Regalcare At Courtyard-Medford

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 out of 5 eligible sampled CNAs. Findings include: During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for 5 out of 5 eligible CNAs. Employee records indicated the following: - A CNA last had an annual review on 7/13/21; - A CNA last had an annual review on 10/23/21; - A CNA last had an annual review on 3/19/20; - A CNA last had an annual review on 2/26/21; - A CNA never had an annual review, but was eligible. During an interview on 3/11/25 at 9:38 A.M., the Director of Nursing (DON) said it is the expectation that annual reviews be done annually and could not say why that was not happening. During an interview on 3/11/25 at 9:48 A.M., the Administrator said that it is the expectation that all staff receive annual performance reviews. The Administrator said that he could not speak to why reviews were not happening in the past but was aware that they were not done.

Based on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of three nurses observed made seven errors out of 29 opportunities, resulting in a medication error rate of 24.14%. Those errors impacted three Residents (#149, #8, and #433), out of three residents observed. Specifically, 1.) For Resident #8, Nurse #4 failed to administer his/her medications within the one-hour time frame. 2.) For Resident #433, Nurse #5 failed to administer his/her medications within the one-hour time frame. 3.) For Resident #149, Nurse #1 failed to administer his/her medications within the one-hour time frame. Findings include: Review of the facility policy titled 'Oral Medication Administration', dated as revised 4/2022, indicated the following: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. - Verify that there is a physician's medication order for this procedure. 1.) Review of Resident #8's physician orders indicated the following: - Phenobarbital…

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 interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on four out of six units. Findings include: During the initial tour of the facility on 3/4/25 the surveyors met with residents, 12 residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility. During the resident group meeting on 3/5/25 at 10:05 A.M. the surveyors met with residents and the following concerns were expressed. - One Resident said that the food was terrible, that some people aren't getting salt and have to get it themselves. - One Resident said it takes half an hour to get food. - 13 out of 13 residents said food was not hot. On 3/7/25 at 9:06 A.M., the E Unit food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 9:15 A.M., and the following was recorded and observed: - Scrambled eggs tasted warm, not hot and bland. - Potatoes tasted warm, not hot. - Toast was soft. - Oatmeal was bland. - Juice tasted cool, not cold. - Milk tasted…

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 food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was dated, that produce with significant signs of decomposition were discarded, and that food was covered in a walk-in refrigerator in the setting of potential environmental contaminants. Findings include: Review of the facility's policy titled 'Food Brought into the Facility', revised May 2022, indicated, but was not limited to, the following: - Visitors and family members should take all food to the nurses station before it is provided to the resident. - Perishable food must be stored and identified with the residents name, food item, and use-by date. These can be stored in the nursing unit kitchen nourishment refrigerator. - The nursing staff is responsible for discarding perishable foods on or before the use-by date. Review of the facility's policy titled 'Food Storage', revised April 2024, indicated, but was not limited to, the following: - Prepared foods in the refrigerator shall be kept…

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 document in the medical record for 2 Residents (#36 and #138) out of 42 total sampled residents. Specifically, 1.) For Resident #36, the facility failed to document accurately that a cervical collar was not applied. 2.) For Resident #138, the facility failed to ensure they maintained complete and accurate medical records related to documentation of activities of daily living (basic tasks everyone needs to do each day, such as eating, dressing, hygiene, and using the toilet). Findings include: Review of the facility policy titled 'Charting and Documentation', revised April 2022, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1.) Resident #36 was admitted to the facility in January 2024 with diagnoses including age related cognitive decline and a history of stroke with left sided hemiplegia (one sided muscle weakness). Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident #36 had…

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

Based on observations and interviews the facility failed to provide a dignified experience for one Resident (#167) out of a total sample of 42 residents and for residents on two of six units. Specifically: 1.) For Resident #167 the facility failed to place the Resident's nephrostomy tube drainage bag in a privacy bag, leaving it exposed to others. 2.) For residents on two of six, units the facility failed to ensure that staff did not refer to residents as feeders within earshot of residents or speak a foreign language while within earshot of residents. Findings include: Review of the facility policy, titled Resident Rights, revised April 2022, indicated the following: - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to a dignified experience. 1.) Resident #167 was admitted to the facility in December 2024 with a diagnosis of prostate cancer with irradiation cystitis with hematuria (caused by radiation therapy, leading to inflammation and bleeding in the bladder, resulting in painful urination and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to obtain written informed consent for the use of psychotropic medication for two Residents (#138 and #40) out of a total sample of 42 residents. Specifically, 1.) For Resident #138, the facility failed to obtain written informed consent for use of ramelteon (a hypnotic medication). 2.) For Resident #40, the facility failed to obtain written informed consent for the use of depakote (a mood stabilizer medication). Findings include: Review of the facility policy titled 'Psychotropic Medications', revised April 2022, indicated, but was not limited to: - An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication. 1.) Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe…

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 one Resident (#117)did not self-administer medications out of a total sample of 42 residents. Specifically, Resident (#117) was observed with a cup of pills left on lunch tray for self-administration without being assessed for self-administration. Findings include: Review of the facility policy titled 'Medication Storage', dated March 2022, indicated the following: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Resident #117 was admitted to the facility in June 2024 with diagnoses including acute transverse myelitis in demyelinating disease of central nervous system (an inflammatory condition that damages the myelin sheath, the protective covering of nerve fibers in the spinal cord). Review of Resident #117's Minimum Data Set (MDS) assessment, dated 2/20/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she was cognitively intact. The MDS further indicated the Resident did not reject…

