Adviniacare At Provincetown

Based on observation, record review, and interview, the facility failed to ensure staff provided care and services consistent with accepted standards of clinical practice for one Resident (#1), out of a total sample of 13 residents. Specifically, the facility failed to ensure a physician's order for Lidocaine 5% patch (topical anesthetic) was complete and included the duration/time of removal.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Resident #1 was admitted to the facility in January 2026 and had…

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

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#1), out of a total sample of 13 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to ensure an air mattress was set according to the physician's order.Findings include:Review of the facility's policy titled Support Surfaces-Air Mattresses, last revised 10/2022, indicated but was not limited to:Low air loss mattress use is indicated as follows:-To assist in the treatment and/or prevention of pressure ulcers as part of a holistic program of pressure ulcer management.-As part of a pain management program when indicated for resident comfortSettings:-The patient weight indication is a close proximation of the correct setting.Resident #1 was admitted to the facility in January 2026 and had diagnoses including one stage 2 pressure ulcer (partial-thickness skin loss involving the epidermis and dermis) to his/her left buttock and one unstageable deep tissue 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.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly date, label, and store food and drink items in one of two kitchenettes.Findings include:Review of the facility's policy titled Unit Food Storage, last revised January 2023, indicated but was not limited to:-Food items stored for nourishment or brought in by residents shall be stored in designated areas only. The unit area designated for food storage will remain clean and safe for food handling.-Food items will be identified with name of the owner and date placed in designated refrigerator.-All resident food items will be dated with use by date.-Dietary and nursing staff will be responsible to ensure food items stored in pantry, refrigerators, and freezers are not expired or past perish dates.Review of the facility's policy titled Food from Outside-Safety, last revised January 2023, indicated but was not limited to:-It 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 observation, interview, and record review, the facility failed to ensure three Residents (#4, #27, and #12), out of a total sample of 12 residents, had their call bell devices accessible and within reach to utilize them to call for staff assistance while in their beds. Findings include: Review of the facility's policy titled Call Bell Policy, revised January 2023, indicated but was not limited to the following: Procedure: -As soon as a call bell is activated a staff member observing the light activation should answer promptly. c. Turn off the call light, make sure it is still within reach of the resident. f. Ensure the resident is safe and the call bell is within reach. -If a resident is unable to manipulate a call bell effectively provide the resident will be provided (sic) with an alternative device. a. Resident #4 was admitted to the facility in December 2020 and had diagnoses including unspecified dementia and overactive bladder. Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a…

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

Based on review of Resident Council Minutes, and interviews, the facility failed to ensure that staff addressed and promptly resolved grievances brought forward during Resident Council Meetings held from 3/4/24 through 1/6/25. Findings include: Review of the facility's policy titled Resident Council, last revised January 2023, included but was not limited to: -The Recreation Department should be responsible for assisting residents in organizing and facilitating a monthly resident council meeting in which residents bring their concerns to Department Heads respectively. -Concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. All supporting documentation (i.e. in-services, staff education, clinical notes) must be attached. Concern/response forms must be completed within seven days of being issued. -Should a resident raise a concern that may need to be investigated, the concern must be escalated to Social…

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 resident protected health information (PHI) was secure and not visible to others on one of one nursing unit. Findings include: According to the National Institute of Health, November 24, 2024: The US Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. HIPAA applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information. HIPAA regulations uphold patients' rights to confidentiality and empower them to control the disclosure of their health information, fostering trust in healthcare systems. On 3/4/25 at 11:27 A.M., the surveyor observed an unattended medication cart positioned outside the main dining room, where seven residents were seated and waiting for food to be served. The computer on top of the cart 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 observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop and consistently implement effective interventions to prevent six unwitnessed falls for one Resident (#15), out of a total sample of 12 residents. Findings include: Review of the facility's policies titled Fall Prevention and Management, last revised January 2023 and Accidents and Incidents, last revised October 2022, indicated but was not limited to: Fall Assessment and Prevention: -Fall risk assessments will be completed for all residents; initially on admission/readmission, quarterly, significant change and after an identified fall. -As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling. Root causes for fall history will be identified. Post Fall: -The nurse will complete an incident report. -Resident will be referred to therapy for a screen-for indication of need for therapy…

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, document review, and interview, the facility failed to ensure sufficient staffing to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. To have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 4, 2024 when no nurse staffing waivers were in place; and 2. To ensure call bell devices were responded to timely to address the residents' needs per Resident Group voiced concerns and review of Resident Council minutes. Findings include: 1a. Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 4, 2024 (7/1/24-9/30/24) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). Excessively Low Weekend Staffing - Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's healthcare Facility Assessment (FA), revised…

