Vantage at Lowell LLC

Based on observation and interview, the facility failed to provide a dignified dining experience for Residents on the Right Wing unit. Findings include: The surveyor made the following observations: - On 5/14/24 at 8:19 A.M., a Certified Nursing Assistant (CNA) was observed feeding a resident in bed while standing over him/her, not at eye level. - On 5/14/24 at 11:47 A.M., a resident was observed sitting at a table in the dining room with a second resident. The first resident received his/her tray at 12:08 P.M. and was being assisted by staff. At 12:08 P.M., the staff assisting the resident told the other resident Your food is in the next truck. The second resident received his/her meal at 12:42 P.M., 55 minutes after the first resident had begun eating. - On 5/15/24 at 8:13 A.M., a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. At 8:17 A.M., a CNA was observed leaning on the initial resident's Broda chair talking to another CNA at a different table. At 8:27 A.M., a CNA sat down with the resident 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, record review, and interview, the facility failed to protect one Resident (#54) from abuse out of a total of 22 sampled residents. Specifically, Occupational Therapist (OT) #1 yelled at Resident #54 in the presence of other residents and staff for not following his/her directions. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families,…

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, record review, policy review and interviews, the facility failed to ensure one Resident (#13) was free from restraints by locking the remote control for the bed, preventing the Resident to reposition him/herself in bed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Physical Restraints, dated 1/1/17, indicated the following: -The facility recognizes each resident's right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical condition. -The policy includes an interdisciplinary process of assessment and reassessment in order to ensure that when a restraint is necessary to treat a resident's medical condition the least restrictive is utilized for the least amount of time to treat the resident's medical condition with the plan for continued assessment and reduction. -Components of constraint use:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff followed its abuse policies and procedures for one Resident (#54) out of a total of 22 sampled residents. Specifically, staff who were present when Occupational Therapist (OT) #1 yelled at Resident #54 did not intervene or remove OT #1 from the unit per policy. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory…

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 report an allegation of neglect to the state agency as required for one Resident (#285) out of a total of 22 sampled residents. Findings include: Review of the facility's Abuse Prohibition policy, dated 2/20/23 indicated: The Administrator is responsible for ensuring that there has been notification [to] local law enforcement and the State Survey Agency within two hours of allegation after identification of alleged/suspected incident. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made. Review of the grievance book included a grievance dated 6/13/23 which indicated that Resident #285's family member had found Resident #285 in his/her room not wearing oxygen (02). The grievance indicated that nurse staff then took Resident #285's 02 saturation level and he/she was at an Oxygen saturation of 81 percent. The family member documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure resident centered care plans were implemented for three Residents (#64, #182, #23) to ensure aspiration risk precautions were followed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated December 2022, indicated To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including hygiene, mobility, elimination, dining, and communication; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. A resident who is unable to carry out activities of daily living will receive the services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and chronic obstructive pulmonary disease…

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, record review, policy review and interviews, the facility failed to provide showers for one Resident (#62) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 12/22/21, indicated the following: -the resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #62 was admitted to the facility in January 2024 with diagnoses including heart failure. Review of Resident #62's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated Resident #62 had moderate cognitive impairment. The MDS also indicated Resident #63 required substantial assistance from staff for bathing tasks. During an interview on 5/14/24 at 7:44 A.M., Resident #62 said he/she had not received a shower in a long time and would…

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

Based on observation, record review and interview, the facility failed to provide vision services as requested for one Resident (#60) out of a total sample of 22 residents. Specifically, the facility failed to follow up with the Resident's and physician's request to schedule an appointment for glasses for Resident #60. Findings include: Review of the facility policy titled Vision and Hearing, dated and revised 12/21/21, indicated the following: - The facility will provide from an outside source ophthalmology and audiology services to meet the needs of the residents. - The facility will, if necessary or requested, assist the resident with: making appointments, arranging transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision of hearing assistive devices. - Assistive devices to maintain vision include, but are not limited to, glasses During an interview on 5/14/24 at 7:49 A.M., Resident #60 told the surveyor that he/she cannot see and he/she needs…

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, observations, and interviews, the facility failed to ensure that a resident admitted with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates continued catheter use is necessary for one Resident (#23) in a total sample of 22 residents. Findings include: Review of the facility policy which is according to the Resident Assessment Instrument (RAI), indicated the following: -Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Resident # 23 was admitted to the facility in 04/18/2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to address the nutritional status in a timely manner for one Resident (#19) out of a total sample of 22 residents. Specifically, the facility failed to address a significant weight loss in a timely manner for Resident #19. Findings include: Review of the facility policy titled Weight Monitoring, revised and dated 12/22/21, indicated the following: - Any weight change of 5% or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the Dietitian, Physician and the resident/responsible party. - The Dietitian will review the weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The plan of care will be updated as needed. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1…