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 (#130) was free from restraints, out of a total sample of 40 residents. Findings include: Review of the facility policy titled, Use of Restraints, dated April 2022, indicated the following: - Restraints should only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline of staff convenience, or for the prevention of falls. - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts the freedom of movement or restricts normal access to one's body. - The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which the staff applied it given that resident's physical condition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for two Residents (#130 and #36) out of a total sample of 42 residents. Specifically, 1.) For Resident #130, the facility failed to accurately code that the Resident had bilateral upper and lower extremity contractures. 2.) For Resident #36, the facility failed to accurately code that the Resident sustained a fall. 1.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #130 was dependent on staff for all care. On 3/4/25 at 9:04 A.M., Resident #130 was observed lying in bed with bilateral upper and lower extremity contractures. Review of section GG of the…

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

Based on observation, record review, and interviews, the facility failed to ensure care and services are provided according to accepted standards of clinical practice for two Residents (#143 and #117) out of a total sample of 42 residents. Specifically: 1.) For Resident #143, the facility failed to obtain daily weights as indicated in physician's orders. 2.) For Resident #117, the facility failed to obtain a physician's order for the use of an air mattress. Findings include: Review of the facility policy titled 'Weight Management', dated April 2022, indicated the purpose is to monitor the Resident's weight from time of admission and to provide interdisciplinary support and/or intervention to avert adverse trends. Review of the facility policy titled 'Preventative Pressure Ulcer', date April 2022, indicated the purpose is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. - Supports surfaces and pressure redistribution: select appropriate support surfaces based on the Resident's mobility, continence, skin…

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 interviews and record review, the facility failed to provide necessary treatment and services to maintain activities of daily living for one Resident (#138) out of a total sample of 42 residents. Specifically, the facility failed to address and provide therapy services for a decline Resident #138's ability to self-feed from set-up assistance to total dependence. Findings include: Review of facility policy titled 'Rehabilitation Services', dated April 2022, indicated: - Physical/Occupational therapy services are part of a constellation of rehabilitative services designed to improve or restore functionality following disease, injury, or loss of a body part. - Impairments, functional limitations, and disabilities thus identified are then addressed by the design and implementation of a therapeutic intervention tailored to the specific needs of the individual Resident. - The goal for a Resident is to return to the highest level of function realistically attainable and within the context of the disability.…

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 consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#8) out of a total sample of 42 residents. Specifically, the facility failed to ensure staff implemented Resident #8's physician ordered right hand carrot orthosis. Findings include: Review of the facility policy titled 'Rehabilitative Nursing Care', revised April 2022, indicated: - General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care. - The facility's rehabilitative nursing care is designed to assist each resident to achieve and maintain an optimal level of selfcare and independence. - Rehabilitative nursing care is performed daily during ADL (activities of daily living) care through passive range of motion. Such services includes, but is not limited to: a. maintaining good body alignment and proper positioning; and f. assisting residents with their routine range of motion exercises. Resident #8…

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 reviews and interviews, the facility failed to ensure weekly weights were obtained for one Resident (#106), with a recent weight loss, out of a total sample of 42 residents. Findings include: Review of the facility policy titled, Weight Management, dated April 2022, indicated the following: - Weekly weights should be done on residents who are assessed as high nutritional risk. Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, which indicated he/she has severe cognitive impairment. The MDS also indicated the Resident is dependent on staff for all self-care tasks. Review of Resident #106's weights indicated that on 11/21/2024, the Resident weighed 117.8 lbs (pounds) and on 2/6/2025, the Resident weighed 109 lbs., which is a -7.47 % loss in three months. Review of Resident #106's physician orders indicated the following orders: - Weekly weights…

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

Based on observation, record review, and interview, the facility failed to provide dental services to one Resident (#93) out of a total sample of 42 residents. Findings include: Resident #93 was admitted to the facility in 6/2023 with diagnoses including dementia and depression. Review of the Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #93 scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the oral section of the MDS indicated Resident #93 had no broken teeth. During an interview on 3/4/25 at 9:58 A.M., Resident #93 said his/her teeth were broken and need to be fixed. Review of the medical record and consents failed to indicate that Resident #93 had been seen by the dentist or signed a consent form to be seen by the dentist. During an interview on 3/11/25 at 10:32 A.M., the Medical Records staff member said that Resident #93 had not been seen by a dentist in house and would find out if he/she had been seen outside of the facility. The facility failed to provide any indication that Resident…

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

Based on interviews and review of the Health Care Facility Reporting System (HCFRS-State Agency reporting system), the facility failed to provide written notice to the State Agency of a change in the Director of Nursing position. Findings include: During an interview on 3/5/25 at 3:28 P.M., the Administrator said there was a recent change in the Director of Nursing position and the new Director of Nursing started in October 2024. Review of HCFRS on 3/4/24, failed to indicate the facility submitted a change in Director of Nursing notice, as required. During an interview on 3/5/25 at 3:59 P.M., the Administrator said they did not report the change in Director of Nursing position to the state agency, as required, but should have.

