Country Gardens Health and Rehabilitation

Based on interview, observation, and document review, the facility failed to ensure residents/resident representatives had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance for one Resident (#51), out of a total sample of 17 residents. Specifically, the facility failed to ensure staff followed their policy and procedure when Resident #51's Health Care Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) notified staff that the Resident's denture (partial plate) was missing. Findings include: Review of the facility's policy titled Complaint/Grievance Policy and Procedure, dated September 2023, indicated but was not limited to: Policy: -All residents and their responsible representative will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication 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 ensure nursing staff developed and provided the resident with a summary of the baseline or comprehensive care plan within 48 hours of admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#168), of a total sample of 17 residents. Specifically, the facility failed to ensure a baseline care plan was developed and a summary provided to the Resident for the use of an indwelling urinary catheter. Findings include: Review of the facility's policy titled, Baseline Care Plan, last revised May 2025, indicated but was not limited to: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. -The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary 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 observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#168), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's indwelling catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised May 2025, included but was not limited to: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. -The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing 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 record review and interview, the facility failed to ensure one Resident (#21), out of a total sample of 17 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically, the facility failed to reposition Resident #21 when he/she was identified to be a very high risk of developing a pressure area resulting in the development of a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue resulting from intense and/or prolonged pressure) to his/her left heel. Findings include: Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to: -Residents with pressure ulcer risk factors are identified, assessed, and provided treatment according to standards of practice. -Residents with actual skin breakdown are identified, assessed and provided treatment according…

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 interviews, the facility failed to ensure staff provided residents with an environment free from accidents and hazards. Specifically, the facility failed to ensure medications were disposed of on the [NAME] Unit in a secure manner to prevent access to those medications on one of two nursing units. Findings include: Review of the facility's policy titled Destruction of Unused Drugs, last revised [DATE], indicated but was not limited to: -All unused, contaminated, or expired prescription and non-prescription drugs shall be disposed of per facility policy. -Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on [DATE] indicated the [NAME] Unit had 37 out of 39 residents with diagnoses of Alzheimer's disease/Dementia. On [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.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made three errors out of 28 opportunities, resulting in a medication error rate of 10.71%. Those errors impacted two Residents (#11 and #18), out of four residents observed. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: - Medications shall be administered in a safe and timely manner, and as prescribed. - Medications must be administered in accordance with the orders. 1. For Resident #18, Nurse #4 administered: - the incorrect formula of a probiotic (live…

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 was alert and oriented and required substantial assistance from staff members when bathing, the Facility failed to ensure that staff treated him/her is a dignified and respectful manner, when related to his/her right to personal privacy when, on 4/03/25 while assisting him/her in the shower, Certified Nurse Aide (CNA) #1 conducted a telephone call using Face Time. Findings include: Review of the Facility Personal Cell Phone Policy, dated as reviewed/revised during January 2025, indicated the Facility prohibited employees from using personal cell phones for any reason on the nursing units. Review of the Facility Resident Rights Policy, dated as reviewed/revised during October 2024, indicated the resident had the right to personal privacy. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during January 2025 and his/her diagnoses included multiple sclerosis. Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/05/25,…

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 review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: During an interview on 6/25/24 at 11:13 A.M., the Activity Director (AD) said she used to be the First [NAME] at the facility and picked up hours every other week as an Activity Assistant for a while. She said she was hired as the AD for the facility in July 2023 when the former AD left. She said a few weeks after she started her position as AD, she had to take a leave of absence, and June 2024 is her first full month back to work. Review of the AD's personnel file on 6/25/24 failed to indicate she was qualified therapeutic recreation specialist or an activities professional who had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, or was a qualified occupational therapist or occupational therapy assistant. During an interview with the AD and Regional Activity Director on 6/27/24 at…

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

Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products and maintain safe and clean equipment in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Food: Safe Handling for Foods from Visitors, revised 2/2023, indicated but was not limited to: - Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. - Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and cleaned weekly. Review of the facility's policy, untitled and undated, indicated but was not limited to: - The foodservice department will check for expired products within the inventory. Discard all expired products. If products such as milk will expire before the next visit, discard to prevent negative…

