Prescott House

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a new Physicians Order on 01/07/2025, for Blood Laboratory work to be conducted on 01/09/25, the Facility failed to ensure Resident #1 was provided with Laboratory Services consistent with his/her Physician Orders, when the laboratory tests were not ordered or obtained, as ordered.Findings include:The Facility Policy titled, Lab and Diagnostic Test Results - Clinical Protocol, dated revised November 2018, indicated the following: the Physician will identify and order diagnostic and laboratory testing based on the Resident's diagnostic and monitoring needs, the staff will process test requisitions and arrange for tests and the laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.The Policy indicated the following: a Nurse will try to determine whether the test was done, as a routine screen or a follow up and if the reason for performing the test cannot be identified, the Nurse should proceed as though the tests were ordered 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 interview, observation and record review, the facility failed to ensure a home-like environment on the A Unit. Findings include: On 1/21/25 at approximately 8:30 A.M., the surveyor observed a sample of bedrooms located on the A Unit. - room [ROOM NUMBER]: bed D, bed frame side rail has approximately 12 inches of chipped enamel. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: unpainted, unsanded plaster on bedroom wall next to bathroom measuring approximately 13 x 6. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: wired wall receptacle for television control is dangling from the wall, wires and wall cavity exposed. Review of the Maintenance Log on 1/23/25 indicated the above items in need of repair were not documented. During an interview with the Consulting Maintenance Director on 1/23/25 at 1:30 P.M., he said the blinds, unpainted wall plaster, chipped bed…

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 resident centered care plans were developed and/or implemented for three Residents (#12, #91 and #13) out of a total sample of 24 residents. Specifically, 1. For Resident #12, the facility failed to a. develop a comprehensive resident centered care plan for a pacemaker and b. failed to implement the Resident's fall intervention of non skid strips on the floor next to his/her bed. 2. For Resident #91, the facility failed to implement a right hand splint and arm wedge as per the plan of care. 3. For Resident #13, the facility failed to implement a right hand roll as per the plan of care. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 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.

Based on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly. Findings include: According to The Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006 by the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, The HBSW (Hospital Bed Safety Workgroup) identified 7 potential entrapment zones for hospital beds. Review of the facility policy titled Bed Safety and Bed Rails, revised and dated August 2022, indicated the following: - Resident beds meet the safety specifications established by the Hospital Bed Safety…

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 policy review, interview and observation, the facility failed to ensure it provided a means for residents to communicate to staff on the A Unit. Findings included: The Facility's policy titled Answering the Call Light dated as revised September 2022, indicated: - The purpose of this procedure (answering the call light) is to ensure timely responses to the resident's requests and needs. - Be sure the call bell is plugged in and functioning at all times. On 1/21/25 at approximately 8:30 A.M., the surveyor observed that the call bell system was broken on the A Unit. The surveyor sampled the call bell system from several bedrooms and noted that the call bell did not sound, either in the hallway of the nursing station, and the call bell board at the nursing station did not illuminate to identify which bedroom requested help. The surveyor observed that in some of the sampled bedrooms the call light button illuminated the light outside the bedroom doorway. The surveyor observed that the call lights in 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 interview, record review and observation, the facility failed to ensure one Resident (#175) was able to dine in a dignified manner. Findings include: Review of the facility policy Dignity dated as revised February 2021, indicated, but was not limited to: - Provided with a dignified dining experience. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. On 1/21/25 at 8:00 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 record review, interview and observation, the facility failed to follow physician's orders for two Residents (#175 and #68) of 24 sampled residents. Specifically: 1. For Resident #175, the facility failed to change a soiled wound dressing for three days. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks because staff did not obtain a physician's treatment order for the procedure. Findings include: Review of the facility policy titled Dressing, Dry/Clean dated as revised September 2013, indicated, but was not limited to: - Review the physician's order. - Label tape or dressing with date, time and initials. - Document the wound appearance, including wound bed, edges, presence of drainage. - How the resident tolerated the wound change procedure. 1. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, muscle wasting and atrophy, difficulty walking, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and observation, the facility failed to ensure it provided one Resident (#175) with the assistance required for meal setup. Findings include: Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. Review of Resident #175's Activities of Daily Living care plan dated 1/21/25, indicated he/she has a self-care performance deficit related to activity Intolerance, deconditioning,…