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 document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly monitor medication refrigeration temperatures in one of one medication storage rooms reviewed to ensure the safety and integrity of medications and vaccines stored; and 2. Ensure medication carts were locked when not in direct supervision of the licensed nurse for two of two medication carts. Findings include: 1. Review of the facility's policy titled Medication Storage, revised October 2022, indicated but was not limited to the following: -This center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines. -Medication will be stored at the appropriate temperatures in accordance with the pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following: c. Cold place…

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 professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label, date and discard food products when past their use by date stored in the free-standing refrigerator and walk-in freezer in the main kitchen. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: - 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A)Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºCelsius (41ºFahrenheit) or less…

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

Based on interviews and record review, the facility failed to ensure staff maintained accurate documentation for one Resident (#140), out of a total sample of 12 residents. Specifically, the facility failed to ensure March 2025 Medication Administration Records (MAR) were accurate in calculating the total daily fluid restriction and staff consistently implemented the prescribed fluid restriction of 1200 milliliters (ml) a day. Findings include: Review of the facility's policy titled Fluid Restrictions, revised January 2023, indicated but was not limited to the following: -It is the policy of this center that fluid restrictions ordered by a physician are carried out by the Nursing and Nutrition Services Department. The physician order should include the number of MLs (cc's) of fluids permitted each day. -The nursing department and dietary should work together to determine the amount of fluids each department will provide. Nursing fluids are divided into medication passes and the individual's daily routine. Nursing is responsible for recording the intake and output of fluids each…

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

Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#12 and #15), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Findings include: Review of the facility's policy titled Side Rails/Bed Rails, last revised 10/24/22, indicated but was not limited to: -The facility shall ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained. -Potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation and maintenance, and use with other devices or supports. -Assuring the correct installation and maintenance of bed rails is an essential component in reducing the risk of injury resulting from entrapment or falls. -Before bed rails are installed, the facility should: -Check with the manufacturer(s) to make sure 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 record review and interview, the facility failed to ensure staff provided the resident and/or their representative with a summary of the baseline care plan for one Resident (#141), out of a total sample of 12 residents. Findings include: Review of the facility's policy titled Care Plan Baseline, revised October 2022, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders b. Physician orders c. Dietary orders d. Therapy services e. Social services; and f. PASARR recommendations, if applicable. -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 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 record review and staff interviews, the facility failed to ensure that care and services were provided according to accepted standards of clinical practice for two Residents (#12 and #15), out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #12, to obtain a physician's order for the provision of Hospice services; and 2. For Resident #15, a. to ensure handwritten physician's telephone orders for Carbidopa-Levodopa Capsule Extended Release (ER) capsules (medication used to treat symptoms of Parkinson's disease-a progressive neurological disorder that affects movement, balance, and coordination) were transcribed into electronic medical record; and b. neurological checks (assessment of consciousness, orientation, and cognitive function) were conducted after Resident #15 sustained unwitnessed falls. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept,…

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 promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for one Resident (#15), out of a total sample of 12 residents. Specifically, the facility failed to ensure two Certified Nursing Assistants (CNAs) did not move a Resident off the floor and into a Broda chair (positioning chair) after the Resident sustained an unwitnessed fall prior to having a nurse assess the Resident. Findings include: Review of the facility's policy titled Fall Prevention and Management, dated as revised January 2023, indicated but was not limited to the following: Post Fall -In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed. -Only move the resident if there is a life-threatening safety concern present. -Remain with the resident while calling for assistance, if at all possible. -Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks 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 observation, interview, and record review, the facility failed for one Resident (#34), out of a total sample of 12 residents, to ensure staff provided the necessary care and services in accordance with professional standards of practice. Specifically, the facility failed to ensure the proper care and storage of respiratory equipment. Findings include: Review of the facility's policy titled Nebulizer Medication/COVID-19, revised January 2023, indicated but was not limited to the following: -When equipment is completely dry, store in a plastic bag with resident's name and the date on it. Review of the facility's policy titled Oxygen-Concentrators, revised January 2023, indicated but was not limited to the following: -Oxygen concentrators are used for residents on continuous oxygen. Procedure: -Rear filter should be checked daily and cleaned with soap and water as needed. Cleaning: -Clean the exterior of the oxygen concentrator with soapy water solution or commercial cleanser to remove any debris. Be careful not to get any liquid into the interior of the unit. -Clean 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 record review, the facility failed to perform assessments for the risk of entrapment with the use of side rails for three Residents (#12, #15, and #33), out of a total sample of 12 residents. Specifically, the facility failed to ensure: 1. For Resident #12, an initial side rail assessment was conducted upon admission and when the Resident received an air overlay pressure reducing mattress to ensure the Resident was not at risk of entrapment and that the bed's dimensions were appropriate for the Resident's size and weight; 2. For Resident #15, an initial side rail assessment was conducted upon admission, appropriate alternatives were attempted prior to installation of the side rails, and an assessment was conducted when the Resident received a perimeter air mattress (mattress with raised edges that create a defined boundary, enhancing fall prevention); and 3. For Resident #33, appropriate alternatives were attempted prior to installation of the side rails, and a quarterly bed rail assessment was conducted to ensure the Resident was not at risk 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 interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three Residents (#7, #16, and #2), out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #7, to ensure the June 2024 consultant pharmacist recommendations were acted upon timely to clarify the need for two as needed Guaifenesin (cough/expectorant medication) orders; 2. For Resident #16, to ensure the June 2024 consultant pharmacist nursing recommendation for an order clarification was acted upon timely; and 3. For Resident #2, to ensure the June 2024 consultant pharmacist recommendations were acted upon timely to re-assess the ongoing need for Protonix (proton pump inhibitor medication used to treat gastroesophageal reflux disease- GERD: a chronic digestive condition where stomach contents flow back up into the esophagus, causing irritation and discomfort) and a recommendation for lab work to monitor thyroid…

