Care Village at Mattapan

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the main kitchen refrigerators, and that dented cans were not accepted into storage/circulation. Findings include: Review of the facility's undated policy titled Food Receiving and Storage, indicated, but was not limited to, the following: - When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. - All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 2/11/25 at 6:51 A.M., the surveyor observed a significantly dented can of carrots, a significantly dented can of beef stew, and three significantly dented cans of tropical fruit salad on the can rack in the kitchen storage room. On 2/11/25 at 6:51 A.M., the surveyor made the following observations in the main kitchen refrigerator: -One opened, undated and unlabeled ham roast. -One pan of cooked meat in juices, undated and unlabeled.…

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 maintain accurate and complete medical records for four Residents (#46, #43, #3 and #20) out of a total sample of 23 residents. Specifically, 1. For Resident #46 the facility failed to maintain an accurate diagnosis list. 2. For Resident #43 the facility failed to document the appropriate location of a blood pressure measurement. 3. For Resident #3 the facility failed to ensure that the medical record included information pertaining only to that resident. 4. For Resident #20 the facility failed to accurately document the intake of enteral feeding per day. Findings include: 1. Resident #46 was admitted in October 2024 with diagnoses including methicillin resistant staphylococcus aureus (MRSA) and human immunodeficiency virus (HIV) disease. Review of the minimum data set (MDS), dated [DATE], indicated Resident #46 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During observations throughout…

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 and interview, the facility failed to provide a dignified existence for one Resident (#3) out of a total sample of 23 residents. Specifically, staff failed to pull the privacy curtain or shut Resident #3's door when he/she was in bed without a top on, which exposed Resident #3 to others passing by in the hallway. Findings include: Review of the facility policy titled Dignity/Quality of Life, dated 12/6/21, indicates the following: - Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with care and treatment procedures. Resident #3 was admitted to the facility in October 2010 with diagnoses including anemia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #3 requires assistance to dependence with activities of daily living. Review of Resident #3's current care plan indicates…

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 notify the physician of a change in condition related to edema for one Resident (#19) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Change of Condition- Physician Notification, dated 1/10/17, indicated the following: - A change in condition is a significant clinical symptom(s) or development, which requires assessment and intervention - It is then the RN supervisor's responsibility to do a follow-up assessment and to ensure that the assessment is documented. - All assessment findings and relevant information should be compiled prior to calling the physician to ensure accuracy of information. - The physician (or alternate) will be contacted to report findings. Resident #19 was admitted in October 2019 with diagnoses including history of an embolism of the lower extremity and hemiplegia of the left side. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 15 out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean and homelike environment for one Resident (#3) out of a total sample of 23 residents. Findings include: Resident #3 was admitted in October 2010 with diagnoses including anemia. Review of the minimum data set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #3 requires assistance to dependence with activities of daily living. During an observation on 2/11/25 at 8:17 A.M., Resident #3 was lying in bed with approximately 6-7 dead cockroaches surrounding his/her bed. During an observation on 2/12/25 at 8:47 A.M., Resident #3 was lying in bed with a soiled brief on the floor next to him/her and approximately 6-7 dead cockroaches surrounding his/her bed. During an observation on 2/13/25 at 7:38 A.M., Resident #3 was lying in bed with a soiled brief on the floor next to him/her and approximately 6-7 dead…

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

Based on record review and interviews, the facility failed to investigate a report of drug and alcohol use in the facility, reported by one Resident (#44), out of a total sample of 23 Residents. Findings Include: Review of the facility policy titled, Abuse Prohibition, revised 2/20/23, indicated the following: Policy -Allegations of abuse will be reported and thoroughly investigated. -The Administrator and Director of Nursing are responsible for investigation and reporting. Investigation -The investigation will begin immediately after reporting the actual or suspected incident. -Initiate the investigative process using factual data. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewed and have information regarding the allegation. -The results of the investigation will be documented. -Conclusion must include whether the allegation was substantiated or not and what information supported the decision. -Corrective measures will be implemented and documented post incident. Follow-up Measure -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 interviews for two Residents (#49 and #67) of 23 sampled residents, the facility failed to ensure staff adequately identified a significant change in the Resident's status and completed a comprehensive Significant Change of Status Assessment Minimum Data Set (MDS) as required. Specifically 1. For Resident #49, the facility failed to identify and complete Significant Change in Status MDS when Resident #49, experienced significant weight loss, had an indwelling urinary catheter removed, and developed a stage 4 pressure wound. 2. For Resident #67, the facility failed to complete a significant change in status MDS when Resident #67 was signed on to hospice care. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated a Significant Change in Status Assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. It defines a significant change as a major decline or…

