Adviniacare Newburyport

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 one out of two nurses observed made two errors out of 25 opportunities, resulting in a medication error rate of 8%. Those errors impacted one Resident (#52), out of two residents observed. Specifically, for Resident #52, Nurse #2 failed to administer the correct doses of his/her medications. Findings Include: Review of facility policy titled Medication Administration, dated as revised 10/2022 indicated the following: -3. Medications must be administered in accordance with the orders, including any required time frame. -6. The medications nurse shall assure that the correct medication is administered by checking the physician's order and the medication label. Review of facility policy titled Physician Orders, dated as revised 10/2022 indicated the following: -Medication orders will include: -c. dosage Resident #52 was admitted to the facility in October 2021 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 record reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#49) out of a sample of 27 residents. Specifically, for Resident #49 nursing documented they obtained blood pressure from his/her left arm when they did not. Findings include: Review of the facility policy, titled Charting and Documentations, revised January 2023, indicated, but was not limited to, the following: - All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Resident #49 was admitted to the facility in February 2024 with a diagnosis of dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #49's active physician orders indicated the following order: - No IVs (intravenous)/ blood draws/BP (blood pressure readings) on left…

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 #3), who required extensive assistance of two staff members for transfers, the Facility failed to ensure staff implemented and followed his/her plan of care, when on 01/30/24, Certified Nurse Aide (CNA) #2 transferred Resident #3 by herself without another staff member present to assist and Resident #3 ended up on the floor. Findings Include: The Facility Policy titled, Care Plan-Comprehensive, dated as last revised 10/22/22, indicated that a comprehensive person-centered Care Plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy indicated that the services provided or arranged by the Facility, as outlined by the comprehensive Care Plan shall be provided by qualified persons in accordance with each resident's written plan of care. Resident #3 was admitted to the Facility in January 2024, diagnoses included chronic obstructive pulmonary disease, pneumonia, weakness, lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who during the provision of personal care on the evening shift on 11/09/23 by a staff member (later identified as Certified Nurse Aide (CNA) #3) experienced a fall out of bed when his/her legs slid off the bed, causing his/her lower torso to slide off the bed and him/her landing on both knees on the floor, the facility failed to ensure he/she was provided with quality of care that met acceptable standards of practice, when CNA #3 picked Resident #1's lower torso/legs up off the floor and placed him/her back into bed, however CNA #3 had not notified his/her nurse or anyone one else in nursing about the fall. The following morning, Resident #1 was observed with extensive swelling to his/her right leg, complained of pain to his/her right leg, x-rays revealed he/she had a right femur (thigh bone) fracture, and he/she was transferred to the Hospital Emergency Department for further evaluation and treatment. Findings 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 records reviewed and interviews for one of three sampled residents (Resident #3), who required extensive assistance of two staff members for transfers, the Facility failed to ensure Resident #1 was provided the necessary level of assistance to maintain his/her safety to prevent an incident or accident, when on 01/30/24 he/she was transferred by Certified Nurse Aide (CNA) #2 without the assistance of another staff member and without the use of a gait belt, per Facility Policy, and he/she sustained a fall. Findings Include: The Facility Policy titled, Fall Prevention and Management, dated as revised 01/2023, indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The Facility Policy titled, Gait Belts-Transfers, dated as revised 01/2023, indicated it was the policy of the Facility to utilize gait belts when applicable to promote safety in transfer, ambulation, and balance to minimize the risk of injury to the resident and caregiver. The Policy 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.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was observed with a right swollen leg, complained of pain, and reported to staff that he/she had fallen out of bed, the Facility failed to ensure the Nurse Practitioner's STAT x-ray order was sent to the Radiology Company in a timely manner. Findings Include: The Facility Policy titled Diagnostic Services, dated as revised 01/2023, indicated clinical laboratory and radiology services shall be available twenty-four hours a day, seven days per week, for all residents onsite. The Policy indicated all diagnostic testing procedures shall be performed as ordered by a Physician or licensed independent Practitioner. Resident #1 was admitted to the Facility in June 2022, diagnoses included chronic kidney disease, diabetes mellitus, vascular dementia, muscle weakness, abnormalities of gait, unsteadiness on feet, and essential tremor. Review of the Facility Incident Report, dated 11/10/23, indicated that a Certified Nurse Aide (CNA, later identified as CNA #2) reported Resident #1 stated he/she fell…

