Vantage at Sudbury LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to provide a dignified dining experience for one Resident (#2), out of a total sample of 19 residents. Specifically, the facility staff stood over and remained standing while assisting Resident #2 during a breakfast meal. Findings include: Resident #2 was admitted to the facility in November 2021, with diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a total possible score of 15. -required substantial/maximum assist with feeding. Review of the facility policy titled Assistance with Meals last revised July 2017, indicated the following: -Residents who cannot feed themselves will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record and policy review, the facility failed to inform three Residents (#5, #4, and #58) and or their Representatives in advance of changes to the plan of care relative to the use of psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications, out of a total sample of 19 residents. Specifically, the facility failed to obtain written consent for the use of psychotropic medications before administering: 1. Seroquel and Zyprexa (antipsychotic - medication that treats psychosis (a collection of symptoms that affects one's ability to tell what's real and what is not) medications to Resident #5 for Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]) and Psychotic Disorder (a mental illness that causes abnormal thinking and perceptions. Psychotic illnesses alter a person's ability to think clearly, make good judgments,…

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 and policy review, and interview, the facility failed to appropriately review and accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#26) out of a total sample of 19 residents. Specifically, the facility failed to ensure that the correct Resident's name was entered on Resident #26's MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form, when another individual's name and Resident #26's date of birth were included on the form placing the Resident at risk for not having his/her final wishes upheld. Findings include: Review of the facility policy titled Massachusetts Advanced Directives, revised 8/3/22, indicated the following: -to maximize the rights of each resident, ensuring that their wish(es) regarding medical decision making is upheld and the safety of each individual is met - . Elected staff will confirm that information is appropriately documented in the medical record . Resident #26 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician (NPP) of a significant change in condition for one Resident (#19) out of a total of 19 total residents. Specifically, the facility failed to notify the Physician/NPP of a recommended change in treatment for Candida Glabrata (yeast infection) made by the Consulting Physician/NPP and obtain treatment orders for Resident #19, resulting in unmanaged itching and discomfort of the Resident's genital (external reproductive organ) area. Findings include: Review of the facility's policy titled Change in Resident's condition or Status and Notification, revised 1/1/20, indicated: -The Registered Nurse (RN) Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident medical/mental conditions and/or status including but not limited to a need to alter the resident's medical treatment. -Regardless of the resident's current mental…

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 and policy review, the facility failed to provide the necessary activities of daily living (ADLs - personal care activities including but not limited to, eating, grooming, and personal hygiene) care and services for one Resident (#4) out of a total sample of 19 residents. Specifically, for Resident #4, the facility failed to provide continual supervision by staff during mealtimes when the Resident required ADL assistance and supervision while eating. Findings include: Review of the facility policy titled Activities of Daily Living, dated 12/22/21, with revision date of December 2022, included: -A resident who is unable to carry out activities of daily living (ADLs) will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. -The facility will provide care and services for the following activities of daily living Dining-eating, including meals and snacks. Resident #4 was admitted to the facility in November 2021, with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#35) out of a total sample of 19 residents. Specifically, for Resident #35, the facility failed to verify and assess that the correct size indwelling urinary/Foley catheter as ordered by the Physician was re-inserted when the Resident required replacement of a urinary catheter after a failed voiding trial (a medical assessment used to determine if a patient can spontaneously urinate after urinary catheter removal). Findings include: Review of the facility policy for Foley Catheter Care, dated 5/1/22, indicated: -it is the policy of this facility to maintain Physician's orders for the care and maintenance of a Foley catheter. -the Physician's orders will include when the Foley is to be inserted, the size of the Foley lumen (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.

Based on record and policy review, and interview, the facility failed to ensure that Physician's orders were correctly administered relative to dialysis care for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5, the facility failed to assess a complete set of vital signs (medical signs such as temperature, pulse rate, blood pressure, and respiratory rate, that indicate the status of the body's vital functions) prior to dialysis (a treatment in which a machine filters wastes, salts and fluids from your blood when your kidneys are no longer healthy enough to do the work) as ordered by the Physician putting the Resident at risk for dialysis related complications. Findings include: Review of the facility policy Titled End Stage Renal Disease(undated), Care of a Resident with, indicated: -Education and training of staff includes specifically: >The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Resident #5 was admitted to the facility in September 2024, with diagnoses including end stage…

