Leominster Rehabilitation and Nursing Center

Based on record review and interview, the facility failed to notify the Physician of a significant change in condition for one Resident (#16), out of a total sample of 17 Residents. Specifically, the facility staff failed to notify the Physician/Nurse Practitioner (NP) so treatment could be altered when Resident #16 was identified with significant weight loss by the Registered Dietician. Findings include: Review of the facility policy titled Weight Management, undated, indicated: -Newly admitted residents are weighed weekly for four weeks. -Residents are weighed a minimum of monthly by the 7th of each month, with more frequent weights obtained as ordered or deemed necessary. -Check the previous monthly weight(s) for any significant weight change. If there is a significant weight change of plus/minus 5 percent (%) in 30 days (1 month), 7.5% in 90 days (3 months) or 10% in 180 days (6 months), schedule the resident to be reweighed within 24 hours. -Weights are verified and documented in the medical record as they are obtained. -The entire interdisciplinary team (IDT) must be involved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure the plan of care was assessed and revised for two Residents (#6, #21) and that a care plan meeting was held for one Resident (#59), out of a total sample of 17 residents. Specifically, the facility staff failed to: 1. For Resident #6, assess and revise the Resident's Care Plan to include measurable goals for falls prevention after the Resident sustained a fall. 2. For Resident #21, obtain a Physician order and revise the Resident's Care Plan to include the use of mattress bolsters and floor mats after the Resident sustained a fall. 3. For Resident #59, provide evidence that an interdisciplinary care plan meeting was held, or that the Resident had participated in the care planning process following an MDS assessment completed on 4/18/24. Findings include: Review of the facility policy titled Care Planning - Interdisciplinary Team, revised March 2022, indicated: -Comprehensive, person-centered care plans are based on 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 and interview, the facility failed to provide services that met professional standards of quality for one Resident (#25), out of a total sample of 17 residents. Specifically, the facility staff failed to transcribe (to put into written word or print) a verbal order (a Physician order that is received in person via spoken word or over the telephone) for a medication change into the medical record, resulting in the verbal order not being implemented and Resident #25 not receiving an updated medication as ordered by the Physician. Findings include: Review of facility policy titled Telephone Orders, revised February 2014, indicated: -Verbal telephone orders may be accepted from each resident's attending Physician. -Verbal telephone orders may only be received by licensed personnel (Registered Nurse (RN), Licensed Professional Nurse (LPN), Pharmacist, Physician, etc.). -Orders must be reduced to writing (transcribed), by the person receiving the order, and recorded in the resident's medical record. Resident #25 was admitted to the facility in March 2024, with…

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, policy and record review, the facility failed to provide activities to meet the needs of one Resident (#28), out of a total sample of 17 residents. Specifically, the facility failed to provide activities of interest for Resident #28 based on their plan of care, comprehensive assessment, and preferences. Findings include: Review of the facility policy titled Activity Evaluation, revised June 2018, indicated: -The activity evaluation is used to develop an individual activities care plan .that will allow the resident to participate in activities of his/her choice and interest. -The activity evaluation and activities care plan identifies if a resident is capable of pursuing activities independently or if supervision and assistance are needed. Resident #28 was admitted to the facility in December 2023 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set…

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

Based on observation, interview, record and policy review, the facility failed to provide an environment was free of accidental hazards, relative to swallowing safety during one meal for one Resident (#10) out of a total sample of 17 residents. Specifically, facility staff failed to provide Resident #10 with necessary interventions, in accordance with the Resident's plan of care, to ensure the Resident's safety while eating his/her breakfast meal when the Resident had a diagnosis of Dysphagia (difficulty swallowing), required staff assistance for securing his/her dentures in place, and required verbal cues for safety while eating, which increased the Resident's risk for choking. Findings include: Review of the facility's policy titled Assistance with Meals, revised March 2022, indicated the following: -Residents should receive assistance with meals in a manner that meets the individual needs of each resident. -Facility staff will serve resident trays and will help residents who require assistance with eating. Resident #10 was admitted to the facility in February 2016 with diagnoses…