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 1) medications with short expirations dates, were dated when opened and 2) Medications were not left in resident's room without an assessment 3) a treatment cart was locked and secured while unattended. Findings include: Review of the facility policy titled 'Medication Storage', revised 10/2022, indicated the following but not limited to: *With the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. *Multi-dose vials which have been opened or accessed (example, needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. *Medications for external use will be stored separately from medications for internal use. Ophthalmic (eye), otic (ear) and nasal (nose) products will be stored separately from other medications for internal use. 1. During a medication pass observation 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 observation, record review and interview, the facility staff failed to ensure that the dietary staff had sufficient competencies to ensure resident safety and the appropriate diet textures were followed. Findings include: Review of the Facility Assessment, dated October 2023, indicated the following are reviewed annually and on hire: - Dementia Training - Explanation of Diets On 10/23/23 at 12:19 P.M., Resident #62 was served a tray with large slices of zucchini, approximately 1.5 inches in size, and dry rice. Review of the facility's therapeutic menu for that day indicated Resident #62 should have received steamed rice covered in gravy or sauce and chopped zucchini. Resident #62's meal ticket indicated: cut up food bite size, mechanical soft. During an observation on 10/24/23 at 12:15 P.M. Resident #53 was prescribed a chopped texture with cut-up solids into bite sized pieces. The Resident received pasta not cut-up, broccoli in full pieces and a full piece of bread. During an interview on 10/26/23 at 10:31 A.M., the Food Service Director said that there has been 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.

Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to: 1) ensure an ongoing QAPI program is implemented and maintained and addressed identified priorities and; 2) ensure the governance and leadership members sustain a QAPI program during transitions in leadership and staffing. Findings include: Review of the facility policy titled QAPI Plan, last reviewed 2/18/22 included, but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care services in an environment of minimal risk. - This facility shall develop, implement, 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 interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to use a systematic approach to determine underlying causes of problems impacting larger systems, develop corrective actions, and monitor effectiveness of its performance improvement activities to ensure improvements are sustained. Findings include: Review of the facility policy titled QAPI Plan, last reviewed 2/18/22 included, but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care services in an environment of minimal risk. - This facility shall develop, implement, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review 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 transmission of communicable diseases and infections. Specifically, the facility failed to: 1) ensure a system was in place for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment; 2) ensure staff utilized the appropriate personal protective equipment prior to entering resident rooms requiring transmission-based precautions for one of two residents (#133) with Clostridium difficile (a contagious bacteria that causes severe diarrhea and inflammation of the colon); 3) ensure staff performed hand hygiene after exiting a room identified as being on contact precaution for C.…

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 implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete antibiotic usage audit tools (Line Listings), 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…

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, policy and Facility Assessment review, the facility failed to provide the designated hours for an Infection Preventionist to carry out the necessary responsibilities of facility's Infection Prevention and Control Program according to the facility's policy. Findings include: Review of the facility policy titled Infection Preventionist, revised 10/2022 indicated the following: - The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. - The amount of time designated to this role should be established by the Facility Assessment - The Infection Preventionist should be an active member of the facility's QAPI Committee - The Infection Preventionist will collect, analyze, and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention and control practices. Review of the Facility Assessment, updated and reviewed with QAPI Committee October 2023 indicated 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 interviews and personnel file review, the facility failed to ensure that 22 of 22 new hires in 2023 were educated on Communication in the facility, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Communication. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed for competencyo, or had dementia training since the current company acquired the facility in January 2023.…

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 personnel file review, the facility failed to ensure that 22 of 22 new hires in 2023 were educated on resident rights, resident bill of rights as well as how to ensure resident safety, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: resident rights, resident bill of rights as well as how to ensure resident safety. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous owner ship. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented,…

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 personnel file review, the facility failed to ensure that 22 of 22 new staff hires in 2023 were educated on abuse, neglect and exploitation training, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Verbal and physical abuse, neglect,, mistreatment, psychological harm and misappropriation of property. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed…

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 personnel file review, the facility failed to ensure that 22 of 22 new staff hires in 2023 were educated on the QAPI (Quality Assurance Performance Improvement) process, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: QAPI process During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed for competency, or had dementia training since the current company…

