The Mansion at Brigham

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift (on 10/04/24 into 10/05/24) was found sitting on the floor by Nurse #1 and Certified Nurse Aide (CNA) #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. The following day shift (7:00 A.M. to 3:00 P.M.) Resident #1 verbalized complaints of pain, reported he/she had fallen during the previous overnight shift, and was transferred to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and fractures of S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). Findings include: Standard Reference:…

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 annually conduct, review, and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Findings include: Review of the facility policy titled, Facility Assessment, dated as 3/4/24, indicated this facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process. 10. The facility assessment will be reviewed 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 observations and interviews, the facility failed to ensure residents on two of two units experienced a homelike dining experience. Findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, dated 3/4/24, indicated that it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. On 9/10/24 between 8:00 A.M., to 9:00 A.M., the surveyors observed Residents on the first floor and second floor being served hot coffee in Styrofoam cups, hot cereal was served in in Styrofoam bowls, and plastic cutlery was utilized for residents. On 9/10/24 at 12:17 P.M., the surveyor observed on the first floor 6 of 6 residents being served their lunch meals on trays in the main dining room and 5 of 6 residents being served their lunch meals on trays with plastic cups and plastic cutlery in the secondary dining area on 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, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for four Residents (#4, #23, #25 and #47), out of a total sample of 17 residents. Specifically: 1.) For Resident #4, the facility failed to implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. 2.) For Resident #23, the facility failed to develop personalized mood, behavior, and substance abuse care plans. 3.) For Resident #25, the facility failed to develop a comprehensive care plan for dialysis and antidepressant medication. 4.) For Resident #47, the facility failed to develop a comprehensive care plan for post-traumatic stress disorder (PTSD) and the use of psychotropic medication. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 3/4/24, indicated: - It is the policy of the facility to develop and implement a comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a plan of care for dialysis and failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#25), out of 17 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia, and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the physician's orders dated September 2024 failed to indicate a physician's order for hemodialysis. Review of the dialysis communication book indicated 3 undated Dialysis…

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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: During the Resident Group interview on 9/10/24 at 1:00 P.M., the Resident Group expressed concern about certified nurse assistant (CNA) staffing. The Resident Group said they do not feel there is enough CNAs, and they often must wait too long for their call lights to be answered. On 9/11/24 at 1:50 P.M., the Chief Nursing Officer (CNO) said there was no facility assessment for the facility. The CNO gave the surveyor a list of current staffing needs for direct care staff. The CNO said this does not include any supervisors. The CNO said the following staffing was determined to be necessary based on the facility needs since at least April 1, 2024: *Nurses - 7-3: 2 - 3-11: 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide Substance Abuse Services for one Resident (#47) out of a sample of 17 Residents, and additionally failed to provide Substance Abuse Services for 6 additional Residents identified by the Social Worker. Findings include: A review of the facility policy titled 'Safety for Residents with Substance Abuse Disorder' with a revision date of 3/4/24 indicated the following: -It is the policy of this facility to create an environment that is free of accident hazards as possible, for residents with a history of substance use disorder. -Substance use disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted…

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 to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#33 and #47) out of a total sample of 17 residents. Findings Include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations dated 10/1/19, indicated that comments and recommendations concerning medication therapy are communicated in a timely fashion. Further review indicated that in the event that a problem requiring the immediate attention of the prescriber, the responsible prescriber is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere is the medical record. 1.) Resident #33 was admitted to the facility in April 2023 with diagnoses including but not limited to dementia and anxiety. Review…

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 ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication room on two of two units. Findings include: Review of the facility policy titled Medication Storage, dated 3/4/24, indicated that all drugs and biological's will be stored in locked compartments (i.e. medication rooms). Further review of the policy indicated that only authorized personnel will have access to the keys to the locked compartments. On 9/10/24 at 8:33 A.M., the surveyor observed the medication room on the first floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. On 9/11/24, at 7:51 A.M., the surveyor observed the medication room on the second floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. During an interview on 9/11/24 at 8:11 A.M. Nurse #1 said she left the medication room open after she went…

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 they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to: 1.) Maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, and 2.) For Resident #19 the facility failed to obtain an albumin level (a test that can help determine liver disease or kidney disease, or if the body is not absorbing enough protein). Findings include: 1.) On [DATE] at 8:30 A.M., during the entrance conference the surveyor requested the facility's CLIA certificate. Review of the facility policy titled, Laboratory Testing Waivers, dated [DATE], indicated the facility will ensure that laboratory services are provided to its residents in a manner that meets State and Federal regulations. 1. An application for a Clinical Laboratory Improvement Amendments (CLIA) will be made through the appropriate State agency for services 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.