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, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice one Resident (#8) out of a total sample of 22 residents. Specifically, the facility failed to follow Resident #8's physician's orders to implement the correct oxygen flow rate and ensure the external filter was clean. Findings include: Review of the facility policy titled Equipment Change/Disinfection, undated, indicated the following: - Oxygen Concentrators: Rinse and dry the external filter weekly and PRN (as needed) when visibly dusty. Resident #8 was admitted to the facility in March 2023 with diagnoses including chronic heart failure, type 2 diabetes mellitus and pneumonia. Review of Resident #8's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #8 requires…

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 provide food in a form to meet the needs of three Resident (#64, #13, and #23) out of a sample of 22 residents. Specifically, for Residents #64 and #24, the facility to provide the correct diet texture during meals. For Resident #13, the facility failed to provide the correct diet during meals and failed to prevent the Resident from consuming food that was of a texture not ordered by the physician. Findings include: 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and COPD chronic obstructive pulmonary disease. Review of Resident #64's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. On 5/14/24 from 11:53 A.M. to 12:01 P.M., the surveyor observed Resident #64 in the hallway with his/her lunch tray. The Residents' tray was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document one Resident's (#2) skin assessment out of a total sample of 22 residents. Findings include: Resident #2 was admitted to the facility in June 2021 with diagnoses including multiple sclerosis. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated the Resident was cognitively intact. Review of the wound documentation dated 5/7/24 and 5/14/24 indicated Resident #2 had a stage 2 pressure wound to his/her right buttock, which first appeared on 5/5/24. Review of Resident #2's skin assessment dated [DATE] failed to indicate a right buttock pressure wound. During an interview on 5/16/24 at 8:41 A.M., Nurse #4 said all residents receive a skin assessment weekly and all skin issues are documented on those assessments regardless of the wound doctor documentation. During an interview on 5/16/24 at 8:51 A.M…

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

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes from concerns brought forth from resident council meetings. Findings Include: Review of facility policy titled 'QAPI Plan' dated 2023 indicated the following: *Performance Improvement Projects The QAPI team at Belvidere Healthcare Center will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems, or if there are opportunities to make improvements. During the group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said they had brought the following concerns to management and had not received resolutions or feedback. - On going issues with laundry not being done in a timely manner - Receiving cold food - Staff being on their own personal phones in resident care areas - Concerns 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.

Based on observation and interview, the facility failed to maintain functioning equipment in the kitchen. Findings include: During an observation, during the breakfast tray line service, on 3/22/23 at 7:17 A.M., the dietary staff was not putting any of the plated breakfasts on a plate warmer to prevent food from getting cold. During an interview on 3/22/23 at 7:28 A.M., the cook said that the plate warmer has been broken for a few days and that maintenance needed to fix it. The plate warmer was broken for the duration of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to 1. provide a timely room transfer to 1 Resident (#49) and 2. provide a dignified dining experience for 1 Resident (#13), and 3. failed to provide linen services for the facility in order for residents personal clothing to be cleaned, and 4. provide a dignified existence for 1 Resident (#9) out of a total sample of 30 residents. Findings include: 1. Resident #49 was admitted in 09/2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the facility policy titled Room to Room Transfers, dated 03/2023, indicated the following: - Where feasible, the facility will make room transfers when requested by the a resident or their representative as it becomes necessary to meet the resident's medical and nursing care needs. - The facility reserves the right to make…

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 On 3/22/23 at 8:30 A.M., the following were observed on the Right Wing unit: *Both entry doors to the unit had significant scuff marks. *In room [ROOM NUMBER], there were gouges in the wall with plaster exposed behind both beds. *In room [ROOM NUMBER], there was a piece of tile missing in the bathroom. The radiator in the bathroom had significant rust and both doors of the bathroom had significant scuff marks. *In room [ROOM NUMBER], two tiles at the end of the B bed were cracked and one tile was missing a piece. The walls were scuffed behind the A bed and there were two spots behind the B bed with paint missing. *In room [ROOM NUMBER], the privacy curtain was soiled with stains. *In room [ROOM NUMBER], the bathroom floor was missing piece of the tile, there were significant stains on wall next to sink, the radiator had significant rusting and there were 3 small holes next to toilet paper dispenser. There were scuff marks on wall next to A bed. *In room [ROOM NUMBER], there was a missing piece of baseboard…