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 personnel file review, the facility failed to ensure that 22 of 22 new staff hires in 2023 were educated on Infection Control, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: infection control policy and procedure, CDC standard precautions, hand hygiene, disease specific isolation, exposure control plan, bloodborne pathogens including transmission; Hepatitis B vaccine; Personal Protective Equipment (PPE); Tuberculosis Policy and Procedure. -New employee orientation also includes general infection prevention information; introduction to the OSHA Exposure Control Plan and its location, TB education, Personal Protective Equipment (PPE) available to all staff and its location. Hepatitis B vaccine availability, post exposure treatment 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 interviews and personnel file review, the facility failed to ensure that 22 of 22 new staff hires in 2023 were educated in Ethics and Compliance, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: mission statement, quality of care, quality of life. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed for competency, or had dementia training since the current company…

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 personnel file review, the facility failed to ensure that 22 of 22 new staff hires in 2023 were educated on Resident Behaviors, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: the characteristics of our resident population, behavior policy, and dementia training. Review of the facility policy titled, Behavioral Health Services: dated 10/22, indicated the following: *Staff must promote dignity, autonomy, privacy, socialization, and safety as appropriate for each resident and are trained in ways to support residents in distress. *Staff training regarding behavioral health services includes, but is not limited to: a. Recognizes changes in behavior that indicate psychological distress; b. Implementing care plan interventions that are…

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 1) provide a dignified dining experience for the residents on 2 of 3 residents units and 2) failed to maintain a dignified experience by using a privacy bag for a Foley catheter drainage bag for 1 Resident (#24) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Quality of Life- Dignity, dated 10/22, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, respect and individuality. *Residents should be treated with dignity and respect at all times. *Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs. *Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. helping the resident 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 record review, interviews and policy review, the facility failed to 1) investigate an allegation of abuse for 1 Resident (#33) and 2) investigate bruises of unknown origin for 2 Residents (#36 and #49) and 3) have evidence an allegation of abuse for 1 Resident (#26) was thoroughly investigated. out of a total sample of 34 residents. Findings include: Review of the policy titled, Abuse, dated, 10/23/22, indicated the following: -The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. -All alleged violations involving abuse, neglect, exploitation, and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation,record review and interview the facility failed to develop care plans for three Residents (#48, #35, and #75), out of a total sample of 34 residents. Specifically, 1. for Resident #48 the facility failed to develop a care plan for the use of psychotropic medications, 2. for Resident #35 the facility failed to develop care plans with person-centered interventions or measurable goals, and 3. the facility failed to develop a dementia care plan with specific interventions for Resident #75. 1. For Resident #48 the facility failed to ensure a person-centered care plan with measurable goals and interventions for the use of psychotropic medication was developed. Resident #48 was admitted to the facility in January 2023 and has diagnoses that include but are not limited to cognitive communication deficit, dysphagia, unspecified dementia, and Parkinson's disease. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #48 scored 4 out of 15 on the Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1. review the effectiveness of a weight loss supplement and address a significant weight loss in a timely manner for 1 Resident (#73), 2. failed to assess a significant weight loss in a timely manner for 3 Residents (#7, #48, and #63), 3. failed to identify and assess a significant weight gain for 1 Resident (#17), and 4. failed to complete an initial nutrition assessment for 1 Resident (#57), out of a total sample of 34 residents. Findings include: Review of the facility policy titled Weighing the Resident, dated 01/2023, indicated the following: - Weights will be obtained and record: upon admission, weekly for first four weeks, then either monthly or more frequently if clinical condition warrants or as ordered by the physician - Any unplanned weight loss/gain is to be reported to the physician, family/responsible party, dietitian, nursing supervisor and addressed at the weekly At Risk Meetings. Review of the facility policy titled Weight Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staffing was sufficient to meet the activities of daily living needs for residents on 1 of 3 resident care units (Highport Unit). Subsequently, 3 Residents (#23, #133, #31) were not provided positioning, bathing, and incontinence care and the opportunity to get out of bed. Findings include: Review of the Highport Resident Census Roster for 10/22/23 indicated 36 residents resided on the unit. Review of the schedule for 10/22/23 indicated three Certified Nursing Assistants (CNA) were scheduled for the day shift. During an interview on 10/22/23 at 8:00 A.M., CNA #2 said there are only two CNAs working on the unit right now. On 10/22/23 the following was observed on the Highport Unit between 7:42 A.M., through 9:21 A.M. -At 7:42 A.M, the hallway between rooms [ROOM NUMBERS] had foul odors detected. -At 7:55 A.M., two male residents were observed in their room. The room had a strong urine odor. One of the residents was sitting on the side…