Based on observations, interviews and facility assessment review, the facility failed to have sufficient number of staff to effectively carry out the function of food and nutrition services. Findings include: A review of the Facility assessment dated /completed on 9/12/24 indicated the following: -Dietary-270 hours. On 9/10/24 at 7:08 A.M., the surveyor observed [NAME] #1 in the kitchen preparing breakfast for the residents. During an interview on 9/10/24 at 7:10 A.M., [NAME] #1 said there should be at least three staff in the kitchen on each shift, he said he is trying to get a Dietary staff to come in and work with him. [NAME] #1 said they have not had a Food Service Director for a while, he said one was hired but she is still in orientation. On 9/11/24 at 7:32 A.M., the surveyor observed Dietary staff #1 and Dietary staff #3 in the kitchen preparing breakfast. During an interview on 9/11/24 at 7:35 A.M., Dietary staff #1 said they never have enough staff in the kitchen. She said they should at least have three staff on each shift. On 9/11/24 at 11:25 A.M., the surveyor observed…

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, staff interviews, and record review, the facility failed to ensure that staff accommodated food preferences for four Residents (#17, #14, #2, and #10), out of a total sample of 17 residents. Specifically, 1.) For Resident #17, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 2.) For Resident #14, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 3.) For Resident #2, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including ham. 4.) For Resident #10, the facility failed to honor the Resident's preferences. Findings include: Review of the facility policy titled Menus and Adequate Nutrition, dated 3/4/24, indicated: - The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. 4. Menus must reflect input from residents…

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 review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility policy titled, Frequency of Meals, dated 3/4/24, indicated the facility will ensure that each resident receives at least three meals daily without extensive time lapses. 1. The facility has scheduled three regular meal times, comparable to normal mealtimes in the community, per day and has scheduled three regular snack times. 3. There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this meal time span. 5. Nutritious snacks and convenience foods (i.e., canned soups, peanut butter, crackers, cereal, and fruit) shall be available on the nursing units for those residents who request food outside scheduled meal and snack times. 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, interviews and policy review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date food in the refrigerator, store food in the freezer with dates opened and expiration dates and failed to store food directly off the floor. Findings include: A review of the facility policy titled 'Storage' effective November 2013 indicated the following: -Policy-To store food in a safe manner. -Dry Storage 4. Store products on shelves no less than six inches from the floor. -Refrigerator Storage 1. Store perishable foods in the refrigerator. 6. Label products with delivery date indicating month and year the product was received. 8. Label all leftovers with recipe name and date (month, day, and year) of storage. -Freezer Storage 5. Label products with delivery date indicating month and year the product was received. On 9/10/24 at 7:20 A.M., the surveyor observed the following in the refrigerator in the kitchen: -Five heads of lettuce wrapped in plastic placed directly on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure they maintained complete and accurate medical records for four Residents (#22, #2, #28, and #23) out of a total sample of 17 residents. Specifically: 1.) For Resident #22, the facility failed to document weights in the Electronic Health Record (EHR). 2.) For Resident #2, the facility nurses documented a broken BiPAP was being used, when it was not. 3.) For Resident #28, the facility failed to document services provided each shift by the Certified Nurse Aide (CNA). 4.) For Resident #23, the facility failed to document weights in the medical record. Findings include: Review of the facility policy titled Documentation in Medical Record, undated, indicated: - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. - Licensed staff and interdisciplinary team…