Based on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure they maintained complete and accurate medical records related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow 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 Charting and Documentation, dated 04/2022, indicated documentation in the medical record will be objective, complete, and accurate. Review of the Facility's Policy tilted Medical Record, dated 04/2022, indicated a medical record, health record, clinical record or chart is a systematic documentation of the resident's medical history and care. Review of the Facility's documentation for care and services provided by CNA's is recorded on the Facility's document titled Documentation Survey Report v2, going forward in this deficiency the document will be referred as the Resident's ADL Flow Sheet. 1) Resident #1 was admitted to…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure nursing staff maintained a complete and accurate medical record, when after Resident #2 experienced a medical emergency, Unit Manager #1 failed to accurately document her findings after assessing him/her. Findings include: The Facility Policy, titled Medical Record, dated 04/2022, indicated documentation would include observations and descriptions of significant changes in the resident's condition. The Facility Policy, titled Charting and Documentation, dated 04/2022, indicated that services provided to the resident or any changes in condition would be documented in the resident's medical record. Resident #2 was admitted to the Facility in May 2024, diagnoses included Amyloidosis (a multisystem, rapidly progressive nature of the disease leads to disability and premature death), dementia, neuropathy, fibromyalgia, and dysphagia. Review of Resident #2's Nurse Progress Note, dated 12/03/24, indicated that at 09:13 A.M., Resident #2 was found without respirations and…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included hemodialysis three times a week, the Facility failed to ensure he/she received care and services consistent with professional standards of practice, when he/she did not receive hemodialysis as ordered, per his/her established schedule, experienced mental status changes, and was transferred to the Hospital to receive dialysis. Findings include: Review of the Facility Policy, titled Care of a Resident With End Stage Renal Disease, dated as revised 04/2022, indicated residents with end stage renal disease (ESRD) would be cared for according to currently recognized standards of care, and the Facility would arrange for the resident to receive dialysis treatment from a dialysis facility. Resident #1 was admitted to the Facility in December 2017, diagnoses included diabetes, ESRD, and dementia. Review of Resident #1's Medication Administration Record (MAR), for August 2024 indicated he/she had a physician's order for nursing staff to transport him/her 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 records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure it maintained complete and accurate medical records when 1) for Resident #1, nursing staff failed to ensure there was documentation of a physician's order to transport him/her to the Hospital Emergency Department on 08/10/24, and 2) for Resident #3, documentation by nursing related to the conduction of weekly skin assessments was not consistently completed. Findings include: Review of the Facility Policy, titled Charting and Documentation, dated 04/2022, indicated that services provided to the resident, any changes in the resident's medical, physical, functional, or psychological condition would be documented in the resident's medical record. 1) Review of the Facility Policy, titled Physician Order, dated 04/2022, indicated physician orders would be maintained in chronological order. Resident #1 was admitted to the Facility in December 2017, diagnoses included diabetes, ESRD, and dementia. Review of Resident #1's Transfer/Discharge Evaluation,…

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

Based on records reviewed and interviews, for 13 of 22 sampled residents (Resident #1, #3, #5, #6, #9, #10, #11, #14, #15, #16, #17, #18, and #22) the Facility failed to ensure nursing staff notified their Attending Physicians when on 06/24/24, during the 07:00 A.M. to 03:00 P.M. shift, the administration of multiple medications to each of these residents, were omitted by nursing. Findings include: The Facility Policy, titled Change of Condition in a Resident Status, dated 03/2017, indicated the Facility would notify the resident's Attending Physician of any changes in the resident's medical condition including accidents or incidents involving the resident. The Facility Policy, titled Oral Medication Administration, dated as revised 04/2022, indicated nursing staff would administer medications as ordered, and would notify the practitioner and document accordingly in the event that a resident refused medications. The Facility Policy, titled Accidents, dated as revised 04/2022, indicated all accidents and incidents would be investigated, including medication errors, and the attending…

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 13 of 22 sampled residents (Resident #1, #3, #5, #6, #9, #10, #11, #14, #15, #16, #17, #18, and #22), the Facility failed to ensure the residents were free from significant medication errors, when on 06/24/24, nursing omitted and did not administer several medications these residents, including critical medications such as insulin doses, anti-hypertensive's, and anticoagulants, placing then at risk for an adverse reaction related to the missed doses of the medications. Findings include: The Facility Policy, titled Medication Monitoring and Management, dated 11/2021, indicated medications would be administered at the frequency and times indicated in the prescriber orders, and medication administrations would be documented. The Facility Policy, titled Oral Medication Administration, dated as revised 04/2022, indicated nursing staff would administer medications as ordered. Review of the Medication Administration Records (MAR) for the following residents indicated the following medication doses were omitted during the 7:00 A.M., to 3:00…