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 review of the grievance log, resident group response and interviews, the facility 1) failed to ensure residents of the facility were aware of the grievance process and had access to grievance forms and 2) resolved a grievance for 1 Resident (#15) out of a total sample of 30 residents. Findings include: 1. Resident group meeting was held on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said they were unaware of the process to file a grievance in the facility. None of the 19 residents were aware of the grievance process, where grievance forms are available, how to fill out a grievance form or who to give the form to. Nineteen of 19 participating residents said when they verbally tell staff of a grievance, they feel the facility does nothing to resolve it. The residents said they feel like they never get any feedback from the administrator or never feel like there is follow through. Nineteen out of 19 residents said they have been complaining of the same things (cold food, long call light wait times and staff members on their phone) for several months without 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 complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs. Findings include: During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for all 5 CNAs. During an interview on 3/24/23 at 10:13 A.M., the Corporate Human Resource Officer said the facility and corporate has fallen behind on training and performance reviews for staff. The Corporate Human Resource Officer said annual reviews for the 5 CNAs were not completed, as well as reviews for most if not all other staff members of the facility.

Based on observation, record review and interview, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. Two of four licensed nurses made errors during a medication administration on 2 out of 2 units. Three medication errors were observed out of 27 opportunities for error, resulting in a medication error rate of 11.11%. Findings include: Review of policy titled' Medication Administration-General Guidelines, undated indicated the following: Procedure: *4. Five rights-Right resident,right drug,right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication pt away. a. Check #1: select the medication-label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide dental services to 3 Residents (#48, #26 and #59) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Dental Services & Denture Services, dated 12/2022, indicated the following: -Purpose: to ensure that residents receive routine and emergent dental services to meet their individual needs. - Our facility has a contract with a dentist that comes to the facility and provides dental services on a routine basis. - Failure of a dentist to provide follow up services will result in the facility's right to use it's consultant dentist to provide the resident's dental needs. - Nursing services or designee is responsible for scheduling dental services as needed. 1. Resident #48 was admitted in 8/2016 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #48 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate…

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.

3. The surveyor made the following observations in the Activity Room: On 3/22/23 at 1:02 P.M., two activity staff members were observed eating lunch at the same table as 1 resident and while other residents were eating at another table. The staff were unable to wear masks while eating. On 3/23/23 at 12:54 P.M., two activity staff were observed eating lunch at a table with other residents who are were also eating. The staff were unable to wear masks while eating. On 3/23/23 at 2:48 P.M. an activity assistant had her mask on her chin. not covering her mouth or nose, eating ice cream with residents close by. During an interview on 3/24/23 at 10:44 A.M., the Infection Preventionist said staff would be wearing masks when around residents. She said she reminds staff of this every day but it is still a work in progress. Based on observations, record review and interviews, the facility failed to implement infection control practices by 1. failing to complete inspections for Legionella and other waterborne pathogens, 2. failing to store dirty linen appropriately for pick up and 3. failing 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.

Based on record review and interview, the facility failed to ensure that 5 of 5 Certified Nursing Assistants reviewed received 12 hours of mandatory in-service training in a year. Review of 5 Certified Nursing Assistants (CNA) employee records indicated that 5 out of 5 did not complete the mandatory 12 hours of education required. During an interview on 3/24/23 at 10:13 A.M., the Corporate Human Resource Officer said the facility and corporate headquarters have fallen behind on training for staff. The Corporate Human Resource Officer said required in-service training for the 5 CNAs were not completed, as well as training for most if not all other CNAs in the facility.

Based on resident group responses and interviews, the facility failed to provide a private space for residents of the facility to meet for resident group. Findings include: Resident group meeting was held on 3/23/23 at 11:00 A.M. During the meetings, 19 out of 19 participating residents said they meet for resident group meeting every month, however, feel the space in which they meet in is not private. The residents said that other staff are often walking through the space when they are meeting, kitchen staff are bringing food trucks through the space, and other residents are being taken out by staff to smoke and need to walk through the group meeting. Nineteen out of 19 residents also said they do not feel they can meet as a group without staff present. During an interview on 3/23/23 at 1:45 P.M., the Activity Director said she attends the resident group every month. She said the group is held in the only room available in the facility large enough to meet. The Activity Director said although the room does not have a closed door the meeting could be private if other staff did not…

