Care One At Randolph

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide education, assess eligibility, and offer influenza (flu) vaccinations and pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#28, #39, #9, and #90), out of a sample of five residents. Specifically, the facility failed to ensure:1. Staff offered, assessed, and provided education on the CDC recommended pneumococcal vaccines (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria) for Residents #28, #39, #9, and #90; and2. Staff administered the seasonal influenza vaccine to Resident #90 who had a signed consent form to receive the vaccine. Findings include: 1. Review of the facility's policy titled Pneumococcal Vaccine, dated as last revised in October 2023, indicated the following:-all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections-upon admission, residents are assessed for…

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

Based on interview and record review, the facility failed to ensure one Resident (#132) had the right to participate in his/her discharge planning process, in a total sample of 32 residents. Specifically, the facility involved the family member of Resident #132 in the discharge planning and did not involve Resident #132 who remained his/her own healthcare decision maker. Findings include:Review of the facility's policy titled Discharge Summary and Plan, dated as last revised in March 2025, indicated: -Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan-The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goalsReview of the facility's policy titled Resident Rights, dated as last revised in February 2021, indicated but was not limited to:-These rights include the resident's right to self-determination and be supported by the facility in exercising his/her rights Resident #132…

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 for one Resident (#71), out of a sample of 32 residents, that informed, written consent was obtained for the administration of psychotropic medications, which include providing the Resident with information related to the risks and benefits of the medications, prior to administering them.Findings include:Review of the facility's policy titled Psychotropic Medication Use, dated as last revised February 2025, indicated but was not limited to:-Prior to the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:-Non-pharmacological alternatives;-Indications and rationale for the recommendation;-Potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and-The resident's/representative's right to accept or decline the treatment.Resident #71 was admitted to the facility in May 2025 and had diagnoses including…

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

Based on interview and document review, the facility failed to promptly resolve a grievance for a missing delivery for one Resident (#17), out of a total sample of 32 residents. Findings include: Review of the facility's policy titled Grievances/Complaints, Filing, dated as revised April 2017, indicated but was not limited to the following: - Residents and their representatives had the right to file grievances, either orally or in writing, to the facility staff- the Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative- upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings within 5 working days of receiving the complaint/grievance- the resident filing the grievance, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems- the Administrator will make such reports orally within 5 working days of the filing 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 record review and interview, the facility failed to ensure for one Resident (#33), from a total sample of 32 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 for Resident #33, to ensure a gradual dose reduction (GDR) was attempted, unless documented by the prescriber as clinically contraindicated in the medical record.Findings include:Review of the facility's policy titled Psychotropic Medication Use, revised February 2025, indicated but was not limited to the following:-Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication.-Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or 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 ensure for one Resident (#101), out of a total sample of 32 residents, that footcare was provided in accordance with professional standards to help prevent potential foot problems. Findings include: Review of the facility's policy titled Foot Care, dated as revised October 2022, indicated but was not limited to the following: - residents receive appropriate foot care and treatment in order to maintain foot health- residents are provided with foot care and treatment in accordance with professional standards of practice- trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes- residents with foot disorders or medical complications associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include nail disorders. Resident #101 was admitted to the facility in May 2025 with diagnoses including: Chronic obstructive pulmonary disease (COPD - a group 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, interview, and record review, the facility failed to provide an environment free from accident hazards for one Resident (#132), in a total sample of 32 residents. Specifically, the facility failed to identify and intervene when the facility staff were writing secure keypad codes on door frames, including a stairwell where Resident #132, who was at risk for falls, at risk for wandering, at risk for eloping, and was experiencing confusion, accessed and descended 26 concrete stairs which lead to an alarmed exit door.Findings include:Resident #132 was admitted to the facility in May 2025 with diagnoses of congestive heart failure (CHF) and alcohol use disorder. Review of the care plans indicated Resident #132 was at risk for wandering and/or elopement, initiated 5/31/25 with interventions including implementing a scheduled toileting program, implementing scheduled hydration and schedule time for regular walks/appropriate activity. An additional care plan indicated Resident #132 was at risk for…