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 for one Resident (#175) to communicate with the Dialysis Center nurse regarding Resident #175's care, document his/her condition after dialysis treatment, and notify the practitioner of fistula bleeds out of a total sample of 24 residents. Findings include: Review of the facility's policy Hemodialysis Catheters - Access Care of dated as revised February 2023, indicated: - Mild bleeding from the site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. - The nurse should document in the resident's medical record every shift as follows: 1. Location of the catheter. 2. Condition of the dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of the report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included dependence on renal dialysis, arteriovenous fistula, chronic kidney disease, muscle wasting and atrophy, and lack…

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

Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for three Residents (#91, #13 and #175), out of a total sample of 24 residents. Specifically: 1 For Resident #91, the nurses documented in the Treatment Administration Record (TAR) the Resident was wearing his/her right hand splint and arm wedge, when he/she was not; 2. For Resident #13, the nurses documented in the TAR the Resident was wearing his/her right hand roll, when he/she was not; 3. For Resident #175, nursing staff documented they changed a dressing when they did not. Findings Include: Review of the facility policy titled Charting and Documentation, dated July 2022, indicated the following: Policy Statement: - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between interdisciplinary team regarding the resident's condition and the response to…

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

Based on observations, record review and interview, the facility failed to ensure that 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair, which the staff attributed to being short staffed. Findings include: 1a.) Review of the facility assessment, dated as reviewed 11/21/23, indicated the following during a typical month: -An average daily resident census of 120 with a facility capacity for 126 residents. -The daily number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 31 full time equivalents (FTE's); 1.00 hours per resident per shift on the 7 A.M.- 3 P.M. and 3 P.M.-11 P.M. shifts and .4 hours per resident per shift on the 11 P.M.-7 A.M. shift. -The Facility Assessment failed to indicate if staffing levels change based on the acuity level of the residents and failed to indicate what the current acuity level of the residents is. Review of the staffing schedules dated 12/1/23,…

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

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff did not store their drinks with resident food ingredients and that food was labeled and not kept beyond the use-by date in the main kitchen and the A unit Kitchenette. Findings include: Review of the undated facility's policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated, but is not limited to, the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. On 1/2/24 at 7:01 A.M., during the initial walkthrough of the main kitchen the surveyor made the following observations: - An energy drink was in the walk-in refrigerator, stored with resident food and ingredients. - Sliced cheddar cheese opened, unlabeled and undated, in the walk-in refrigerator. - A container labeled chicken with a use-by date of 12/31/23 in the walk-in refrigerator. - A container labeled egg salad with a use-by date 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 maintain an accurate medical record for three Residents (#110, #67 and #76 ) out of a total sample of 28 residents. Specifically, 1. For Resident #110 the facility failed to ensure that Enteral feeding orders were not conflicting. 2. For Resident #67, who has a stage III pressure ulcer on his/her foot, the facility documented that his/her heels were offload, as ordered by the physician and wound physician, when they were not. 3. For Resident #76, the facility failed to accurately transcribe the physician order for an alternate wound dressing. Findings include: Review of the facility policy titled Enteral Feedings- Safety precautions, dated revised November 2018 indicated the following: Check the Enteral nutrition label against the order and the rate of administration, before administration. 1. Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty swallowing) and stroke. Review of the…