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

Based on interview, record and policy review, the facility failed to provide appropriate care and services for a nephrostomy tube (a thin flexible tube that drains urine from the kidney into a bag outside the body) according to professional standards of practice for one Resident (#372), out of a total sample of 17 residents. Specifically, the facility staff failed to flush Resident #372's nephrostomy tubes as ordered by the Physician to prevent blockage and increased risk of infection. Findings include: Review of the facility policy titled Nephrostomy Tube Care, revised October 2010, indicated: -The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous (through the skin) nephrostomy tube. -Verify that there is a Physician's Order. -Review the resident's care plan to assess for any special needs of the resident. Review of the facility policy titled Catheter Care, Urinary, revised 9/2014 indicated: to maintain an unobstructed urine flow. Review of the Management of Patients with Nephrostomy Tubes: Nursing toolkit, revised November…

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 provide appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one Resident (#59), out of a total sample of 19 residents. Specifically, the facility failed: -to develop an individualized care plan to address the emotional and psychosocial needs of Resident #59, -to monitor and provide ongoing assessment as to whether the care approaches were meeting the emotional and psychosocial needs of the Resident after he/she experienced Suicidal Ideation (SI- verbal expressions of thoughts of harming oneself that may or may not lack specific intent), and -to review and revise the Resident's care plan after expression of SI, hospitalization, and re-admission to the facility. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated: -Nursing staff will identify, document, and inform the Physician about specific details…

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 policy and record review, and interview, the facility failed to review and address the Pharmacist Medication Review recommendations for two Residents (#6 and #56), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #6, verify and/or confirm that the Pharmacist recommendations were reviewed or addressed. 2. For Resident #56, verify and/or confirm that the Pharmacist recommendations were reviewed or addressed. Findings include: Review of the facility's policy, titled Documentation and Communication of Consultant Pharmacist Recommendations, undated, indicated: -A record of the Consultant Pharmacist's observations and recommendations is made available in an easily retrievable form to Nurses, Physicians, and the care planning team. -Comments and recommendations concerning drug therapy are communicated in a timely fashion. -The Consultant Pharmacist and the facility follows up on his/her recommendations to verify action has been taken. 1. Resident #6 was admitted 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 interview, policy and record review, the facility failed to ensure that one Resident (#59), out of a total sample of 17 residents, was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility failed to ensure that appropriate monitoring for adverse consequences and side effects via an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare Provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) was completed timely in accordance with standards of practice. Findings include: Review of the facility policy titled Psychotropic Medication Use, revised July 2022, indicated: -Psychotropic medication management includes: <adequate monitoring for efficacy and adverse consequences; and <preventing, identifying, and responding to adverse consequences. -Residents receiving psychotropic medications are monitored for adverse…

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 maintain complete and accurate medical records in accordance with accepted professional standards and practices for one Resident (#14), out of a total sample of 17 residents. Specifically, the facility staff failed to document medicated lotion treatments administered to Resident #14's lower extremities as ordered by the Physician. Findings include: Review of the facility policy titled Charting and Documentation, revised July 2017, indicated: -All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident condition and response to care. -The following information is to be documented in the resident medical record: <Treatments or services performed <Medications administered Resident #14 was admitted to the facility in August 2024 with diagnoses including Need for Assistance With Personal Care, Adult…

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, policy and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for three Residents (#14, #42 and #45) out of a total sample of 17 residents. Specifically, the facility failed to: 1. implement Enhanced Barrier Precautions (EBP - infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug resistant organisms [MDRO's-resistant bacteria that are resistant to three or more types of antimicrobial drugs] during high contact [touching] Resident care for Resident #14 as ordered by the Physician. 2. ensure that Resident's #42 and #45 were free from the risk of infection when Resident #38 expelled emesis (vomit) while seated at the same lunch table, and the facility staff did not offer to replace the Resident #42 and #45's plated meals. Findings include: Review of facility policy titled Enhanced Barrier Precautions (EBP), revised…

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 had severe cognitive impairment, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 07/31/24, Certified Nurse Aide (CNA) #1 sat next to Resident #1, with her legs outstretched crossed, raised and extended on top of Resident #1's lap, across both armrests of his/her wheelchair, and enticed him/her to play with her legs and hair to keep him/her calm. Findings include: Review of the Facility's Policy, titled Resident Rights, dated as revised February 2021, indicated that Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in December 2023, diagnoses included Parkinson Disease, dementia, history of falling, schizoaffective disorder, and depression. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/24, indicated Resident #1 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 observation, records reviewed, and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment, the Facility failed to ensure Resident #1 was free from the use of a physical restraint when Facility staff failed to assess whether or not the use of a concave mattress and bed rails on his/her bed, prevented him/her from getting out of his/her bed. Findings include: Review of the Facility's Policy, titled Use of Restraints, dated as revised April 2017, indicated the following: -physical restraints are defined as any manual method, or physical, or mechanical device, material or equipment attached to adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body, and -the definition of a restraint if based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability change position or place,…