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

Based on interviews and personnel file review, the facility failed to ensure that 7 of 7 newly hired staff into the Nursing Department in 2023 were assessed for competency, as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, in October 2023, indicated that the Governing Body included, but was not limited to, the Administrator, Director of Nursing (DON), Assistant Director of Nursing, the Chief Operating Officer and the Medical Director. The Facility Assessment indicated the following: New Admissions: The admissions director reviews as needed with the Administrator, DON, Medical Director, Regional Nurse Consultant, and Staff Educator to ensure staff competencies and staffing needs can be met. - Every new hire must meet- the minimum education and training requirements to hold and maintain their professional licenses and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care,…

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 reviews, policy review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of three nurses observed made four errors in 47 opportunities on two of three units resulting in a medication error rate of 8.51%. These errors impacted four Residents (#14, #12, #60 and #17), out of 7 residents observed during medication administration pass. Findings include: Review of the facility policy titled 'Medication Administration' revised 10/2022, indicated the following but not limited to the following: *Medications must be administered in accordance with the orders, including any required time frame. *As required or indicated for a medication, the individual administering the medication will record in the resident's medical record this may include EHR (Electronic Health Record) if being utilized: -The date and time the medication was administered -The dosage -Route of administration -Any complaints or symptoms for which the drug was administered -Any results achieved and when those results were…

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, policy review and interview the facility failed for 1 Resident (#48), out of a total sample of 34 residents, that informed consent for the administration of an antidepressant medication, including the risk/benefits of the medication and potential side effects, was obtained from the resident representative. Findings include: Review of the facility's policy, entitled Psychotropic Medication, dated as reviewed 10/2022, indicated the following: *The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medication in the long-term care facility to include regular review for continue need, appropriate dosage, side effects, risk and/or benefits. Resident #48 was admitted to the facility in January 2023 and has diagnoses that include but are not limited to cognitive communication deficit, dysphagia, unspecified dementia, and Parkinson's Disease. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #48 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 reviews and interviews, the facility failed provide 1 Resident (#33) the right to choose his/her participation in a group activity out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Quality of Life- Dignity, dated 10/22, indicated the following: -Residents shall be assisted in transporting throughout the facility as needed. -Residents shall be assisted in attending activities of their choice, including activities outside the facility. Resident #33 was admitted to the facility in September 2022 with diagnoses including diabetes, feeding difficulties and glaucoma. Review of Resident #33's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #33 required extensive assistance from staff for mobility throughout the unit and facility. The resident group…

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 notify the physician of a resident's return to the facility following an emergency room visit for 1 Resident (#55), who was diagnosed with urinary tract infection and initiation of antibiotics, out of a total sample of 34 residents, resulting in the delay of antibiotic treatment for two days. Findings include: Resident #55 was admitted to the facility in October 2023 with a diagnosis of a hip fracture, frequents falls, and a history of urinary tract infections. Review of the Minimum Data Set (MDS), dated [DATE] indicated Resident #55 has a Brief Interview for Mental Status (BIMS) score of zero out of a possible fifteen indicating he/she had severe cognitive impairment. The MDS further indicated Resident #55 was dependent for toileting and hygiene. On 10/30/23 at 12:10 P.M., the surveyor observed Resident #55 sitting in the hallway, across from the nurse's station, waiting for lunch. A catheter tube was observed hanging from his/her left…

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 review of the grievance book, interviews and policy review, the facility failed to 1) resolve 3 resident grievances and 2) file a grievance for a lost denture for 1 Resident (#75), out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Grievances dated 10/2022, indicated the following: * The facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form when concerns are expressed. The facility will investigate and resolve resident grievances timely to ensure residents' safety and protect residents' rights. *The Director of Social Work should be the facilities grievance officer and is responsible for facilitating the complaint/grievance process. *The Grievance Officer coordinates adequate and timely handling of grievances/complaints and ensures the grievances/complaints and resolutions are maintained and reviewed with administration routinely. *The resident and/or resident representative following the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and policy review, the facility failed to report an allegation of abuse to the State Agency for one Resident (#33) out of a total sample of 34 residents. Findings include: Review of the policy titled, Abuse, dated, 10/23/22, indicated the following: *The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. *Staff should notify the shift supervisor/charge nurse/manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. *Once an allegation of abuse has been made, the supervisor who initially received…

