Maristhill Nursing & Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#53) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 30 sampled residents. Specifically, the facility failed to ensure that the head of the bed was elevated to prevent potential aspiration while receiving enteral feedings. Findings include: Review of facility policy titled Care and Treatment of Feeding Tubes, revised 5/9/25, indicated the following:-It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.-The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. Resident #53 was readmitted to the facility in September 2025 with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status. Review…

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 interviews, the facility failed to provide behavioral health care services in a person-centered environment for one Resident # 88 out of a sample of 30 Residents. Specifically, the facility failed to implement psychiatric recommendations provided after the Resident expressed suicidal ideations. Findings include: A review of the facility policy titled 'Behavioral Health Services' revised 5/9/25 indicated the following:-It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychological functioning and well-being.-The facility will ensure that necessary behavioral health services are person centered and reflect the resident's goals of care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety.Resident #88 was admitted to the facility in September 2021 with diagnoses including suicidal ideations and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to implement treatment orders recommended by the Wound Physician for three Residents (#74, #40 and #55) out of a total of 22 sampled Residents. Specifically: 1. For Resident #74, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 2. For Resident #40, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 3. For Resident #55, the facility failed to transcribe and consistently implement a treatment order for wound care to the coccyx as ordered by the Wound Physician. Findings include: Review of the facility policy titled Pressure Ulcers, dated and revised 1/27/21 indicted the following: - The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. - The Unit Nurse will: provide wound care as prescribed by the physician…

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

Based on observation and interview, the facility failed to ensure staff followed proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Review of the facility policy titled, General Food Preparation and Handling, dated 2021, indicated the following: -Bare hands must never touch ready to eat raw food directly. Disposable gloves are single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and off after removing gloves. On 10/8/24 at 8:12 A.M., the following was observed on the third-floor unit during the breakfast meal: -The server changed gloves twice without washing his hands in between. -The server touched the serving utensils, plastic wrap, plates and toaster buttons potentially contaminating his gloves. He then put eight pieces of toast into and out of the toaster and buttered them with the potentially contaminated gloves. On 10/8/24 at 12:54 P.M., the following was observed on the third-floor unit during the lunch meal: -The server prepared a tuna fish sandwich while wearing one glove. 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, policy review and interviews, the facility failed to report allegations of abuse to the state agency within two hours as required for one Resident (#65) out of a total sample of 22 residents. Specifically, on 10/8/24 at 9:00 A.M., the Director of Nursing (DON) was made aware of Resident #65's allegations of abuse. The DON did not report to the state agency until 10/9/24 at 11:15 P.M., when the surveyor inquired about the follow up, more than 24 hours after becoming aware of the allegations. Findings include: Review of the facility policy Abuse, Neglect, Mistreatment, Exploitation & Misappropriation of Property Policy Including Elder Justice Act, revised September 2018, indicated the following: -When staff have knowledge of an allegation of abuse or a serious bodily injury of unknown source then an immediate report (within 2 hours of knowledge) of the incident will be sent to the Department of Public Health via HCFRS (health care facility reporting system). Administrator and the DON must…

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, policy review and interview, the facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation for one Resident (#61), out of a total sample of 22 residents. Specifically, for Resident #61, the facility failed to accurately complete a Level 1 PASARR indicating that the Resident had a diagnosis of schizotypal disorder which is a SMI, resulting in a Level II PASARR evaluation not being completed as required. Findings include: Review of facility policy titled admission Criteria' date revised March 2019, indicated the following but not limited to: -All new admissions and readmission are screened for mental disorders (MD), intellectual disorder (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. -If the level 1 screen indicates 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.

Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#63) out of a total sample of 22 Residents. Specifically, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker for Resident #63. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with, revised 12/15, indicated the following: Purpose: -The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker Monitoring: -Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia's. -The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. -Make sure the resident has a medical identification care that indicated he or she has a pacemaker. The medical record must contain this information as well. When 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 observation, record review and interview, the facility failed to provide services that met professional standards of practice for one Resident #55 out of a sample of 22 residents. Specifically, for Resident #55 the facility failed to ensure nursing implemented Teds (compression) stockings according to the physician's orders. Findings include: Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, instability of left knee, and localized edema (fluid retention). Review of Resident #55's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident was dependent on staff for activities of daily living. On 10/9/24 at 7:11 A.M., the surveyor observed the Resident lying in bed, the Resident did not have ted stockings on his/her legs. On 10/9/24 at 9:10 A.M., the surveyor observed Resident #55…