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 had severe cognitive impairment and had been repeatedly attempting to stand unassisted, the Facility failed to ensure they reported an allegation of abuse by use of a restraint by a staff member, to the Massachusetts Department of Public Health (DPH), when after being notified by the Director of Social Services, the Director of Nurses witnessed Certified Nurse Aide (CNA #1 sitting next to Resident #1 (who was seated in his/her wheelchair) with her legs raised, crossed and extended across his/her lap, with her legs positioned across both of the armrests to Resident #1's wheelchair. Findings include: Review of the Facility's Policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated as revised, September 2022, indicated the following: -all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state, and federal agencies, (as required by current…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 07/31/24 of an allegation of a possible restraint, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated as revised, September 2022, indicated the following: -all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state, and federal agencies, (as required by current regulations), and thoroughly investigated by facility management. Findings of all investigations are documented and reported, Resident #1 was admitted to the Facility in December 2024, diagnoses included Parkinson Disease, dementia, history of falling, schizoaffective disorder, and depression. 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 observation, records reviewed, and interviews for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure a Bed Rail Entrapment Assessment was completed prior to putting two quarter rails in the upright position while he/she was in bed. Findings include: Review of the Facility's Policy titled Bed Safety and Bed Rails, dated as revised August 2022, indicated the following: -the resident's sleeping environment is evaluated by the interdisciplinary team, -bed frames, mattresses, and bed rails are checked for comparability and size prior to use, and -the use of bed rails or side rails (including temporarily raising the sides rails for episodic use during care) is prohibited unless certain criteria for use of the bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The Policy also indicated that Resident assessment also determines potential risks to the resident associated with the use of bed rails,…

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 one sampled Employee Files, the Facility failed to ensure staff implemented and followed their Abuse Policy when a Criminal Offender Record Inquiry (CORI) was not conducted on Certified Nurse Aide (CNA) #1 prior to his date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy. Findings include: Review of the Facility's Policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated as revised April 2021, indicated that as part of resident abuse prevention, the administration will: - develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents; and/or theft, exploitation or misappropriation of resident property - conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Review of CNA #1's Employee File indicated his first date of employment at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine into a drainage bag), the Facility failed to ensure nursing developed an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed his/her risk for complications associated with an indwelling urinary catheter. Findings include: Review of the Facility's policy, titled Comprehensive Person-Centered Care Plans, with a revision date of March 2022, indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Resident #1 was admitted to the Facility in May 2023, diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to the coccyx and an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine into a drainage bag), the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to transcribe his/her wound care orders and indwelling urinary catheter care orders, in a timely manner, upon readmission to the Facility. Findings include: Review of the Facility's policy, titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a revision date of December 2023, indicated the following: -The physician will order pertinent wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents. -The nurse shall describe and document current treatments. Review of the Facility's policy, titled Catheter Care, Urinary,…

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

Based on record review and interview, the facility failed to inspect all resident beds annually for the 2022 year, including mattresses, frames, and bedrails for possible areas of entrapment as required. Findings include: Review of the facility's policy titled, Bed Safety and Bed Rails, dated August 2022, included: - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. - The Maintenance department provides a copy of inspections to the Administrator . Review of the facility's Center Bed Rail Assessment Tracking Log, undated, included no evidence that all resident beds, including mattresses, frames, and bedrails had been assessed for possible areas of entrapment in 2022. During an interview on 6/21/23 at 9:47 A.M., the Administrator said the facility required all resident beds to be assessed annually for potential areas of entrapment. She said the Center Bed Rail Assessment Tracking Log provided to the surveyor included no evidence that all resident beds were assessed in the 2022 year for potential…