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 staff interviews, the facility failed to allow 1 Resident (#48) out of 34 sampled residents, to return to the facility following a transfer to the hospital for psychiatric evaluation, failed to document any information to support the basis for discharge despite having been cleared by hospital staff to return, and refused to allow the Resident to return citing that he/she was financially unable to pay for his/her bill. Findings include: Resident #48 was admitted to the facility in January 2023 with diagnoses including dementia and Parkinson's Disease. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. Review of Resident #48's medical record indicated he/she was sent out to the hospital on [DATE] 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, interviews and policy review the facility failed to update and revise the plan of care at the time of the comprehensive quarterly review for three Residents (#62, #24 and #7) when their plan of care changed, out of a total sample of 34 residents. Specifically, 1. for Resident (#62) who has a known history of choking twice at the facility, requiring the Heimlich maneuver, the care plan was not updated to reflect the current level of supervision and assist he/she requires with meals and 2. for Resident #24 the facility failed to revise by not discontinuing a care plan related to urinary incontinence and use of a external urinary collection system, and 3. failed to update and revise the fall care plan for Resident #7 after he/she had a fall resulting in a fracture. Findings include: The facility policy titled Care Plan-Comprehensive, dated as revised 10/22/22, indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to meet professional standards of practice during a medication pass. Specifically, 1. during a medication pass a nurse was observed crushing medications without physician orders for one Resident (#60) out of a total 5 residents observed, 2. the facility failed to ensure for two Residents (#50 and #24) that medication were administered timely and 3. the facility failed to adhere to professional standards of care on one of three resident units (Highport Unit), when staff left before the end of their shift and failed to provide report for the oncoming shift. Findings include: Review of facility policy titled 'Medication Administration' date revised 10/2022, indicated the following but not limited to: -Medications must be administered in accordance with the orders, including any required time frame. On 10/22/23 at 10:54 A.M., Nurse #2 was observed preparing, and administering morning medications to Resident #60, Nurse #2 crushed all the…

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

Based on observation, record review and interview, the facility failed to provide care and services in accordance with physician's orders and wound physician's recommendations for one Resident (#286) out of a total sample of 34 residents. Specifically, the facility failed to perform wound care dressing to the left lower extremity hematoma (front of lower leg) as ordered. Findings include: Resident #286 was admitted to the facility in October 2023 with diagnoses including nontraumatic hematoma of soft tissue, repeated falls. Review of Resident #286's Minimum Data Set (MDS) assessment, dated 10/16/23, indicated Resident #286 scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) score which indicated moderately impaired cognition. During a observation and interview on 10/22/23 at 8:01 A.M., the surveyor observed Resident #286 lying in his/her bed. Resident #286 said (using Google translate) he/she had a wound on his/her leg and proceeded to show the surveyor. The surveyor observed a large open wound to the front of the left lower leg. The wound was not covered,…

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, policy review and interviews, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers for three Residents (#286, #17 and #31) out of a total sample of 34 residents. Findings include: Review of facility policy titled 'Pressure Wound Prevention' dated as revised 1/2023, indicated the following but not limited to: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -When in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by physician. Review of the facility policy titled 'Supportive surfaces- Air Mattress' date revised October 2022, indicated the following but not limited to: -To assist in the treatment and/or prevention of pressure ulcers as part of a holistic program of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure 1 Resident (#24) out of a total sample of 34 residents was provided the correct Foley catheter (a Foley catheter is a tube that drains urine from the bladder) in accordance with the medical plan of care. Resident #24 was admitted to the facility in March 2023 and has diagnoses that include but are not limited to neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessments dated 3/20/23, 6/13/23 and 8/24/23 indicated Resident #24 has an indwelling urinary catheter. Further, the MDS dated [DATE] indicated Resident #24 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status exam and was dependent on staff for all care. During an interview and observation 10/22/23 at 8:25 A.M., Resident #24 was observed with a urinary collection bag hanging on the side of his/her bed. Resident #24 said he/she has used a catheter for a long time due to retention. Resident #24 said he/she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically the facility failed to 1. follow physician orders for oxygen setting for one Resident (#292), and 2. failed to administer oxygen in accordance with the physician's orders and failed to develop a plan of care for oxygen use for one Resident (#23) out of a total sample of 34 residents. Findings include: Review of facility policy titled 'Oxygen Administration' date revised 10/2022 indicated the following but not limited to: -Oxygen is administered by Licensed Nurses with a physician's order in order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (As needed). -Check the physician order. If it is unclear, clarification must be obtained. 1. Resident #292 was admitted to the facility in October 2023 with diagnoses…

