Marlborough Hills Rehabilitation & Health Care Cen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that two Residents (#379 and #42) out of a total sample of 34 residents, were free from significant medication errors. Specifically, the facility failed to: 1. For Resident #379, ensure the appropriate medication administration syringe was available to administer Physician ordered medications through the Resident's Percutaneous Gastronomy (PEG) tube (a tube that provides a direct route to the stomach for delivering nutrition, fluids and medication to a person who is unable to eat or drink through their mouth) resulting in missed doses of the ordered medications. 2. For Resident #42, the facility failed to ensure that Permethrin (medication used to treat scabies [a contagious skin infestation caused by tiny mites]) cream was accurately transcribed on the Medication Administration Record (MAR), resulting in the Resident receiving five doses instead of one prescribed dose, and increasing the risk for adverse reaction to the medication. Findings…

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 residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#108) out of a total sample of 34 residents. Specifically, for Resident #108, the facility failed to obtain informed consent from the Resident's invoked (made active) Health Care Proxy (HCP - a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) with notification of the risks and benefits for the use of Abilify ( antipsychotic medication) prior to administering the medication to the Resident. Findings include: Review of the facility policy titled Psychotropic Medication Management, dated April 2015, included but was not limited to: -Notify resident or responsible party of initiation 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 interview and record review, the facility failed to report an allegation of misappropriation to the State Agency timely, for one Resident (#14) out of a total sample of 34 Residents. Specifically, the facility failed to ensure that an incident report form was submitted to the State Agency within two hours as required, of the Director of Nursing (DON) being notified of an allegation of misappropriation of Resident #14's personal property on 2/27/25. Findings include: Review of the facility's Policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without resident consent. -The facility will designate an Abuse Prevention…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessments for three Residents (#132, #64, and #81) out of a total sample of 34 Residents. Specifically, the facility failed to: 1. For Resident #132, accurately code that the Resident was taking a diuretic medication during the observation period for the MDS assessment, while the Resident was in the facility. 2. For Resident #132, accurately code that the Resident was receiving oxygen therapy during the observation period for the MDS assessment, while the Resident was in the facility. 3. For Resident #64, accurately code that the Resident was taking an anticoagulant medication during the observation period for the MDS assessment, while the Resident was in the facility. 4. For Resident #81, accurately code that the Resident was taking an anticoagulant medication, not an antiplatelet medication during the observation period for the MDS assessment, while the Resident was in the facility. Finding include:…

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

Based on record review, and interview, the facility failed to provide the resident and/or their representative with a summary of the baseline care plan for one Resident (#279), out of a total sample of 34 residents. Specifically, the facility failed to provide the Resident's Representative and invoked Health Care Proxy (HCP) with a written summary of the baseline care plan, medications, and dietary instructions when the Resident was determined to lack capacity for medical decision making. Findings include: Review of the facility policy titled Care Plan-Baseline, revised November 2017, indicated: -A baseline plan of care is developed within 48-hours of admission to the facility based on information obtained during the admission process as a guide for care until the comprehensive care plan is developed. - Process: >Obtain Physician's Orders on admission. >Complete Nursing admission Assessment. Begin interdisciplinary assessment process. >Review inquiry and transfer information. >Interview resident and family accompanying resident/patient for additional information (if appropriate).…

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 provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#176), of two applicable residents, out of a total sample of 34 residents. Specifically, for Resident #176, the facility failed to: -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). -measure and document arm circumference. -document ordered Normal Saline (NS) flushes. Findings include: Review of facility policy titled Central Venous Access Device (VAD) Catheter Dressing Change, dated January 2022, indicated but was not limited to the following: - .The intravenous (IV) therapy order for care and maintenance is required. - .With each assessment of the VAD,…

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 care and services consistent with professional standards of practice for one Resident (#109), of one applicable resident, out of a total sample of 34 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly). Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident #109. Findings include: Review of the facility policy titled Hemodialysis, dated April 2015, included but was not limited to: -Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: >vital signs, >Copy of MAR (Medication Administration Record) >any change of condition from last hemodialysis treatment -Documentation will be completed prior to dialysis treatment -The communication book/sheet will be reviewed upon return from…