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

Based on record review and interview, the facility failed to ensure that for one Resident (#16), out of a total sample of 12 residents, their drug regimen was free of unnecessary drugs. Specifically, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting, a blood thinner). Findings include: Review of the Eliquis (apixaban-anticoagulant) package insert, revised December 2012, indicated but was not limited to the following: -Eliquis is a factor Xa inhibitor anticoagulant indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Warnings and Precautions: -Eliquis can cause serious, potentially fatal bleeding. Promptly evaluate signs and symptoms of blood loss. Adverse Reactions: -Most common adverse reactions (>1%) are related to bleeding. Resident #16 was admitted to the facility in February 2018 and had diagnoses including thrombophlebitis (a condition in which a blood clot in a vein causes inflammation and pain). Review of the Minimum Data Set (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 interview, the facility failed to ensure for two Residents (#7 and #16), out of a total sample of 12 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #7, to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of an antipsychotic medication; and 2. For Resident #16, to ensure signs and symptoms were monitored to evaluate the effectiveness of an antidepressant and antipsychotic medication. Findings include: Review of the facility's policy titled Psychotropic Medication, dated 7/2018, indicated but was not limited to: -Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Psychotropic drugs - any drug that affects brain activities associated with mental processes 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 staff interviews, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD), when the facility did not employ a full-time dietitian. Findings include: During an interview on 2/14/24 at 10:26 A.M., the Food Service Manager (FSM) said she was not certified but was in the process and had been in her role as an FSM for almost two years at the facility. She said she was not a certified FSM or certified dietary manager, was not a nationally certified food service manager, and did not have her associates as an FSM. She said the facility's registered dietitian (RD) worked part-time at the facility. During an interview on 2/14/24 at 10:25 A.M., the Administrator said the RD only worked part-time on Wednesdays for about eight hours total. During an interview on 2/14/24 at 11:33 A.M., the RD said she was only part-time at the facility and worked a maximum of eight hours a week. She said she was the only RD employed by the facility and had frequent consults with the FSM because she needed the support. The RD said the FSM…

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 document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to have a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Findings include: Review of Centers for Medicare & Medicaid Services (CMS) Memorandum titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease, revised July 2018, indicated but was not limited to the following: - In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least [AGE] years old, smokers, and those with underlying…

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 records reviewed, for four Residents (#16, #19, #34, and #35), of 12 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed, consistently implemented, and revised as needed. Specifically, the facility failed: 1. For Resident #16, to ensure that a care plan was developed to address the Resident's Foley catheter (medical device that helps drain urine from the bladder); 2. For Resident #19, to revise a care plan after five of six falls to ensure approaches were effective, individualized, and appropriate for the Resident; 3. For Resident #34, to ensure an interdisciplinary comprehensive care plan was developed and individualized to address: a. his/her dementia care needs and psychosocial needs as it related to his/her diagnoses of depression, anxiety, and adjustment disorder, and b. the Resident's use of psychotropic medications and identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; and 4. For Resident #35, to revise the plan of care to ensure…

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

Based on observations, policy review, interviews, and record reviews for two Residents (#19 and #34) of 12 sampled residents, the facility failed to provide adequate supervision to prevent accidents. Specifically, the facility failed to: 1. For Resident #19, ensure falls were thoroughly investigated and interventions were initiated/implemented to prevent further falls per facility policy; and 2. For Resident #34, who was assessed by nursing to be a high risk for falls, to ensure staff provided adequate supervision and updated the falls care plan with appropriate goals and interventions to help prevent future falls. Findings include: Review of the facility's policy titled Fall Prevention and Management, dated as revised January 2023, indicated but was not limited to the following: - Policy: The Fall Risk Evaluation (completed on admission) will determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. -Assessment and Prevention 1. The staff will:…