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, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Infection Preventionist failed to attend the last two quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), dated as revised 3/4/24, indicated but was not limited to: - The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. - The QAA Committee shall be interdisciplinary and shall consist at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and the Infection Preventionist. Review of the QAPI Attendance Sheets, dated 1/19/24, 2/26/24, 3/15/24, and 4/26/24, failed to indicate the Infection Preventionist…

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 a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response. Findings include: Review of the facility's policy titled Resident Council, dated 3/2/24, indicated but was not limited to: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The group may appoint a resident to take notes/maintain meeting minutes, or may elect that the Activity Director/designated liaison to take notes/maintain minutes. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the Resident Council Minutes, dated 3/21/24, indicated eight residents participated in the meeting, and brought forward the following grievance: -One 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure the privacy and confidentiality of resident records were maintained. Specifically, the facility failed to ensure residents' private health information was securely stored and not accessible in the facility's copy room and Staff Development Coordinator's (SDC) office, which were located on the main hallway on the first floor of the facility. Findings include: Review of the facility's policy titled Safeguarding of Resident Identifiable Information, last revised 3/4/24, indicated but was not limited to the following: -Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records. -Policy Explanation and Compliance Guidelines: 1. The facility may not release information that is resident-identifiable to the public. 4. Medical records shall…

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

Based on observations, interviews, and records reviewed, for nine Residents (#55, #231, #48, #78, #74, #20, #72, #30 and #47), out of 19 sampled residents, the facility failed to develop and/or implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #55, a. to implement a care plan for an indwelling Foley catheter (tube placed in the body to drain and collect urine from the bladder), and b. to develop and implement a care plan for psychotropic medications; 2. For Resident #231, to develop and implement a care plan for an anticoagulant (blood thinning) medication; 3. For Resident #48, to implement a care plan for an anticoagulant medication; 4. For Resident #78, to implement a care plan for antidepressant medication; 5. For Resident #74, to develop a comprehensive care plan for the Resident's diagnosis of endocarditis (infection of the heart's inner lining, usually involving the heart valves), presence of a Peripherally Inserted Central Catheter (PICC: a thin, flexible tube inserted into a vein in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #20 was admitted to the facility in April 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 4/19/24, indicated Resident #20 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, was diabetic, required a therapeutic diet and received insulin injections. a. Review of Physician's Orders included, but was not limited to: - Glipizide ER 2.5 milligrams (mg) (insulin), give one tablet one time a day for type 2 diabetes mellitus (4/16/24) - Metformin HCI 500 mg (insulin), give one tablet two times a day for type 2 diabetes mellitus (4/16/24) - Ozempic Subcutaneous Solution Pen Injector 4mg/3mL (injectable treatment for type 2 diabetes mellitus similar to insulin), inject 1 mg subcutaneously (under the skin) one time a day for type 2 diabetes mellitus (4/16/24) - Humalog Injection Solution 100 unit/milliliters (mL) (insulin), inject per sliding scale for type 2 diabetes mellitus (4/16/24) - blood sugar levels less than 70 or greater than 300, call…

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 its staff provided a meaningful and engaging activity program for residents on one Unit (West Unit), out of two units observed. Specifically, the facility failed to ensure staff implemented facility sponsored group activities for all residents on the [NAME] Unit. Findings include: Review of the facility's policy titled Activities, last revised 3/4/24, indicated but was not limited to the following: -Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. -Activities will be conducted in different ways: a. One-to-One Programs. b. Person Appropriate-activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities-to include a combination of large 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 observation, record review, and interview, the facility failed to ensure licensed nursing staff possessed the appropriate competency and skills to care for one Resident (#74), who required intravenous (IV) administration of antibiotics through a Peripherally Inserted Central Catheter (PICC), out of a total sample of 19 residents. Specifically, the facility failed to ensure that nine Nursing staff (#1, #3, #5, #8, #10, #12, #13, Unit Manager #1, and the Director of Nursing ) had demonstrated necessary competencies to care for residents in the facility with specialized needs, inclusive of IV/PICC line care and treatment. Findings include: Review of the facility's policy titled Competency Evaluation, last revised 3/4/24, indicated but was not limited to: - Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. - Evaluating competency of staff is accomplished through the facility's training program. - Initial competency is evaluated during the…