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 meet professional standards of quality for four Residents (#17, #33, #164, and #434), out of a total sample of 41 residents. Specifically, the facility failed to: 1.) For Resident #17, the facility failed to ensure nursing transcribed physician's orders accurately and failed to implement the 24-hour chart check policy to identify and correct improper physician's orders. 2.) For Resident #33, the facility failed to ensure nursing transcribed physician's orders accurately and failed to implement the 24-hour chart check policy to identify and correct improper physician's orders. 3.) For Resident #164, the facility failed to obtain a physician order for the use of a suction machine. 4.) Resident #434 the facility failed to obtain daily weights as ordered. Findings include: 1.) For Resident #17, the facility failed to ensure nursing transcribed physician's orders accurately and failed to implement the 24-hour chart check policy to identify and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide respiratory care services consistent with professional standards of practice for four Residents (#36, #133, #95, #163) out of a total sample of 41 residents. Specifically: 1. For Resident #133 the facility failed to develop and maintain a plan for the care of the nebulizer machine, (a small machine that turns liquid medicine into a mist that can be easily inhaled), mask and tubing. 2. For Resident #36 the facility failed to develop and maintain a plan for the care for the CPAP (continuous positive airway pressure) machine, including the mask, and tubing. 3. For Resident #95 the facility failed to change oxygen tubing per physician's orders 4. For Resident #163 the facility failed to change oxygen tubing per physician's orders. Findings include: Review of facility Procedure, titled Respiratory Equipment/ Supply/ Cleaning/ Disinfection, revised 7/15/21, indicated 5. Schedule for Supply Changes: Oxygen delivery devices should be…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 4 nurses observed made 5 errors out of 25 opportunities, resulting in a medication error rate of 20%. Those errors impacted 3 Residents (#69, #19, and #17), out of 4 residents observed. Findings include: Review of the facility policy, General Dose Preparation and Medication Administration, dated as revised 1/1/22, indicated: 3.7 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. 3.11 Facility staff should not split tablets. 3.12 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure that medications and biologicals were appropriately stored in locked compartments and not accessible to unauthorized individuals, medication with shortened expiration were dated, and topical medications were stored separately from oral medications on four of six units. Specifically; 1.) the facility was observed to have multiple medications and biologicals that were left unlocked at the resident's bedside on two of six resident units for five Residents (#125, #30, #37 #133 and #105), out of a total sample of 41 residents. 2.) the facility failed to ensure the medication cart on one of six units had dated medication when opened and properly stored topical medication from by mouth medication. 3.) the facility failed to ensure that one of six medication rooms was locked and secured. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals, revised 8/7/23, indicated, but was not…

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

Based on observation, record review and interview the facility failed to ensure that care was provided in a manner that promoted dignity and enhanced the quality of life for three Residents (#14, #130, and #132) in a total sample of 41 residents. Specifically, 1. For Resident #14, Resident #130, and Resident #132, the facility failed to provide a dignified meal service and 2. For Resident #132, the facility failed to provide privacy for a Foley catheter bag (a urinary collection bag). Findings include: Review of the facility's policy titled OPS206 Resident Rights Under Federal Law, dated February 2023, indicated: 1. Resident Rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1.1 The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. 8. Privacy and confidentiality: the resident has a right…

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 one Resident (#156) had the right to be informed and provide consent for the administration of psychotropic medication, out of a total sample of 41 residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, dated 10/24/22, indicated the following: - Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations. Resident #156 was admitted in April 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #156 scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident #156 has a health care proxy, and the health care proxy was activated on 10/17/22. Review of the active physician's orders indicated that Resident #156 was…

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

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#37), out of 41 total sampled residents, was assessed for the ability to self-administer medications. Specifically, a nurse left medications unattended with Resident #37 to self-administer without a physician's order and an assessment for self-administration completed. Findings include: Review of the facility policy titled NSG309 Medications: Self-Administration, revised 3/1/22, indicated: -Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined the patient is able to self administer: -A physician/advanced practice provider (APP) order is required. -Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. Resident #37 was admitted to the facility in June 2020 with diagnoses including diabetes and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/6/24, indicated 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 observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#164, and #2), out of 41 total sampled residents. Specifically, 1. For Resident #164, the facility failed to develop a care plan related to the use of a suction machine. 2. For Resident #2, the facility failed to apply braces as indicated in his/her plan of care. Findings include: 1. Resident #164 was admitted in April 2023 with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #164 did not score on the Brief Interview for Mental Status (BIMS) and is severely cognitively impaired. Review of the MDS indicated that Resident #164 is dependent with all activities of daily living. During an observation on 3/19/24 at 11:25 A.M., Resident #164 was lying in bed and had a suction machine sitting on his/her bedside table. The cannister of the suction contained a yellowish/red fluid inside and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide assistance with activities of daily living (ADLs) as needed for one Resident (#130) out of a total of 41 sampled residents. Findings include: Review of the policy titled NSG270 Meal Service dated, June 2021, indicated: Practice Standards: 4. Staff will provide assistance during meal services to meet patient needs. 4.1 Provide cueing, prompting, or assist a patient to eat, when applicable. Resident #130 was admitted to the facility in March 2021 and has diagnosis including but not limited to dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #130 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating a severe cognitive impairment. Review of Resident #130's care plan indicated the following: Provide resident/patient with limited assist with cuing of one for eating, dated 2/16/24. Review of Resident #130's [NAME] (a form indicating a residents care needs) , dated…