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 accurately reflect the status of one Resident (#42) out of a total sample of 23 residents, when the Minimum Data Set (MDS) assessment failed to indicate that the Resident had an indwelling urinary catheter. Findings include: Resident #42 was admitted to the facility in May 2023 with diagnoses that include neuromuscular dysfunction of the bladder. Review of Resident #42's most recent Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated a Brief Interview for Mental Status score of 15 out of 15 indicating that the Resident is cognitively intact. The MDS failed to indicate the use of an indwelling catheter. On 2/11/25 at 8:00 A.M., Resident #42 was observed lying in bed, a urinary catheter drainage bag was observed hanging from the frame of his/her bed. Review of Resident #42's active Physician's orders indicated the following: -Foley Catheter Order: size: 16 french, 10 balloon Size, dated 5/19/23. -Empty Foley drainage bag and record 24 HOUR output, every night shift for Foley Output (TOTAL OUTPUT),…

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 create a baseline plan of care within the required 48 hours of admission for one Resident (#373) out of a total sample of 23 residents. Findings include: Resident #373 was admitted to the facility in January 2025 with diagnoses including acute embolism and deep vein thrombosis of the left upper extremity. Review of the medical record failed to indicate a baseline care plan was completed within 48 hours of admission. During an interview on 2/12/25 at 11:44 A.M., Unit Manager #1 said a baseline care plan should be completed within two days of admission, she further said that the care plan is necessary to guide the care givers on the resident's care needs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to develop and implement a comprehensive resident-centered care plan for one Resident (#371) out of a total sample of 23 residents. Specifically, for Resident #371 the facility failed to develop a care plan for dialysis and for an actual skin impairment. Findings include: Resident #371 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, renal dialysis dependence and osteomyelitis left ankle and foot. Review of Resident #371's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. The MDS further indicated the Resident was on dialysis, had a surgical wound and infections of the wound. Review of physician orders dated 1/30/25 indicated the following: -Resident to have dialysis on days Monday, Wednesday and Friday. -Dialysis catheter site left chest monitor…

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 assistance with Activities of Daily Living (ADLs), for one Resident (#28) out of a total sample of 23 residents. Specifically, for Resident #28 the facility failed to provide assistance and/or supervision with meals. Findings include: Review of the facility policy titled Activity of Daily Living, dated 12/22, indicated the following: -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain nutrition, grooming, and personal and oral hygiene. -Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that it is unavoidable. -The facility will ensure a resident is given the appropriate treatment and services to maintain…

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 a change in condition related to edema management for one Resident (#19) out of a total sample of 23 residents. Findings include: Resident #19 was admitted in October 2019 with diagnoses including history of an embolism of the lower extremity and hemiplegia of the left side. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated Resident #19 requires substantial assistance to dependence with activities of daily living. During an observation on 2/11/25 at 8:14 A.M., Resident #19 was lying in bed with his/her left leg exposed. Resident #19's left leg was large and swollen throughout the leg. Resident #19 said that he/she has had increased leg swelling and pain in his/her left calf since last week. Resident #19 said he told his occupational therapist about it, but no one has…