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, interview and policy review, the facility failed to ensure residents were treated with dignity for one Resident (#28) out of a total sample of 17 residents. Specifically, for Resident #28, the facility failed to provide assistance with removal of unwanted chin hair. Findings include: Review of the facility policy titled Promoting/Maintaining Resident Dignity, dated 3/4/24, indicated that it is the practice of this facility to protect resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. Further review of the policy indicated that residents are to be groomed and dressed according to resident preference. Resident #28 was admitted to the facility in March 2021 with diagnoses including heart disease, kidney disease and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide a notice of transfer and failed to send a copy of the notice to the Ombudsman for one Resident (#30) and the facility failed to send a copy of the transfer notice to the Ombudsman for one Resident (#22) out of a total sample of 17 residents who were transferred to the hospital. Findings include: A review of the facility policy titled 'Transfer and Discharge (including AMA)', revised in March 2024, indicated the following: - Transfer and discharge include movement of a resident outside of the certified facility whether that bed is in the same physical place or not. 12. Emergency Transfers/Discharges initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. (g) Provide a notice of transfer to the resident and representative as indicated. (h) The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman. 1.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a bed hold policy for two Residents (#30 and #22) out of a sample of 17 residents. Specifically, the facility failed to provide a facility bed hold policies to the Residents or Resident Representatives before Resident #30 and Resident #22 were transferred to the hospital. Findings include: A review of the facility policy titled 'Transfer and Discharge (including AMA)', revised in March 2024, indicated the following: - Transfer and discharge include movement of a resident outside of the certified facility whether that bed is in the same physical place or not. 12. Emergency Transfers/Discharges initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. (g) Provide the facility's bed hold policy to the resident and representative as indicated. 1.) Resident #30 was admitted to the facility in July 2024 with diagnoses including dementia. A review of the most recent…

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 its staff completed a Preadmission Screening and Resident Review (PASRR - a federal and state required process that is used to identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities in all individuals seeking admission to a nursing facility), in a timely manner after the expected length of stay exceeded 30 days for one Resident (#14) with SMI, out of 17 sampled residents. Findings include: Review of the facility policy titled Resident Assessment - Coordination with PASARR [sic] Program, dated 3/4/24, indicated: 9. If a resident who was not screened due to an exception and the resident remains in the facility longer than 30 days: e. The facility must screen the individual using the State's Level I screening process to the appropriate state-designated authority for Level II PASARR [sic] evaluation and determination. Resident #14 was admitted to the facility in August 2024 with diagnoses including bipolar disorder and depression. Review of the PASRR Level I Screening,…

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 to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for three Residents (#25, #47 and #49), in a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #25, a baseline care plan was developed for the Resident's dialysis treatment. 2. For Resident #47, a baseline care plan was developed. 3. For Resident #49, a baseline care plan was developed. Findings include: Review of the facility policy titled Comprehensive Care Plans dated 3/4/24, failed to indicate that a baseline care plan would be developed to ensure the minimum healthcare information necessary to properly care for each resident upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury,…

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 staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for two Residents (#14 and #47) out of a total sample of 17 residents. Specifically: 1.) For Resident #14, the facility failed to update the comprehensive care plan to indicate a new change in advanced directives from full code to do not resuscitate (DNR) and failed to ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment. 2.) For Resident #47, the facility failed ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 3/4/24, indicated: - The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS…

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 provide services that met professional standards of quality for one Resident (#19) out of a sample of 17 Residents. Specifically, for Resident #19 the facility failed the ensure nursing implemented an air mattress setting according to the physician's order. Findings include: Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the facility policy titled, Use of Support Surfaces, dated as 3/4/24, indicated that support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. 5. Except for the facility's standard mattresses and wheelchair cushions, support surfaces will be utilized in accordance with physician orders. 6. Support surfaces will be utilized in accordance with manufacturer recommendations (including considerations for contraindications) 7. For powered devices, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning 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.

Based on observation, record review, and interview, for one Resident (#34) out of a total sample of 17 residents, the facility failed provide services and treatment for a resident who was assessed to have a reduction in range of motion of his/her left hand. Findings include: Review of the facility policy titled, Brace and Splint Program, dated as revised January 2020, indicated the facility will ensure that any resident with a limited range of motion receives treatment and services to increase range of motion and prevent further decrease in range of motion. The facility will ensure that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline of range of motion. - If a resident enters the facility with a brace or splint, or if there is evidence of a decrease in range of motion and/or contractures are evident a physician's order will be obtained for a therapy evaluation. - If it is determined that a brace or splint is appropriate/needed a physician's order will be obtained and will define the following information: a. Where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the size of an indwelling urinary catheter was documented in the physician's orders for one Resident #23 out of a sample of 17 Residents. Findings include: A review of the facility policy titled 'Catheter Care' with a revision date of 3/4/24 indicated the following: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Resident #23 was admitted to the facility in July 2024 with diagnoses including retention of urine. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #23 had an indwelling catheter. On 9/10/24 at 9:24 A.M., and 9/11/24 at 9:09 A.M., Resident #24 was observed in bed with a Foley (urinary) catheter in place. A review of the Nurse's progress note dated 8/25/24 indicated the following:…

