Brush Hill Care Center

Based on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (3A), out of four units in the facility. Specifically, the facility failed to ensure residents were involved in activities. Findings include: Review of the facility's policy titled Activity Programs, last revised June 2018, indicated but was not limited to: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities -Activities are considered any endeavor, other than routine activities of daily living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance, physical, cognitive or emotional health -Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting cleanup and critique of the programs -Activities are not necessarily limited to formal activities being provided only by activities…

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

Based on observations, interviews, and record review, the facility failed to implement nutritional interventions as ordered to maintain acceptable parameters of nutritional status for one Resident (#90), with an unplanned gradual weight loss, in a total sample of 24 residents. Specifically, the facility failed to provide as needed nutritional supplements when his/her meal intake was less than 50% as ordered. Findings include: Resident #90 was admitted to the facility in February 2022 with the following diagnoses: dementia, adult failure to thrive, and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/26/24, indicated Resident #90 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #90 was 63 inches, weighted 95 pounds, had experienced weight loss and was not on a prescribed weight loss regimen. Review of Resident #90's medical record indicated he/she had progressive weight loss as evidenced by the following weights: -1/08/24 =…

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

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#19 and #76), out of 24 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, last revised September 2010, indicated but was not limited to: -Policy Statement with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of practice. -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b) how information will be exchanged between the facilities. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, 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 record review and interview, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for three Residents (#31, #112, and #173), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #31, that the prn order for Ativan (antianxiety) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 2. For Resident #112, that the prn order for Valium (hypnotic) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 3. For Resident #173, that the prn order for Valium was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use. Findings include: Review of the facility's policies titled Psychotropic Medication Use and Antipsychotic Medication Use, last revised July 2022, indicated but were not limited 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, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 1 out of 2 test trays conducted. Findings include: During the initial resident screening on 9/17/24, the residents expressed the following concerns about the food at the facility: - Food usually comes up cool - Food is always cold - Food usually comes up cool, even the hot foods - The food is cold sometimes. - Food is often cold; the facility has a tough time controlling that - Food is often cold Review of Food Committee Meeting Minutes, dated 8/27/24, indicated but was not limited to: - French fries are cold Review of Food Committee Meeting Minutes, dated 7/31/24, indicated but was not limited to: - Hard boiled eggs are sometimes undercooked Review of Food Committee Meeting Minutes, dated 4/23/24, indicated but was not limited to: - Food Temps (temperatures) inconsistent On 9/19/24 at 11:53 A.M., the surveyor requested a lunch test tray to the 2A Unit.…

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

Based on observations, interviews, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain the ice machine in a clean and sanitary manner in three out of four kitchenettes. Findings include: Review of the facility's policy titled Ice Machines and Ice Storage Chests, undated, indicated but was not limited to: - Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. - Policy Interpretation and Implementation: - Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures. On 9/17/24 at 10:37 A.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one 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, interview, and policy review, for five Residents (#68, #173, #112, #31, and #19), of 24 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for the following Residents: A. For Resident #68, who has chronic wounds, putting him/her at increased risk for infection; B. For Resident #173, who has wounds and a gastrostomy tube; C. For Resident #112, who has a gastrostomy tube and a tracheostomy; D. For Resident #31, who has an indwelling urinary catheter; and E. For Resident #19, who has a wound, putting him/her at increased risk for infection. Findings include: Review of the Centers for…

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

Based on document review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent…

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

Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), of 24 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance. Findings include: Review of the facility's policy titled Call System, dated as revised September 2022, indicated but was not limited to: -each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #68 was admitted to the facility in March 2020 with the following diagnoses: dementia, venous insufficiency, and chronic wounds to lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident #68 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #68 had impaired mobility to both lower extremities. On 9/17/24 at 10:14 A.M., the surveyor observed Resident #68…

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

Based on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#31), out of a total sample of 24 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of anticoagulant therapy (medication to break down existing clots or prevent clots from forming). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised July 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #31 was admitted to the facility in August 2017 and had diagnoses including a…