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

Based on record review and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one Resident (#71), out of a total sample of 32 residents. Specifically, the facility failed to ensure that Resident #71's Behavioral Health Services providers were informed and provided appropriate psychiatric follow-up when the Resident was sent to the emergency room from the dialysis center for a concern of a suicide attempt after hearing auditory hallucinations, verbalizing wanting to die, and pulling out a dialysis line. Findings include:Review of the facility's policy titled Behavioral Assessment, Intervention, and Monitoring, revised February 2025, indicated the following:- Behavioral Interventions refers to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as…

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

Based on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#33 and #15), out of a total sample of 32 residents. Specifically, the facility failed:1. For Resident #33, to ensure April 2025 consultant pharmacist recommendations were provided to the physician/nurse practitioner (NP) for review and response to the recommendation; and2. For Resident #15, to maintain the facility policy of documenting monthly MRR in the medical record, ensure the physician documented review of the April 2025 irregularity in the medical record and ensure the irregularity was addressed timely.Findings include:Review of the facility's policy titled Medication Regimen Reviews, last revised in May 2019, indicated the following: -The consultant pharmacist performs a medication regimen reviews (MRR) for every resident in the facility receiving medications -Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each…

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

Based on record review and interview, the facility failed to ensure laboratory results were reported and acted on timely for one Resident (#9), out of a total sample of 32 residents. Specifically, the facility failed to report his/her 6/12/25 and 6/20/25 sodium (a vital electrolyte that helps regulate fluid balance, blood pressure, nerve and muscle function with a reference range of 136 to 145 milliequivalents per liter (mEq/L) levels to the provider resulting in a delayed hospital transfer on two occasions.Findings include:Review of the facility's policy titled Lab and Diagnostic Test Results, dated as revised 11/2018, indicated but was not limited to:-When test results are reported to the facility, a nurse will first review the results. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting or documenting the results and their implications another nurse in the facility should follow or coordinate the procedure-A nurse will identify the urgency of communicating with the attending physician based on physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for two of six sampled residents (Resident #5 and #6), who were alert, oriented, and able to make their own health care decisions, the Facility failed to ensure that they obtained signed written consent for the administration of psychotropic medications, which include providing each resident with information related to the risks and benefits of the medications, prior to administering them. Findings include: Review of the Facility Policy Psychotropic Medication Use, dated as last revised 02/2025, indicated prior to the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal; -Non-pharmacological alternatives; -Indications and rationale for the recommendation; -Potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and -The resident's/representative's right 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 records reviewed, interviews, and observations for three of five sampled residents (Resident #1, #2 and #4) and three non-sampled residents (NS RT #A, #B and #C), the facility the Facility failed to ensure 1) that the call bell system button was accessible and within reach for residents to call for assistance and 2) that staff responded to sounding call bells in a timely manner, per facility policy. Findings include: Review of the Facility Policy titled, Answering the Call Light, dated as last revised 9/2022, indicated that the purpose of answering a call light is to ensure timely response to the resident's requests and needs. The Policy further indicated that staff are to ensure that the call light is accessible to the resident when in bed, on the toilet, in the shower or bathing facility. 1) During a tour of the facility on 05/27/25, Surveyor #1 observed the following: -9:42 A.M., room [ROOM NUMBER], NS RT #A was in bed, the call bell was hanging on the wall, out of his/her reach -9:43 A.M., room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for two of six sampled residents, (Resident #3 and #5), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals and outcomes that addressed the residents' overall immediate care needs. Findings include: Review of the Facility Policy titled Baseline Care Plans, dated as last revised 03/2022, indicated that a baseline care plan will be developed for each resident within 48-hours of admission to meet the resident's immediate health and safety needs. The Policy further indicated the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. The baseline care plan is updated as needed to meet the residents' needs until the comprehensive care plan is developed. 