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 document review, the facility failed to ensure that nursing staff possessed the appropriate competencies and skills to assure resident safety when providing nursing and related services for one Resident (#14), out of a total of 51 residents who smoke as identified through smoking assessments. Specifically, for Resident #14, Certified Nurses Aide (CNA) #5 failed to demonstrate competency in skills and techniques necessary to provide safe smoking care and services during assigned smoking sessions when CNA #5 lit a cigarette in the Resident's mouth while he/she was using oxygen. Findings include: Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis that included paraplegia (paralysis of the legs and lower body) and required physical assistance from staff for mobility and positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed and flow sheets were often left completely blank. Findings Include: Review of the Facility's Policy tilted Nursing Documentation, dated February 20216, indicated the licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. The Policy indicated documentation should be clear, concise and not subject to misinterpretation. During an interview on 2/28/2024 at 11:15 A.M., the Administrator said the Facility did not have a specific charting and documentation policy for Certified Nurse Aides…

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 review, record review and interview, the facility failed to ensure that one Resident (#43), out of a total sample of 33 residents, had the right to make healthcare decisions. Specifically, -For Resident #43, the facility failed to obtain written consent from, and provide education on the risks and benefits related to the use of an anti-psychotic (medication primarily used to manage psychosis) medication and an anti-depressant (medication used to treat depression) medication prior to administering psychotropic (any drug that affects behavior, mood, thoughts or perception) medication. Findings Include: Review of the facility policy titled Psychotropic Medication Informed Consent, revised February 2016, indicated the following: -Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident. -Informed consent shall include the following information: purpose for administering the medication, the prescribed dosage, and any known effect or side…

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 include one Resident (#43) out of a total sample of 33 residents, in the care planning process. Specifically, the facility staff was unable to provide evidence of a care plan meeting for Resident #43, and that he/she had been invited to and/or participated in a care plan meeting as required. Findings Include: Resident #43 was admitted to the facility in October 2023. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderately impaired cognition as evidenced by Brief Interview for Mental Status (BIMS) score of 10 out of 15, and no Health Care Proxy (HCP- legal document that designates a Resident Representative to make medical decisions) was invoked (Physician documentation of resident incapacity to make medical decision). During an interview on 12/19/23 at 8:40 A.M., the Resident said that he/she had not participated in any care plan meetings and did not recall being invited to any care plan meetings since he/she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to implement a care plan for one Resident (#87) out of a total sample of 33 residents. Specifically, the facility staff failed to ensure that Resident #87's left palm guard was applied daily as ordered for contracture prevention, prevent skin breakdown and to increase range of motion (ROM). Findings include: Review of the facility policy for Splints/Orthotics/Prosthetics, last revised April 2015, indicated: -nursing staff will apply/remove the designated splint/orthotic/prosthetic device during scheduled wearing times. -nursing staff should notify the rehabilitation department of any .misplaced splint/orthotic/prosthetic device. -devices are to be labeled with the resident's name and maintained in a safe place when not in use. Resident #87 was admitted to the facility in October 2022 with diagnoses including Multiple Sclerosis (auto-immune disease that destroys the nerves and causes communication problems between the brain and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide or arrange for care and services that accepted standards of quality dictate should have been provided for one Resident (#43) out of a total sample of 33 residents. Specifically, the facility staff failed to ensure that Resident #43 was weighed weekly as ordered by the Physician and recommended by the Registered Dietitian (RD) post hospitalization and Jejunostomy tube (J-tube- tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine) placement, which resulted in delayed identification of a significant weight loss for the Resident. Findings include: Review of the facility policy titled Weights, dated August 2015, indicated that Residents are weighed weekly, times four weeks for the following: -A newly admitted resident, with a new feeding tube, and -Residents with a Physician order for weekly weights. -Thereafter, residents will be weighed monthly unless clinically…