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

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#1) out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with weekly showers for Resident #1. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), undated, indicated the following: - A program of activities of daily living (ADL) is provided to residents to prevent disability and return residents to a maximum level of independence. - Hygiene: Frequent showers or baths are scheduled and assistance provided when required. Resident #1 was admitted to the facility in September 2022 with diagnoses including chronic congestive heart failure and bradycardia. Review of Resident #1's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental score of 15 out of 15 indicating intact cognition. Further review of the Resident's MDS indicated that the Resident is dependent on staff for all activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure standards of quality of care were implemented for one Resident (#32), out of a total sample of 22 residents. Specifically, the facility failed to identify a skin injury on the Resident's left upper arm. Findings include: Review of the facility policy titled Skin Assessment, revised and dated 1/27/21 indicated the following: - The Unit Nurse will: Complete a comprehensive head to toe assessment of the resident's skin with each scheduled assessment and with any significant change of condition, that includes evaluating risk factors. - Instruct Nursing Assistants to identify and report signs of skin breakdown, such as: purple or dark area. Resident #32 was admitted to the facility in January 2023 with diagnoses including unspecified dementia and anxiety disorder. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the resident has a Brief Interview for Mental Status score of 9 out of 15…

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

Based on observation, interview, record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication were utilized for one Resident (#63), out of a total sample of 22 residents. Specifically, for Resident #63, the facility failed to consistently implement his/her hearing aids. Finding Included: Review of the facility policy titled, Hearing Impaired Resident, Care of, last revised 2/18, indicated the following: Policy: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors. -Staff will assist residents with care and maintenance of hearing devices. Resident #63 was admitted to the facility in April 2023 with diagnoses that included unspecified symptoms and signs involving cognitive functions and awareness, heart failure, paroxysmal atrial fibrillation, presence of cardiac pacemaker, and chronic systolic heart failure. Review of Resident #63's most recent Minimum Data Set (MDS) assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure a resident who required respiratory care (continuous oxygen) received care consistent with professional standard of practice for one Resident (#27) out of a total sample of 22 residents. Specifically, for Resident #27, the facility failed to follow the physician's order for supplemental oxygen. Findings include: Review of the facility policy titled Oxygen, undated, indicated the following: - There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered. - Setting up Oxygen Administration: adjust the liter flow to the prescribed amount, check that oxygen is flowing properly. Resident #27 was admitted to the facility in June 2024 with diagnoses including acute systolic congestive heart failure and chronic obstructive pulmonary disease (COPD). Further review of Resident #27's most recent Minimum Data Set Assessment (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#16), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 22 residents. Findings include: Review of the facility policy titled Trauma-Informed and Culturally Competent Care, dated and revised August 2022 indicated the following: -Purpose: To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards of practice. - Resident Care Planning: Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. Resident #16 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain an accurate medical record for two Residents (#55) out of a total sample of 22 residents. Specifically, Nurses documented in the Treatment Administration Record (TAR) that Resident #55 wore teds stocking while in bed, contrary to direct observation of the teds stockings not being worn. Findings include: Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, instability of left knee localized edema (fluid retention). Review of Resident #55's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident was dependent on staff for activities of daily living. On 10/9/24 at 7:11 A.M., the surveyor observed the Resident lying in bed, the Resident did not have ted stockings on his/her legs. On 10/9/24 at 2:00 P.M., 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 interviews, the facility failed to assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#6) out of a total of five residents reviewed. Findings include: Review of the facility policy titled, Pneumococcal Vaccine, dated October 2022, indicated that all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative receives…

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 food was handled in a manner to prevent the risk for potential foodborne illness in the kitchen and during the meal service on one of three resident care units. Specifically, 1) A Diet Aide #3 handled cups with her fingers inside the cup and eating utensils by the end that touches food and enters the mouth. 2) Diet Aide #1 and Diet Aide #2 touched ready to eat food directly with potentially contaminated gloves during meal service on the C unit. 3)Cook #1 and [NAME] #2 were observed preparing food without hair restraints. Review of the 2022 Food Code, U.S. Food and Drug Administration, Code of Federal Regulations Title 21, indicated the following: 110.10 Personnel. The plant management shall take all reasonable measures and precautions to ensure the following: The methods for maintaining cleanliness include, but are not limited to: (2) Maintaining adequate personal cleanliness. (3) Washing hands thoroughly (and sanitizing if necessary to protect against contamination with undesirable microorganisms) in 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 observation and interview the facility failed to provide a dignified dining experience for one Resident (#19) out of a total sample of 21 residents. Findings include: Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease, anxiety disorder and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 sometimes understands, is sometimes understood and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 required total assistance with feeding and had no behaviors. Review of Resident #19's current Activities of Daily Living (ADL) care plan indicated Resident #19 is totally dependent on 1 staff for eating. Review of the most recent Licensed Nursing Summary, dated 9/21/23, indicated Resident #19 is totally dependent on staff for eating. On 10/02/23 at 10:10 A.M., the surveyor observed a Certified Nursing Assistant (CNA) enter Resident #19's room briefly, place a breakfast tray in the room, 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 observations, record review and interview the facility failed to ensure, for one Resident (#77), was free from the use of a restraint, out of a total sample of 21 residents. Findings include: Review of the facility's policy, entitled, subject: Restraints-Program, not dated, indicated the following: 1. The facility's goal is to achieve a restraint-free environment. 2. The facility will ensure that the resident is free from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. 4. A restraint assessment will be completed before any restraint is applied. Resident #77 was admitted to the facility in May 2021 with diagnoses that include but not limited to polymyalgia rheumatica, unspecified dementia and repeated falls. Review of Resident #77's most recent Minimum Data Set assessment, with an Assessment Reference Date of 7/27/23 indicated Resident #77 scored an 8 out of 15 on the Brief Interview for Mental Status exam, indicating he/she is moderately cognitively intact, requires extensive…

