Saugus Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide oral mouth care to one Resident (#7) who does not receive food or drink by mouth resulting in oral thrush (a fungal infection of the mouth) developing out of a total sample of 27 residents. Findings include: Resident #7 was admitted to the facility in January 2018 with diagnoses including muscle wasting, depression and dysphagia. Review of Resident #7's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 13 out of 15 indicating no cognitive impairment. Further review of the MDS indicated that the Resident requires substantial/maximal assistance with oral hygiene and is currently receiving tube feeding therapy. During an observation on 6/8/25 at approximately 10:00 A.M., Resident #7 was lying in his/her bed, he/she has a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach through a small incision in the abdomen to provide artificial nutrition)…

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 the necessary vision services were provided for one Resident (#26) out of a total sample of 27 residents. Findings include: Resident #26 was admitted to the facility in August 2024 with diagnoses that include Hyperglycemia (high blood sugar level, with common symptoms that include blurred vision) and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/14/25, indicated that on the Brief Interview for Mental Status exam, Resident #26 scored a 9 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #26's vision is adequate and that he/she does not wear corrective lenses. Review of the clinical record indicated the following: -A Nurse Practitioner (NP) progress note, dated 1/21/25,: Pt. (patient) would like referral for cataract surgery as he/she has missed recent surgical dates d/t (due to) acute illnesses. - An NP note, dated 2/4/2025,: Patient seen today at his/her request. He/she is wondering about his/her referral to the eye surgeon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure nursing implemented a splinting device as ordered for contracture prevention for one Resident (#16) out of a total sample of 27 residents. Specifically, the facility failed to ensure Resident #16 was wearing a hand roll as ordered and recommended by the therapy department. Findings include: Resident #16 was admitted to the facility in January 2016 with diagnoses including muscle weakness, dementia and arthritis. Review of the Resident's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated the Resident has impairment on one side, is dependent on staff for activities of daily living. The surveyor made the following observations: -On 6/8/25 at 10:14 A.M., Resident #16 was lying in his/her bed, and he/she said his/her right hand was stuck and his/her last three fingers could not straighten…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure one Resident (#32) was receiving oxygen at the correct flow rate and failed to ensure there was water in the humidifier bottle while the Resident was receiving oxygen, out of a total sample of 27 residents. Findings include: Review of the facility policy titled Oxygen Administration per Nasal Cannula, dated September 2024, indicated the following: - Policy: A physician's order shall be required for administering oxygen, humidifier shall be changed every 72 hours and when needed. - Procedure: Verify order in the resident's medical record, attach pre-filled humidifier bottle to the concentrator (if indicated). Resident #32 was admitted to the facility in August 2019 with diagnoses including acute bronchitis, chronic respiratory failure and anxiety disorder. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15…

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 develop a trauma care plan related to Post Traumatic Stress Disorder (PTSD) or identify triggers for one Resident (#48) out of a total of 27 sampled Residents. Findings include: Review of the facility's policy titled, Trauma Informed Care, dated 2025 indicated the following: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. 7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected and hopeful regarding their own recovery. 8. The facility will evaluate whether the interventions…

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 staff failed to ensure a care plan was developed with individualized-person centered interventions for one Resident (#12), who has a diagnosis of dementia, out of a total sample of 27 residents. Findings include: Review of the facility policy titled Dementia Treatment Plan, dated September 2024, indicated the following: - For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. - The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes etc. Resident #12 was admitted to the facility in October 2024 with diagnoses including unspecified dementia, major depressive disorder and psychotic disorder. Review of Resident #12's most recent Minimum Data Set…