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 ensure staff stored, prepared, distributed, and served food in the facility kitchen in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure all food items were properly labeled and dated in one of one walk-in refrigerators in the main kitchen; 2. Ensure the floor in the main kitchen was maintained in a sanitary condition, specifically the floor tile grout was free from built up dirt and dust and the main kitchen floor was free from dirt, dust, and debris, including under stationary tables, rolling racks, dishwashing area, and the meal preparation area; 3. Maintain adequate cooking and proper holding temperatures of food for safety to help prevent the growth of pathogens that can cause foodborne illness; and 4. Follow proper sanitation and safe food handling practices to help prevent cross contamination (transfer of pathogens from one surface to another) and potential foodborne illnesses during the facility's lunch service. Findings include: 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, interview, record review, and policy review, the facility failed, for one Resident (#9), out of a total sample of 12 residents, to provide care and services consistent with professional standards of practice. Specifically, the facility failed to communicate timely to the physician a newly identified skin tear on the Resident's right thigh, obtain a physician's order prior to providing a wound care treatment, complete a comprehensive assessment of the wound with documentation in the electronic health record (EHR), initiate an incident report, and review and revise the care plan for new goals and interventions. Findings include: Review of the facility's policy titled Protocol-Wound Care and Rounds, revised January 2023, indicated but was not limited to the following: New Wound Identified In-House: -Licensed nurse should complete an assessment of wound including shape, size, depth, staging (if applicable) condition of wound. -Licensed nurse/manager/supervisor will notify the physician and obtain a treatment order. -The manager or designee will notify the family.…

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 one Resident (#4), out of a total sample of 12 residents, received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess Resident #4 and identify triggers of trauma to prevent potential re-traumatization. Findings include: Review of the facility's policy titled Trauma-Informed Care, dated as revised 10/22/22, indicated but was not limited to: -Each resident should be screened for a history of trauma upon admission -The facility social worker or designee should conduct the screening in a private setting -The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident -Potential causes of re-traumatization by staff may include, but are not limited to: -Being unaware of the resident's traumatic history -Failing to screen resident for trauma history prior to treatment planning -Challenging or discounting reports 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 record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#34), out of a total sample of 12 residents. Specifically, the facility failed to ensure that the December 2023 and February 2024 consultant pharmacist's recommendations were maintained in the facility, readily available for review, and/or acted upon in a timely manner to ensure there was a stop date for an as needed (prn) medication, Lorazepam (sedative that can relieve anxiety), as required. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, revised January 2023, indicated but was not limited to the following: -The facility shall employ/contract and maintain the services of a licensed pharmacist (pharmacy consultant), who shall review the medication regimen review (MRR) of each resident at least monthly and more frequently, as needed. -The primary purpose of this review is to assist the facility to maintain each resident's highest…

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 for one Resident (#35), out of a total sample of 12 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Resident #35, the facility failed to ensure psychotropic medications were monitored for adverse consequences of their use. Findings include: Review of the facility's policy titled Psychotropic Medication, last revised 10/2022, included but was not limited to: -Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring -The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits -Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs -Monitoring of the use 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 interviews and record review, the facility failed to ensure its staff maintained accurate documentation for one Resident (#4), out of a total sample of 12 residents. Specifically, the facility failed to ensure January 2024 and February 2024 Medication Administration Records (MAR) were accurate and reflected the administration of porta cath (implanted venous port, a small device, about the size of a quarter. It is used to carry medicine into the bloodstream. It can also be used to draw blood for testing) flushes according to physician's orders. Findings include: Resident #4 was admitted to the facility in February 2023 with diagnoses including schizoaffective disorder, implanted porta cath, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of current Physician's Orders included but was not limited to: -Biweekly Complete Blood Count (CBC) while on Clozaril (antipsychotic used to treat schizophrenia) every 14 days, dated 12/19/23 -Draw CBC with differential from implanted port every 2 weeks on Tuesday, dated 10/12/23 -Implanted port: Flush with 10…

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, hospice contract review, and policy review, the facility failed to ensure for one Resident (#34), out of a total sample of 12 Residents, that hospice services were provided in accordance with professional standards and principles between the hospice service provider and the facility. Specifically, the facility failed to: a. Ensure the Hospice agency provided a list of hospice staff to retain overall professional management of the Resident; b. Designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care to the Resident; c. Ensure an integrated care plan was developed to accurately reflect services provided by both the hospice provider and facility; and d. Ensure both the hospice and nursing facility maintained the appropriate documentation of hospice services provided in the medical record including all hospice visits to ensure prompt communication and continuity of care. Findings include: Review of the facility's policy titled Hospice Services, revised January 2023,…

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