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

Based on observations, interviews and record review, the facility failed to 1. Perform hand hygiene before entering and exiting a room with isolation droplet/contact precautions, specifically, a room with a resident positive with COVID-19 (Coronavirus disease 2019) on the B unit. 2. Maintain monthly chlorine water testing and weekly water pressure testing as a measure to prevent the growth of Legionella and other waterborne pathogens and 3. Failed to disinfect blood pressure cuffs between residents. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, with a revision date of August 2019, indicated the following: -Use an alcohol-based hand rub containing at least 62%alcohol or alternatively soap and water for the following situations: (f) Before donning gloves (m)After removing gloves (n) Before and after entering isolation precaution settings Review of the facility policy tilted Legionella Water Management Program. with a revision date of July 2017, indicated the following: -Our facility is committed to the prevention, detection and control of water borne…

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 grievances voiced in the monthly Resident Council meetings were adequately addressed or resolved. Findings include: The facility policy titled Nursing Home Resident Rights: Grievances, undated, indicated the following: -Grievance is meant to be broad and includes: concerns with respect to care and treatment (which has been provided or not provided), the behavior of staff and of other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 1. The nursing home must create an environment whereby every resident feels safe to report a concern/file a grievance. 2. The facility must make prompt efforts to resolve grievances the resident may have and the resident has the right to receive the written result of the grievance. 3. The facility must make information on how to file a grievance of complaint available to the resident. 4. Standard Grievances must be resolved within 5-7 business days. During an initial tour of the [NAME]…

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 maintain a safe environment for two Residents (#18 and #21) out of a total sample of 28 residents. Specifically, 1. For Resident #18, the facility failed to ensure adequate supervision was provided, resulting in eight falls in 2023, including two that required emergency room evaluations. 2. For Resident #21, who has a diagnosis of epilepsy, the facility failed to ensure bilateral padded side rails were in place to prevent injury in the event of a seizure. Findings include: 1. For Resident #18, the facility failed to provide adequate supervision and implement effective interventions to prevent falls, resulting in eight falls in 2023, including two that required emergency room evaluations. The facility policy titled Falls-Clinical Protocol, dated as revised March 2018, indicated the following: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, or if a fall may have a significant medical…

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 facility document review and interview, the facility failed to provide Certified Nursing Assistants (CNA) in-services, for at least 12 hours in a year, based on the outcome of performance reviews for 3 out of 3 CNA inservice records reviewed. Findings include: During review of 3 sampled CNA records, the Surveyor was unable to locate annual performance reviews for 1 of the 3. Further review failed to indicate that 3 out of 3 CNA's had been provided with at least 12 hours of training per year. During an interview on 1/4/24, the Administrator and the Director of Nursing said that all CNA's are required to complete at least 12 hours of inservices per year.

Based on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of three units: Findings include: During an initial tour of the C Unit on 1/2/24 the surveyors met with the residents and the following concerns were expressed: -At 7:54 A.M. Resident #71 said the food is terrible and explained it was the taste, a lot of rice and mashed potatoes and the unit was short-staffed, so food is always late. -At 8:02 A.M. Resident #34 said he/she dislikes the food served in the facility. -At 8:10 A.M. Resident #8 said he/she dislikes the food served in the facility. -At 8:15 A.M., Resident #61 said the food does not taste good. -At 8:05 A.M., Resident #90 said the food looks like garbage and tastes like garbage. -At 8:21 A.M. Resident #65 said he/she dislikes the food served in the facility. -At 8:24 A.M., Resident #12 said that the only concern he/she had was the food is not good. Review of the last three months of Resident Council Minutes indicated the following: -October 2023 actions items included juice is…

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

Based on record review policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for three of three Certified Nurse Aides (CNAs). Findings include: Review of the Facility Assessment Tool, most recent revision dated 11/21/2023, indicated but was not limited to the following: Staff training/education and competencies Training for nurses' aides includes: -Required in-service training for nurses' aides, in-service and training must: -Be sufficient to ensure the continuing competence of nurses' aides and must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurses' aide performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurses' aides providing services to individuals with cognitive impairments, also addresses the care of cognitively impaired. -Identification of resident changes in condition including how to identify medical issues…