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 staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure the high side medication cart was locked while a nurse was not present on the first floor unit. 2. The facility failed to ensure treatment carts were locked while a nurse was not present on the second floor unit. Findings include: Review of the facility policy titled, Medication Storage, dated 9/24, indicated the following: -The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 6/8/25 from 8:52 A.M. to 8:58 A.M., the surveyor observed the high side medication cart unlocked and unsupervised in the hallway. Multiple staff and residents were observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure laboratory services were obtained timely for three Residents (#60, #68, #40), out of a total 27 sampled Residents. Findings include: Review of the Specimen Collection policy, dated April 2007, indicated: 1. All specimens, sputum's, etc, order for testing shall be obtained in accordance with established nursing service procedures. 2. Specimen collections must be placed in their proper container, securely sealed and properly labeled for transfer to the laboratory. 1. Resident #60 was admitted to the facility April 2025 with diagnoses including metabolic encephalopathy and acute kidney failure. Review of his/her Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #60 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status exam. Review of Resident #60's physician's orders indicated the following orders: -4/17/25: CMP, CBC next lab day -5/6/25: CMP and CBC never done…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure follow-up dental services were provided for two Residents (#22 and #24) out of a total of 27 sampled residents. Specifically, the facility failed to ensure recommendations related to the fabrication of dentures for Resident #22 and Resident #24 were implemented. Findings include: Review of the facility policy titled, Dental Services, undated indicated the following: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 1. Resident #22 was admitted to the facility in March 2024 with diagnoses including dysphagia and Alzheimer's. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #22 is severely cognitively impaired as evidenced by a score of seven out of a possible 15 on the Brief Interview for Mental Status Exam. During an interview on 6/8/25 at approximately 9:02 A.M., the surveyor observed 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 record review and interview, the facility failed to provide the appropriate diet texture for one Resident (#56) out of a total sample of 27 residents. Specifically, Resident #56, who has a known history of choking at the facility, was given a peanut butter and jelly sandwich while being prescribed a puree diet. Findings include: Resident #56 was admitted to the facility in April 2024 with diagnoses that included dysphagia, Huntington's Disease, adult failure to thrive, and severe protein-calorie malnutrition. Review of Resident #56's Minimum Data Set (MDS) assessment, dated 4/2/25, indicated he/she scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive deficits. Further review of the MDS indicated mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of Resident #56's active physician order, dated 9/3/24, indicated Regular diet, Puree texture, Nectar consistency. On 6/10/25 at 8:45 A.M., the surveyor observed the Resident walk to the nurses station 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 document review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility developed QAPI plans related to staff education and infection control once these concerns were identified by the Administrator. Findings include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2025, indicated the following: -Purpose: To ensure that (the facility) implements a comprehensive QAPI program which addresses all the care and unique services that the facility provides. -To ensure continuous evaluation of the facility's systems with the objectives of: ensuring that care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available; Preventing deviation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), who were admitted to the Facility with pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful) the Facility failed to ensure that nursing adequately assessed and documented their wounds, including but not limited to measurements of each wound, as well as notification of and obtaining orders for wound care treatments from the provider. Findings include: The Facility Policy, titled, Pressure Injury Prevention and Management, dated 08/2024, indicated: -Pressure injuries were defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Licensed nurses would conduct a pressure injury assessment and full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included orders for insulin administration and blood glucose monitoring, the Facility failed to ensure he/she was free from significant medication errors, when the physician's orders were not accurately reconciled by nursing, he/she was not administered insulin and his/her blood glucose levels were not monitored for three days. Findings include: The Facility Procedure, titled, Reconciliation of Medications on Admission, dated 07/2017, indicated: -Nursing would ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission to the Facility. -Medication reconciliation was the process of comparing pre-discharge medications to post-discharge medications. -Nursing would obtain a medication history from the residents or their family. -Nursing would use an approved medication reconciliation form or other record to list all medications, their doses,…