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 complete a thorough background screening for one staff member (Nurse #1), out of three sampled staff members, prior to Nurse #1's employment start at the facility. Specifically, the facility failed to complete a criminal background check or Professional Nurse License Check for Nurse #1 before the Nurse began working at the facility on a resident unit. Findings include: Review of the facility policy titled, Background Screening Investigations, dated March 2019, included: - Background checks would be completed for all potential direct access employees . - Background checks would be initiated within two days of an offer of employment .and completed prior to employment. - For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board would be contacted to determine if any sanctions have been assessed against the applicant's license. Review of the Nursing Daily Attendance Reports, dated 4/26/23 and 4/27/23, indicated Nurse #1 worked at 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 1b. The facility failed to ensure its staff comprehensively assessed Resident #170's cognitive patterns and mood on one MDS Assessment, when the Resident was identified as having adequate hearing, usually understood others, and was sometimes understood. Review of Resident #170's MDS Assessment, dated 5/17/23, Section B, indicated the Resident had adequate hearing, usually understood others, and was sometimes understood. Further review of Sections C (Cognitive Patterns) and D (Mood) indicated : Not Assessed. During an interview on 6/22/23 at 11:34 A.M., the MDS Coordinator said staff were required to assess cognitive patterns and mood on the MDS assessment for residents who usually understood others and were usually understood. The MDS Coordinator reviewed Resident #170's comprehensive MDS assessment, dated 5/17/23, at that time and said staff should have assessed the Resident's cognitive patterns and mood when they completed the MDS assessment as required, but they did not. Based on record review and interview,…

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 notify the Physician and the Resident's Responsible Party/ family member in a timely manner, of the unavailability and multiple missed doses of the anxiolytic (anti-anxiety) medication for one Resident (#271), out of a total sample of 18 residents. Specifically, the facility staff failed to: -Notify the Physician and the Responsible Party/ family member when multiple missed doses of prescribed anti-anxiety medication, Klonopin was not administered to Resident #271. Findings include: Review of facility policy last revised June 2023, indicated: -medications are administered in a safe and timely manner, and as prescribed. -if a drug is withheld, refused, or omitted, the individual administering the medication shall document in the EMAR (Electronic Medication Administration Record), notify the Physician and responsible party if necessary. Resident #271 was admitted to the facility in June 2023 with diagnoses including Anxiety Disorder and Major Depressive Disorder. Review of the Physician's Orders for June 2023 indicated an…

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 implement the facility's policies relative to abuse reporting. Specifically, the facility staff failed to immediately report two incidents of resident to resident altercations, involving three Residents (#170, #30, and #19), but not later than two hours after the altercations occurred. Findings include: Review of the Abuse Investigation and Reporting Policy, dated 2001 and provided by the facility, included: -An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury . a. Facility staff failed to report a physical resident to resident altercation within the required time frame of immediately or not later than two hours after Certified Nurse Aide (CNA) #1 witnessed Resident #170 pull Resident #30's facial hair. Resident #170 was admitted to the facility in May 2023 with diagnoses including Vascular Dementia with agitation. Resident #30 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 record review and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission for one Resident (#18), out of a total sample of 18 residents. Findings include: Review of the facility policy for Baseline Care Plans, last revised March 2022, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident with forty-eight hours of admission. Resident #18 was admitted to the facility in June 2023 with diagnoses including Wedge Compression Fracture of the Second Lumbar Vertebra and Lower Back Pain. Review of Resident #18's clinical record did not indicate any evidence that a Baseline Care Plan had been developed within 48 hours, as required. During an interview on 6/22/23 at 7:27 A.M., Nurse #6 said that he was unable to locate Resident #18's Baseline Care Plan and that he would speak to his Director of Nurses (DON). During an interview on 6/22/23 at 8:09 A.M., the Minimum Data Set (MDS) Coordinator said that the Baseline Care Plan should be completed within 48 hours of admission or on…

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

Based on observations, interview and record review, the facility failed to provide Activities of Daily Living (ADLs-bathing, dressing, grooming) care for one Resident (#42), out of a total sample of 18 residents. Specifically, the facility staff failed to ensure Resident #42 was provided grooming per his/her preference/comfort. Findings include: Resident #42 was admitted to the facility in April 2022 with a diagnosis of Dementia. Review of the ADL Care Plan, initiated 4/15/22, indicated Resident #42 had a self care deficit and included the following interventions: -Provide assist of one staff with dressing, grooming and bathing. -Can be dependent at times related to weakness/fatigue. Review of the Minimum Data Set (MDS) Assessment, dated 4/1/23, indicated Resident #42 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of 15, had no behaviors including rejection of care, and required extensive assistance of one staff with dressing and personal hygiene/grooming. On 6/21/23 at 8:58 A.M., the surveyor observed Resident #42 near…