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

Based on observations, interviews, and policy review, the facility failed to maintain an environment free of accident hazards. Specifically, the facility failed to ensure smoking material was stored securely for one Resident (#100), out of 17 identified facility smokers, out of 24 sampled residents. Findings include: Review of the facility's policy titled Smoking Policy & Procedure, undated, indicated but was not limited to: -[Facility Name] shall establish and maintain safe resident smoking practices. -No lighters or matches will be retained in the possession of the residents. -All lighting material will be kept with staff to be given out to independent smokers as they go out and shall be returned to the designated area once done with your cigarette, either at the front desk or nurses' station. -Staff will ensure smoking materials are stored safely. Review of the facility provided list of residents who smoke indicated Resident #100 was an independent smoker. Resident #100 was admitted to the facility in April 2024 with the following diagnoses including peripheral vascular disease…

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

Based on record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#31), with a history of trauma, out of a total sample of 24 residents. Findings include: Resident #31 was admitted to the facility in April 2022 with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD- occurs in some individuals who have encountered a shocking, scary, or dangerous situation). Review of the Minimum Data Set (MDS) assessment, dated 7/12/24, indicated that Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had PTSD. Review of the facility's consultant psychiatric service provider's documentation indicated the clinician identified trauma as one of the areas of focus for the therapy sessions on 5/22/24, 6/13/24, and 6/19/24. Review of the…

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

Based on interview and record review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two Residents (#10 and #69), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendations to obtain labs in order to help assess the efficacy of medications. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as revised May 2019, indicated but was not limited to: -the consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports -the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it -copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record 1. Resident #10 was admitted to the facility in August 2023 with diagnoses which included dementia…

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 failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for one Resident (#173), out of a total sample of 24 residents, to ensure medicated mouthwash was not left unsecured and unattended in the Resident's room. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: Medication Storage - The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Resident #173 was admitted to the facility in July 2024 with diagnoses including presence of a gastrostomy (feeding tube). Review of the Minimum Data Set (MDS) assessment, dated 7/17/24, indicated Resident #173 had moderate cognitive impairment as evidenced by a Brief…

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 maintain accurate medical records in accordance with professional standards and practices for two Residents (#19 and #112), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #19, to document weekly comprehensive skin assessment per physician orders; and 2. For Resident #112, to ensure a diagnosis of allergic dermatitis from adhesives, diagnosed by the facility's consultant wound physician, was prominently documented in the medical record as an allergy. Findings include: 1. Review of the facility's policy titled Prevention of Pressure Injuries, last revised April 2020, indicated but was not limited to: - Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. - Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Risk Assessment: 1. Assess 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 one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 12/27/23 Resident #2 reported to a staff member that Resident #1 had acted in a sexually inappropriate manner towards him/her, and although several staff members became aware of the allegation, they did not report the allegation to administration until the following day. Findings include: Review of the Facility's Policy titled Resident Abuse, Neglect, Exploitation, or Misappropriation, dated as revised April 2021, indicated that if resident abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the Facility's Policy titled Resident-to-Resident Altercations, dated as revised September 2022, indicated that facility staff will monitor…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 12/28/23 of an allegation of an unwanted sexual advance made by Resident #1 toward Resident #2 that occurred on 12/27/23, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigating, dated as revised April 2021, indicated the following: -all reports of resident abuse will be thoroughly investigated by facility management, and -the individual conducting the investigation will interview the person reporting the incident and the resident. Review of the Facility's Policy, titled Abuse and Neglect-Clinical Protocol, dated as revised March 2018, indicated the following: -instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, and -the nurse will assess the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on three of three units (Unit 1 A, Unit 2 ABC, and Unit 3). Specifically, the survey team observed: environmental cleanliness concerns in resident rooms, resident showers and hallways which included dirty wall surfaces, wall surfaces in disrepair, missing tiles, floors in need of washing, mouse droppings, dead mice, ants and black flies. Findings include: The surveyor observed the following in room [ROOM NUMBER]: -On 7/11/23 at 8:22 A.M., mouse droppings located in the corner of the room and behind the resident's dresser. Dust and debris were observed on the floors. -On 7/17/23 at 10:03 A.M., mouse droppings were in the corner of the room, beside the resident's dresser and under the heating vent. The surveyor observed the following in room [ROOM NUMBER]: -On 7/13/23 at 9:19 A.M., a dead mouse in the corner of the room on a sticky board. Mouse droppings were observed under 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, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised October 2008, indicated the following: *Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated the following: *The facility recognizes that the critical factors implicated in foodborne illness are: -Poor personal hygiene of food service employees; -Inadequate cooking and improper holding temperatures -Contaminated equipment Review of the current United States Department of Agriculture (USDA) food safety guidelines indicate that undercooked or raw unpasteurized eggs should not be consumed as they pose a significant risk for Salmonella (a potentially serious bacterial food-borne infection),…