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, the facility failed to have sufficient staffing. Specifically, the facility failed to provide sufficient staffing, particularly on the weekend shift, during FY 24 (fiscal year) Quarter 2. Findings include: Review of the Centers of Medicare and Medicaid (CMS) PBJ (payroll-based journal) Staffing Data Report FY (fiscal year) Quarter 2 (January 1-March 31) indicated the facility triggered for excessively low weekend staffing. Review of the Facility's Assessment 2024 indicated the following: The facility services individuals who have one or more chronic or co-morbid conditions. Our overall resident consists of residents with diagnosis (sic) of CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease, high blood pressure and diabetes. -Staffing plan. The interdisciplinary team along with the Nurses CNAs (certified Nursing assistants) review each resident and assignment. Resident care needs are reviewed and updated (as needed) to assist both resident and staff to provide consistent care. The Director of Nursing reviews with 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 and interview, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the transmission of disease and infection. Specifically: 1. the facility failed to develop a water management program to prevent the spread of water borne diseases and, 2. failed to disinfect reusable medical equipment between residents. Findings include: 1. Review of the facility policy titled Water Management- Quarterly Flush dated 5/16/19, indicated that an initial assessment will be completed by members of the water management team, documenting at risk areas. Review of the water management program binder given to the surveyor failed to indicate that an initial assessment was completed and ongoing assessments were completed by members of the water management team. During an interview on 7/08/24, at 2:20 P.M., with the Administrator and the Maintenance Director they said that the facility had not developed a complete water management program. They said that the facility had not performed an assessment to identify where…

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 2a. For Resident #15 the facility failed to provide dignity by failing to remove chin hair. Resident #15 was admitted to the facility in August of 2023 with diagnoses that include but are not limited to Alzheimer's disease, lupus anticoagulant syndrome, muscle weakness, and unsteadiness on feet. Review of Resident #15's MDS dated [DATE] indicated staff assessed Resident #15 as having severely impaired cognition and required supervision/or touching assistance as resident completes the activity for personal hygiene and had one to three days of rejecting care. Review of Resident #15's care plans failed to indicate he/she resisted care or resisted having assistance with removing his/her chin hair. On 7/2/24 at 7:15 A.M., Resident #15 was observed, dressed in clothes resting on his/her bed. Resident #15 was observed to have thick hair approximately over one-half inch on his/her chin. Resident #15 said he/she was interested in having it removed, then said someone would need to get me a razor. On 7/2/24 at 3:48 P.M.,…

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 3. Resident 21 was admitted to the facility in January of 2016 and with diagnoses that include but are not limited to type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, and anxiety. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] indicated Resident #21 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating severely impaired cognition, is dependent on staff for toileting, bathing, dressing and hygiene and receives hospice services. Review of Resident #21's medical record indicated the following: -A physician's order to admit to hospice for care and comfort on 2/4/22. Review of Resident #21's care plans indicated the following: -Resident requires assistance with ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, toileting r/t (related to) cognitive loss, dated 6/16/2018 with an intervention dated 6/16/2018, Resident is dependent on 2 staff for toileting and incontinence care. -In the aftermath of the rape abuse…

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 3. The surveyor made the following observation: - On 7/2/24 at 1:25 P.M., the door to the medication storage room was left opened, the surveyor was able to push it open, no staff were in the medication room. On the door was a sign that said 1/1/23 Please lock the med room at all times. During an interview, Nurse #1 said the medication room should be locked at all times. - On 7/3/24 at 8:20 A.M., the surveyor observed an unattended medication cart on the first floor, no staff were within sight of the cart. The surveyor was able to pull open the drawers of the medication cart containing medication. Nurse #3 came back to the cart and said the cart should be locked when unattended. Nurse #3 proceeded to lock the cart but the surveyor was able to open the cart when it was locked. Nurse #3 said it is not locking properly. The Maintenance Director approached the cart and said the cart is not locking properly as it should not be able to be opened when it is in the locked setting. The Assistant Director of Nursing said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide dental services to one Resident (#22) out of a total sample of 27 Residents. Findings include: Review of the facility policy titled Dental Services, undated, indicated the following: -Routine and 24-hour emergency dental services are provided to our residents through: -a contract agreement with a licensed dentist that comes to the facility - referral to the resident's personal dentist - referral to community dentists - referral to other health care organizations that provide dental services - Resident's have the right to select dentists of their choice when dental care or services are needed - Social services representatives will assist residents with appointments, transportation arrangements - All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred Resident #22 was admitted to the facility in April 2016…