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 an environment free of accidental hazards for one Resident (#170), out of a total sample of 18 residents. Specifically, for Resident #170, the facility staff failed to: -provide adequate supervision and assistance when the Resident was identified at risk for elopement, and had eloped from the facility. -investigate the elopement incident, and review and implement interventions to reduce further episodes of wandering/attempts to elope. Findings include: Review of the facility's policy titled Wandering and Elopement revised, 10/1/10 indicated the following: -Patients will be assessed for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. -Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. -Purpose: To provide a process for managing patients at risk for elopement. -Individual risk factors and patterns will be identified and addressed within the care plan. Review of the facility's 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.

Based on observation, interview and record review, the facility failed to ensure dialysis (a process by which waste substances are removed from a patient's body) care and services were provided for one Resident (#121), out of one applicable resident who receive dialysis, out of a total sample of 18 residents. Specifically, the facility failed to ensure that its staff: A. Coordinated timing of medication administration around the Resident's dialysis schedule. B. Maintained an ongoing communication record with the Dialysis clinic. Findings include: Review of the State Operations Manual (SOM), Appendix PP, (Rev. 211, 02-03-23), included the following guidance under Dialysis Care and Services under Shared Communication between the Nursing Home and the Dialysis facility: >It is essential that a communication process be established between the nursing home and the dialysis facility to be used 24-hours a day. >The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. >The…

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

Based on observation, interview and record review, the facility failed to assess and provide individualized interventions for two Residents (#30 and #121), out of four applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to assess and provide interventions for Resident's #30 and #121 who were identified as having Post Traumatic Stress Disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being), in order to mitigate and eliminate potential triggers that may cause re-traumatization. Findings include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care, revised August 2022, included the following: -Purpose: to address the needs of trauma survivors by minimizing triggers and/or re-traumatization -perform universal screening of…

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

Based on observation, interview and record review, the facility failed to ensure the staff provided appropriate treatment/services for one Resident (#30), out of a total sample of 18 residents, who was identified as having Post Traumatic Stress Disorder (PTSD) and was exhibiting signs/symptoms related to his/her possible trauma. Findings include: Resident #30 was admitted to the facility in May 2023 and had a diagnosis of Depression. Review of the Resident Matrix, provided to the survey team shortly after entrance on 6/21/23, indicated Resident #30 was identified as having PTSD/Trauma. Review of the Minimum Data Set (MDS) Assessment, dated 5/10/23, indicated Resident #30 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and had bilateral upper and lower range of motion deficits. During an interview on 6/21/23 at 9:59 A.M., Resident #30 said that he/she served in the military, was on active duty during the war and had experienced bodily harm related to his/her service, had recently lost his/her spouse unexpectedly, had a daughter…

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 (#271), out of a total sample of 18 residents, was free of significant medication errors per facility policy and professional standards. Specifically, the facility failed to administer 15 doses of an anxiolytic (anti-anxiety) medication as ordered by a Physician for a total of eight days. Findings include: Review of facility policy last revised June 2023, indicated: -medications are administered in a safe and timely manner, and as prescribed. -if a drug is withheld, refused, or omitted, the individual administering the medication shall document in the EMAR (Electronic Medication Administration Record), notify the MD (Physician) and Responsible Party if necessary. Resident #271 admitted to the facility in June 2023 with diagnoses including Anxiety Disorder and Major Depressive Disorder. Review of the Physician's orders for June 2023 indicated an order for Klonopin (anti-anxiety medication) 0.5 milligrams(mg) by mouth two times a day for Anxiety. Review of Resident #271's Medication Administration…

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 reviews, the facility failed to ensure the required staff attended the scheduled quarterly Quality Assurance and Performance Improvement (QAPI) Program Meetings, as required. Findings include: During a review of the facility's quarterly QAPI meeting attendance sheets with the Administrator and Director of Nurses (DON) on 6/27/23 at 2:06 P.M., the Administrator said the staff required to attend the meetings include the Medical Director, the DON, and the Infection Preventionist (IP), and that these meetings occurred in January, April, July and October. The Administrator further said that there was no documented evidence that a quarterly QAPI meeting was held in January 2023, and that there was no documented evidence that the IP attended the April 2023 meeting, as required.