1) Resident #3 was admitted to the Facility in May 2025, diagnoses included acute respiratory failure, Stage Four(IV, full…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had experienced a change in condition related to an incident of elopement, the Facility failed to ensure that nursing notified Resident #2's Health Care Agent (HCA, Family Member #3 aka, his/her Resident Representative), when on 02/21/25 at approximately 5:45 A.M., an individual that had dropped off a staff member for work, found a person (later identified as Resident #2) outside the Facility sitting on the pavement in the middle of the facility's driveway, and Family Member #3 was not made until much later that day (around 2:00 P.M.) when she came into visit Resident #2 and questioned staff about the areas of bruising to Resident #2's knees. Findings include: Review of the Facility Policy titled Change in a Resident's Condition or Status, dated as last revised February 2021, indicated that the Facility promptly notifies the resident, his/her attending physician, and the resident's representative of changes 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 records reviewed, interviews and for two of three unit kitchenettes, the facility failed to ensure they maintained a pest free environment, when live and dead cockroaches were observed during an environmental tour on the units. Findings include: Review of the Facility's Policy, titled Pest Control, dated as revised May 2008, indicated the Facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of the Pest Control Site Inspection Report, dated 11/01/24, indicated that there were cockroaches: -on monitors (location not specified); -behind the freezer (location not specified); -by the cart storage area (location not specified). Review of the Pest Control Invoice, dated 11/26/24, indicated that the following were treated for cockroaches: -room [ROOM NUMBER] on the Two [NAME] Unit; -room [ROOM NUMBER] on the Two East Unit; -the Activities Office; -room [ROOM NUMBER] on the Three [NAME] Unit had cockroaches on the monitors and in the bathroom.…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of diabetes mellitus and received two oral hypoglycemic medications daily, the Facility failed to ensure nursing developed and implemented an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed Resident #1's risk for hyper/hypoglycemia (high/low blood sugar). Findings include: Review of the Facility's policy titled, Care Plans Comprehensive Person-Centered, dated as revised December 2106, indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -the comprehensive person-centered care plan will incorporate identified problem areas, risk factors associated with identified problems, aid in preventing or reducing decline…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnosis of diabetes mellitus and received two oral hypoglycemic medications daily, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality related to monitoring and assessment of Resident #1 for signs and symptoms of hyper/hypoglycemia (high/low blood sugar). Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing immediately notified his/her Health Care Agent (HCA) and physician, when on 09/20/24, Resident #1 was found sitting on the floor after an unwitnessed fall. Resident #1 was noted with a closed, swollen, puffy right eye several hours later and was transferred to the Hospital Emergency Department (ED) for evaluation. Findings include: Review of the Facility's Policy, titled Change in a Resident's Condition or Status, dated as revised February 2021, indicated the following: -our facility promptly notifies the resident's attending physician, the resident representative of change in the resident's medical/mental condition and/or status; -the nurse will notify the resident's attending physician when there has been an accident or incident involving the resident, discovery of injuries of unknown source; -a nurse will notify the resident's representative when the resident is involved in any accident or incident 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.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plans of Care indicated that he/she required the physical assistance of one staff member with transfers and ambulation, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in their Plans of Care, when on 09/20/24, a short time after Resident #1 had been found on the floor by staff after an unwitnessed fall, Nurse #1 witnessed Resident #1 walking in his/her room, unassisted, and did not intervene to assist him/her, did not notify a staff member that he/she was ambulating in his/her room without assistance and proceeded to leave the facility and go home. Findings include: Review of the Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised December 2016, indicated the following: -an comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -the Facility's…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, required supervision to substantial/maximal assistance from staff to meet his/her care needs, and was assessed by nursing as being at high risk for falls, the Facility failed to ensure he/she was provided nursing care and treatment in accordance with professional standards of practice, when on 09/20/24, after Resident #1 was found lying on the floor in his/her room by Certified Nurse Aide (CNA) #1 after an unwitnessed fall, CNA #1 proceeded get him/her up off the floor, walk him/her to the bathroom and then transfer him/her back to bed, before informing and having nursing assess him/her for any potential injury. After being made aware of Resident #1's unwitnessed fall, Nurse #1 did not assess Resident #1 for injuries, did not document the incident, did not complete an incident report, did not report the incident to his/her physician, or the oncoming shift nurse. Findings include: Standard Reference: Standard of Practice Reference: Pursuant 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and was assessed by nursing at high risk for falls, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 09/20/24, after finding Resident #1 lying on the floor in his/her room after an unwitnessed fall, Certified Nurse Aide (CNA) #1 got him/her up off the floor, proceeded to walk with him/her to the bathroom and transfer him/her back to bed, before informing and having the nurse assess him/her for the potential for physical injury, and as a result, Resident #1 was found in bed the next morning with a swollen, puffy, closed right eye and was transferred to the Hospital Emergency Department (ED) for evaluation. Findings include: Review of a Certified Nurse Aide (CNA) Job Description, dated 2003, indicated the following: -the primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's…