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

Based on observations, record review, policy review, and interviews, the facility failed to ensure one Resident (#13), out of 27 total sampled residents, was assessed for the ability to self-administer medications. Specifically, for Resident #13 the facility failed to ensure he/she was assessed to self-administer Centrum vitamins and Nystatin powder (used to treat fungal infections of the skin). Findings include: Review of the facility policy titled Safety and Supervision of Residents, dated 4/2018 indicated the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Further review indicated that as part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical abilities to determine whither self-administering medications is clinically appropriate for the resident. Resident #13 was admitted to the facility in September 2019 with diagnoses including bipolar disorder, psychosis and psychoactive substance abuse.…

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 for one Resident (#32), out of a total sample of 27 residents, the facility failed to ensure advanced directives were implemented consistently in the medical record in accordance with the resident's/health care agent wishes. Findings include: Review of the facility's policy titled, 'Advanced Directives', not dated indicated Advanced directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation included but not limited to the following: Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical, or surgical treatment and to formulate an advance directive if he or she chooses to do so. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident his/her family members and/or his or her legal representative, about the existence of any written advanced directives. Information about whether or not the resident has…

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 for two Residents (#20 and #32) out of a sample of 27 Residents, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the resident's status. Specifically,1. The MDS failed to indicate Resident #20 was at risk for developing a pressure ulcer/injury, and 2. The MDS failed to indicate Resident #32 had a significant weight gain, resulting in no further assessment of the accuracy of the weight gain and care planning process. Findings include: 1. Resident #20 was admitted to the facility in November of 2020 with diagnoses that include but are not limited to post traumatic seizures, atherosclerotic heart disease, muscle weakness, Crohn's disease of small intestine, cognitive communication deficit, cerebral infarction, and anxiety disorder. Review of Resident #20's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated staff assessed Resident #20 with a severely impaired cognition and he/she was dependent on staff for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to meet professional standards of nursing practice for one Resident ( #221) out of a sample of 27 Residents. Specifically, the facility failed to obtain a leave of absence physician's order for a resident with a history of drug dependence and recent relapse. Findings include: A review of the facility policy titled 'Substance Use Disorder Policy' with a revision date of November 2017 indicated the following: -The purpose of this policy is to identify residents prior to admission as they relate to substance use disorder. To identify all appropriate diagnoses or specific services needed as they relate to substance abuse/use on addiction and to determine risk for relapse and the level of supervision needed. Resident #221 was admitted to the facility in June 2024 with diagnoses including opioid dependence, alcohol use unspecified with alcohol induced mood disorder, and bacteremia. A review of the most recent Minimum Data Set (MDS) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to adhere to quality standards of care for one Resident (#20), out of a total sample of 27 residents. Specifically, the facility failed to identify skin injuries on Resident #20. Findings include: Resident #20 was admitted to the facility in November of 2020 with diagnoses that include but are not limited to post traumatic seizures, atherosclerotic heart disease, muscle weakness, Crohn's disease of small intestine, cognitive communication deficit, cerebral infarction, and anxiety disorder. Review of Resident #20's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated staff assessed Resident #20 with severely impaired cognition and he/she was dependent on staff for all care and is incontinent of bladder and bowel. On 7/02/24 at 7:34 A.M., Resident #20 was observed resting on his/her bed. Resident #20 was uncovered and was observed to have a small dark, raised area on his/her left second toe. His/her third toe had a small area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure for one Resident (#20) out of a total sample of 27 residents that professional standards of practice were adhered to for the prevention of developing pressure ulcers/skin injuries. Specifically, the facility failed to implement physician's orders for weekly skin evaluations. Findings include: Review of the facility's policy, entitled Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated included but was not limited to the following: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example immobility, recent weight loss, and a history of pressure ulcer(s) Review of the facility's policy entitled 'Pressure Injury Risk Assessment, not dated included but was not limited to the following: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents, as risk of developing pressure injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards for one Resident (#34) out of a total sample of 27 residents. Specifically, the facility failed to ensure that the smoking policy was adhered to, resulting in Resident #34 having numerous smoking materials in his/her room and smoking in his/her room. Findings include: Review of the facility policy titled Smoking Policy - Residents, undated, indicated the following: -Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. - Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. - Any smoking -related privileges, restrictions, and concerns (for example, need for close monitoring) shall be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to address the nutrition and hydration status of three Residents (#57, #32, #34) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure a physician's order for an altered diet was obtained and appropriate for Resident #57. 