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

Based on observation and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were available to meet the needs of each resident. Specifically, the facility failed to ensure: -that emergency medication kits (E-Kits) were re-ordered and replaced by the Pharmacy after being opened. -that appropriate documentation was completed as required for medications removed from the E-Kits. Findings include: On 12/20/23 at 10:50 A.M., the surveyor and Nurse #2 observed the First Floor [NAME] Wing Medication Storage Room and identified the following: a. Intravenous (IV) Kit was opened with no paper documentation indicating what was removed from the kit and for which resident. b. An emergency kit Super Kit (a kit that had most of the facility's used medications for the residents, example blood pressure medications) was laying directly on the floor in the Medication Storage Room. The Super Kit contained a paper that itemized all the medications that should…

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 store medications in a safe, and secure manner as required. Specifically, the facility staff failed to secure the medication Escitalopram (a psychotropic medication used to treat Depression) in a secure manner after the medication was delivered from the Pharmacy. Findings include: Per §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. On 12/21/2023 at 9:17 A.M., the surveyor observed two blister pack medication cards, each containing thirty tablets of Escitalopram (a psychotropic medication used to treat Depression) laying unsecured on a desk, behind the nurses station on the East Wing. During an interview on 12/21/2023 at 9:20 A.M., Unit Manager (UM) #1 said that the medication observed by the surveyor on the nurses station desk had been delivered from the Pharmacy at 4:00 A.M., and that the medication belonged to a resident who had moved to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to maintain accurate documentation for two Residents (#87 and #26) out of 33 residents sampled. Specifically: 1. For Resident #87, the facility staff erroneously documented that a left palm guard was being applied when the device had been misplaced and was not being used by the Resident. 2. For Resident #26, the facility staff failed to maintain accurate records related to Advanced Directive planning for the Resident. Findings include: Review of the facility policy for Splints/Orthotics/Prosthetics last revised [DATE], indicated: -nursing staff will apply/remove the designated splint/orthotic/prosthetic device during scheduled wearing times. -nursing staff should notify the rehabilitation department of any .misplaced splint/orthotic/prosthetic device. -devices are to be labeled with the resident's name and maintained in a safe place when not in use. 1. Resident #87 was admitted to the facility in [DATE] with diagnoses including…

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 two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure they received nursing care and services that met professional standards of practice when, 1) after Nurse#1 found Resident #1 on the floor after an unwitnessed fall from his/her wheelchair, Nurse #1 did not immediately attend to or assess him/her for the potential for injury, but instead instructed staff to transfer him/her up off the floor, before adequately assess him/her and 2) Nurse #2 attempted to administer medications to Resident #4, however Nurse #2 had not prepared and/or dispensed the medications herself, was unaware of what the medications were, and admitted that the nurse from the previous shift had dispensed them and asked her to administer them to the resident. Findings include: Review of the Facility's Policy titled Falls Management, dated April 2018, indicated a fall is defined as any incident in which a resident/patient unintentionally has change in elevation/plane, an occasion where the resident would have lost their balance without…

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 four sampled residents (Resident #4), the Facility failed to ensure they maintained a complete and accurate medical record related to nursing documentation in his/her Medication Administration Record (MAR). Findings include: Review of the Facility's Policy titled, Nursing Documentation, dated February 2016, indicated the licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. The Policy indicated documentation should be clear, concise and not subject to misinterpretation. Resident #4 was admitted to the Facility in November 2016, diagnoses included seizures, Hypertension, Depression, unspecified Mood Disorder, Borderline Personality Disorder, Substance Abuse, Alcohol Dependence, Gastro-Esophageal Reflux Disease (GERD), difficulty in walking and muscle weakness. Review of Resident #4's Medication Administration Record (MAR), dated 11/30/23, indicated he/she had Physician's Orders to receive during the 11:00 P.M. to 7:00 A.M. shift, the following…

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

Based on observation, record review, and interview, the facility failed to ensure sufficient nursing staff levels to provide nursing and related services to assure resident safety and maintain the highest practicable well-being for each resident as determined by resident assessments, individual plans of care, and considering the number and acuity of the facility's resident population, in accordance with the Facility Assessment. Specifically, the facility failed to ensure sufficient nursing staff levels to: 1) provide adequate supervision, assistance, and opportunities for meaningful activity engagement for one Resident (#108) of 32 total sampled residents, which resulted in the Resident wandering alone in his/her room and sustaining a fall, 2) ensure sufficient nursing staff levels to provide a) timely A.M. resident care and assist residents out of bed, and b) showers for two Residents (#123 and #145) out of four applicable Residents, without evidence of refusal when the Residents were scheduled to receive showers, and 3) complete two Minimum Data Set (MDS) Assessments for one…