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

Based on observation, record review and interview for one Resident (#19) of 17 sampled residents the facility failed to ensure acceptable parameters of nutritional status were maintained. Specifically, for Resident #19, a resident with weight loss, the facility failed consistently provide fortified foods and nutritional supplements. Findings include: Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated that Resident #19 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. This MDS indicated Resident #19 was dependent on staff for eating and had experienced weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and received a mechanically altered diet. On 9/10/24 at 8:58 A.M., the surveyor observed Resident #19's breakfast tray which included the following: - Cream of wheat with cinnamon, regular apple juice, eggs, and pureed bread. Review…

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

Based on observation, record review, and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach) for one Resident (#34) out of a total sample of 17 residents. Specifically, for Resident #34 the facility failed to administer enteral feedings in accordance to manufactures guidelines (product exceeded the expiration date). Findings include: Review of the facility policy titled, Care and Treatment of Feeding Tubes, dated as 3/4/24, indicated it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: p. Ensuring that the selection and use of enteral nutrition is consistent with manufacturer's recommendations. r. Ensuring that the product has not exceeded the expiration date. Resident #34 was admitted to the facility in May 2024 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.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#2 and #22), out of a total sample of 17 residents. Specifically: 1.) For Resident #2, the facility failed to ensure a bilevel positive airway pressure (BiPAP) machine, which is a device which assists with breathing, was repaired after identifying it was unable to be utilized because it was broken. 2.) For Resident #22 the facility failed to ensure nursing consistently provided respiratory care in accordance with professional standards of practice. Findings include: 1.) Review of the facility policy titled Noninvasive Ventilation (CPAP), BiPAP, AVAPS, Trilogy TM), undated, indicated: - Replace equipment immediately when it is broken or malfunctions. Resident #2 was admitted to the facility in August 2017 with diagnoses including sleep apnea (a respiratory condition in which your breathing stops and restarts many times while you sleep) and asthma. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated 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 record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#47), who was admitted to the facility with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 17 sampled residents. Findings include: Review of the facility policy titled Trauma Informed Care dated 3/4/24, indicated that the facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . Further review indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to indicate the duration of a PRN (as needed) psychotropic medication for one Resident (#23) out of a sample of 17 residents. Specifically, the facility failed to indicate the duration of a PRN (as needed) antipsychotic medication. Findings include: A review of the facility policy titled 'Use of Psychotropic Medication', with a revision date of 3/4/24, indicated the following: - PRN orders for all psychotropic drugs shall be used only when the medications is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). - If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration of the PRN order. Resident #23 was admitted to the facility in July 2024 with diagnoses including borderline personality disorder,…

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 ensure that the physician ordered therapeutic diet was followed for one Resident (#34), in a total sample of 17 residents. Findings include: Review of the facility policy titled, Therapeutic Diet Orders, dated 3/4/24, indicated the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. 1. Each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies. 2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: a. Inadequate nutrition b. Nutritional deficits c. Weight loss d. Medical conditions such as diabetes, renal disease, or heart…

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 adaptive equipment for one Resident (#19) of 17 sampled residents. Specifically, the facility failed to ensure Resident #19 was consistently provided with a lip plate for use during his/her meals. Findings include: Review of the facility policy titled, Adaptive Feeding Equipment, dated 3/4/24, indicated that residents requiring assistance in feeding are potential candidates for a restorative dining program or adaptive utensil use, as determined by the occupational therapist. Any staff member may refer a resident for a program evaluation. 5. The dietary department should be notified of residents needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization. Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the most recent…