2. Ensure the physician's orders were implemented for weekly weights and a re-weigh was obtained for Resident #32 whose recorded weight had a gain of 5% more than the previous month weight. 3. Obtain weights for pre and post dialysis treatment for Resident #34. Findings include: Review of the policy entitled 'Interdepartmental Notification of Diet (Including Changes and Reports), not dated indicated the following: Nursing services shall notify the food and nutrition service department of a residence diet orders, including any changes in the residence diet, meal service, and food preferences. 1. When a new resident is admitted , or a diet has been changed, the nurse supervisor shall 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and interview the facility failed to ensure staff provided professional standards of care related to replacing the oxygen tubing as ordered by the physician and maintaining the nasal cannula in a sanitary condition for one Residents (#22) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Oxygen Use, dated and revised April 2022, indicated the following: - Verify that there is a physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Resident #22 was admitted to the facility in April 2016 with diagnoses including Chronic Obstructive Pulmonary Disease, shortness of breath and schizophrenia. Review of Resident #22's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that the Resident has moderate cognitive impairment. Further review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure services consistent with professional standards were provided for one Resident (#34) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 27 residents. Specifically, the facility failed to keep an updated communication book for dialysis care and ensure it was accompanying Resident #34 to and from dialysis care. Findings include: Review of the facility policy titled Dialysis Patients, undated, indicated the following: - A dialysis communication form will be sent with the patient in case of documentation with the facility and the dialysis center Resident #34 was admitted to the facility in August 2023 with diagnoses including end stage renal disease and type 2 diabetes mellitus. Review of Resident #34's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide substance use services for one Resident (#221) out of a sample of 27 Residents. Specifically, the facility failed to: 1. Provide mental health services for Resident #221, who had a recent substance use relapse. 2. Offer and provide Resident #221 support programs that include Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings. 3. Have qualified staff to manage the support program meetings, AA and NA in the facility. Findings include: A review of the facility policy titled 'Substance Use Disorder Policy' with a revision date of November 2017 indicated the following: -The purpose of this policy is to identify residents prior to admission as they relate to substance use disorder. To identify all appropriate diagnoses or specific services needed as they relate to substance abuse/use on addiction and to determine risk for relapse and the level of supervision needed. -The clinical liaisons/admission coordinators will be responsible to…

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

Based on observations, interviews and policy review, the facility failed to 1. properly store food items in the kitchen to prevent the risk of foodborne illness and in accordance with professional standards for food service safety and 2. failed to ensure food was stored in the meal carts to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Food Storage, undated, indicated the following: - Chemicals must be clearly labeled, kept in original containers, when possible, kept in a locked area and stored away from food. - All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. - Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (Time and Temperature Contol Foods) food should be consumed, sold, or discarded. - Refrigerated food storage: All foods should be covered, labeled and dated. All foods will be checked to assure the foods (including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to maintain accurate medical records. Specifically, staff signed off on the Treatment Administration Record (TAR) that oxygen tubing was changed, when it had not been changed, for one Resident (#22) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Oxygen Use, dated and revised April 2022, indicated the following: - Verify that there is a physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Resident #22 was admitted to the facility in April 2016 with diagnoses including Chronic Obstructive Pulmonary Disease, shortness of breath and schizophrenia. Review of Resident #22's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that the Resident has moderate cognitive impairment. Further review of the MDS indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one Resident (#9), out of a total sample of 27 residents had a bed that was in operating condition. Specifically, Resident #9's top part of his/her bed was leaning toward his/her left side and was not level. Findings include: Resident #9 was admitted to the facility in February of 2007 and has diagnoses that include but not limited to major depressive disorder, osteoporosis, anemia, limitation of activities due to disability and epilepsy. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] indicated staff assessed Resident #9's with a severely impaired cognition and required substantial/maximal assistance from staff for bathing and transfers. On 7/ 2/24 at 7:56 A.M., Resident #9 was observed resting in his/her bed. The upper top of the bed was leaning to his/her left and Resident #9 was leaning to the left side of the bed towards the wall. Resident #9 said he/she was okay in his/her position. Resident #9 said he/she does not get…