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 annual evaluations for Certified Nurse Aides (CNA) were completed for four out of five sampled CNAs. Findings include: 1. Review of CNA #1's personnel file indicated the last annual evaluation was completed on 7/8/21. 2. Review of CNA #2's personnel file indicated the last annual evaluation was completed on 6/2/21. 3. Review of CNA #3's personnel file indicated the last annual evaluation was completed on 4/14/21. 4. Review of CNA #4's personnel file indicated the last annual evaluation was completed on 5/27/21. Review of the facility's Competency Schedule indicated competencies would be done at CNA job specific orientation and annually. Review of the CNA Skills Refresher Class attendance sheets indicated four CNAs (none of the CNAs listed above) had completed the class and obtained evaluations for the current 2022 year. During an interview on 12/01/22 at 2:46 P.M., the Director of Nurses (DON) said they had recently started to do the annual skills and evaluations for this year. She said only a few CNAs had their…

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

Based on record review, and interview, the facility failed to ensure its staff completed a baseline care plan for one Resident (#157), out of 32 sampled residents within 48 hours of admission to the facility. Specifically, the facility failed to ensure its staff completed the baseline care plan to include the Resident's risk for wandering and elopement when the Resident was identified as being at risk for wandering and elopement and had a history of wandering. Findings include: Review of the facility's policy titled: Care Plan - Baseline, dated November 2017, included the following: - Baseline care plans were to be developed within 48 hours of a resident's admission to the facility. - Baseline care plans were developed based on information obtained during the admission process as a guide for care until the comprehensive care plan was developed. Resident #157 was admitted to the facility in August 2022 with diagnoses including Dementia, altered mental status, and wandering in diseases classified elsewhere. Review of the Wandering and Elopement Assessment, date 8/5/22, included the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that its staff developed and implemented a plan of care for one Resident (#88), out of a total sample of 32 residents. Specifically, the facility failed to develop a plan of care for smoking for Resident #88. Findings include: Resident #88 was admitted to the facility in October 2022. During an interview on 11/29/22 at 4:01 P.M., Resident #88 told the surveyor that he/she smoked two times each day, and that he/she wore a smoking apron. On 11/30/22 at 11:00 A.M., the surveyor observed the smoking activity group. The surveyor observed that Resident #88 wore a smoking apron and was able to hold his/her own cigarette without difficulty. Review of the [NAME] Hills Smoking List updated 11/18/22, posted at the designated smoking area of the facility, did not indicate that Resident #88 required a smoking apron. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated: - Section C Brief Interview of Mental Status (BIMS) was coded a 15 out 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, record review, and interview, the facility failed to ensure its staff provided quality of care, according to plans of care and professional standards of practice, for two Residents (#123 and #85) out of 32 sampled residents relative to non-pressure related skin conditions. Specifically, the facility failed to ensure its staff: 1) assessed bruising (an injury caused by ruptured blood vessels that can result in pain, swelling, and discoloration of the skin) of unknown origin to Resident #123's upper extremity, and monitored the bruising for changes which increased the Resident's risk for further bleeding into injured areas, 2) recorded an assessment for a change in skin condition, implemented a Physician Order for treatment of a non-pressure related skin condition, and monitored for changes in skin condition after Resident #85 sustained breaks in the skin on his/her bilateral first toes which increased the Resident's risk for further skin breakdown and infection. Findings include: Review of the facility's policy, titled Weekly Body Audit, dated July 2017,…

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

Based on observation, record review, and interview, the facility failed to ensure that its staff provided an environment that was as free of accident hazards as possible, adequate supervision and assistance for one Resident (#108), out of 32 sampled residents. Specifically, the facility failed to ensure that its staff provided a safe environment, continual supervision, and physical assistance, according to the Resident's plan of care to prevent an avoidable accident, resulting in a sustained fall by the Resident. Findings include: Review of the facility's policy titled Falls Management, dated August 2018, included the following: - A fall is defined as any incident in which a resident unintentionally has a change in elevation/plane, an occasion where the resident would have lost their balance without staff intervention . - Unless there is evidence suggesting otherwise, anytime a resident is found on the floor, a fall is considered to have occurred. - Residents identified as at risk for falls will have a fall risk care plan developed. Review of the Centers for Medicare and Medicaid…