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

Based on record review, policy review, and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting, a blood thinner) and anti-hypoglycemic medications (used to lower blood sugar) prescribed for three Residents (#231, #48, and #10), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Residents #231 and #48, to monitor for side effects of anticoagulant medication; and 2. For Resident #10, to monitor for side effects of hypoglycemic medications. Findings include: 1. Review of the facility's policy titled High Risk, dated 3/4/24, indicated but was not limited to the following: - Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety. Policy Explanation and Compliance Guidelines: - The resident's plan of care shall alert 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 ensure each Resident's drug regimen was free from unnecessary psychotropic medications for five Residents (#55, #78, #30, #32, and #10), out of a total sample of 19 residents. Specifically, the facility failed to ensure psychotropic medications were monitored for adverse consequences (side effects) of their use. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, dated 3/4/24, indicated but was not limited to: - Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: - The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. Resident #55 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.

Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles prior to administration and in 1 of 4 medication carts and 1 of 2 medication rooms. Specifically, the facility failed to ensure: - For Resident #74, Intravenous (IV) medication was stored in the medication cart and not left at the bedside; - Schedule II-V controlled substance medications were maintained in a separately locked, permanently affixed compartment; - Loose pills were properly discarded; and - A multi-dose vial of Tuberculin (used to perform a skin test to diagnose Tuberculosis) which had been opened/accessed was dated and discarded within 30 days. Findings include: Review of the facility's policy titled Medication Storage, dated 3/4/24, indicated but was not limited to the following: - It is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations; -…

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

Based on observation, record review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for five Residents (#74, #20, #6, #231, and #48), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #74, to accurately document the recommendations from the consultant infectious disease Physician regarding the plan of care for a peripherally inserted central catheter (PICC); 2. For Resident #20, to ensure his/her electronic medical record contained scanned documents pertaining only to Resident #20; and 3. For Residents #6, #231, and #48, to document weekly comprehensive skin assessment per physician orders. Findings include: Review of the facility's Confidentiality of Personal and Medical Records policy and Safeguarding of Resident Identifiable Information, both dated 3/4/24, indicated but was not limited to: - This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained…

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

Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for five Residents (#72, #74, #17, #6, and #55) of 19 sampled residents. Specifically, the facility failed to: 1. For Resident #72, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) and Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); 2. For Resident #74, ensure staff wore PPE as required for EBP while providing care to a resident with a Peripherally Inserted Central Catheter (PICC); 3. For Resident #17, ensure staff wore PPE while in contact with the Resident's blood; 4. For Resident #6, ensure staff wore the appropriate PPE as required for EBP while…

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 implement and maintain an effective training program for all new and existing staff. Specifically, for eight direct care staff (Nurse #1, Nurse #9, Nurse #8, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA #11, and CNA #10), out of eight direct care staff education records reviewed, the facility failed to provide all of the required training necessary to meet the needs of each resident. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: a. Effective communication for direct care staff b. Resident rights and facility responsibilities for caring for residents c. Elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program d. Written standards, policies, and procedures for 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 interviews and staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistants (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on effective communications was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: a. Effective communication for direct care staff -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #4, #11, and #10 failed to include…

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 staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on resident rights was included as mandatory training for direct care staff. Findings include: Review of the facility policy titled, Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: b. Resident rights and facility responsibilities for caring for residents -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #4, #11, and #10 failed 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 interviews and staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: c. Elements and goals of the facility's QAPI program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the…