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 for one Resident (#120) out of three discharged resident records reviewed, out of a total sample of 27 residents, the facility failed to implement their abuse prohibition policy. Specifically, for Resident #120 the nurse failed to report an allegation of neglect to the Director of Nursing or Administrator as required. Findings include: Review of the facility's policy, entitled 'Clinical Services Subject: Abuse', Policy: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's symptoms. It is the philosophy of all the facilities to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: Neglect means the failure of the facility, its…

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 for one Resident (#120) out of three discharged resident records reviewed, out of a total sample of 27 residents, the facility failed to report an allegation of neglect, no later than two hours after the abuse allegation was received, to the Department of Public Health. Findings include: Review of the facility's policy, entitled 'Clinical Services Subject: Abuse', Policy: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's symptoms. It is the philosophy of all the facilities to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: Neglect means the failure of the facility, its employees or service providers to provide goods and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview for two out of two applicable residents (#15 and #9) out of a total sample of 27 residents and one out of one applicable discharged Resident (#120), out of a total of three discharge residents, the facility failed to implement professional standards of practice for residents who have a colostomy or ileostomy. Specifically: 1. For Resident #15 the facility failed to have physician's orders for the care of his/her ileostomy including changing the appliance, 2. For Resident #9 the facility failed to have orders or documentation to indicate when the colostomy appliance was changed. and 3. The facility failed to ensure orders to indicate when the colostomy appliance is to be changed. Findings include: Review of the facility's policy, entitled Colostomy/Ileostomy Care not dated indicated the following: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. 1. Review the resident's care plan 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 record review and interviews, the facility failed to obtain consent for the use pf psychotropic medications for two Residents (#162 and #48), out of a total sample of 21 residents. Findings include: Review of the facility policy titled, Psychotropic Consent, dated 2/20/17, indicated the following: *The facility will obtain informed written consent prior to administration of any psychotropic medication. Psychotropic medications include but are not limited to: antipsychotic medications, antidepressant medication, antianxiety medication, hypnotic medications and any medication prescribed to treat a psychiatric disorder. 1. Resident #162 was admitted to the facility in May 2021 with diagnoses including major depression and anxiety. Review of Resident #162's most recent Minimum Data Set (MDS) assessment, dated 1/18/23, indicated the Resident was unable to participate in the Brief Interview for Mental Status (BIMS) and staff assessed him/her as having severe cognitive impairment. The MDS also indicated Resident #162 is dependent on staff for all daily tasks. Review of 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 observations and interviews the facility failed to maintain a home like environment for two Residents (#10 and #15) out of a total sample of 21 residents. Findings include: 1. During environmental rounds on 4/30/23 at 11:31 A.M., the surveyor observed Resident #15's room. The privacy curtain between bed A and bed B was covered with dark brown matter on both sides of the curtain. During an observation on 5/1/23 at 8:38 A.M., the surveyor observed Resident #15's room. The privacy curtain between bed A and bed B was covered with dark brown matter on both sides of the curtain. During an interview on 5/1/23 at 1:15 P.M., the House Keeping Manager said the privacy curtains are cleaned every three months and as needed. He said all staff are responsible to ensure residents are in a clean environment and are expected to report immediately to housekeeping if something needs to be cleaned. 2. During an observation on 4/30/23 at 9:04 A.M., the surveyor observed Resident #10's room. There was a bed pan on the floor in the corner of the Resident's room with dry dark brown matter on it.…