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 complete a Significant Change in Status Minimum Data Set (MDS) assessment for one Resident (#11) out of a total sample of 21 residents. Findings include: Resident #11 was admitted to the facility in July 2019 with diagnoses including a stroke with residual hemiparesis and dementia. Review of Resident #11's Quarterly MDS assessment dated [DATE], indicated he/she required limited assistance for toilet use, personal hygiene, and bed mobility. Review of Resident #11's nursing progress notes indicated he/she sustained a fall which resulted in a fracture of his/her left femur on 7/7/23. Review of Resident #11's Nutritional assessment dated [DATE], indicated severe weight loss of 11.4% over the past 6 months. Review of Resident #11's most recent Quarterly MDS assessment dated [DATE], indicated a significant decline in status in four areas. Resident #11 required extensive assist for toilet use, personal hygiene, and bed mobility. The MDS also indicated…

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 meet professional standards of quality for three Residents (#18, #1 and #55), out of a total sample of 21 residents. Specifically: 1. For Resident #18 the facility failed to ensure nursing implemented a physician's order for medications ordered to be administered with breakfast and supper (with meals). 2. For Resident #55 the facility failed to ensure an order was obtained for the use, including the proper setting, and plan for monitoring the setting and function of the air mattress in use. 3. For Resident #1 the facility failed to implement a physician's order for contact precautions. Findings include: 1. For Resident #18 the facility failed to ensure nursing implemented a physician's order for medications ordered to be administered with breakfast and supper (with meals). Review of the facility policy titled, Medication and Treatment orders, dated as revised 7/18/22, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Resident #18 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 observation, interview, record review and policy review the facility failed to ensure quality care was provided for two Residents (#44 and #33) out of a total sample of 21 residents. Specifically: 1.) For Resident #44 the facility failed to ensure geri sleeves were placed on the resident, as ordered by the Physician, on all days of survey. 2.) For Resident #33 the facility failed to identify and investigate bruising. Findings include: 1.) Resident #44 was admitted to the facility in November 2022 and had diagnoses that include cerebral infarction and inclusion body myositis. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #44 was assessed by staff to have both short and long term memory loss and required extensive assistance with his/her care. Review of the current Physician's orders indicated an order, start date 6/10/23, for: Geri sleeves to BUE (bilateral upper extremities). On in am off in PM. Review of the clinical progress notes failed to indicate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to ensure measures were in place to address the risk for pressure ulcers for three Residents (#53, #2, and #19) out of 21 sampled residents. Specifically: 1. Wound physician recommendations were not addressed and transcribed resulting in a delay of treatment for a skin injury on the right heel for Resident #53. 2. The physician orders for management/prevention of a pressure ulcer for Residents #2, and #19 were not followed. 3. The physician orders for the application of a bunny boot and the air mattress pressure setting was not followed for Resident #19. Findings include: 1. Resident #53 was admitted to the facility in January 2023 with diagnoses including chronic atrial fibrillation, depression, and anxiety disorder. On 9/29/23 at 8:52 A.M., the surveyor observed Resident #53 sleeping on an air mattress bed. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #53 is dependent on staff for daily care. 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, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#19) out of a total sample of 21 Residents. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #19 as ordered by the physician. Findings include: Review of the facility policy titled, Catheter Care, Urinary, dated August 2022, indicated the purpose of this procedure is to: 1. Prevent urinary catheter- associated complications, including urinary tract infections. Changing Catheters 2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Resident #19 was admitted to the facility in August 2022 with diagnosis including urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 required an indwelling urinary catheter. On 10/4/23 at 8:49 A.M., 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 observation, record review, and interview the facility failed to develop and implement a plan of care and maintain oxygen equipment for 2 Residents (#61 and #25) out of 21 sampled residents. Specifically: 1) For Resident #61 the facility failed to ensure the oxygen concentrator filter was clean and free of dust build up. 2) For Resident #25 the facility failed to obtain a physician's order for the use of an oxygen concentrator, oxygen liter amount to be given, and ensure the oxygen concentrator filter was clean and free of dust build up. Findings include: Review of the facility policy titled Oxygen Administration (undated) indicated: - A physician order is required for continuous administration of oxygen. The order must include the percentage of oxygen concentration to be delivered expressed as liters/minute or percentage of FiO2 [fraction of inspired oxygen]. - When oxygen therapy is ordered, the licensed clinician will verify the physician's order. Review of the facility's policy titled Respiratory…