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

Based on observation, record review, and interview, the facility failed to ensure that its staff provided respiratory care in accordance with professional standards of practice and the plan of care for one Resident (#85), out of 32 sampled residents, relative to Oxygen administration. Specifically, the facility failed to ensure that its staff: a) obtained a Physician order for Oxygen liter flow when the Resident no longer required continuous use of Oxygen and began using supplemental Oxygen as needed (PRN), and b) documented evidence that instructions were provided to the Resident on how to participate in his/her own respiratory care or that the Resident was monitored for his/her ability to independently manage the use of Oxygen. Findings include: Review of the facility's Oxygen Administration Policy, dated November 2020, indicated that low flow oxygen (generally one to six liters per minute (LPM) of flow) would be delivered in accordance with the Physician's orders. Resident #85 was admitted to the facility in March 2016 with diagnoses including Congestive Diastolic Heart Failure…

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

Based on record review and interview, the facility failed to ensure its staff provided care and services consistent with professional standards for one Resident (#51), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of 32 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication documentation with the dialysis facility as required. Findings include: Review of the facility policy titled Hemodialysis, dated April 2015, indicated the following: - Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consist(s) of vital signs, a copy of the Medication Administration Record (MAR), and any changes in condition from the last hemodialysis treatment. - Documentation will be completed prior to dialysis treatment. - The communication book/sheet will be reviewed upon return from dialysis. Resident #51 was admitted to the facility in November of 2020 with diagnoses including Chronic Kidney 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.

Based on observation, record review, and interview, the facility failed to ensure that its staff provided appropriate treatment interventions for one Resident (#108), out of a sample of 32 residents, who was diagnosed with Dementia, according to the Resident's plan of care. Specifically, the facility failed to ensure that its staff offered the Resident opportunities for social engagement or preferred diversional activities when the Resident was observed to wander alone in his/her room. Findings include: Resident #108 was admitted to the facility in April 2019 with diagnoses including Dementia, Depression, legal blindness, and difficulty walking. Review of Resident #108's active care plan included the following focus areas and interventions: - The Resident's cognition was impaired related to dementia. - Encourage socialization and recreation activity. - The Resident enjoyed going to coffee socials, socializing with others, religious activities, lock box, and listening to music, such as Gospel or Spanish music. - Staff were to address the Resident's wandering behavior by walking 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, record review, and interview, the facility failed to ensure accurate documentation in the clinical record for two Residents (#60 and #88) out of 32 total sampled residents. Specifically, the facility failed to ensure its staff completed accurate documentation related to 1) a continuous therapeutic feeding via a gastrostomy tube (g-tube: inserted through the abdomen to deliver nutrients directly into the stomach) for one Resident (#60) and 2) a smoking assessment for one Resident (#88) regarding the use of a smoking apron when smoking, awareness of when smoking was allowed to occur, and his/her ability to hold a cigarette. Findings include: 1. Resident #60 was admitted to the facility in August 2020. Review of the October 2022 Medication Administration Record (MAR) indicated: -a Physician's order to administer Jevity (therapeutic nutrient) 1.2 at 55 milliliters (ml) per hour (hr) continuously via g-tube. -The order was not signed off as being administered on the 11:00 P.M.- 7:00 A.M. shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to ensure its staff offered the appropriate pneumococcal vaccine to three Residents (#86, #159 and #470) at risk for developing facility acquired pneumonia, out of five applicable sampled residents. Findings include: Review of the facility's policy, Immunization of Residents, dated July 2017, indicated the following: -All eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. -Each resident or their responsible party will be asked on admission if they have previously had the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13) vaccination and their age at the time of vaccination. Recommendations are available from the Centers for Disease Control and Prevention (CDC) on specific situations in which vaccination is administered. Review of the CDC's Pneumococcal Vaccine Timing for Adults, dated 4/1/22, indicated the following: -CDC recommends…

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.