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 report an allegation of abuse in the required timeframe for 1 Resident (#59) out of a total of 30 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, last revised 12/1/18, indicated the following: *Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. *Allegations of abuse will be reported promptly and thoroughly investigated. *The administrator and director of nursing are responsible for investigation and reporting. *Notify the shift supervisor/charge nurse/manager immediately if person is suspected abuse, neglect, mistreatment or misappropriation of property occurs. *Report the incident immediately to the Director of Nursing, and Administrator the Administrator, Director 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 interviews and record review, the facility failed to investigate an alleged incident for 1 Resident (#9) out of a sample of 30 Residents. Findings include: Review of the facility policy titled Abuse Prohibition last revised 12/1/18 indicated the following: *The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends. *Allegations of abuse will be reported promptly and thoroughly investigated. *The shift supervisor is identified as responsible for immediate initiation of the reporting process. *The Administrator and Director of Nursing are responsible for the investigation and reporting. Resident #9 was admitted to the facility in July 2021 with diagnoses including depression. Review of the most recent Minimum Data Set (MDS) indicated a Brief Interview for Mental status (BIMS) score of 14 out of possible 15 indicating intact cognition. During a Resident group meeting held on 3/23/23 at 11:00 A.M., Resident #9 reported that staff do not take him/her to activities…

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 meet professional standards for 2 Residents (#14 and #23) by 1). checking the pacemaker for Resident #14 and 2). not following physician's order for Resident #23, out of a total of 30 sampled residents. Findings include: 1. Resident #14 was admitted to the facility in November 2019 with diagnoses including heart failure and presence of a cardiac pacemaker. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #14 requires extensive assistance from staff for functional tasks. Review of Resident #14's pacemaker care plan last revised 12/6/22 indicated the following intervention: *Arrange for pacemaker checks as needed. Review of Resident #14's physician orders and nursing notes failed to indicate pacemaker checks were regularly scheduled 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 observations, record reviews and interviews, the facility failed to provide assistance during mealtime for 2 Residents (#13 and #14) out of a total of 30 residents sampled. Findings include: Review of the facility policy titled, Activities of Daily Living, dated December 2022, indicated the following: *The facility will provide care and services for the following activities of daily living: Dining - eating, including meals and snacks. 1. Resident #13 was admitted to the facility in January 2023 with diagnoses including high blood pressure and spinal stenosis. Review of Resident #13's most recent Minimum Data Set, dated , 1/12/23, indicated the Resident has a Brief Interview for Mental Status score of 8 out of a possible 15 indicating he/she has moderate cognitive impairment. On 3/23/23 at 8:05 A.M., Resident #13 was observed lying in bed with his/her meal in front of him/her. From 8:05 A.M., to 9:00 A.M., the Resident attempted to feed him/herself. The Resident was able to drink his/her coffee but was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and interview the facility failed to maintain a urinary catheter in a manner to reduce infection for 1 Resident (#225) out of a total 30 sampled residents. Findings include: Review of the facility policy titled 'Catheter Care' undated, indicated the following: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: *2. (b) Be sure the catheter tubing and drainage bag are kept off the floor. Resident #225 was admitted to the facility in March 2023, with diagnoses including, benign prostatic hyperplasia with lower urinary tract infection. Review of Resident #225's Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview of Mental Status (BIMS) score of 2 out of possible 15 indicating severe cognitive impairment. The MDS also indicates Resident #225 requires total dependence from staff for toileting. Section H of MDS indicates Resident has an indwelling urinary catheter. Review of physician's…

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, policy review and interview the facility failed to 1) provide oxygen as ordered and store oxygen supplies in a manner that would reduce infection for 1 Residents (#14) and 2) failed to store nebulizer equipment in a manner that will reduce infection for 1 Resident (#225) out of a total 30 sampled residents. Findings include: 1. Review of the facility policy titled, Oxygen Administration Policy and Procedure, dated 12/6/22, indicated the following: *Oxygen is administered by licensed nurses with the physician's order in order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (as needed). Resident #14 was admitted to the facility in November 2019 with diagnoses including hemiplegia, dependence on supplemental O2 (oxygen), and heart failure. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a physician order for pain management for 1 Resident (#48) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Pain Management and Management Program, dated 10/2021, indicated the following: - Purpose: to provide a consistent method for the assessment, observation, planning, development and evaluation of an effective pain management plan of care. - Pain is whatever the person experiencing it says it is, whenever he/she states it does exist. Resident #48 was admitted in 8/2016 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #48 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the progress note, dated 11/15/22, indicated the following: - Resident complained of pain in his/her teeth and is not able to chew because of the pain. Resident said his/her dentist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that an as needed (PRN) psychotropic medication did not exceed 14 days unless the prescriber documented the rationale and duration of use of the medication for one Resident (#46) out of a total sample of 30 residents. Findings include: Review of facility policy titled 'Use of Psychotropic Drugs', revised 12/6/21 indicated the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition,as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Procedure/Guidelines *8. As needed (PRN) orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (example 14 days). a. If the attending physician or prescribing…