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 staff failed to honor a choice of smoking for two Residents (#424 and #425), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Smoking Policy; Residents, revised 10/25/22, indicated but was not limited to the following: -Prior to, and upon admission, residents are informed of the Center's smoking policies including the location of designated outdoor smoking area(s) if any, and the extent to which the Center can accommodate their smoking or non-smoking preferences. -If the Center permits outdoor smoking in designated areas and time, then residents who express a desire to smoke are evaluated to determine their ability to make informed decisions regarding smoking, accepting liability for any smoking-related harm(s) and follow safety protocols, with or without supervision. -Matches, lighters, electronic cigarettes, and vaping devices are not stored in resident rooms regardless of a resident's level of cognition. The purpose of this policy is to: -Ensure that residents who…

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, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 2 out of 2 test trays conducted. Findings include: During initial resident screening on 8/8/24, the residents expressed the following concerns about the food served at the facility: -Food that was served was not often hot -The food was served cool to warm -The food was sometimes cold -The food was not palatable and was ice cold most of the time. On 8/12/24 at 1:40 P.M., the residents at the Resident Group Meeting expressed concern regarding the palatability of the food served at the facility with concerns that included but was not limited to: -The food leaves a lot to be desired -Some of the food looked like vomit -The portions were terrible reports that he/she received one chicken wing cut in half as their protein serving -Chicken with pieces of bone in it had been served During an interview on 8/12/24 at 11:20 A.M., Resident #22 said over the weekend the food was terrible. Resident #22 said on 8/11/24 the residents were…

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

Based on observations, staff interviews, and record review, the facility failed to ensure that staff accommodate food preferences for two Residents (#18 and #37), out of a total sample of 25 residents. Specifically, 1. For Resident #18, the facility failed to offer preferred food and portion size requested by the Resident, which included scrambled eggs and double meal portions. 2. For Resident #37, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including coffee and oatmeal, on a daily basis. Findings include: 1. Resident #18 was admitted to the facility in July 2023 with diagnoses that included adult failure to thrive and ileostomy status. Review of the Minimum Data Set (MDS) assessment, dated 7/9/24, indicated Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. The MDS also indicated the Resident had the ability to make his/herself understood and had the ability to understand others with clear comprehension. The MDS also indicated the Resident…

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

Based on observation, policy review, and interview, the facility failed to follow their policy and 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: 1. Ensure two of four-unit kitchenettes were maintained in a clean and sanitary condition; and 2. Ensure food items were properly labeled, dated, and stored four of four-unit kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. -4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. -6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them…