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, interviews and observations, the Facility failed to ensure the Dietary/Kitchen Department staff consistently prepared and followed the established, as posted, weekly menu for the resident meals. Findings include: Review of the Facility Policy, titled Menus and Adequate Nutrition, dated 03/04/24, indicated the Facility would assure menus were developed and prepared to meet resident choices including their nutritional needs, would be posted in areas accessible to residents one week in advance, and would be followed as posted. The Policy indicated that notification of any deviations from the posted menu would be made as soon as practicable, and substitutions would comprise of food with comparable nutritive value. Review of the Facility's Week 4 Menu, dated 09/03/24 indicated the planned breakfast meal was biscuits with gravy, oatmeal, hashbrowns, orange juice, milk, coffee or tea, and a choice of cold cereal. During a tour of the kitchen at on 09/03/24 at 07:10 A.M., which included 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.

Based on records reviewed, interviews and observations, for one of two sampled resident care units (Unit 1), the Facility failed to ensure food and beverages provided to the residents were served at safe and appetizing temperatures, when food temperatures were not consistently measured and recorded, and the results of a test tray observation indicated that the food items were not served at appetizing temperatures and food items were not palatable. Findings include: Review of the Facility Policy, titled Maintaining a Sanitary Tray Line, dated 03/04/24, indicated hot foods would be maintained at or above 135 degrees Fahrenheit (F) and cold foods would be maintained at or below 41 degrees F, and staff would periodically monitor food temperatures throughout the meal service to ensure proper temperatures. Review of the Facility Policy, titled Food Safety Requirements, dated 03/04/24, indicated food and beverages would be distributed and served to residents in a manner to maintain food at proper temperature. Review of the Food Committee Notes, dated 08/21/24, with 11 residents in…

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

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when documentation by nursing related to the conduction of weekly skin assessments was not consistently completed. Findings include: Review of the Facility Policy, titled Skin Assessment, dated 03/04/24, indicated a full body skin assessment would be conducted and documented by a licensed or registered nurse upon admission, readmission, daily for three days, and weekly thereafter. Review of the Facility Policy, titled Documentation in the Medical Record, dated 0/04/24, indicated licensed staff would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and Facility policy. 1) Resident #1 was admitted to the Facility in April 2024, diagnoses included epilepsy and hypertension. Review of Resident #1's Skin Integrity Care Plan, dated 04/22/24, indicated he/she would have weekly skin checks conducted by nursing. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had been admitted on to Hospice Services, the Facility failed to ensure nursing notified his/her Health Care Agent(s) (HCA) and the Hospice Agency in a timely manner that he/she had died. On [DATE] Resident #1 died shortly after midnight, however the HCA(s) and Hospice Agency were not made aware until the following morning when, Resident #1's Family Member arrived to the Facility expecting to visit with him/her. Findings include: Review of the Facility's Policy titled, Notification of Changes, dated [DATE], indicated the Facility must inform the residents, consult with the resident's Physician and/or notify the Resident's Family Member or Legal Representative when there is a change requiring such notification. The Facility's Policy indicates a circumstance requiring notification would include a death of a resident. Resident #1 was admitted to the Facility in [DATE],…

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, interviews and observations for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained Resident #1's dignity when he/she was observed with stains and what appeared to be dried food on the front of both of his/her sneakers. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in March 2016, diagnoses included hemiplegia (partial paralysis on one side of the body) affecting the right non-dominant side, psychotic disorder with delusions, vascular dementia with behavioral disturbance, anxiety, depression,…

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, interviews and observations, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff provided a clean homelike environment when his/her wheelchair was observed to be dirty with dried food stuck to the seatbelt of Resident #1's wheelchair, with dried food also noted to be stuck to each side of his/her wheelchair. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that each resident's rights included the resident has a right to a safe, clean, comfortable, and homelike environment. Resident #1 was admitted to the Facility in March 2016, diagnoses included hemiplegia (partial paralysis on one side of the body) affecting the right non-dominant side, psychotic disorder with delusions, vascular dementia with behavioral…