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 policy review, the facility failed to follow safe and sanitary food service practices in accordance with professional standards for food service safety to prevent the risk of foodborne illnesses for one Resident (#66), on the [NAME] Nursing Unit during a meal service observation. Specifically, the facility failed to ensure that staff training on food service safety was implemented when Certified Nurses Aide (CNA) #3 replaced a domed lid from a breakfast meal, that had fallen onto the floor in the [NAME] Unit hallway, over a meal plate on a breakfast tray and served the breakfast tray with the contaminated dome lid to Resident #66. Findings include: Review of the facility policy titled Assistance with Meals revised July 2017 indicated the following: -All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of food borne illness, including personal hygiene practices and safe food handling. Resident #66 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, interview, policy and record review, the facility failed to adhere to infection control standards of practice for two Residents (#34 and #56) out of a total sample size of 19 residents. Specifically, the facility failed to: 1. For Resident #34, follow Physician orders for Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), increasing the risk of organism transmission to the Resident and other Residents within the facility. 2. For Resident #56, perform hand washing procedure as required between glove changes while providing wound care to the Resident and appropriately disinfecting equipment to prevent contamination and the spread of infections. Findings include: 1. Review of the facility policy titled Enhanced Barrier Precautions, dated December 2022 with revision date February 2024 indicated: -EBP's are indicated for residents with any of the following: >Chronic wounds (a wound 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 interviews and records reviewed, for one of three sampled residents (Resident #1), who had a physicians order, dated 5/12/24, for discharge to his/her Assisted Living Facility (ALF) with Hospice services, when family members arrived at the facility on 5/12/24, the day they anticipated him/her to be discharged , facility staff told them them Resident #1 was not scheduled to be discharged until the following day (5/13/24). Family members said the discharge plan all along was for Resident #1 to be discharged home by Mother's Day and that the facility needed to make it happen, and although Resident #1 was discharged to his/her ALF that day, the Facility failed to ensure Resident #1's (unplanned) transfer/discharge was safe and orderly, when his/her necessary medical information including physicians orders with his/her list of medications, (either in the form of discharge paperwork or discharge instructions), were not sent to or communicated to nursing staff at the receiving facility (ALF) so that his/her medical and personal care needs could be met. Findings include: 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a physicians order for discharge home with Hospice Services to the Assisted Living Facility on 5/12/24, the Facility failed to ensure they maintained a complete and accurate medical record when nursing staff and the provider, failed to document his/her discharge in the medical record. Findings include: Review of the Facility's policy, titled Charting and Documentation, undated, indicated the following: -all services provided to the resident, progress toward the care plan goals, or changes in the resident's physical, functional or psychosocial condition, shall be documented in the resident's medical record; -objective observations, treatments and changes in the resident's condition shall be documented in the resident medical record. Review of the Facility's policy, titled Discharge Planning Process, dated as revised 12/06/21, indicated the following; -evaluation of the resident's discharge needs and discharge plan would be completely documented on a timely basis in the clinical record.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policies reviewed, the facility failed to ensure that residents were treated with dignity during communal dining on one unit ([NAME]) out of three units observed. Specifically, the facility staff failed to ensure that residents: -were provided their meals off meal trays -were served at the same time when seated with others -were offered timely assistance with meals, if required -were provided with non-disposable cups while dining Findings include: Review of the facility policy titled Dignity/Quality of Life, dated 12/6/21, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated that all residents will be treated with dignity and respect which means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth. Review of the facility policy titled Activities of Daily Living (ADLs), reviewed December 2022, indicated that a resident who is unable…

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 that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#57) out of a total sample of 18 residents. Specifically, for Resident #57, the facility failed to: -provide the Resident's invoked (made active) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) notification of the risks and benefits of the use of antipsychotic and antidepressant medications. -obtain informed consent to administer psychotropic medication as required. Findings include: Review of the facility's policy titled Psychotropic Medication Treatment in Long Term Care Centers, dated January 2021, included: -it is (the facility)'s policy to abide by state 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 record review and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made, if you become unable to speak for yourself) for one Resident (#60) out of a total sample of 18 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) decisions were made by the designated and invoked [made active] Health Care Proxy (HCP-a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) for Resident #60, who had been deemed as lacking the capacity for informed decision making by the facility's Physician. Findings include: Review of the facility policy for Advance Directives, last revised 8/3/2022, indicated that the Physician, Nurse Practitioner (NP) or Physician Assistant (PA) will identify, review, and offer to complete a MOLST form with residents/responsible parties who they deem appropriate. Resident #60…