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 the right to a dignified existence for two Residents (#44 and #8) out of a total sample of 28 residents. Specifically, 1. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair. 2. For Resident #8 the facility failed to provide a dignified dining experience. Findings include: 1. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair. Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, dated as revised March 2018, indicated that residents who are unable to carry out ADL's independently will receive the services necessary to maintain good grooming. Resident #44 was admitted to the facility in December 2023 with diagnoses including heart failure and generalized muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/19/23, indicated that Resident #44 scored a 13 out of 15 on the Brief Interview…

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 a plan of care for two Residents (#110 and #11) out of a total sample of 28 residents. Specifically: 1. For Resident #110 the facility failed to provide assistance with eating. 2. For Resident #11, the facility failed to ensure that the air mattress was set to the correct setting as ordered by the Physician. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) dated revised March 2018, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition . 1. Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and stroke. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/23, indicated that Resident #110 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that Resident #110 required substantial/maximal…

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 interview, the facility failed to provide care in accordance with professional standards of practice for two Residents (#112 and #83) out of a total sample of 28 Residents. Specifically, 1) for Resident #112, the facility failed to follow the most current doctor's order for G-tube (gastric tube, a tube placed directly through the abdomen for the purpose of instilling nutrition) feeding and failed to label and date the tube feeding bottle and water flush bag with the date and time hung. 2) for Resident #83 the facility failed to label and date the tube feeding bottle and water flush bag with the date and time hung. Findings include: Review of the facility policy titled Enteral Feedings-Safety precautions, dated revised November 2018 indicated the following: Sterile formula in a closed system has a maximum hang time of 48 hours. Check the Enteral nutrition label against the order and the rate of administration, before administration. On the formula label document the initials, date and time the formula was hung and initial that the label was…

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

Based on observations, interviews and record review, the facility failed to assist one Resident (#90) out of a sample of 28 residents to replace lost hearing aids. Specifically, the facility failed to assist the Resident in obtaining services to replace hearing devices lost at the facility. Findings include: A review of the facility policy titled Hearing Impaired Resident, Care of, dated as revised February 2018, indicated the following: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. -Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices. Resident #90 was admitted to the facility in March 2023 with diagnoses including hearing loss. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/7/23, indicated Resident #90 had a Brief Interview for Mental Status examination score of 14 out of a possible 15, indicating intact cognition. The MDS indicated Resident #90 did not have a hearing aid. Review of the MDS assessments…

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 implement the plan of care for one Resident (#67) out of a total sample of 28 residents. Specifically, for Resident #67 who has a Stage 3 pressure ulcer on his/her foot, the facility failed to offload his/her feet as ordered by the Physician and Wound Physician. Findings include: The facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised April 2018, indicated the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss and a history of pressure ulcer(s). -In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. -The Physician will order pertinent wound treatments, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to address continued weight loss in a timely manner for one Resident (#110) out of a total sample of 28 residents. Findings include: Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and stroke. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #110 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that Resident #110 required substantial/maximal assistance-helper does more than half the effort for eating. Review of the current nutrition care plan, dated 12/8/23, written by the dietitian included the following intervention: Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing. Review of the medical record indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, and interview the facility failed to ensure two medication carts were locked when unattended. Findings include: Review of the facility policy titled Storage of Medications, dated revised November 2020, indicated that Compartments (including but not limited to . carts) containing drugs and biological's are locked when not in use. Unlocked medication carts are not left unattended. On 1/2/24, at 8:02 A.M., the surveyor observed a medication cart unlocked in the Unit A hallway. The surveyor observed a resident sitting next to the medication cart. The surveyor was able to access the medication cart, open all of the drawers, have full access to the medications in the cart for a period of 15 minutes. During an interview on 1/2/24, at 8:17 A.M. Nurse #1 was informed by the surveyor that the medication cart was not locked and the surveyor was able to access the medications for 15 minutes. Nurse #1 said that she was in a resident's room and forgot to lock the medication cart before…

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.