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 and interviews, the facility failed to ensure they stored and prepared food in accordance with professional standards for food service safety, when on 1/31/24, during a tour of the kitchen, the surveyor observed food items stored or placed in unsanitary conditions, expired food items, kitchen equipment used to prepare and/or store food items that were in need of cleaning, and a kitchen sink and dishwasher not functioning properly, all of which placed residents at risk for contracting food bourne illnesses. Findings include: Review of the Facility Policy Food: Preparation as revised 2/2023 indicated the following: - All foods are prepared in accordance with the Food and Drug Administration (FDA) Food Code. - All staff will practice proper handwashing techniques and glove use. - Dining Services Staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. - The [NAME] thaws frozen items that requires defrosting prior to preparation using 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, the facility failed to ensure open medications were dated as required on two out of four sampled medication carts. Findings include: Review of the facility policy titled, Medication Storage in the Facility, dated October 2019, indicated the following: -Beyond use dating, after initially entering or opening multi-dose containers is 30 days unless otherwise specified by the manufacturer. -No expired medication will be administered to a resident. -All expired medications will be removed from the active supply and destroyed in the facility regardless of the amount remaining. On 8/23/23, at 09:41 A.M., the surveyor observed the following in the second floor Unit medication cart: -One Fluticasone Propionate Nasal Spray 50 mcg (micrograms) dated as opened on 4/30/23. No expiration date indicated. Review of the manufacturer's instruction indicated it expires two months after opening. -One Albuterol inhaler 90 mcg dated as opened 1/20/23. No expiration date indicated. Review of the manufacturer's instruction indicated that the inhaler…

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 maintain accurate medical records for four Residents (#22, #45, #13 and #15) out of a total sample of 29 residents. Findings include: 1. Resident #22 was admitted to the facility in October 2017 with diagnoses including Alzheimer's disease, dysphagia, and vitamin B12 deficiency. Review of the most recent Minimum Data Set assessment dated [DATE], indicated Resident #22 was rarely understood and cognitive skills for decision making were severely impaired. The MDS further indicated Resident #22 was at risk for pressure ulcers. On 8/22/23 at 9:02 A.M., 12:08 P.M. and 3:03 P.M., the surveyor observed Resident #22 lying in bed with heels directly on the surface of the mattress. On 8/23/23 at 7:44 A.M., and 11:13 A.M., resident sitting up in bed socks on and his/her heels directly on the surface of the mattress. Review of Resident #22's medical record indicated a physician's order dated 2/22/23, to float heels every shift while in bed for redness. Review of…

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

Based on observation, record review and interview the facility failed to implement practices for the prevention of potential infection on 2 out of 2 resident units. Specifically, nursing staff failed to 1. perform adequate hand hygiene during a dressing change, 2. failed to perform hand hygiene and disinfect equipment used for multiple residents during the medication pass. Findings include: Review of the facility policy titled, Hand Hygiene effective date 3/8/20 included the following: -Alcohol based hand sanitizers are the most effective product for reducing the number of germs on the hands and is the preferred method of cleaning the hands in most clinical situations. Soap and water is appropriate for use whenever hands are visibly dirty, before eating and after using the restroom. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching patient or the patient environment. -Perform hand hygiene immediately after removing gloves. Use alcohol-based hand rub: -After touching a patient or the patients…

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 review and revise the plan of care for one Residents (#20) out of a total of 29 sampled residents. Findings include: 1. Resident #20 was admitted to the facility in May 2020 with diagnoses including traumatic subarachnoid hemorrhage, cognitive communication deficit and dysphagia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #20 is severely cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #20's nurse progress notes indicated the following: 7/26/23: Resident was found to be nibbling on an ice cream cup lid and earlier this week, doing the same with his/her paper napkin. Diet slip sent to the kitchen, NO PAPER PRODUCTS on meal trays. 8/5/23: Received in report that resident has been observed eating, chewing non-food items, paper items on tray, chewing his/her sheets. Review of Resident #20's care plans failed to indicate any care plan focus, interventions 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 observations, record reviews and interviews the facility failed to ensure professional standards of care were followed specifically related to physician's orders for two Resident's (#15 and #22) out of a total sample of 21 residents; Findings Include: 1. Resident admitted to the facility in February 2023 with diagnoses including diastolic congestive heart failure. Review of Resident #15's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 6 out of total 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated the Resident requires total dependence of one-person physical assist for personal hygiene On 8/22/23 at 8:25 A.M., the surveyor observed Resident #15 sitting in his/her room. Resident #15 did not have tubi grips/ ted stocking on his/her legs. On 8/23/23 at 8:11 A.M., the surveyor observed Resident #15 sitting in his/her room. Resident #15 did not have tubi grips/ ted stockings on his/her legs. Review of current…