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 ensure that one Resident (#37) was seen by a physician every 90 days out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Physician Visits, dated 10/22, indicated the following: *The Attending Physician will visit residents in a timely fashion, consistent with the applicable state and federal requirements, and dependent on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. *The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every 60 days thereafter. Resident #37 was admitted to the Facility in September 2022 with diagnoses including heart failure and diabetes. Review of Resident #37's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 15 out of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews, the facility failed to provide behavioral psychiatric services for one Resident (#48) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Behavioral Health Services:, dated 10/22, indicated the following: *The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. *Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. *Residents who exhibit signs of emotional/psychosocial distress receive services and support to address their individual needs and goals for care. *Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. Review of the facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure staff had appropriate competencies and skill sets to provide nursing and related services to attain the highest practicable psychosocial well-being for one Resident (#48) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Behavioral Health Services:, dated 10/22, indicated the following: *Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. *Staff training regarding behavioral health services includes, but is not limited to: a. Recognizes changes in behavior that indicate psychological distress; b. Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; c. Monitoring care plan interventions and reporting changes in condition; d. Protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide sufficient and appropriate social services to meet one Resident's (#48) needs out of a total sample of 34 residents. Findings include: Resident #48 was admitted to the facility in January 2023 with diagnoses including dementia and Parkinson's Disease. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. During an interview on 10/30/23 at 1:45 P.M., Resident #48's daughter and health care proxy said she does not believe the facility is managing the Resident's care well and she has not been kept up to date with his/her treatment plan, especially in regards to behavioral/psychiatric care. Review of Resident #48's medical record indicated the following nursing notes:…

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 pharmacy recommendations were reviewed and addressed by the attending physician for one sampled Resident (#297) out of a total of 34 sampled residents. Findings include: Review of the facility policy titled 'Pharmacy Consultant Medication Review' date revised 1/2023, indicated the following but not limited to: *The pharmacy consultant reviews each medication regimen of all residents in the facility once per month. *The pharmacy consultant will document his/her findings and recommendations on the monthly drug/regimen review. *The pharmacy consultant should report irregularities to the attending physician, medical director, and director of nursing with the resident's medication regimen. *The unit manager/designee will notify the resident's physician of the pharmacy consultant's recommendations and document in the resident's chart that this is done. Resident #297 was admitted to the facility in August 2023 with diagnosis including, anxiety, right femur fracture. Review of Resident #297's Consultant Pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility 1) failed to ensure a diagnosis was in place for the use of antipsychotic medications for one Resident (#48) and 2) failed to complete an Abnormal Involuntary Movement (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) for one Resident (#75) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Antipsychotic Medication Use, dated 10/22 indicated the following: *Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re review. *Residents will only receive antipsychotic medications when necessary to treat specific…

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 as needed (PRN) orders for psychotropic medications were limited to 14 days and the orders were not renewed unless the attending physician or prescribing practitioner evaluated the Resident for the appropriateness of that medication for two Residents (#297 and #73) and failed to ensure a psychotropic medication was not continued to be administered after a three day trial for one resident (#48), out of a total sample of 34 residents. Findings Include: Review of facility policy titled 'Psychotropic Medication' date revised 10/2022 indicated the following but not limited to: *The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. *The need to continue as needed orders for psychotropic medications beyond 14 days requires that 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, policy review and interviews, the facility failed to provide dental services to replace a missing partial denture for one Resident (#75) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Dentures, dated 10/22, indicated the following: *If dentures are damaged or lost, residents should be referred for dental services within three (7) (sic)days. Documentation will be completed regarding what is being done to ensure the resident is able to eat and drink adequately until seen by dentist. Resident #75 was admitted to the facility in August 2023 with diagnoses including dementia. Review of Resident #75's most recent Minimum Data Set, dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, which indicated he/she had moderate cognitive impairment. During an interview on 10/22/23 at 12:30 P.M., Resident #75 said he/she was missing a bridge (partial denture) for about 2 months.…