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

Based on interviews and staff education records reviewed for four direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #7, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on written standards, policies and procedures for the facility's infection prevention and control program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: d. Written standards, policies and procedures for the facility's infection prevention and control program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers The facility was unable to provide the surveyor with an education…

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 staff education records reviewed for eight direct care staff employees (Nurse #8, Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA # 11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on written standards, policies, and procedures for the facility's compliance and ethics program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: e. Written standards, policies, and procedures for the facility's compliance and ethics program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers During survey the facility was unable to provide an…

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 staff education records reviewed for eight direct care staff employees (Nurse #8, Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA # 11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on behavioral health was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: f. Behavioral health -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for Nurse #8, CNA #1, CNA #7, CNA #4, CNA # 11, and CNA #10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Physician/Practitioner was notified of a change in treatment for one Resident (#44), out of a total sample of 14 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when a prescribed anticoagulant (blood thinner) was not available from the pharmacy and administered as ordered. Findings include: Resident #44 was originally admitted to the facility in June 2022 and had diagnoses including dementia. Review of the medical record indicated Resident #44 was admitted to the hospital on [DATE] after sustaining a right hip fracture following a fall. The hospital Discharge summary, dated [DATE], indicated Resident #44 underwent an open reduction internal fixation (surgery to re-align and stabilize serious fractures) on 8/15/24. The summary and discharge medications indicated the Resident was to receive enoxaparin (anticoagulant) 40 milligrams/0.4 mL injection every 24 hours starting on 8/19/24 for Deep Vein…

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

Based on record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#20 and #74), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #20, to develop a baseline care plan for the Resident's diagnosis of diabetes mellitus; and 2. For Resident #74, to develop a baseline care plan for the Resident's diagnosis of endocarditis (infection of the heart's inner lining, usually involving the heart valves), presence of a Peripherally Inserted Central Catheter (PICC: a thin, flexible tube inserted into a vein in the upper arm then guided (threaded) into a large vein above the right side of the heart called the superior vena cava), and administration of intravenous antibiotic therapy. Findings include: Review of the facility's Baseline Care Plan policy, last revised 3/4/24, indicated but was not limited to: -The facility will develop and implement a baseline…

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

Based on record review and staff interview, the facility failed to document the recapitulation (a summary) of the Resident's stay from the facility for one Resident (#80), out of two closed records reviewed. Findings include: Review of the facility's policy titled Transfer Discharge (including AMA), last Reviewed/Revised 3/4/24, indicated but was not limited to: Policy: Anticipated Transfers or Discharges - resident-initiated discharges. - A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to the following: - i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. - ii. A final summary of the residents' status. - iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). - iv. A post discharge plan of care that is…

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

Based on record review and interviews, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for one Resident (#32), out of a total sample of 19 residents. Specifically, the facility failed to ensure a Certified Nursing Assistant (CNA) did not move a resident off the floor after the Resident sustained an unwitnessed fall with a head strike, prior to having a nurse assess the Resident. Findings include: Review of the facility's Fall Reduction policy, last reviewed 6/22/22, included but was not limited to: In the event a resident falls, the following measures will be instituted: -Conduct a physical assessment to determine if there are any injuries. Notify the nursing supervisor/Director of Nursing Services immediately. Administer appropriate first aid. -If the resident fall was unwitnessed or if a head injury is suspected, monitor neurological signs. Resident #32 was admitted to the facility in January 2024 with diagnoses including dementia, abnormalities of gait and mobility, and unsteadiness on his/her…

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

Based on observation, interview, and policy review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava to deliver medications and other treatments directly to the large central veins near your heart) was provided in accordance with professional standards of practice for one Resident (#74), out of a total sample of 19 residents. Specifically, the facility failed to ensure: -nursing staff measured the external length of the PICC line catheter as ordered by the Physician to ensure the catheter had not migrated (moved) out of place, and -the insertion site was visible for routine assessment by the licensed nurses. Findings include: Review of the Peripherally Inserted Central Catheter/Midline/Central Venous Access Device (CVAD) Dressing Change policy and Documentation Guidelines, last revised 3/4/24, included but was not limited to: -It is the policy of this facility to change PICC, midline or…

