrigerator and consumed during breaks. -Employees may have a glass of water if thirsty but only in the supervisor's office or the dish room. Review of the facility's Safety and Sanitation Best Practice Guidelines, revised 1/2011 indicated: - Ovens: should be cleaned daily, weekly, or as needed. Daily: Wipe up spills as they occur, remove shelves, scrape burned particles from hearth, brush out interior, shelf ledges, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure its staff maintained an infection prevention program to prevent the transmission of a communicable disease for one Resident (#223), out of a total sample of 18 residents. Specifically, they failed to: 1) utilize the appropriate personal protective equipment (PPE) while providing care to the Resident, and 2) initiate precautions appropriate to the Resident's condition. Findings include: Review of the facility's policy titled, Isolation - Categories of Transmission Based Precautions, revised April 2022, indicated the following under Contact Precautions: - In addition to Standard Precautions (minimum infection prevention practices which apply to all patient care regardless of suspected or confirmed infection status of the patient, in the setting where health care is delivered), implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility and its staff failed to provide a dignified existence for two Residents (#8 and #174), out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. provide a urinary catheter bag privacy cover (covers a catheter bag so urine is not visible) for Resident #8, and 2. provide activities of daily living (ADL) care that included removal of unwanted facial hair for Resident #174. Findings Include: 1. Resident #8 was admitted in April 2022 with a diagnosis of urine retention (the inability for a person to voluntarily release urine from the bladder). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had an indwelling foley catheter (tubing that is inserted into the bladder to help drain urine). During observations on 2/14/23 at 8:22 A.M., and 2/15/23 at 9:53 A.M., the surveyor observed Resident #8 lying in bed. His/her foley catheter bag was hanging at the foot of the Resident's bed 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 interview and record review, the facility and its staff failed to provide a notice of rights and services to residents during the residents stay. Findings include: Review of the facility policy titled Resident Rights, revised 4/2022, indicated .these rights include the resident's right to be informed about his/her rights and responsibilities. Review of the Resident Council Meeting minutes for 11/30/22, 12/28/22 and 1/21/23 did not indicate that any resident rights had been reviewed. On 2/16/23 at 10:31 A.M., the survey team held a group meeting with 11 residents. The Resident group stated to the survey team that they could not recall when the last in-person meeting was held. They said that the activities department came around to some of them to discuss any concerns. Additionally, the group said that no staff had reviewed their rights with them. During an interview on 2/16/23 at 1:18 P.M., the Activities Director said that she was new and did not know how the facility notified the residents in the past of the residents rights, and the facility had not done so since she…

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 interviews, the facility failed to ensure its staff provided a safe, clean, comfortable homelike environment on one (Unit Four) out of three units. Findings include: During an observation and interview on 2/14/23 at 9:05 A.M., on Unit Four, the surveyor observed Resident #11's carpet next to his/her bed full of crumbs, the area under his/her bed cluttered with items such as clothing in bags, opened soda bottles, a plastic pitcher of juice, an opened bag of potato chips, an open bowl with candy way underneath his/her bed against the wall, and visible dirt all over the floor surrounding the Resident's multiple totes, containers and belongings. The Resident said housekeeping had not been in to clean his/her room since Saturday (three days prior). During observations on 2/14/23 between 9:18 A.M. until 10:12 A.M., on Unit Four, the surveyor observed the following: -room [ROOM NUMBER] - Bathroom with visible dirt/dust over the corners of the floor and the caulk underneath the toilet, dried,…

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 referred one Resident (#2), out of a total sample of 18 residents, for a Level II evaluation (an evaluation to determine if a resident needs specialized services to address his/her Mental Illness (MI)) once it was identified post admission that the Resident had a diagnosis of MI. Findings Include: Resident #2 was admitted the facility in March 2022. Review of the Resident's Level I Preadmission Screening and Resident Review (PASRR-an evaluation to determine if a Resident has MI or Intellectual or Developmental Disability (ID/DD) and needs an additional Level II evaluation) dated 4/19/22, indicated Resident #2 did not have any diagnosis of MI. Review of the Physician's Progress Note dated 4/21/22, indicated the Resident had a previous medical history of Schizoaffective Disorder (a MI that is a combination of symptoms of Schizophrenia and mood disorder). Review of the Behavioral Health Care Team's progress note dated 4/27/22, indicated the Resident had a diagnosis of Schizoaffective Disorder, and had a…