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, observations and interviews the facility failed to ensure two Residents (#26 and #15) were provided required care out of a total sample of 29 residents. Specifically; 1. For Resident #26 the facility failed to provide with supervision with meals, and 2. For Resident #15 the facility failed to provide nail care to a dependent resident. Findings include: Review of the facility policy titled Activities of Daily Living, dated 12/22, indicated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #26 was admitted to the facility in November 2017 with diagnoses including Alzheimer's disease, dysphagia, adult failure to thrive, and anorexia. Review of Resident #26's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 7 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide audiology services for one Resident (#2) out of a total sample of 29 residents. Findings include: Resident #2 was admitted to the facility in November 2020 with diagnoses including bell's palsy, bilateral hearing loss, cognitive communication deficit, and mild cognitive impairment. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment. The MDS also indicated Resident #2 requires extensive assistance from staff for functional daily tasks. On 8/22/23 at 8:22 A.M., Resident #2 was observed sitting on the edge of his/her bed eating breakfast unassisted. Resident #2 did not respond to questions when asked and did not acknowledge the surveyor when knocking on the door. Review of Resident #2's medical record indicated an audiology referral on 1/10/23 due to recent fall and/or imbalance.…

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

Based on observation, record review and interview the facility failed to ensure an air mattress was on the correct setting for one Resident (#45) who had actual skin breakdown out of a total sample of 29 Residents. Findings include: Resident #45 was admitted to the facility in January 2022 with diagnoses including, adult failure to thrive, Parkinson's disease, and hemiplegia of nondominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/29/23, indicated a Brief Interview for Mental Status Score of 15 out of possible 15 indicating intact cognition. Further review of the MDS indicated Resident #45 has a stage 4 pressure ulcer which is full thickness tissue loss with exposed bone, tendon or muscle. On 8/22/23 at 9:04 A.M., Resident #45 was observed lying in bed with an air mattress set to a setting of 100 (lbs.) pounds. On 8/22/23 at 3:02 P.M., Resident #45 was observed lying in bed asleep with an air mattress set to a setting of 100 lbs. On 8/23/23 at 7:50 A.M., 10:50 A.M., and 11:29 A.M., Resident #45 was observed lying in bed with an air mattress set to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure nursing provided respiratory care consistent with professional standards of practice for two Residents (#1 and #13), out of a total sample of 29 residents. Specifically, the facility failed: 1. For Resident #1 to ensure nursing changed oxygen tubing as ordered; and 2. For Resident #13, to ensure nursing provided the correct concentration of Oxygen as ordered. Findings include: 1. Resident #1 was admitted to the facility in October 2019 with diagnoses including chronic diastolic heart failure, COVID-19, dysphagia and hypertension. Review of Resident #1's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. The MDS further indicated he/she was dependent on staff for activities of daily living. On 8/22/23 at 7:38 A.M., the surveyor observed Resident #1 in bed with oxygen on, the oxygen tubing was not dated. Resident #1 said that no one ever comes in to change…

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

Based on observation and interview, the facility failed to follow proper sanitation and food handling practices during meal service to prevent the risk of foodborne illness. Findings include: During the lunch service line on 8/22/23 the surveyor made the following observations in the kitchen: *At 11:27 A.M., the cook was observed touching hamburger buns and sliced cheese directly with gloved hands. The cook was then observed touching utensils with the same hands. The cook was then observed touching his glasses repeatedly with gloved hands. The cook then proceeded to touch food directly with the same gloved hands without performing hand hygiene or changing gloves. *At 11:31 A.M., the cook left the serving line to get a bowl, he then proceeded to change his gloves without washing his hands. He was then observed touching his glasses with his gloved hands and then directly touching hamburger buns and sliced cheese repeatedly with the same gloved hands. *At 11:46 A.M., the cook grabbed a metal cart and then the meal delivery cart with his gloved hands. He then proceeded to change his…

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.