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 review, the facility failed to maintain respiratory equipment according to professional standards of practice for one Resident (#78), out of a total sample of 19 residents. Specifically, the facility failed to obtain a physician's order for the use of a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea). Findings include: Review of the facility's policy titled Continuous Positive Airway Pressure (CPAP), undated, indicated but was not limited to: - Policy: The operation of the CPAP machine is the responsibility of licensed staff. - Procedure: 1. Check physician orders. They should include the level of CPAP pressure and the oxygen liter flow if required. - Documentation: 1. Date and Time 2. CPAP mode 3. CPAP pressure 5. Patient's tolerance of procedure Resident #78 was admitted to the facility in April 2024 with diagnoses including hypertension and hyperlipidemia (high cholesterol). Review of Resident #78's Brief Interview for Mental Status (BIMS) assessment, dated 4/4/24, indicated Resident #78 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, interviews, and record review, the facility failed to ensure staff had the skills necessary to meet the behavioral needs of one Resident (#10), out of a sample of 19 residents. Specifically, the facility failed to ensure staff had training in areas such as mental health needs and care of cognitively impaired residents. Findings include: Review of the Facility Assessment, updated 6/1/24, indicated but was not limited to the following: - To achieve strong clinical out-comes, we continue to strive to develop skill set/competency of associates. We recognize the resident population we serve is affected by multiple co-morbidities requiring a well-rounded clinical team. - Category: Psychiatric/Mood Disorders; Common Diagnoses or Conditions: Impaired cognition, depression, anxiety disorder, Schizophrenia, Bipolar Disorder, Dementia - Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one Resident (#44) out of a total sample of 14 residents, was free from significant medication error when an anticoagulant (blood thinner) medication was not administered according to physician's orders Findings include: Review of the facility policy, Unavailable Medications, last revised 2/2024, indicated, but was not limited to: -The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (prn), and emergency medication. -An urgent (STAT) supply of commonly used medications is maintained in-house for timely initiation of medications. -Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: -Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on…

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 staff education records reviewed for two direct care staff employees (Nurse #1 and Nurse #9) of eight employees reviewed, the facility failed to ensure that training on abuse, neglect, and exploitation prevention was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: h. Abuse, neglect, and exploitation prevention -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The…

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

Based on observation, interview, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests and per manufacturer's instructions. Specifically, the facility failed to properly perform iHealth COVID-19 antigen rapid self-testing for four out of four staff members observed. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Specimen Collection, updated May 2022, indicated but was not limited to the following: -Proper specimen collection is the most important step in the laboratory diagnosis of infectious diseases. A specimen that is not collected correctly may lead to false or inconclusive test results. -Follow the manufacturer's instructions for specimen collection. Review of the iHealth COVID-19 antigen rapid test instructions for use (IFU), revised December 2021, indicated the following: -Immediately after adding sample to the sample port, the result will be ready in 15 minutes Note: Do NOT interpret your…

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, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#29, #53, and #63), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #29, to initiate a bowel protocol per physician's orders; 2. For Resident #53, to administer medications in accordance with standards of practice, instead leaving them with the Resident for self-administration; and 3. For Resident #63, to ensure orders were accurately transcribed and administered. Findings include: 1. Review of the facility's policy titled Bowel Protocol, revised 7/26/21, indicated but was not limited to the following: Purpose: -To assure residents have periodic bowel movements (BM) to prevent constipation Protocol: -The 7-3 charge nurse will initiate the laxative list on a daily basis (based on no BM x 3 days or however specified by MD) -The 7-3 charge nurse will either use a laxative form or document on the 24-hour report those residents who need to start a bowel…

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.