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

Based on record review and interview the facility failed to ensure that one Resident (#58) out of a total sample of 23 residents received proper treatment and assistive devices to maintain their vision. Specifically, the facility failed to ensure that Resident #58 had a follow up and consultation for cataract surgery as recommended by the consulting eye doctor. Findings include: Resident #58 was admitted to the facility in April 2024 with diagnoses that include stiff man syndrome and anxiety. Review of Resident #58's most recent Minimum Data Set (MDS) Assessment, dated 1/10/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident's vision is impaired and he/she does not utilize corrective lenses. Review of the consultant eye doctor visit note, dated 7/11/24 indicated the following: -Assessment: 1. Cataract, mixed; Bothersome; L > R (left greater than right). -Plan: 1. Cataract surgery recommended; ophthalmology consult; Follow-Up: 3-4 Months; Referral: Ophthalmology…

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 provide care and services consistent with professional standards of practice by not following a physician's order for air mattress settings to promote the healing of existing pressure ulcer for one Residents (#20), out of a total sample of 23 residents. Findings include: Resident #20 was admitted to the facility in March 2024 with diagnoses including multiple sclerosis, pressure ulcers stage 3 and 4 of back and sacrum. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had pressure ulcers. On 2/11/25 at 7:47 A.M., the surveyor observed Resident #20 lying in his/her bed the air mattress was set at 100 lbs. (pounds). On 2/12/25 at 6:45 A.M., the surveyor observed Resident #20 lying in his/her bed the air mattress was set at 100 lbs.…

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 adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine) for one Resident (#20) out of a total sample of 23 residents. Specifically, the facility failed to implement the enteral feeding in accordance with the physician's order to receive the enteral feeding for 24 hours per day. Findings include: Resident #20 was admitted to the facility in March 2024 with diagnoses including multiple sclerosis, dysphagia, gastrostomy status. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident utilizes a feeding tube. During an interview on 2/12/25 at 6:45 A.M., Resident #20 was observed lying in his/her bed, the Resident told the surveyor he/she had gone on 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 observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#3 and #11), out of a total sample of 23 residents. Specifically, 1. For Resident #3, the facility failed to label and date the oxygen tubing and maintain a clean oxygen filter. 2. For Resident #11, the facility failed to label and date nebulizer tubing and store it in properly in a bag. Findings include: Review of the facility policy titled Oxygen Administration Policy and Procedure, dated 12/6/22, indicates the following: - Procedures: Check the physician order. If it is unclear, clarification must be obtained. - Precautions: Do not operate a concentrator without a filter or with a dirty filter. 1. Resident #3 was admitted in October 2010 with diagnoses including anemia. Review of the minimum data set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status…

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 reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#28) out of a total sample of 23 residents. Specifically, for Resident #28, the facility failed to ensure a psychiatric consult was completed. Findings Include: Resident #28 was admitted to the facility in December 2024 with diagnoses that included dementia without behaviors, dysphagia, and schizophrenia. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a six out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating severe cognitive impairments. Further review of the MDS indicated the Resident is receiving an antipsychotic medication. Review of Resident #28's physician order, dated 7/24/24, indicated Psychological evaluation and treatment for: Adjustment to need for placement in facility and Med…

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 residents were free of unnecessary medications and were properly assessed for possible adverse reactions to psychotropic medications for one Resident (#28) out of a total of 23 sampled residents. Specifically, for Resident #28, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings Include: According to CMS guidelines, an AIMS (Abnormal Involuntary Movement Scale) test should be conducted on a nursing home resident when a resident starts or has significant changes to medications that can cause tardive dyskinesia, like certain antipsychotics. Review of facility policy titled [Outside Vendor] Behavioral Health, dated April 2023, indicated the purpose is to ensure all residents taking antipsychotic are monitored for adverse side effects. It is the policy of [Outside Vendor]…

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 adhere to infection control practices and standards increasing the risk of contamination and spread of infection for residents in the facility. Specifically, the facility failed to unglove hands after bagging soiled linens and proceeded to wear the contaminated gloves in the hallway and potentially contaminate the soiled linen chute. Findings include: During an observation on 2/11/25 at 7:59 A.M., a certified nursing aide exited a Resident room with a bag of soiled linen wearing the same gloves that were used to bag the linen. The certified nursing aide walked through the hallway and disposed of the dirty linen in the linen chute. The certified nursing aide then removed the potentially contaminated gloves. During an observation on 2/12/25 at 8:45 A.M., a certified nursing aide exited a Resident room with a bag of soiled linen wearing the same gloves that were used to bag the linen. The certified nursing aide walked through the hallway and disposed of the dirty linen in the linen chute. The certified nursing aide then removed…