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 notify the Physician in a timely manner, that an ordered medication was not available for one Resident (#6) out of a total sample of 18 residents. Specifically, the facility failed to notify the Physician that the medication Ingrezza (medication used to treat involuntary movements) was expensive, was not covered by insurance and was not available to be administered to Resident #6. Findings include: Review of the facility's policy titled, Change in Resident's Condition or Status and Notification, revised June 2021, indicated the following: -The Registered Nurse (RN) will notify the resident's attending Physician when there has been a significant change in the residents medical/mental conditions and/or status. -Regardless of the resident's current mental or physical condition, the RN nursing supervisor/charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. Resident #6 was admitted in November 2021 with diagnoses of major depressive disorder (low mood), psychotic…

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

Based on observation, interviews, and record and policy review, the facility failed to ensure that a device utilized for one Resident (#77), was assessed and consent was obtained by the Resident Representative, when used as a physical restraint (defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body), out of one applicable Resident who had a gastrostomy tube (G-tube: tube inserted through the stomach that delivers nutrition/hydration), in a total sample of 18 residents. Specifically, the facility applied an abdominal binder (wide compression belt that velcros and encircles the abdomen) to cover Resident #77's G-tube site in order to prevent him/her from pulling the tube out. Findings include: Review of the facility policy titled Physical Restraints, reviewed December 2022, indicated the facility recognizes the necessity of maintaining 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 interview and records reviewed, the facility failed to refer one Resident (#43) out of a total sample of 18 residents, for a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure individuals are not inappropriately placed in long term care ) Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen (a preadmission screening used to determine if a person has a diagnosis or suspected diagnosis of developmental disabilities/related conditions or mental illness) for Mental Illness (MI), intellectual disability, or related condition to determine if they require specialized services). Specifically, the facility failed to refer Resident #43 for a Level II evaluation when the Resident had documented diagnoses of mental illness and had experienced limitations in major life activities within the six months prior to the facility admission (A positive Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as Level II PASARR, which must be conducted prior 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 observations, record and policy review, and interview, the facility failed to develop and implement a plan of care for two Residents (#60 and #79) out of a total sample of 18 residents. Specifically: 1) For Resident #60 the facility failed to implement a plan of care for a nutritional supplement three times daily. 2) For Resident #79, the facility failed to develop a comprehensive care plan timely for communication related to severe hearing loss and the Resident's inability to read or write. Findings Include: Review of the facility policy titled Comprehensive Care Plan, revision date unknown, indicated the following: -The facility care planning and interdisciplinary team .develops and maintains a comprehensive care plan for each resident that identifies the highest level of function the resident may be expected to attain -The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set assessment). -The resident's comprehensive care plan will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to develop a discharge plan for one Resident (#79) out of a total sample of 18 residents. Findings include: Review of the facility policy titled Discharge Planning Process, revised 12/6/21, indicated the following: -The facility will support each resident in the exercise of their right to participate in his or her care and treatment, including planning for discharge. -The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. -Discharge goals will be included in the Resident's baseline care plan and comprehensive plan of care. -In cases where resident wishes to be discharged to a setting that does not appear to meet his or her post discharge needs, or appears unsafe, the interdisciplinary team will .discuss with the resident (and/or their representative, if applicable), and document the implications and/or risks of being discharged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#38), out of a total sample of 18 residents. Specifically, the facility staff failed to recognize that stool softeners (medications that increase the amount of water absorbed by stool in the intestines, to make it softer and easier to pass) and laxatives (work by softening hard stools or stimulating the bowels to get stool moving) continued to be administered to a Resident undergoing medical treatment for diarrhea (a condition in which stool is discharged from the bowels frequently and in a liquid form). Findings include: Review of the [NAME] Drug Guide for Nurses-18th edition, (2023) indicated the following: -Docusate (stool softener medication) - Adverse reactions/side effects: abdominal cramps, nausea, vomiting and diarrhea. -Senna (stool softener medication)- Adverse reactions/side effects: abdominal cramps, nausea, vomiting and diarrhea.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policy review, the facility failed to ensure that one Resident (#38) out of one applicable resident with wounds, in a total sample of 18 residents, received the care/services as recommended by the Wound Care Practitioner, for treatment of a Stage 3 Pressure Ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue [pink healthy tissue] and epibole [rolled wound edges] are often present. Slough [yellow/white material in a wound bed] and/or eschar [dead tissue] may be visible but does not obscure the depth of tissue loss) which had been assessed to have increased drainage. Specifically, the facility failed to follow the Wound Care Practitioner's recommendations to change the frequency of the wound treatments from daily to twice daily for Resident #38's sacral pressure ulcer which had an increase in the amount of wound drainage. The Resident's sacral wound became bigger in size (length and width) and was assessed 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, record and policy review, the facility failed to provide adequate supervision/assistance and implemented interventions in order to reduce/prevent falls for one sampled Resident (#65), out of a total sample of 18 residents. Specifically, the facility failed to provide assistance when the Resident was observed ambulating unassisted, failed to implement interventions to prevent falls as addressed in his/her plan of care, failed to investigate fall incidents, determine the root cause, and provide effective interventions to prevent further falls. Findings include: Review of the facility policy titled Fall Reduction, revised 6/22/22, indicated the following: -The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs -In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls -In the event a resident falls, the following measures will be instituted:…