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

Based on record review and interview, the facility failed to ensure that its staff provided care and services in accordance with professional standards for one Resident (#46) with an intravenous line out of a total sample of 18 residents. Specifically, the facility failed to ensure staff developed and implemented measures to ensure the peripherally inserted central catheter (PICC: an intravenous line that is inserted in the arm, threaded through the veins and ends in the larger vein of the heart) was assessed for migration (movement), flushed to maintain patency and that the needleless connection caps were changed per facility policy and professional standards. Findings include: Review of an online article by the Infusion Nurses Society titled Infusion Therapy Standards of Practice, 8th edition, revised 2021, indicated: -The Infusion Therapy Standards of Practice is applicable to any patient population and any setting in which vascular access devices (VADs: intravenous lines) are inserted and/or managed and where infusion therapies are administered -Change the needleless connector…

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 and its staff failed to ensure: 1. development of a policy that provided time frames for the different steps of the Medication Regime Review (MRR-review done by the facility Pharmacist that provides recommendations monthly for each resident regarding their medications), and 2. the attending Physician reviewed and documented they accepted and/or declined the MRR for one Resident (#43), out of a total sample of 18 residents. Findings Include: Review of the facility policy titled Medication Regimen Review (MRR), revised December 2019, indicated the following: -Recommendations are acted upon and documented by the facility staff and/or the prescriber. -Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. -The Director of Nursing or designated licensed nurse addresses and documents recommendations that do not require a Physician intervention . Further review of the facility policy indicated no indication of the time frames for the different steps of the MRR. Resident #43 was admitted 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 limited a PRN (as needed) antipsychotic medication order to 14 days for one Resident (#43), out of a total sample of 18 residents. Findings Include: Resident #43 was admitted to the facility July 2022 with diagnoses including Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, and was on Hospice Services. Review of the January 2023 Order Summary Report indicated the following order: -ABH gel (a topical gel used to treat terminal restlessness at the end of life made from the combination of Lorazepam (an antianxiety medication), Diphenhydramine (an antihistamine), and Haloperidol (an antipsychotic) . every four hours PRN with a start date of 10/17/22 and no stop date indicated. Review of the January 2023 Medication Administration Record (MAR) indicated the Resident received the PRN ABH gel eight times during the month of January 2023. During an interview on 2/21/23 at 8:40 A.M., Nurse #2 said when a resident is on a PRN antipsychotic medication it should have a stop date after 14 days so it can…

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

Based on record review and interview, the facility failed to ensure its staff provided specialized rehabilitative services relative to Speech and Language Pathology (SLP) for one Resident ( #44) out of a sample of 18 residents. Findings include: Resident #44 was admitted to the facility in January 2019 with diagnoses including Parkinson's Disease, Epilepsy (neurological disorder where brain activity becomes abnormal causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), significant weight loss in the last six months, and oropharyngeal Dysphagia (difficulty swallowing). Review of the SLP Therapy Note dated 11/21/22, indicated the following: -Resident was alert, but had severely impaired swallow function. -He/she tolerated only several bites of pureed foods, holding each bite for many minutes before swallowing. -He/she was unable to tolerate liquids except via teaspoon on this day. Review of the of the February 2023 Physician's Orders included the following ordered on 11/28/22: -Speech Therapy: ten visits for oral/pharyngeal swallow evaluation…

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 staff failed to ensure a secure handrail was in place on one Unit (Unit Three) out of three total Units. Findings include: During an observation on 2/16/23 at 11:49 A.M., the surveyor observed an unsecured handrail on the left side of the nurses' station on Unit Three. The left side of the handrail was no longer attached to the wall and there was broken plaster on the wall where the handrail should have been attached. During an observation and interview on 2/16/23 at 2:10 P.M., the Administrator said the handrail was not secured as required and was in need of repair.