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 for four Residents (#3, #4, #15, and #13) that care plans were implemented, out of a total sample of 24 residents. Specifically: 1. For Residents #3, #4 and #15, the facility failed to provide supervision with meals, per the plan of care. 2. For Resident #13, the facility failed to ensure his/her call light was within reach, per the plan of care. Findings include: 1a. Resident #3 was admitted to the facility in January 2002 with diagnoses including, cerebrovascular disease, dementia, and aphasia (difficulty communicating). Review of Resident #3's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident has severe cognitive deficits. The MDS also indicated Resident #3 requires maximum to dependent assistance with self-care activities, including eating. Review of Resident #3's care plan indicated: Focus: I need assistance with my ADLs (Activities of Daily Living) due to impaired mobility/decreased ROM (Range…

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 for three Residents, (#37, #7, #30) out of a total of 24 sampled residents, the facility failed to implement interventions for the prevention and treatment of pressure ulcers. Specifically: 1. For Resident #37, the facility failed to implement the Wound Physician's order for a wound dressing. 2. For Resident #30, who had actual skin breakdown, the facility failed to consistently implement the physician's orders for an air mattress, prevalon boots and heel offloading to prevent further skin breakdown/decline. 3. For Resident #7, the facility failed to implement the Wound Physician's order to offload heels. Findings include: 1. Resident #37 was admitted to the facility in June 2018 with diagnoses including anoxic brain damage, dysphagia, and quadriplegia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #37 is severely cognitively impaired and totally dependent on staff for all activities of daily living. On 3/8/24 at approximately 7:55…

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

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) ensure medication carts were locked and secured on one of two units, 2.) ensure medications were labeled and stored according with manufacture's guidelines, and 3.) ensure the medication cart keys were not left unattended. Findings include: Review of the facility policy, titled Storage of Medications, undated, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access E.…

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 adhere to professional standards of practice to prevent possible infections. Specifically, the facility failed to: 1. Doff (remove) personal protection equipment properly and failed to perform hand hygiene. 2. Ensure nursing disinfected a glucometer (device that measure how much sugar is in a blood sample) according to manufactures guidelines. Findings include: Review of the facility's policy 'Transmission Based Precautions with PPE (personal protection equipment) Grid for COVID-19 Endemic' dated as last reviewed June 2/20/20, indicated: -Transmission based precautions are designed for patients documented or suspected of being infected or colonized with transmissible pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission in the healthcare setting. Transmission based precautions may be used on an empiric or temporary basis. Use of precautions will be reassessed in these instances once laboratory and other clinical testing information is available. -Procedure:…

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 two of three Certified Nursing Assistant educational files reviewed had no less than 12 hours of in-service training per year. Findings include: Review of two of three Certified Nursing Assistant (CNA) employee files indicated they failed to have 12 hours of in-service training. During an interview on 3/7/24 at 2:30 P.M., the Director of Nursing (DON) said CNAs require 12 hours of in-service training annually. Nurse #7, who was present, said she believed the files provided had all the education that was available. During an interview on 3/7/24 at 4:32 P.M., the DON said she has additional education for the two CNAs. When asked why she could not produce the education at this time, the DON said the supervisor, who is out, has access to the education. At the time of exit on 3/8/24 at 3:00 P.M., no further education was provided to the surveyor for the two CNAs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to 1. speak respectfully to one Resident (#14) and 2. staff failed to respect the resident environment as evidenced by using cell phones and conducting private conversations in a resident area, from a total sample of 24 residents. Findings Include: Review of the facility policy Dignity/Quality of Life dated 12/6/21, indicated: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Procedure: - Residents shall always be treated with dignity and respect. - Staff shall always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the residents by his or her room number, diagnosis, or care needs. 1. Resident #14 was admitted to the facility in February 2023 with diagnoses including end stage renal disease and Type 2 Diabetes Mellitus. Review of Resident #14's most recent Minimum Data Set (MDS) assessment…