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, record and policy review, the facility failed to ensure one Resident (#77) out of a total sample of 18 residents who received enteral (delivery of nutrients via a feeding tube) nutrition via a gastrostomy tube (G-tube: opening into the stomach made surgically for enteral nutrition/tube feeding), received appropriate care and services to reduce the risk of dehydration. Specifically the facility failed to provide the bolus fluids (rapid infusion of fluids over a short period of time) as ordered by the Physician for Resident #77 who had a history of abnormal labs and Acute Kidney Failure (a condition in which the kidneys suddenly cannot filter waste from the blood). Findings include: Review of the facility policy titled Enteral Feedings, undated, indicated all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The policy also included the following: -Check the enteral nutrition label against the order before administration. -Rate of…

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

Based on record review and interview the facility failed to ensure recommendations made by the Consultant Pharmacist during a monthly Medication Regime Review (MRR) were reviewed by the Physician and responded to as required, for one Resident (#57) out of a total sample of 18 residents. Specifically, for Resident #57, the facility failed to respond to the Pharmacist Consultant's request to limit the use of an as needed (PRN) antipsychotic medication to 14 days or less. Findings include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist recommendations, dated 1/1/21, indicated: -Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a timely response prior to the next medication regime review. -Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the Consultant Pharmacist may contact the Medical…

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

Based on record review and interview, the facility failed to include a duration for an as needed (PRN) psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) for one Resident (#57) out of a total sample of 18 residents. Specifically, the facility staff failed to add a stop date of 14 days or less as required for a PRN Olanzapine (an antipsychotic medication) order for Resident #57. Findings include: Resident #57 was admitted to the facility in June 2023 with diagnoses including Dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities) and unspecified psychosis (a mental disorder characterized by a disconnection from reality). Review of the Resident's current Physician's orders included Olanzapine (an antipsychotic medication) 5 milligram (mg) Oral Tablet, Give 1 (one) tablet by mouth every 12 hours as needed for antipsychotic/antimanic agents. Start date 6/14/23. Review of the Resident's Medication Administration Record (MAR) for the month of July 2023 indicated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#6 and #54), out of five applicable residents, out of 36 opportunities of medication administration observation. Specifically, the medication error rate was observed to be 11.11%: 1. For Resident #6, relative to the administration of eye drops and two (Ingrezza and Metoprolol) oral medications that were not given as ordered. 2. For Resident #54, relative to Trelegy Ellipta Aerosol Powder Breath inhaler (an inhaled medication used to relieve bronchial congestion) which was not administered as ordered. Findings include: Review of the Facility's policy, titled Medication Administration-General Guidelines, undated, indicated: -If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot 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.

Based on observation, record review and interview, the facility failed to ensure a significant medication error did not occur for one Resident (#6), out of five applicable residents, out of 36 opportunities. Specifically, the facility failed to ensure Ingrezza (a medication used to treat symptoms of involuntary movements) was available for administration before discontinuing Benztropine (a medication used to treat movement disorders) as ordered by the Prescriber. Findings include: Review of the Facility's policy, titled Medication Administration-General Guidelines, dated January 1, 2021, indicated: -If a medication with a current, active order cannot be in the medication cart/drawer, other areas of the medication, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit. -Medications are administered in accordance with written orders of the prescriber. -Select the medication - label, container and contents are checked…

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, for one of three sampled employee personnel files (Certified Nurse Aide #1), the Facility failed to ensure CNA #1 received Abuse training as required, and in accordance with Facility Policy. Findings include: Review of the Facility's Abuse Prohibition Policy, updated on 02/20/23, indicated resident abuse education is required on hire for all employees as part of the employee orientation process and annually thereafter. Review of Certified Nurse Aide (CNA) #1 personnel file indicated that CNA #1 was hired on 04/28/23. Further review of the indicated that since CNA #1's date of hire, there was no documenation to support she had received education on abuse, in accordance with the Facility's Abuse Prohibition Policy. During an interview on 08/24/23 at 10:40 A.M., the Administrator said that CNA #1 had not received education on Abuse, in accordance with the Facility's Policy.