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 keep an accurate medical record for one Resident (#17) out of a total sample of 34 residents. Specifically, for Resident #17 the facility documented in the Treatment Administration Record (TAR) that ordered treatments were provided that were not. Findings include: Resident #17 was admitted to the facility in July 2021 and has diagnoses that included hemiplegia affecting left non-dominant side and DTI (deep tissue injury) to the right distal, lateral foot and the left distal, lateral foot. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/5/23, indicated that on the Brief Interview for Mental Status exam Resident #17 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #17 required extensive physical assistance for all activities of daily living. Review of the most recent Licensed Nursing Summary, dated 8/31/23 indicated Resident #17 is totally dependent for dressing, grooming and personal hygiene. The Summary indicated 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 records reviewed and interviews for one of three sampled residents (Resident #2), who upon admission was noted to multiple skin issues including the presence of non-pressure related wounds to his/her bilateral lower extremities, the Facility failed to ensure they developed and implemented a Comprehensive Person-Centered Care Plan related to his/her actual wounds, that included treatment interventions, measurable goals, and objectives with established timeframes related to the promotion of wound healing and the prevention of wound deterioration. Findings Include: The Facility Policy titled, Care Plan-Comprehensive, dated as revised 10/22/22, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy indicated the comprehensive, person-centered care plan will include measurable objectives, describe services that are to be furnished to attain the resident's highest practicable physical, mental, 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 reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at risk for altered nutritional status which included the potential for weight loss, the Facility failed to ensure Resident #1's nutritional status including body weight was monitored appropriately by nursing and per facility policy, and that meals percentages consumed were adequately monitored by nursing in an effort to help him/her maintain acceptable parameters of nutrition to prevent unplanned/undesired weight loss. Findings Include: The Facility Policy titled Weight Assessment and Interventions, dated as revised 05/2019, indicated: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for residents. -Nursing staff will measure resident weights within twenty-four hours of admission, weekly for four weeks, and then monthly thereafter. -Monthly weights would be obtained each month or as ordered by the Physician. -Weights would be recorded in the medical record (electronic health record where available) for each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #2), who had a history of clostridium difficile (c-diff, an intestinal bacteria that causes diarrhea), the Facility failed to ensure stool sample laboratory results were promptly reported to his/her Health Care Providers (Physician or Physician Assistant). On 05/31/23 Resident #2's laboratory results from his/her stool sample were reported to the Facility via phone by the laboratory, however the results were not reported to his/her Health Care Provider until the following day. Findings Include: The Facility Policy titled Diagnostic Services, dated as revised 01/2023, indicated clinical laboratory and imaging services shall be available twenty-four hours a day, seven days a week for all residents onsite. The Policy indicated results should be called to the ordering Physician in an organized timely manner. Resident #2 was admitted to the Facility in April 2023, diagnoses included heart failure, hypertension, chronic obstructive…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who experienced a fall, and for whom they had obtained Physician's Orders on 07/03/22 for a STAT x-ray of his/her left arm, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders. On 07/03/23 an x-ray was obtained of Resident #1's left hand only and not of his/her left arm. Resident #1 was transferred to the Hospital Emergency Department on 07/04/23 for a left arm x-ray and results revealed a left arm fracture and he/she returned to the Facility with his/her left arm in a sling. Findings Include: The Facility Policy titled Diagnostic Services, dated as revised 01/2023, indicated clinical laboratory and radiology services shall be available twenty-four hours a day, seven days per week, for all residents onsite. The Policy indicated all diagnostic testing procedures shall be performed as ordered by a Physician or licensed independent Practitioner. The Policy indicated the results should be called to the ordering Physician in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure they maintained complete and accurate Medical Records when Certified Nurse Aide Activity of Daily Living (ADL) Flow Sheet documentation was not consistently completed for Resident #1 during the Months of June 2023 and July 2023 and for Resident #2 during the month of May 2023. Findings Include: Review of the Facility Policy titled Charting and Documentation, dated as revised 01/2023, indicated all services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. The Policy indicated that Certified Nursing Assistants (CNAs) may make entries in the resident's medical record for all care rendered to residents such as activity of daily living (ADL) care, food and fluid consumption. The Policy indicated CNAs were encouraged to document care as close to the completion of task as possible and if 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.