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 documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on three of three units. Findings include: During the Resident Group meeting on 7/12/23 at 10:20 A.M., 21 residents were in attendance. Twenty-one out of twenty-one residents in the group indicated that there are rodents on all floors in the building. They said that pest service company comes in but changes nothing. When you report the concerns to maintenance, nothing gets done. They said there are little black bugs everywhere in the building. The group expressed frustration that the facility is fixing everything but the rooms. They said they are upset the facility put in a golf course that nobody uses, and redesigned the lobbies, the pub, and new trees all around perimeter, however; it seems housekeeping is barely working and does not wash floors or the toilets. During an interview on 7/17/23 at 12:51 P.M., 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 observations, interviews, policy review, and record review, the facility failed to provide dignified experiences for four Residents (#140, #4, #108, #142), out of a sample of 40 residents. The facility also failed to provide a dignified dining experience on 2 out of 5 units. Specifically, the facility failed: 1. For Resident #140, to provide a dignified dining experience and dignified age-appropriate activities; 2. For Residents #4, #108, and #142, to ensure a catheter bag was covered for privacy; and 3. To address residents requiring assistance in a dignified manner on 2 out of 5 units. Findings include: Review of the facility's policy titled Quality of Life-Dignity, revised August 2009, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, indicated 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 observations, record review, policy review, and interviews, the facility failed to ensure for two Residents (#24 and #112), who required dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 40 sampled residents. Specifically, the facility failed: 1. For Resident #24, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks; and 2. For Resident #112, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks. Findings include: Review of the facility's policy titled Dialysis Management, dated as revised January 2019, indicated the facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents/patients regardless if the procedure is performed at the dialysis center or at the facility. 16. Assure plan of care indicates which limb contains the vascular access. Blood pressures and draws should not be done on the access arm. 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.

Based on observation, interviews and record review, the facility failed to provide behavioral health services, for one Resident (# 95), out of a sample of 40 residents and 31 residents out of the facility census of 149 residents. Specifically, the facility failed to provide substance abuse counseling services for residents with a history of substance abuse. Findings include: Review of the facility's policy titled 'Providing care to residents experiencing addiction or substance abuse disorder', with no revision date, indicted the following: *Educate residents on how to make better lifestyle choices and enjoy their recovery. This includes providing residents with access to programs and resources that can structure the process for a greater potential for success. Resources include mental health providers and therapists, crisis hotlines, pain management practices and inpatient substance abuse treatment options. Resident #95 was admitted to the facility in July 2018 with diagnoses including a history of alcohol abuse. Review of the Minimum Data Set (MDS) assessment, initiated 6/23/23,…

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 2 out of 4 nurses observed made 3 errors out of 30 opportunities resulting in a medication error rate of 10%. Those errors impacted 2 Residents (#25 and #64), out of 4 residents observed. Findings include: Review of the facility's policy titled Documentation of Medication Administration, dated as revised April 2007, indicated the facility shall maintain a medication administration record to document all medications administered. 2. Administration of medication must be documented immediately after it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g. oral) Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within one hour of their prescribed time. 10. The individual…

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

Based on interview and record review, the facility failed to take into consideration the dietary preferences of each resident. Specifically, the facility failed to accommodate residents' preferences for eating pork. Findings include: During the Resident Group Meeting on 7/12/23 at 10:20 A.M., 17 of 21 residents in attendance said they have been told they are not allowed to have pork because the facility is Jewish owned. The Resident Group said that turkey bacon is not an acceptable alternative and that they want real bacon, real ham and real pork products offered and provided. Resident #116 was admitted to the facility in July 2022 with diagnoses including Anemia. Review of the Minimum Data Set (MDS) assessment, dated 4/18/23, indicated that Resident #116 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. During an interview on 7/14/23 at 12:34 P.M., Resident #116 said he/she has asked for pork but was told that he/she could not have pork because this is a Jewish facility and because the owners of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure bedroom furniture and was in good working condition on one of three resident floors. Findings include: 2nd floor Unit 2A On 9/21/23 between 8:25 A.M., to 9:40 A.M., the surveyor observed the following: room [ROOM NUMBER]: Two broken bureau drawers. room [ROOM NUMBER]: Rusted bathroom trash can with missing lid. room [ROOM NUMBER]: Nightstand drawer unable to be opened. room [ROOM NUMBER]: Nightstand drawer has a broken handle. 2nd floor Unit 2B On 9/21/23 between 9:00 A.M. to 11:40 A.M., the surveyor observed the following: room [ROOM NUMBER]: Window screen missing from middle window. Missing closet door handle. During an interview with the Administrator and Maintenance Director on 9/21/23 at 1:42 P.M., they said they were aware the second floor resident rooms needed repairs. The Administrator and Maintenance Director said they were in the process of replacing broken furniture, but that there had not been sufficient time to complete the large…