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 menu review, the facility failed to follow the menu for a breakfast meal. Findings include: During resident group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said the food given at meals frequently does not match what is on the facility menu and it is very frustrating to them. Review of the menu for the date of 3/22/23, during the breakfast meal, indicated that residents should have received 2 pancakes with syrup and a 2 ounce piece of sausage. During an observation on 3/22/23 at 7:17 A.M., on the breakfast tray line, there were no 2 ounce pieces of sausage prepared.

Based on observation, interview, and test trays, the facility failed to maintain appropriate temperatures of the food to prevent foodborne illness. Findings include: During an observation, during the breakfast tray line service, on 3/22/23 at 7:17 A.M., the dietary staff was not putting any of the plated breakfasts on a plate warmer to prevent food from getting cold. During an interview on 3/22/23 at 7:28 A.M., the cook said that the plate warmer has been broken for a few days and that maintenance needed to fix it. During the resident group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participants said that the food is cold every day at every meal. During a test tray on 3/22/23 at 8:31 A.M., the following temperatures were taken: - Pancakes: 88 degrees Fahrenheit - Oatmeal: 93.7 degrees Fahrenheit - Coffee: 113.7 degrees Fahrenheit - Milk: 61 degrees Fahrenheit During a test tray on 3/23/23 at 12:12 P.M., the following temperatures were taken: - Milk: 46.5 degrees Fahrenheit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide the prescribed therapeutic diet for 2 Residents (#5 and #28), out of a total sample of 30 residents. Findings include: 1. Resident #28 was admitted in 04/2010 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #28 scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During an observation on 3/22/23 at 9:37 A.M., Resident #28 was laying in bed with his/her breakfast tray in front of him/her. Resident #28 had cheerios on his/her tray. Behind Resident #28's bed was a sign that stated Resident #28 should not have hard, crunchy items and is on a dysphagia diet. Review of Resident #28's diet order and speech therapy Discharge summary, dated [DATE], indicated that Resident #28 was on a dysphagia diet with thin liquids. During an interview on 3/23/23 at 12:07 P.M., the Speech Therapist said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and tray ticket review, the facility failed to provide the dietary preferences for 1 Resident (#42) out of a total sample of 30 residents. Findings include: Resident #42 was admitted in 12/2022 with diagnoses including depression and type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #42 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #42 is independent with eating. During an observation on 3/22/23 at 8:45 A.M., Resident #42 was lying in bed with his/her breakfast untouched. Resident #42 said that he/she did not get what he/she ordered and was not going to eat breakfast. Review of the tray ticket for Resident #42 indicated that he/she was supposed to receive 1/2 cup of scrambled eggs and 1 slice of white toast. Resident #42's tray only contained 2 pancakes. During an interview on 3/22/23 at 8:50 A.M., Nurse #3 said that she checks the…

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

Based on observation, record review, and interview, the facility failed to 1. maintain kitchen sanitation practices and 2. failed to record and log temperatures of the food and dish machine. Findings include: Review of the facility policy titled Food Receiving and Storage, undated, indicated the following: - Food services, or other designated staff, will maintain clean food storage areas at all times. - Food in designated dry storage areas will be kept off the floor (at least 18 inches) and clear of sprinkler heads. - All foods stored in the refrigerator will or freezer will be covered, labeled and dated. 1. During the kitchen walk through on 3/22/23 at 7:17 A.M., the following was observed: - a box of juice was on the floor in the dry storage room - a container of fruit medley was not labeled or dated in the walk in refrigerator - a package of sliced ham was open and undated in the refrigerator - a container of vegetable soup was labeled 3/16/22 - a container of shredded cheese and sliced cheese was opened and unlabeled or dated. During an observation on 3/23/23 at 1:20 P.M., 3…

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.