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

Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for four Residents (#59, #104, #1A, and #74) of 25 sampled residents and for three of four units in the facility. Specifically, the facility failed to: 1. For Resident #59, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) while providing direct care to a Resident requiring tube feeding; 2. For Residents #104 and #1A, ensure staff wore PPE as required for contact precautions (an infection control intervention designed to reduce transmission of infections) while providing care; and 3. For Resident #74, ensure staff wore PPE as required for Isolation Precautions (an infection control intervention designed to reduce transmission of infections) while in his/her room. Findings include: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure advanced directives were reviewed and followed-up on for one Resident (#44), out of 25 sampled residents. Specifically, the facility failed to ensure the wishes for Do Not Resuscitate (DNR) were pursued as legally allowed for Resident #110. Findings include: Review of the facility's policy titled Advanced Directives, dates as revised in [DATE], indicated the following: -Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. - Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives -The plan of care for each resident is consistent with his or her documented treatment…

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 the Physician/Practitioner was notified of a change in treatment for one Resident (#59), out of a total sample of 25 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when an antibiotic prescribed to treat a urinary tract infection (UTI) was not available from the pharmacy and administered as ordered. Findings include: The Facility Policy titled Miscellaneous Special Situations, Unavailable Medications, dated February 2019, indicated that medications used by residents in the Nursing Facility may be unavailable for dispensing from the pharmacy on occasion. The Policy indicated that the Facility must make every effort to ensure that medications were available to meet the needs of each resident. The Policy indicated that nursing staff shall notify the attending Physician of the situation and explain the circumstances, expected availability, and optional therapy/therapies that are available. Resident #59 was admitted to the facility in April 2024 and diagnoses including a…

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

Based on record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#424 and #425), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #424, to develop a baseline care plan for the Resident's diagnosis of diabetes mellitus and sarcoidosis; and 2.For Resident #425, to develop and implement a baseline care plan related to falls. Findings include: Review of the facility's policy title Care Plans - Baseline, last revised March 2022, indicated but was not limited to: - Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information…

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 staff provided care and services consistent with accepted standards of clinical practice for two Residents (#59 and #47), out of a total sample of 25 residents. Specifically, the facility failed to ensure: 1. For Resident #59, a. the Physician's order for antibiotics to treat a urinary tract infection (UTI) was implemented timely which resulted in a delay in treatment and was administered for the duration of the order; and b. the Physician's order was followed for tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and measuring gastric volume; 2. For Resident #425, care and treatment to the Resident's implanted cardiac pacemaker met professional standards of quality. Findings include: 1. Resident #59 was admitted to the facility in April 2024 and diagnoses including a history of a stroke, chronic kidney disease and diabetes mellitus. Review of the Minimum Data Set assessment, dated…

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 the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#65), out of a total sample of 25 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her dominant language of Cantonese and failed to implement their Limited English Proficiency policy. Findings include: Review of the facility's policy titled, Communication with Persons with Limited English Proficiency, last revised October 2022, indicated but was not limited to the following: - It is the policy of this Center to: -take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. -All interpreters, translators and other aids needed to comply with this policy shall be provided without cost…

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 (#276) of 25 sampled residents the facility failed to ensure acceptable parameters of nutritional status were maintained. Specifically, for Resident #276 a resident with nutritional risk factors, the facility failed to timely obtain a reweigh when significant weight loss was identified. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, dated as revised March 2022, indicated but was not limited to: -residents are weighed upon admission and at intervals established by the interdisciplinary team such as: weekly for four weeks, then monthly unless otherwise indicated or as ordered -weights are recorded in each individual's medical record -any weight change of 5 pounds or more in a patient weighing more than 100 pounds or of 2 pounds in a patient weighing less than 100 pounds since the last weight assessment will be retaken for verification. If the weight is verified, nursing notifies the dietitian -the dietitian will respond timely to a verified significant weight change -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 records reviewed, interviews and observations for one of four sampled resident care units (2 East), the Facility failed to ensure food and beverages provided to the residents were served at safe and appetizing temperatures, when on 05/28/24, results of test trays observations indicated that the food items were not served at appetizing temperatures, and some foods items were not palatable. Findings include: Review of the Facility Policy titled Food Temperatures, undated, indicated that hot foods should be maintained at a minimum of 140 degrees Fahrenheit (F) and cold foods should be maintained at a maximum of 40 degrees F. Review of the Facility Policy titled Food Safety, undated, indicated temperatures of food will be monitored daily and be in compliance with the Department of Public Health Guidelines in the fold service department. Review of the Resident Council Group meeting minutes held on 04/16/24 at 1:30 P.M., with eight residents in attendance, indicated the residents voiced complaints about food…