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

Based on record review and interviews, the facility failed to ensure that one Resident (#24), out of a total sample of 40 residents, whose right to be informed of, and participate in his/her treatment plan, was honored, when his/her Health Care Agent, which was not invoked, signed Resident #24's advanced directive form, consent to treatment form, consent for wound services form, consent for bed rails form, and consent to psychotropic medication form. Findings include: Review of the facility's policy titled Advanced Directives, dated January 2017, indicated the facility staff will abide by resident advanced directives. Resident #24 was admitted to the facility in March 2023 with diagnoses including diabetes, heart failure, dysphagia, end stage renal disease, and convulsions. Review of the Minimum Data Set (MDS) assessment, dated 7/3/23, indicated Resident #24 can make self understood and he/she can understand others. The Brief Interview for Mental Status indicated a score of 12 out of a possible 15, and he/she had no behaviors. Further review of the MDS indicated Resident #24 had a…

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

NOT CORRECTED Based on observation, record review, policy review, and interview, the facility failed to ensure one Resident (#11) was assessed for the ability to self-administer medications, out of a total sample of 39 residents. Findings include: Review of the facility's policy titled Administering Medications, dated as revised December 2012, indicated medications shall be administered in a safe and timely manner, and as prescribed. Further review indicated that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Resident #11 was admitted to the facility in May 2018 with diagnoses including schizophrenia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 6/16/23, indicated Resident #11 could understand others and he/she could make self-understood. The Brief Interview for Mental Status assessment indicated a score of 11 out of 15, indicating he/she had moderate cognitive…

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

Based on observations, interviews and policy review, the facility failed to implement their Abuse Investigation and Reporting policy for two Residents (#13 and #116) out of a total sample of 16 residents. Specifically, 1) Resident #13 reported to a Certified Nursing Assistant (CNA) that he/she was not provided with incontinence care over night and the CNA failed to promptly report the allegation to any staff, delaying the initiation of an investigation. 2) Resident #116 reported that staff had threatened him/her to the Assistant Director of Nursing (ADON) who had failed to report the allegation to the Administrator or initiate an investigation. Findings include: The facility policy titled Abuse Investigation and Reporting, dated as revised July 2017 indicated: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 1) Resident #13 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 Interview and policy review the facility failed to report an allegation of verbal abuse to the Department of Public Health within 2 hours of when the allegation was made for 1 Resident (#116) out of a total sample of 16 residents. Findings Include: Review of the facility policy titled Abuse Investigation and Reporting, dated as revised July 2017 indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Resident #116 was admitted to the facility in July 2023 with diagnosis including anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated that Resident #116 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. Further review of the MDS indicated Resident #116 requires the extensive assistance of two staff with toileting…

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

Based on record review and interviews, the facility failed to update and revise care plans for two Residents (#19 and #142), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #19, to update a behavior care plan after he/she was involved in two physical altercations with other residents; and 2. For Resident #142, to revise a care plan related to the size of an indwelling catheter. Findings include: 1. Review of the care plan policy titled 'Behavior management/Trauma informed Care', with no revision date, indicated the following: *It is the policy of this facility to provide an interdisciplinary approach for the care of residents who have a diagnosis of a mental disorder. Residents demonstrating changes in behavior and mood shall be evaluated to ensure appropriate interventions. *Diagnosis with resulting behavioral symptoms and approaches shall be placed in the resident specific plan of care and communicated to the care staff and other departments as appropriate. Resident #19 was admitted to the facility in October 2022 with diagnoses including…