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 file a grievance for one Resident (#14) out of a total sample of 24 residents. Findings Include: Review of the facility policy titled Grievances/Concerns, dated as last revised December 2021, indicated the following: Policy: -Residents or their representatives may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, lost clothing, etc. Employees of the facility will assist residents and or their representatives in the grievance/complaint process when such requests are made. Procedure: -Grievances/concerns may be submitted orally or in writing. The person/staff receiving an oral grievance/concern will fill out the grievance/concern form for submission to leadership. Written complaints or grievances must be signed by the resident or the person filing the grievance/complaint on behalf of the resident. The resident/representative has the right to choose to remain anonymous. -Any…

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 interviews, the facility failed to implement their abuse prohibition policy for three Residents (#39, #25, and #10) out of a total sample of 24 residents. Specifically, 1. For Resident #39 and #25, the facility failed to ensure nursing immediately reported an allegation of potential abuse (resident to resident altercation) to the Director of Nursing or Administrator, as required. 2. For Resident #10, failed to ensure nursing immediately reported an allegation of potential abuse to the Director of Nursing or Administrator, as required. Findings include: Review of the facility policy, Abuse Prohibition, dated as revised 7/13/22, indicated allegations of abuse will be reported promptly and thoroughly investigated. Reporting: 1. All alleged violations can be observed by staff, residents, relative, visitor, another health care provider, or others. 2. Notify the Shift Supervisor / Charge Nurse/ Manager immediately in person if suspected abuse, neglect, mistreatment or misappropriation of property occurs. 3. Report the incident immediately to the…

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

Based on record review, interviews and policy review, the facility failed to report an injury of unknown source to the state agency within two hours, as required for one Resident (#10) out of a total sample of 24 residents. Specifically, on 7/14/23 at 1:50 P.M., the Director of Nursing (DON) was made aware of Resident #10's new pain and diagnosis of an angulated supracondylar fracture of the femur. The DON did not report this injury to the state agency until 7/19/23 at 3:43 P.M., almost 120 hours after becoming aware of the new fracture. Findings include: Review of the facility policy, Abuse Prohibition, dated as revised 7/13/22, indicated allegations of abuse will be reported promptly and thoroughly investigated. III. Injuries of Unknown Origin- An injury will be classified as an injury of unknown source when all of the following criteria are met: a. The source of the injury was not observed by any person AND b. The source of the injury could not be explained by the resident AND c. The injury is suspicious because of the extent of the injury or the location of the injury (for…

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 interviews, the facility failed to thoroughly investigate an injury of unknown origin and failed to maintain evidence of a thorough investigation was completed for one Resident (#10) out of a total sample of 24 residents. Findings include: Review of the facility policy, Abuse Prohibition, dated as revised 7/13/22, indicated allegations of abuse will be reported promptly and thoroughly investigated. III. Injuries of Unknown Origin- An injury will be classified as an injury of unknown source when all of the following criteria are met: a. The source of the injury was not observed by any person AND b. The source of the injury could not be explained by the resident AND c. The injury is suspicious because of the extent of the injury or the location of the injury (for example, an injury is located in an area that not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Injuries of unknown origin will be considered potential abuse until otherwise proven through 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 observation, record review and interview, the facility failed to ensure that care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#10), out of a total sample of 24 residents. Specifically, the facility staff failed to review and revise the Resident #10's care plans with the IDT after each Minimum Data Set (MDS) assessment. Findings include: Review of the facility policy, titled Comprehensive Care Plan, undated, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 10. The Care Planning/Interdisciplinary Team along with the resident/representative is responsible for the review and updating of care plans: b. When the desired outcome is not met. d. At least quarterly. Resident #10 was admitted to the facility in February 2023 with diagnoses including dementia, cerebral infraction, and major depression. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and interviews, the facility failed to follow professional standards of practice for two Residents (#30 and #39), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #30, the facility failed to implement the physician's order for seizure pads. 2. For Resident #39, the facility failed to ensure staff had supporting testing to diagnosis paranoid schizophrenia and who was receiving antipsychotic medication. Findings include: 1. For Resident #30, the facility failed to implement the physician's order for seizure pads. Resident #30 was admitted to the facility in July 2022 and diagnoses included catatonic disorder, epilepsy, and cerebral infarction with hemiplegia and hemiparesis. Review of the Minimum Data Set (MDS) assessment, dated 2/15/24, indicated Resident #30 required staff assistance with activities of daily living. Review of Resident #30's plan of care related to seizures, dated 7/9/22, indicated: - Please keep 2 1/2 padded side rails…