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 (#114), out of a total sample of 41 residents, the facility failed to ensure quality of care that met professional standards of practice when Resident #144 sustained two purple and blue areas on his/her skin on his/her left arm, which was not identified by staff performing daily care nor identified by nursing staff performing weekly skin checks in accordance with the physician's orders and plan of care. Findings include: Review of the facility's policy titled Skin Integrity and Wound Management revised 2/1/23, indicated the following: To provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to patients. 6. The license nurse will: evaluate any reported or suspected skin changes or wounds; document newly identified skin/wound impairments as a change in condition, document skin/wound findings on the 24-hour report and perform and document skin inspection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to identify and prevent a decrease in range of motion for one Resident (#48) out of a total sample of 41 residents. Findings include: Review of the facility's policy titled NSG259 Range of Motion and Mobility, dated June 2022, indicated: Policy: Centers will provide services care and equipment to ensure that a patient: Who enters the center without limited range of motion (ROM) does not experience reduction in ROM unless a clinical condition demonstrates that a reduction in ROM is clinically unavoidable; With limited ROM receives appropriate treatment and services to increase and/or prevent further decrease in ROM; With limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Nursing and rehabilitation will collaborate to identify services, care, and equipment based on individual patient…

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 provide care according to professional standards of practice for one Resident (#136) with a gastrostomy tube (g-tube) a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications, out of a total sample of 41 residents. Findings include: Resident #136 was admitted to the facility in February 2024 with diagnoses including dysphagia, diverticulum of esophagus, gastrostomy tube. Review of Resident #136's Minimum Data Set (MDS) dated [DATE] indicated the Resident scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated that the Resident had a gastrostomy tube. Review of the current physician's orders indicated the following: -Enteral feed order continuous for nutrition Nepro 1.8 continuous at 45 ml/hr. (milliliter/hour), 60 ml of free water before and after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1 (c.) Resident #36 was admitted to the facility in January 2024 with diagnoses that include but not limited to end stage renal disease and dependence on renal dialysis. Review of Resident #36's MDS, dated [DATE], indicated he/she scored 11 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #36 as having moderately impaired cognition. Review of Resident #36's medical record indicated the following: -External hemodialysis catheter double lumen CVC internal jugular right tunneled, dated 12/5/2023. -Check smooth clamps at the bedside and on patient wheelchair (if applicable) every shift, dated 12/4/2023. -A care plan focus, risk for impaired renal function and is at risk for complications related to hemodialysis, dated as initiated 1/11/2024, with the intervention dated 1/11/24 maintain smooth catheter clamps at the bedside (and on patient when out of bed) in case of breakage or excessive bleeding from catheter. During an interview on 3/19/24 at 10:40 A.M., Resident #36 said he/she went to…

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

Based on observation, policy review, record review and interview, the facility failed to ensure pharmaceutical services met the needs of each resident for one Resident (#17) in a total sample of 41 residents. Specifically, for Resident #17 the facility failed to ensure routine drugs were available for administration. Findings include: Review of the facility policy, Medication Shortages/ Unavailable Medications, dated as Revised 1/1/22, indicated: 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy. Resident #17 was admitted to the facility in December 2020 with diagnosis including chronic obstructive pulmonary disease, allergic rhinitis, and overactive bladder. Review of the Minimum Data Set (MDS) assessment, dated 1/3/24, indicated Resident #17 had a Brief Interview for Mental Status (BIMS)…

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 two Residents out of a total sample of 41 residents. Specifically, for Resident #2 and Resident #33 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 facility policy titled Behaviors: Management of Symptoms, revised 10/24/22, indicated Complete the Abnormal Involuntary Movement Scale (AIMS) per nursing schedule for patients receiving antipsychotic medications. Review of the Assessment Grid attached to the policy indicated that an AIMS assessment should be completed Upon new order for an antipsychotic and every 6 months when on an antipsychotic. 1. Resident #2 was admitted to the facility in August 2020 with diagnoses that included major depressive…

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 distribute food in a sanitary manner during the breakfast meal. Specifically, ensure the management of pests to prevent the potential contamination of food. Findings include: During an observation on 3/19/24 at 8:39 A.M., the food truck on one of the units was open and contained several trays that had not been passed out. Inside the back of the food truck was a large cockroach climbing up the inside of the food transport truck. The trays were removed from the truck and checked. The surveyor immediately notified the Director of Nursing and she said that she would implement a plan right away to clean all of the food transport trucks.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews for two Residents (#17 and #49) of 41 sampled Residents, the facility failed to ensure nursing maintained accurate documentation. 1.) For Resident #17 the facility failed to ensure nursing maintained accurate documentation in the medical record for a.) nebulizer tubing changes documented as completed and b.) wound treatments documented as completed. 2.) For Resident #49 the facility failed to ensure nursing maintained accurate documentation in the medical record for an implanted port valved catheter that the Resident did not have. Findings include: 1.) For Resident #17 the facility failed to ensure nursing maintained accurate documentation in the medical record for a.) nebulizer tubing changes documented as completed and b.) wound treatments documented as completed. Resident #17 was admitted to the facility in December 2020 with diagnoses including chronic obstructive pulmonary disease, allergic rhinitis, and overactive bladder. Review of the Minimum Data Set…