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

Based on record review, policy review, and staff interviews, the facility failed to: 1. Implement the facility's policy to obtain a physician's order to administer COVID-19 vaccine for five Residents (#37, #19, #95, #84, and #5); 2. Ensure that a physician's telephone order for a medication was transcribed by the nurse according to professional standards of practice to include the name of the medication being ordered for two Residents (#124 and #45); and 3. Implement a physician's order for an ace wrap for one Resident (#13), out of a total sample of 40 residents. Findings include: 1. Review of the facility's policy titled medication and treatment orders, dated July 2016, indicated the following: -Medications shall be administered only upon written order of a person duly licensed and authorized to prescribe such medication in this state. -Drug and biological orders must be recorded on the Physician's order sheet in the resident chart. -Orders for medications must include. *Name and strength of drug *Number of doses, start and stop date, and/or specific duration of therapy *Dosage…

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

Based on observations, interviews, and record review, the facility failed to provide a language manual to assist staff in communicating with one Resident (#140), out of a sample of 40 residents. Findings include: Review of the facility's policy titled 'Foreign Language', with no revision date, indicated the following: *The facility will maintain an up-to-date language manual for use by staff. *Staff will utilize the manual to assist in communicating with Residents in their dominant language of understanding. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely understood and rarely interviewable. On 7/11/23 at 9:35 A.M., the surveyor observed Certified Nurse's Assistant (CNA) #1 assisting the Resident with breakfast. CNA #1 was struggling to cue and communicate with the Resident in English. No communication book was observed in the room. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to two dependent Residents (#13 and #23), out of a total sample of 40 residents. Specifically, the facility failed to provide assistance with bed mobility and eating. Findings include: 1. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/19/23, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 requires extensive two person physical assistance with bed mobility and one person physical assistance with eating. On 7/11/23 at 8:18 A.M., the surveyor observed Resident #13 lying in bed, with the head of the bed nearly flat. There was a tray table directly in front of Resident #13 with a breakfast tray placed on…

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

Based on observations, record review, and interviews, the facility failed to provide appropriate activities for one Resident (#140), out of a sample of 40 residents. Specifically, the facility failed to provide age-appropriate activities in the Resident's dominant language. Findings include: Review of the facility's policy titled 'Activity Programs', with no revision date, indicated the following: *Activity programs are designed to meet the needs of each resident and are available on a daily basis. *Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. *Social activities are scheduled to increase self-esteem, to stimulate interest and friendships and to provide fun and enjoyment. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, did not indicate a Brief Interview for Mental Status score because the Resident is rarely understood and rarely interviewable. On 7/11/23 at 9:35…

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, policy review, and interviews, the facility failed to: 1. Follow the recommendations of the eye doctor and schedule an appointment with a retina specialist for one Resident (#79); and 2. Develop and implement a plan of care for hearing and communication for one Resident (#142) who required a cochlear implant to maintain his/her hearing and communication, out of a total sample of 40 residents. Findings include: 1. For Resident #79, the facility failed to ensure an appointment with a Retina Specialist was rescheduled after the Resident missed the appointment in December 2022. During that time Resident #79 reports significant deterioration in vision affecting his/her day-to-day life. Review of the facility's policy titled Visually Impaired Resident, Care of, dated as revised March 2021, indicated the following: * While it is not required that our facility provide devices to assist with vision, it is our responsibility to assist the resident and representatives in locating available resources (e.g., Medicare, Medicaid or local organizations), scheduling…

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

Based on observation, interview, and record review, the facility failed to provide proper foot care for one Resident (#83), out of a total sample of 40 residents. Findings include: Resident #83 was admitted to the facility in May 2021 with diagnoses including traumatic brain injury (TBI). Review of the Minimum Data Set (MDS) assessment, dated 5/19/23, indicated that Resident #83 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Further review of the MDS indicated Resident #83 requires one person physical assist with grooming. On 7/11/23 at 9:30 A.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. On 7/12/23 at 9:47 A.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. On 7/12/23 at 12:17 P.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. During an interview on 7/11/23 at 9:30 A.M., Resident #83 said his/her toenails are too…

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, policy review, and interview, the facility failed for one Resident (#108), out of a total sample of 40 residents, to maintain professional standards in the managing and care for urinary catheter devices. Specifically, the facility failed to maintain Resident #108's urinary catheter in a manner to prevent the possibility of infection. Findings include: Review of the facility's policy titled Catheter Care, Urinary, dated as revised September 2014, indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. -Preparation 1. Review the resident's care plan to assess for any special needs -Infection Control b. Be sure the catheter tubing and drainage bag are kept off the floor Resident #108 was admitted to the facility in May 2023 with diagnoses including anxiety, depression, dysphagia, diabetes, atrial fibrillation, and convulsions. Review of the Minimum Data Set (MDS) assessment, dated 6/20/23, indicated Resident #108 did not have behaviors and did not refuse care. The MDS indicated he/she 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.