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 1. implement the plan of care for one Resident (#164) and failed to 2. develop an individualized care plan for one Resident (#6) out of a total sample of 21 Residents. Findings include: 1. For Resident #164, the facility failed to follow the physician order for obtaining weights. Review of the facility policy Weight Assessment and Intervention, dated 12/2022, indicated the following: *The nursing staff will measure resident weights on admission, and as ordered. Resident #164 was admitted to the facility in April 2023 with diagnoses including protein-calorie malnutrition. Review of Resident #164's physician orders indicated the following order: * WEIGH WEEKLY on THURSDAY during AM shift, every day shift every Thu (sic) for 4 Weeks. Review of Resident #164's weight log failed to indicate the Resident has been weighed weekly, with the only weight taken on the day of admission. During an interview on 5/01/23 at 10:39 A.M., the Director of Nursing said weights should be taken as ordered by the physician. 2. For…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure assistance with Activities of Daily Living was provided to two Residents (#14 and #16) out of a total sample of 21 residents. Findings include: The facility policy titled Activities of Daily Living (ADLs), Supporting, dated 4/2018, indicated the following: * Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care); Mobility (transfer and ambulation, including walking); Elimination (toileting); Dining (meals and snacks); and Communication. 1. Resident #14 was admitted to the facility in May 2016 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/8/23, indicated Resident #14 was assessed by staff 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 record review and interview, the facility failed to follow the recommendations of the hospital and obtain a lung biopsy for one Resident (#52) out of a total sample of 21 residents. Findings include: Resident #52 was admitted to facility in December 2014 with diagnoses including malignant neoplasm of the lung. Review of Resident #52's most recent Minimum Data Set (MDS) assessment, dated 3/24/23, indicated the Resident had a Brief interview of Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #52 requires supervision for daily functional tasks. During an interview on 4/30/23 at approximately 8:45 A.M., Resident #52 said he/she has been feeling very anxious about his/her medical condition. The Resident said that while in the hospital prior to admitting to this facility, a lung mass was found. Resident #52 said he/she was told by the physician at the hospital to have a biopsy immediately to find out if it was cancerous and if he/she should begin treatment. Resident #52 said he/she has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to utilize an orthotic for contracture management for one Resident (#162) out of a total sample of 21 residents. Findings Include: Resident #162 was admitted to the facility in May 2021 with diagnoses including stroke and hemiplegia (paralysis) of the left side. Review of Resident #162's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to participate in the Brief Interview for Mental Status (BIMS) and staff assessed him/her as having severe cognitive impairment. The MDS also indicated Resident #162 is dependent on staff for all daily tasks. During an observation on 4/30/23 at 7:54 A.M., Resident #162 was observed lying in bed with a washcloth in his/her left hand. Review of Resident #162's physician orders indicated the following order written on 5/26/22: *Pt (patient) to wear carrot in left hand daily with skin checks as needed during daily care and off at night to decrease the risk for further…

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 infection control practices were maintained for a nebulizer machine, mask and tubing for one Resident (#19) out of a total sample of 21 residents. Findings Include: Resident #19 was admitted to the facility in April 2018 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Acute Respiratory Failure with Hypoxia. Review of Resident #19's most recent Minimum Data Set (MDS) assessment, dated 1/26/23, indicated Resident #19 scored a 15 out of a possible 15, indicating intact cognition. During an observation on 4/30/23 at 7:05 A.M., Resident #19 was observed with a nebulizer mask on receiving a nebulizer treatment. During an observation and interview on 4/30/23 at 7:29 A.M., the surveyor observed a nebulizer machine and nebulizer mask with tubing in a basket next to Resident #19's dresser on top of personal items. Resident #19 said that staff have not offered him/her an oxygen bag to keep the nebulizer mask in after use. Review of Resident #19's April 2023 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.