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 nursing provided care and services that met professional standards, when on 05/28/24, nursing failed to follow acceptable standards of practice related to medication administration. Findings include: Review of the Facility Policy titled, Administrating Medications, dated as last revised 04/2019, indicated that medications are administered in a safe and timely manner and as prescribed. The Policy further indicated the following; -The individual administering the medication verifies the resident's identity before administering any medication; -The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dose, right time and right method of administration before giving the medication; and -Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nurses. Resident #1 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 and interview, the facility failed to ensure the nourishment kitchenettes were maintained in a clean sanitary manner to prevent potential foodborne illness for 4 out of 4 nourishment kitchenettes. Findings include: On 5/22/2023 at 3:37 P.M., the surveyor toured the four kitchenettes and made the following observations: 3 East Unit nourishment kitchenette: -Shelves that stored the bottles of juices and soda was sticky with a thick layer gelled type of liquid. -Styrofoam take out container on top of the microwave, not labeled or dated. -Floor was sticky with visible food particles and dirt. 3 [NAME] Unit nourishment kitchenette: -Beside the refrigerator was a sticky pest trap with a cockroache and sugar pack stuck to it and paper trash. -Behind the refrigerator was plastic silverware, empty water bottles, sugar packets, butter containers and the floor was visible dirty. -Microwave front panel was rusting out along bottom portion. -Inside the microwave, the top and right side was dirty with food debris. -Under the sink there was a quarter filled bottle of apple…

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 1) a medication cart was locked, 2) medications were stored (refrigerated), and dated once opened, according to manufacturer's guidelines in three out of seven medication carts and 3) medication room was maintained according to facility policy. Findings include: Review of the facility policy titled, Medication Labeling and Storage, dated as revised November 2020, indicated but was not limited to: - Medication Labeling: Multi-dose vials that have been opened or accessed (e.g., needle punctured are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.) - Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration. Review of the facility policy titled, Storage of Medications, dated as revised August 2022, indicated but was not limited to: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner. - Drugs and biologicals used in the facility are stored in locked compartments…

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 test tray results, the facility failed to ensure foods and beverages were prepared by methods which conserved nutritional value, flavor, appearance, palatability, and appetizing temperatures for one of two test trays observed. Findings include: During an interview on 5/21/23 at 8:51 A.M., Resident #114 said the food was not so good, no flavor and was cold. During an interview on 5/21/23 at 8:26 A.M., Resident #276 said the food was terrible, the hot dog last night wasn't even cooked, it was cold. During an interview on 5/21/23 at 10:29 A.M., Resident #56 said the food was bad, same old stuff all the time pasta and chicken. He/she said the hamburger was cold and the cheese wasn't even melted. During an interview on 5/21/23 at 10:47 A.M., Resident #21 said the food was plain and the temperature was terrible. During an interview on 5/21/23 at 2:03 P.M., Resident #34 said the food was not even luke warm. During an interview on 5/21/23 at 2:10 P.M., Resident #62 said the food was most often cold. On 5/23/23 at 7:35 A.M., the surveyor observed 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, interview, and policy review, the facility failed to ensure residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#20) out of a total sample of 28 Residents. Findings include: Review of the facility's policy titled Psychopharmacologic Medication Policy, last revised on 9/6/2018, indicated but was not limited to: - Prior to administering [a listed/specified] psychotropic medication, a facility shall obtain the informed written consent of the resident, the resident's health care proxy (HCP) or the resident's guardian. - Written informed consent must be obtained each time a new or renewed prescription falls outside the dosage to which the resident or the resident's legal representative previously consented, or once a year, whichever is shorter. Resident #20 was admitted to the facility on January, 2022, with diagnoses which included Alzheimer's disease and chronic obstructive pulmonary disease (disease…