Based on observation, record review, and interview, the facility failed to address significant weight changes for one Resident (#45), out of a total sample of 40 residents. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, indicated the following: *Weights will be recorded in each unit's Weight Record Chart or notebook and in the individual's medical record. *Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. *The Dietitian will respond within 24 hours if receipt of notification. *The Dietitian will review the Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. *The threshold for significant unplanned weight loss will be based on the following criteria [where…

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

Based on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) was provided in accordance of professional standards of practice and his/her physician's orders for one Resident (#112), out of a total sample of 40 residents. Specifically, Resident #112's physician ordered tube feed was ordered as continuous and did not account for a dialysis schedule and a meal schedule. Findings include: Review of the facility's policy titled, Enteral Feedings- Safety Precautions, dated as revised May 2014, indicated the facility will remain current in and follow accepted best practice in enteral nutrition. Resident #112 was admitted to the facility in February 2023 with diagnoses including cerebral infraction, dysphagia, end stage renal disease, atrial fibrillation, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 5/14/23, indicated Resident #112 required total dependence of one staff member for eating and required a feeding tube. The…

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

Based on observation, interview, and policy review, the facility failed to ensure medications once opened were dated as required on 2 of 4 sampled medication carts. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised April 2007, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. a. On 7/12/23 at 6:52 A.M., the surveyor observed the following on the 2A Medication Cart 2 with Nurse #6: - one bottle of Dorzolamide, Hydrochloride and Timolol Maleate Ophthalmic Solution (eye drops), opened and undated - one bottle of Brimonidine Tartrate Solution 0.2% Ophthalmic Solution, opened and undated - one bottle Pro-Stat liquid protein, opened and undated. Review of manufacturer's guidelines indicated to discard 3 months after opening. During an interview at 7/12/23 at 6:58 A.M., Nurse #6 said that Pro-stat liquid protein and eye drops should be dated when opened. b. On 7/12/23 at 7:19 A.M., the surveyor…

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 maintain an accurate medical record for four Residents (#13, #23, #4, and #112), out of a total sample of 40 residents. Specifically, 1. For Resident #13, the nurses documented in the Treatment Administration Record (TAR) that they had applied ace wraps to the Resident's legs, when they had not; 2. For Resident #23, the nurses documented in the TAR that the Resident was wearing a boot, when he/she was not; 3. For Resident #4, the facility failed to maintain an accurate record for a medication's dose as required; and 4. For Resident #112, the facility failed to ensure nursing maintained an accurate medical record related to the route of administration of a medication. Findings include: 1. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/19/23, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of 15, indicating moderate…

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

Based on observations, policy review, and interview, the facility failed to ensure staff disinfected reusable resident care equipment (a blood pressure cuff) between residents. Findings include: Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated as revised July 2014, indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standards. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. On 7/12/23 at 9:40 A.M., the surveyor observed Nurse #3 obtain a Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. The surveyor continued to observe Nurse #3. On 7/12/23 at 9:55 A.M., Nurse #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure a smoke detector in a resident bedroom, located on the second floor, was free of obstruction and functioned properly. Findings include: On 9/21/23 at 9:07 A.M., the surveyor observed a smoke detector, located on the ceiling in room [ROOM NUMBER], and approximately four feet from the entry door. A clear yellow piece of thin plastic covered the smoke detector, preventing the device from sensing potential smoke in the bedroom. During an interview with Certified Nurse Aide (CNA) #2 on 9/21/23 at 9:10 A.M., she observed the plastic covering the smoke detector in room [ROOM NUMBER]. CNA #2 said she had been unaware the smoke detector had been covered. During an interview with Nurse #1 on 9/21/23 at 9:15 A.M., she observed the plastic covering the smoke detector in room [ROOM NUMBER]. Nurse #1 said she had been unaware the smoke detector had been covered. During interviews with both residents who occupied room [ROOM NUMBER] on 9/21/23 at 9:15 A.M., they…

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.