Based on record review and interview the facility failed to develop a person centered care plan for two Residents (#35 and #39 ) who have a diagnosis of Post-Traumatic Stress Disorder (PTSD) out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated 8/19, indicated: * Trauma-informed care is culturally sensitive and person centered. * Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. 1. Resident #35 was admitted to the facility in August 2019 with diagnoses including PTSD, anxiety disorder and depression. Review of Resident #35's most recent Minimum Data Set (MDS) assessment, dated 2/22/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating intact cognition. During a record review the following was indicated: * Resident #35's medical record indicated behavioral medication management progress notes dated 1/9/23 and 1/20/23 indicating a post-traumatic stress disorder (PTSD) diagnosis. * The record failed to indicate 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 implement Pharmacy Medication Regimen Review recommendations timely for one Resident (#19) out of a total sample of 21 residents. Findings Include: Review of the facility's policy titled Medication Regimen Review, dated 4/2017, indicated the following: * The consultant pharmacist reviews the medication regimen of each resident at least monthly. * The physician may accept and act on a recommendation or reject a recommendation and provide an explanation for disagreement. This should be determined within 15 days of the pharmacist's report. Resident #19 was admitted to the facility in April 2018 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Acute Respiratory Failure with Hypoxia. Review of Resident #19's most recent Minimum Data Set (MDS) assessment, dated 1/26/23, indicated Resident #19 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of Resident #19's Consultant Pharmacy Medication Regimen Review, dated 4/11/23,…

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

Based on observations, record reviews and interviews the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of 3 nurses observed made 5 errors in 27 opportunities on two of two units resulting in a medication error rate of 18.52%. These errors impacted 3 (#A1, #37 and #10) out of 10 residents observed. Findings include: Review of facility policy titled Administering medications, undated, indicated the following: Policy Interpretation and Implementation *3. Medications must be administered in accordance with the orders, including any required time frame. *7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. *22. Staff shall follow established facility infection control procedures (e.g, handwashing,antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. *23. Medications ordered for a particular…

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 trays the facility failed to maintain appropriate food temperatures. Findings include: A breakfast test tray was completed on the second floor unit on 5/01/23 at 8:03 A.M., with the following results: *oatmeal: 142.5 degrees Fahrenheit, tasted warm and flavorless *coffee: 153 degrees Fahrenheit, tasted hot *eggs: 121.3 degrees Fahrenheit, tasted warm and bland *milk: 43 degrees Fahrenheit, tasted cool not cold *juice: 47.1 degrees Fahrenheit, tasted cool not cold A lunch test tray was completed on the first floor unit on 4/30/23 at 12:35 P.M., with the following results: *coffee: 172 degrees Fahrenheit, tasted extremely hot and burned throat as swallowing *milk: 47 degrees Fahrenheit, tasted cool not cold *Pasta: 14 degrees Fahrenheit, tasted cool, not hot *meatball: 124 degrees Fahrenheit, tasted lukewarm not hot *spinach: 121 degrees Fahrenheit, tasted lukewarm, not hot *vanilla cake: 61 degrees Fahrenheit, tasted cool A breakfast test tray was completed on the first floor unit on 5/01/23 at 8:23 A.M., with the following results: *oatmeal:…

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

Based on observations, record reviews and interviews the facility failed to ensure infection control practices were maintained to prevent the spread of infection during medication pass. Findings include: Review of facility policy titled Administering medications, undated, indicated the following: Policy Interpretation and Implementation: *22. Staff shall follow established facility infection control procedures (e.g, handwashing,antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During medication pass on 4/30/23 at 8:26 A.M., the surveyor observed Nurse #1 place a medication from the medication card directly on to his hands. The surveyor asked Nurse #1 to discard the medication as he had it in contact with his bare hand. During an interview on 4/30/23 at 1:11 P.M., the Assistant Director of Nursing said the expectation is for the nurses to follow proper infection control practices during medication pass, and place the pill directly into a plastic medication cup.