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

Based on observation, record review and interview the facility failed to ensure infection control practices were implemented to prevent the spread of infection on one of six resident care units. Specifically, 1. staff failed to remove gloves and perform hand hygiene when exiting a resident room and 2. failed to adhere to infection control practices, when staff removed food that was handled and consumed by a resident and placed the food on another resident's tray where it was consumed by the other resident, increasing the risk of communicable infection. Findings include: Review of the facility's policy titled, Infection Control Policies and Procedures, dared 6/30/23 indicated: Hand Hygiene: HCP (Health Care Personnel) will perform hand hygiene per CDC guidelines and policy. Review of the Centers for Disease Control and Prevention, Hand Hygiene Guidance, not dated indicated the following: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) 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 observation, record review and interview, the facility failed to ensure that food is stored, prepared, and distributed in accordance with professional standards in the main kitchen and in four out of six nourishment kitchens. Findings include: Review of the Facility's policy titled Food Storage, revised 9/2017 indicated the following: Dry Goods: All dry goods will be appropriately stored will be appropriately stored in accordance with the Food and Drug Administration Food Code. Procedures: - 1 All items will be stored on shelves at least 6 inches above the floor. -5 All packaged and canned food items will be kept clean, dry, and properly sealed. -6 Storage areas will be neat, arranged for easy identification, and date marked as appropriate. -7 Toxic materials will not be stored with food Cold Foods: All time/temperature control for safety foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDS food code. Procedures: -5 All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner 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, the facility failed to ensure the plan of care was implemented for 6 residents out of a total sample of 36 residents. Specifically, the facility 1) failed to implement orders related to Peripherally Inserted Central Catheter (PICC) line care for 1 Resident (#4), 2) failed to implement orders to offload heels while in bed for 1 Resident (#289), 3) failed to implement an orthotic care plan for 1 Resident (#6), 4) failed to implement orders for skin checks for 2 Residents (#161 and #100), and 5) failed to develop a communication care plan for a non-English speaking resident for 1 Resident (#136) out of a total sample of 36 residents. Findings include: 1. For Resident #4, the facility failed to implement orders related to PICC (a long catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body used when intravenous treatment is required over a long period) line care. Resident #4 was admitted to the facility in November 2022 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 reviews and interviews, the facility failed to provide needed assistance for activities of daily living (ADLs) for 4 Residents (#32, #131, #22 and #161) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, revised 6/01/21, indicated the following: *Based on a comprehensive assessment of the resident/patient (hereinafter patient) and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrates that a change was unavoidable. *Practice Standards: 4. Encourage the patient to perform ADL's as much as the patient is able. -4.2 A patient who is unable to carry out ADL's will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility 1) failed to identify and investigate bruises on unknown origin for 1 Resident (#14) and 2) failed to assess and treat edema for 1 Resident (#100) out of a total sample of 36 residents. Findings include: 1. For Resident #14, the facility failed to assess and investigate a bruise of unknown origin that was not suspected to be abuse. Resident #14 was admitted to the facility in June 2017 with diagnoses including stroke. Review of Resident #14's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating he/she is cognitively intact. On 1/03/23 at 9:07 A.M., Resident #14 was observed lying in bed. He/she had a small green discoloration approximately the size of a quarter resembling a bruise on his/her right hand and dime sized yellow discoloration on his/her left bicep. On 1/03/23 at 1:55 P.M., the surveyor informed Nurse #2 of the two areas on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure that interventions to prevent further weight loss or maintain nutritional status were implemented for 4 Residents (#166, #121 and #138 and #159) out of a total sample of 36 residents. Specifically, for Resident #166 the facility failed to do a re-weigh timely to confirm a significant weight loss, for Resident #121 and #138 staff failed to ensure nutritional interventions were implemented in accordance with the plan of care and for Resident #159 staff failed to obtain weekly weights as ordered. Findings include: Review of the facility's policy titled Weights and Heights dated 6/15/22 indicated the following: Patients are weighed upon admission and /or readmission, then weekly for four weeks and monthly thereafter. Patient height will be measured upon admission, readmission and annually and recorded in the patient's medical record. Additional weights may be obtained at the discretion of the interdisciplinary team. Purpose: to obtain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Findings included: Review of the facility assessment indicated the following: *Staff personal required: 1 full time equivalent (FTE) for Director of Nursing (DON) Registered Nurse (RN) full-time days and Assistant Director of Nursing (ADON), RN full time days; Days: 16 Licensed Nurses for the Center; Evenings: 13 Licensed Nurses for the Center; and Nights: 9 Licensed Nurses for the Center. *Courtyard provides multiple different types of care such as: activities of daily living, mobility and fall with injury prevention, bowel/bladder, skin integrity, mental health and behaviors, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and other special care needs as they arise. The Administrator provided the surveyor with the hours per patient per day (HPPD) report 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.

Based on observation, interview, and policy review, the facility: 1) failed to ensure medications were stored securely and unlocked medication carts were not unattended on 2 of 6 resident care units and 2) failed to ensure outdated medications were not available for administration in 3 of 3 medication rooms and 4 of 6 medication carts inspected. Findings include: Review of facility policy titled 'Storage and Expiration Dating of Medications, Biologicals, revised July 2022, indicated the following: *Procedure: 3.3. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 1. The facility failed to ensure…

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 care was provided in a dignified manner for 1 Resident (#166) out of a total sample of 36 residents. Findings include: Review of the Facility's policy dated 11/28/22, titled Resident Rights Under Federal Law, indicated the following: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. Resident #166 was admitted to the facility in in March, 2022 and has diagnoses that include chronic kidney disease, type 2 diabetes mellitus, metabolic encephalopathy, dysphagia, and dementia. Review of the quarterly Minimum Data Set Assessment with an Assessment Reference Date of 11/17/22 indicated Resident #166 scored 3 out of possible 15 on the Brief Interview for Mental Status Exam, indicating severe cognitive impairment and his/her primary language was not English. Further review of the MDS indicated Resident #166 was dependent on staff…