2. Resident #29 was admitted to the facility in November 2020 with diagnoses including chronic obstructive pulmonary disease (COPD) and pneumonia. Review of current Physician's Orders indicated the following: -Change oxygen tubing weekly on Sunday, 11-7 shift and as needed (PRN) every night shift every Sunday related to COPD, 8/15/21 -Clean filter on oxygen concentrator weekly Sunday 11-7 every night shift every Sunday for maintenance, 9/5/21 During an observation with interview on 3/26/23 at 8:37 A.M., the surveyor observed Resident #29 lying in bed with a nasal cannula (lightweight tube in which one end splits into two prongs which are placed in the nostrils from which a mixture of oxygen (O2) and air flows) in place attached to an oxygen concentrator device. A nebulizer machine was observed on top of the Resident's bedside table. The facemask was resting on top of the nebulizer machine, not contained, and exposed to potential environmental contaminants. Resident #29 said he/she was on continuous O2 for his/her breathing. During an observation with interview on 3/27/23 at 10:00…

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 policy review, the facility failed to ensure that a licensed nurse had the completed competencies to administer medications independently for Resident #49, resulting in medication errors. Findings include: Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). -Five rights- right resident, right drug, right dose, right route and right time, are applied for each medication being administered. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted…

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 policy review, the facility failed to ensure that the medication error rate was not 5% or greater. A medication error rate of 7.41% was calculated following two observed errors of a total of 27 opportunities for error. Findings include: Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). -Five rights- right resident, right drug, right dose, right route and right time, are applied for each medication being administered. The surveyor conducted medication administration observations of four nurses on two of two units between 3/27/23 and 3/28/23 with the following medication error observation. On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 preparing and administering medications to Resident #49 as ordered for 9:00 A.M. (The surveyor was…

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

Based on observations, interview, and policy review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Follow infection control standards during a medication pass which included hand hygiene and proper handling of medication, and 2. Minimize the potential for cross-contamination (transfer of pathogens (biological contaminant) from one surface to another) of iHealth COVID-19 Antigen Rapid testing cards during the processing time. Findings include: 1. Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Handwashing and hand sanitization: the person administering a medication adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass and prior to handling any medication. On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 during medication administration. Nurse #6 was in orientation and unsupervised by a preceptor during the medication pass.…

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 reviews, interviews, and policy review, the facility failed to accurately transcribe an eye drop medication for both eyes and clarify the order to obtain the dose to be administered for one Resident (#3), out of a total sample of 19 residents. Findings include: Review the facility's policy titled Consultants, undated, indicated but was not limited to the following: -Consultants provide the Director of Nurses or Designee with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's: a. Recommendations; b. Plans for implementation of his or her recommendations; c. Findings; and d. Plans for continued assessments. -The facility retains the professional and administrative responsibility for all services provided by the consultants. Resident #3 was admitted to the facility in July 2019 with diagnoses which included primary open angle glaucoma, bilateral, severe stage, presence of intraocular lens, secondary cataract, left eye, cortical age related cataract right eye, age related nuclear cataract, right eye. Review of the Report…

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

Based on record review and interviews, the facility failed to ensure a resident's drug regimen was free from unnecessary medications by continuing to administer an antibiotic, after it was determined the bacteria was resistant to the prescribed antibiotic for one Resident (#54), out of a total sample of 19 residents. Findings include: Resident #54 was admitted to the facility in July 2022 with a diagnosis which included dementia. Review of a Nursing Note, dated 3/17/23 at 7:57 P.M., indicated but was not limited to the following: -At approximately 5:45 P.M., Resident #54 was noted to have a flush-warm face. Temperature checked and noted to be at 100.3 degrees Fahrenheit. As needed APAP (Tylenol) 650 mg given at this time. -Resident was unable to say what is wrong. -Physician paged to notify of temperature. Review of a Nursing Note, dated 3/17/23 at 8:10 P.M., indicated but was not limited to the following: -Physician returned page and gave new order to check CBC (Complete blood count)/BMP (basic metabolic panel) blood test on the next lab day and obtain Urinalysis with culture 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.