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

Based on observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and implemented for two Residents (#33 and #4), out of a total sample of 28 residents. Specifically, the facility failed to: 1) For Resident #33 implement bilateral quarter side rails used for mobility and security; and, 2) For Resident #4 ensure a comprehensive care plan was developed for a resident receiving Dialysis treatment. Findings include: 1. Resident was admitted to the facility 12/19/2019 with diagnosis which included, schizophrenia, conversion disorder with seizures/convulsions, and stroke. Review of the Minimum Data Set (MDS) assessment, dated 3/28/2023, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the Resident was cognitively intact. Review of Resident #33's care plan indicated the following: -Activity of daily living self-care deficit related to physical limitations related to decline in functional mobility initiated 12/30/2019. -Interventions, bilateral quarter side…

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

Based on record review, policy review and interview, the facility failed to ensure staff administered medication which met professional standards of care for one Resident (#21) out of a total sample of 28 residents. Specifically, staff failed to follow the Physician's order, and administered medication when the Resident's blood pressure was outside the Physician's ordered parameters. Findings include: Review of the facility policy titled, Administering Medications, dated 5/21/19, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -The policy indicated medications are administered in accordance of physician's order. Resident #21 was admitted to the facility April 2023 with diagnoses which included heart failure and orthostatic hypotension. Review of the Minimum Data Set (MDS) assessment, dated 5/1/23, indicated Resident #21 could make self understood and understood others. Review of the Physician's order, dated 5/15/23, indicated: -Midodrine (medication used to treat low blood pressure) HCl Oral Tablet 2.5…

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 staff provided appropriate care and services related to indwelling urinary catheter drainage bags for one Resident (#120) who required an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine), out of a total sample of 28 residents. Findings included: Review of the facility policy titled, Catheter Care, Urinary, dated as revised August 2022, indicated but was not limited to: -To prevent urinary catheter-associated complicates, including urine tract infections to be sure the catheter tubing and drainage bag are kept off the floor. Resident #120 was admitted to the facility in April 2023 with diagnoses which included cerebral infraction, sepsis, muscle weakness, urinary tract infection, hypertension, anxiety and urine retention. Review of the Minimum Data Set assessment, dated 5/4/23, indicated Resident #120 required an indwelling urinary catheter. On 5/21/23 at 9:10 A.M., the surveyor observed Resident #120's indwelling urinary catheter drainage bag. The catheter…

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, records review, interview and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube, a feeding tube in the abdomen used to provide nutrition) was provided in accordance with professional standards of practice for two Residents (#120 and #52), out of a total sample of 28 residents. Specifically, 1.) For Resident #120, nursing administered an enteral nutrition formula which was not correct, the bottle was undated and therefor unable to ensure the enteral nutrition was not expired and 2.) For Resident #52, the enteral bottle was undated and therefor unable to ensure the enteral nutrition was not expired. Review of the facility policy titled, Enteral Feedings - Safety Precautions, dated as [DATE], indicated but was not limited to the following: -To ensure the safe administration of enteral nutrition: *Preparation 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and…

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

Based on interview and record review, the facility failed to provide care and maintenance of an intravenous catheter, consistent with professional standards of practice for one Resident (#227) out of a total sample of 28 residents. Specifically, for Resident #227, the facility failed to flush his/her intravenous device to maintain patency. Findings Include: Review of the facility policy titled, Maintaining Patency of Peripheral and Central Vascular Access Devices, dated 8/16, indicated, but was not limited to: -All vascular access devices should be flushed routinely when not in use to maintain patency. Review of the facility policy titled, Infusion Therapy Procedures Flush Chart, dated 8/16, indicated but was not limited to: -For a tunneled Catheter at a minimum should be flushed with 10 milliliters (mL) of saline pre- use, post-use, every eight hours and as needed. Resident #227 was admitted to the facility May 2023 with diagnoses which included laminectomy (a surgical procedure performed on the spine) and surgical wound infection. Review of the medical record 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.