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 1 Resident (#172) out of a total sample of 36 residents, was free from unnecessary physical restraint when Resident #172 had a recliner and other furniture around the perimeter of his/her bed. Findings include: Review of the facility's policy titled Restraints: Use of, with a revision date of 6/15/22 indicated the following: *Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. *Definitions: Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body; cannot be removed easily by the patient and restricts patients' freedom of movement or normal access to his/her body. *Patients will be evaluated for the use of restraints or protective devices during the nursing…

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 report a potential incident of abuse for 1 Resident (#161) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, dated 4/9/21, indicated the following: * Injuries of unknown source are defined as an injury with both of the following conditions: -the source of the injury was not observed by any person or the source of the injury cannot be explained by the patient -the injury is suspicious because of the extent of the injury or the location of the injury (i.e., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. * immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following: -report allegations no later than two hours after 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 investigate a potential incident of abuse for 1 Resident (#161) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, dated 4/9/21, indicated the following: * Injuries of unknown source are defined as an injury with both of the following conditions: -the source of the injury was not observed by any person or the source of the injury cannot be explained by the patient -the injury is suspicious because of the extent of the injury or the location of the injury (i.e., the injury is located in an area 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 investigated to determine if abuse or neglect as suspected. Resident #161 was admitted to the facility in December 2021 with diagnoses including dementia, adult failure to thrive and abnormal weight loss.…

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 a notice of transfer/discharge was issued for 1 Resident (#160) out of 6 applicable residents in a total sample of 36 residents. Findings include: Resident #120 was admitted to the facility in 12/2021 and has diagnoses that include anemia, hypertension and dementia. Review of the comprehensive Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 11/10/22 indicated Resident #160 scored 1 out of a possible 15 on the Brief Interview for Mental Status Exam indicating severe cognitive impairment. The MDS also indicated Resident #160 is dependent on staff for daily care. Further review of the MDS assessments indicated an MDS dated [DATE] for discharge with return anticipated and an MDS dated [DATE] for re-entry. Review of Resident #160's medical record indicated the following: A Social Service Progress note dated 12/19/22, that Resident #160 was transferred to the hospital. The note failed to indicate if the required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to notify the physician of a new pressure area for 1 Resident (#33) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Change in condition: Notification of, dated 6/1/21 indicated the following: *A center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where it is a significant change in the patient's physical, mental or psychosocial status. Resident #33 was re-admitted to the facility in April 2020 with diagnoses including diabetes mellitus and cerebral infarction. Review of Resident #33's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated he/she had no behaviors, did not reject care and required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise the plan of care for 2 Residents (#4 and #289) out of a total sample of 36 residents. Findings include: 1. For Resident #4, the facility failed to revise the plan of care after documenting the Resident was caught smoking in the facility. Resident #4 was admitted to the facility in November 2022 with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Chronic Obstructive Pulmonary Disease (COPD) and difficulty in walking. Review of Resident #4's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status Exam (BIMS), had no behaviors, did not reject care, required supervision with care activities and received Intravenous (IV) medications. On 1/03/23 at 9:18 A.M., Resident #4 was observed in bed. Resident #4 said he/she is a smoker but doesn't smoke while in the facility. Review of Resident #4's medical record indicated…

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 a) implement a comprehensive plan of care related to a pacemaker (a surgically implanted device used to help control the heartbeat) and b) failed to communicate abnormal lab results to the provider for 1 Resident (#290), out of a total sample of 36 residents. Findings include: 1a.) Review of facility policy titled 'Pacemaker Care' revised 6/01/21, indicated the following: *Upon admission of patient who has a pacemaker: Identify pacemaker type, serial number, and manufacturer of pacemaker, date and site of implementation, and cardiologist's/surgeon's name and document in medical record; contact cardiologist for specifics regarding patient's pacemaker, if available. Resident #290 was admitted to the facility in December 2022 with diagnoses including vascular dementia, end stage renal disease and paroxysmal atrial fibrillation. Review of Resident #290's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide vision services for 1 Resident (#23) out of a total sample of 36 residents. Findings include: Resident #23 was admitted to the facility in August 2020 with diagnoses including diabetes, Alzheimer's Disease, and heart disease. Review of Resident #23's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 indicating he/she has severe cognitive impairment. The MDS also indicated Resident #23 requires extensive assistance from staff for activities of daily living. Review of Resident #23's medical record indicated a signed consent for contracted eye services provider (the company providing vision services to the facility) to provide vision services dated 11/12/20. Review of Resident #23's physician orders indicated the following order written on 8/18/20: *Podiatry, Dental and Ophthalmology Consult and treatment as needed for patient health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide an activity program for 1 Resident (#161) out of a total sample of 36 residents. Findings include: Resident #161 was admitted to the facility in December 2021 with diagnoses including dementia, adult failure to thrive and abnormal weight loss. Review of Resident #161's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #161 requires limited assistance from staff for self-feeding tasks. On 1/3/23, Resident #161 was observed sitting in the dining room, facing the wall from 8:30 A.M., to 2:00 P.M. Other than the times the Resident was provided with meals, there were no staff observed to have interacted with him/her. The television (TV) was on in the dining room, however Resident #161 was unable to see the TV due to him/her facing the opposite wall.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to implement treatment of a new pressure area for 1 Resident (#33) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Skin Integrity and Wound Management, dated 9/1/22 indicated the following: *The licensed nurse staff will: 1) evaluate any reported or suspected skin changes or wounds, 2) document newly identified skin/wound impairments as a change in condition, 3) document skin/wound findings on the 24 hour report, 4) choose wound products per the Wound Treatment Guidelines and Medical Supply Guide. Obtain physician/AAP orders for wound/skin care treatments. Resident #33 was re-admitted to the facility in April, 2020 with diagnoses including diabetes mellitus and cerebral infarction. Review of Resident #33's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated…