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

Based on observation, record review and interview for two Residents (#41 and #30), out of a total sample of 24 residents, the facility failed provide activities of daily living in accordance with their plan of care. Specifically: 1. For Resident #41, the facility failed to provide incontinence care and positioning in accordance with the plan of care. 2. For Resident #30, the facility failed to provide meals in accordance with physician's orders and the plan of care. Findings include: Review of the facility's policy, titled Activities of Daily Living, dated as revised December 2022 indicated the following: -Purpose: 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. -Policy: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming…

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

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#39), out of a total sample of 24 residents received proper care and treatment to maintain good foot health. Findings include: Review of the facility policy titled, Care of the Fingernails/ Toenails, undated, indicated the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 5. Stop and report to the nurse supervisor if there is evidence of ingrown toenails, infections, pain or if the nails are too hard or too thick to trim or file with ease. 7. Toenails will be trimmed/cut by the podiatrist. Add resident to the podiatry list as needed. Resident #39 was admitted to the facility in July 2023 with diagnoses including coagulation defect, unspecified fracture of the first lumbar vertebra, paranoid schizophrenia, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 2/19/24, indicated Resident #39 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 which indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, for one Resident (#25) out of a total sample of 24 residents, the facility failed to ensure staff provided adequate supervision to maintain safety. Specifically, for Resident #25, the staff knowingly allowed Resident #25 to keep his/her own smoking materials, including a lighter, and allowed Resident #25 to smoke unsupervised between designated supervised smoking times. Findings Include: Review of the facility's policy titled Smoking, dated 5/26/2022, indicated the following: Policy: It is the policy of this facility to maintain a safe resident smoking/nicotine environment. This policy respects resident's rights and preferences and is in accordance with Life Safety Code requirements, and state and local laws governing safe practices for the facility. Smoking articles include but are not limited to cigarettes, cigars, vapor, e-cigarettes, and any nicotine related product. To provide a structured framework to ensure the safety and well-being of residents who…

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 interviews, the facility failed to identify and address a significant weight gain for one Resident (#39) out of a total sample of 24 Residents. Specifically, for Resident #39 on 2/28/24, the Resident weighed 157.4 pound (lbs) and on 2/29/24, the Resident weighed 172.2 pounds which is a 9.40 % gain. Findings include: Review of the facility policy titled, Weight Monitoring, dated as revised 12/21/22, indicated, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain for our residents. 2. Weights will be recorded in the individual's medical record. 3. 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. Resident #39 was admitted to the facility in July 2023 with diagnoses including coagulation defect, hypertension, atrial fibrillation, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 2/19/24,…

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 for one Resident (#37) out of three applicable residents in a total sample of 24 residents, the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine). Specifically, the facility failed to implement the physician's order for continuous feed, failed to notify the physician or nurse practitioner the continuous feed was not implemented and failed to obtain orders for an alternate way to support Resident #37's nutritional needs. Findings include: Review of the facility's policy, titled 'Enteral Feedings, not dated, indicated: -Purpose: To ensure the safe administration of enteral nutrition. -Preparation: All personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. -The facility will remain current in and follow accepted best practices in enteral…

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 reviews and interviews, for one Resident (#25), out of a total sample of 24 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #25, with a known history of trauma and mental illness, the facility failed to provide services to include psychotherapy. Findings include: Review of the document titled Facility Assessment dated 12/11/23 indicated the facility accepts residents with psychiatric/mood disorders including the following common diagnoses: psychosis (hallucinations, delusions, etc.), impaired cognition, mental disorder, depression, bipolar disorder (i.e. mania/depression), post-traumatic stress disorder, anxiety disorder, behavior that needs intervention, schizophrenia. Further review of the document indicated contracted behavioral health services, in-house services and telehealth as needed to psychiatric services and medication management as needed. The…