Based on observation, record review and interview, the facility failed to maintain respiratory equipment according to professional standards of practice for 1 Resident (#120) out of a total sample of 28 residents. Findings include: Resident #120 was admitted to the facility April 2023 with diagnoses which included cerebral infraction, sepsis, muscle weakness, urinary tract infection, hypertension, anxiety and urine retention. Review of the Minimum Data Set (MDS) assessment, dated 5/4/23, indicated Resident #120 had no speech, was rarely/ never understood and could rarely/ never make self-understood. Review of the MDS indicated Resident #120 required tracheostomy care and oxygen administration. On 5/22/23 at 6:42 A.M., 5/22/23 at 10:59 A.M. and 5/22/23 at 3:36 P.M., the surveyor observed Resident #120's oxygen tubing attached to the wall with oxygen flowing to his/her tracheostomy. The tubing was in a basin on the floor and was intertwined with an indwelling urinary catheter bag with urine in the bag. Review of the physician's order, dated 4/5/23, indicated: -Cool mist aerosol via…

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

Based on observations, records reviewed, policy review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 2 errors out of 25 opportunities resulting in a medication error rate of 8%. Those errors impacted 2 Residents (#115 and #21) out of 3 residents observed. Findings include: Review of the facility policy titled, Administering Medications, dated 5/21/19, indicated, but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. The policy indicated medications are administered in accordance of physician's order and the individual administering the medication will verify the dose. On at 5/22/23 at 8:00 A.M., the Surveyor observed Nurse #1 prepare and administer medications for Resident #115 including: -Miralax (medication used for constipation), mixed in 4 ounces of water. Nurse #1 measured the dose in the cap up to the first line. Further review indicated Nurse #1 did not measure to the line in the cap with the arrow indicating a full dose…

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 one Resident (#276) was free from a significant medication error, out of a total sample of 28 residents. Specifically, Resident #276 was administered the physician's ordered antibiotic daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M.; for 26 doses instead of every eight hours as indicated by the hospital discharge summary. Findings include: Resident #276 was admitted to the facility in May 2023 with diagnoses which included diabetes, gangrene and bacteremia (infection in the blood). Review of the Minimum Data Set assessment, dated 5/17/23, indicated Resident #276 required intravenous therapy. Review of the hospital Discharge summary, dated [DATE] , indicated for nursing to administer Cefepime (antibiotic medication) 2,000 milligrams (mg) intravenous (IV) every eight hours. Review of the nursing note, dated 5/12/23, indicated [cefepime] not arrived from the pharmacy, rescheduled time and notified physician. Review of the Physician's order dated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure staff implemented and followed facility policy for proper Enhanced Barrier Precautions in an effort to help prevent the possible transmission of diseases and infections, such as multi-drug resistant organisms (MDROs) for two Residents (#73 and #115) out of a total sample of 28 residents. Findings included: Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, indicated the following: - Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. - Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care of use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and wound…

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 maintain essential equipment in the main kitchen in working order. Specifically, the facility failed to: 1. Ensure the dishwasher sanitation rise temperature reached 180 degrees Fahrenheit as required for sanitation process to be completed; and, 2. Ensure the steam oven was repaired in a timely manner. Findings include: 1. During an interview on 5/22/23 at 1:32 P.M., the Food Service Manager (FSM) said the dishwasher was a high temperature machine. He said the wash cycle should be 160 Fahrenheit (F) and the the sanitation temperature is 180 degrees F. On 5/22/23 at 1:40 P.M., the surveyor observed the dietary staff operating the dishwasher for lunch service dishes. The wash temperature was observed to be 160 degrees F and the sanitation was observed to 160 degrees F. The surveyor reviewed the dishwasher temperature logs, which indicated the wash cycle consistently at 160 degrees F and the sanitation was consistently 180 to 183 degrees F. The surveyor observed a total of five sets of dishes run through the dishwasher with…

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