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 a functional maintenance program (FMP) was implement when rehabilitation services were discontinued for 1 Resident (#159) out of a total sample of 36 residents. Findings include: Resident #159 was admitted to the facility in October 2022 with diagnoses that include type 2 diabetes mellitus, essential hypertension and chronic kidney disease. Review of Resident #159's most recent Minimum Data Set, dated [DATE] revealed that he/she had a Brief Interview for Mental Status sore of 14 out of a possible 15 indicating that he/she is cognitively intact. Further review of the Resident's MDS indicated that he/she requires extensive assistance with activities of daily living. During an interview on 1/4/23 at 8:03 A.M., Resident #159 said he/she has not walked since Thanksgiving and his/her insurance ran out, so he/she has not seen therapy since then. During an interview on 1/9/23 at 8:05 A.M., Resident #159 said she would like to walk but…

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 incontinence care to 1 Resident (#161) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Continence Management, dated 6/15/22, indicated the following: *Provide routine incontinence care. Resident #161 was admitted to the facility in December 2021 with diagnoses including dementia, adult failure to thrive and abnormal weight loss. Review of Resident #161's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #161 requires limited assistance from staff for self-feeding tasks. On 1/3/23, Resident #161 was observed sitting in the dining room, facing the wall from 8:30 A.M., to 2:00 P.M. Other than the times the Resident was provided with meals, there were no staff observed to have interacted with him/her no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain an order for oxygen (O2) use for 1 Resident (#289) out of a total sample of 36 residents. Findings include: Resident #289 was admitted to the facility in October 2022 with diagnoses including trouble swallowing, type 2 diabetes, and mild-protein calorie malnutrition. Review of Resident #289's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was severely cognitively impaired and scored a 7 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated he/she had no behaviors and did not reject care, required extensive assistance with care activities and had a risk of developing pressure ulcers/injuries. On 1/03/23 at 8:18 A.M., Resident #289 was observed lying in bed. He/she was wearing O2 at 2 liters/min (L/min) via nasala cannula. Resident #289 said he/she wears O2 all the time. Review of Resident #289's medical record on 1/03/23 at 11:40 A.M. failed to indicate any orders for O2 use and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide dental services for 1 Resident (#23) out of a total sample of 36 residents. Findings include: Resident #23 was admitted to the facility in August 2020 with diagnoses including Alzheimer's Disease, diabetes and heart disease. Review of Resident #23's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 indicated he/she has severe cognitive impairment. The MDS also indicated Resident #23 requires extensive assistance from staff for activities of daily living. During interviews on 1/3/23 at approximately 12:30 P.M., and 1/5/23 at 9:32 A.M., Resident #23 was observed to have several missing teeth and the teeth present in his/her mouth were brown in color and his/her bottom right corner tooth appeared broken at the top. Resident #23 was unable to say the last time he/she had been seen by the dentist. Review of Resident #23's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide rehabilitation services for 1 Resident (#76) out of a total sample of 36 residents. Findings include: Resident #76 was admitted to the facility in May 2022 with diagnoses that include multiple sclerosis, atrial fibrillation, generalized anxiety disorder and major depressive disorder. Review of Resident #76's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS revealed that the Resident requires total dependence with transfers and extensive assistance with all activities of daily living. During an interview on 1/3/23 at 2:18 P.M., Resident #76 said he/she has been requesting to see physical therapy for his/her feet as they do not move well and wants to walk. The surveyor observed the Resident's feet to be pointing downward. During an interview on 1/5/23 at 1:12 P.M., the Director…

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 follow infection control protocols to prevent the possible spread of infection by 1) failing to insure a COVID positive resident was kept isolated from non-positive residents and 2) failed to properly use personal protective equipment and glove hygiene to possibly prevent the spread of infection on 1 out of 6 units. Findings include: Review of the facility policy titled, Personal Protective Equipment, dated 11/28/17, indicated the following: *The purpose of using personal protective equipment is to prevent transmission of microorganisms from employee to resident or resident to employee. *Change gloves after contact with each individual resident or after contact with contaminated articles. * Wash hands after removing gloves. 1. On 1/3/23 at approximately 7:30 A.M., the Minimum Data Set Nurse informed the surveyors that Resident #65 was positive for COVID-19. Upon entry to the C Unit on 1/3/23 at 8:00 A.M., the surveyor observed Resident #65's room. The room failed to have a precaution sign or precaution cart outside 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.