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

Based on record review, policy review, and interviews, the facility failed to act upon recommendations made by the consultant pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#10), out of a total sample of 24 residents. Specifically, the facility failed to ensure the 11/29/23, 12/25/23, 1/25/24, and 2/26/24 consultant pharmacist's recommendations were acted upon. Findings include: Review of the facility policy titled, Medication Regimen Review, undated, indicated the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. A. Prescriber accepts and acts upon suggestion or…

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 ensure that each Resident's drug regimen was free from unnecessary psychotropic medications for one Resident (#10), out of a total sample of 24 residents. Specifically, for Resident #10, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility policy titled, AIMS Testing, dated as revised 2023, indicated to ensure all residents taking anti-psychotics are monitor for adverse side effects. Anyone at the facility who is treated with an anti-psychotic medication is assessed with an AIMS every 6 months. Resident #10 was admitted to the facility in February 2023 with diagnoses including dementia, cerebral infraction, and major depression. Review of the Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident #10 received an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were accurate for two Residents (#63, #30) out of a total of 24 sampled Residents. Specifically: 1. For Resident #63, the facility failed to ensure his/her code status was accurate. 2. For Resident #30, the facility failed to ensure nursing maintained complete and accurate comprehensive weekly skin checks. Findings include: 1. Resident #63 was admitted to the facility in [DATE] with diagnoses including Lewy body dementia, cirrhosis, and chronic obstructive pulmonary disease. Review of Resident #63's Minimum Data Set assessment dated [DATE] indicated Resident #63 was severely cognitively impaired and did not elect a DNR/DNI (do not resuscitate/do not intubate) status. Review of Resident #63's admission check list dated [DATE] and signed by Resident #63's activated healthcare proxy indicated the facility did not obtain code status information upon admission. Review of the physicians' orders failed to indicate orders related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview for one Resident (#41), out of a total sample of 24 residents, the facility failed to ensure a coordinated person-centered care plan with individualized interventions was developed for the provision of hospice care services. Findings include: Review of the facility's policy titled: Hospice Program, dated as last revised 12/6/21, indicated the following: -Purpose: to ensure that residents are provided with Hospice Services when appropriate. -Policy: The facility contracts for hospice services for residents who wish to participate in such programs. 4. When a resident participates in the hospice program, a coordinated plan of care between the facility hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. Resident #41 was admitted to the facility in February 2019 and has diagnoses 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 record review and interview, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan related to the accuracy of resident code status. Specifically, the facility identified inconsistencies in the accurate documentation of advanced directives on [DATE] but failed to conduct a facility-wide Performance Improvement Project or to monitor for lapses. Subsequently, staff failed to provide Cardiopulmonary Resuscitation (CPR) to one Resident (#63) who had an incomplete MOLST form and therefore, continued as a full code status. Findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy, dated as reviewed [DATE] indicated: *QAPI encompasses all administrative, managerial, clinical and environmental services as well as performance of external providers and suppliers of care and services. QAPI is a comprehensive program by which the facility identifies problems or issues early on, develops a plan to address the root causes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at increased risk for elopement and exhibited exit seeking behaviors, the Facility failed to ensure they provided adequate safety equipment, specifically that facility emergency exit doors located at the far end of each unit, were equipped with alarms that sounded at levels loud enough for staff to be able to hear alarms from anywhere on the unit and therefore respond appropriately in an effort to maintain resident safety to prevent an incident of elopement. On [DATE], Resident #1 successfully eloped from the Facility through an emergency exit door unbeknownst to staff, and although the emergency exit door alarm sounded, staff did not hear or respond to the alarm because of it's low volume setting. Findings include: The Facility's Policy titled, Resident Elopement/Prevention, dated [DATE], indicated that the Facility will ensure that residents who exhibit wandering behavior and are at risk for…

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.