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, interview and observation, the facility failed to: assess for the use of an installed bed rail, obtain informed consent or a physician's order, for one Resident (#25) out of 21 sampled residents. Findings include: 1. Review of the facility policy titled Bed Safety and Bed Rails (last revised August 2022) indicated: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Resident #25 was admitted to the facility in July 2021 and had diagnoses which included dementia. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE], indicated: Brief Interview for Mental Status score of 13 representing intact cognition, and independent with bed mobility and transfers. Review of Resident #25's medical record indicated there was no assessment,…

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 licensed Registered Nurse (RN) had the appropriate competency and skill set to provide the necessary care and treatment for one Resident (#19) with skin protocol in place out of total sample of 21 residents. Findings include: For Resident #19, a Resident at high risk for developing pressure ulcers, Nurse (#6) failed to: a.) apply bunny boots (booties that are placed on the feet to protect a person's heels) as ordered by the physician; and b.) maintain the air mattress at the correct setting, as ordered by the physician. Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 had no behaviors, was at risk of developing pressure areas and required extensive two person physical assistance for bed mobility and care. Review of the current…

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 ensure that the pharmacy recommendations were addressed by the attending physician for one Resident (#53), out of 21 sampled residents. Findings include: Resident #53 was admitted to the facility in January 2023 with diagnoses including chronic atrial fibrillation, depression, and anxiety disorder. Review of the monthly pharmacist recommendations for Resident #53 indicated the following: -May 18, 2023, the licensed pharmacist recommends to the physician discontinuing PRN (as needed) Melatonin (a medication used to help sleep disorder). -June 12, 2023, the licensed pharmacist recommends to the physician evaluation PRN order of Ativan (a medication used to treat anxiety). -August 24, 2023, the licensed pharmacist recommends to the physician evaluation PRN order of Ativan, Benadryl (an antihistamine), Melatonin, and Ondansetron (a medication used to help prevent nausea/vomiting). Review of Resident #53's medical record failed to indicate the physician responded to the pharmacist's recommendations. During an interview 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 records reviewed, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitioner documents a rational to extend the medication for two Residents (#18 and #84), in a total sample of 21 residents. Specifically, 1.) For Resident #18 the facility failed to ensure an as needed (PRN) alprazolam (psychotropic medication) had a stop date as required. 2.) For Resident #84 the facility failed to ensure an as needed (PRN) diazepam (psychotropic medication) had a stop date as required. Findings included: Review of the facility policy for psychotropic medication use, dated as revised July 2022, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. * Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosis specific condition that is documented in the clinical record. * PRN orders for psychotropic medications are limited to 14 days. * For psychotropic…

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: 1. medications were secured and stored for one Resident (#55) out of a total sample of 21 residents and 2. failed to ensure that insulin (vials/flex pen), and lancets were stored safely on one of three resident care units. Findings include: Review of the facility's s policy titled 4.1 Storage of Medication, dated 01/23 indicated the following: Policy: Medications and biologicals are stored properly, following the manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective Drug Administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures, 1. The provider pharmacy dispenses medication in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled…

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

Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#84, #19 and #44) out of a total sample of 21 Residents. Specifically, 1. For Resident #84 nursing failed to accurately update the physician's order for tube feedings. 2. For Resident #19 nursing failed to accurately document in the Treatment Administration Record (TAR) regarding bunny boots and the air mattress setting. 3. For Resident #44 nursing failed to accurately document in the TAR regarding geri sleeves. Findings include: 1). For Resident #84 nursing failed to accurately update the physician's order for tube feedings. Specifically, on 9/26/23 the Nurse Practitioner decreased Resident #84's tube feeding from three times daily to twice daily, nursing did not update the wording of the physician's order which indicated for nursing to administer the tube feeding to twice daily and TID (three times daily). Resident #84 was admitted to the facility in February 2023 with diagnoses including malignant neoplasm of the oropharynx, insomnia and depression.…

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 adhere to standards of practice to prevent the spread of potential infection on two of three resident care units. Specifically, housekeeping staff failed to perform hand hygiene when exiting resident rooms, between glove changes, and wore potentially contaminated gloves in the hall when disposing of soiled items. Findings include: Review of the Centers of Disease Control and Preventions document entitled Hand Hygiene Guidance, indicated the following: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from…

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

Based on record review, policy review, and interview the facility failed to ensure that residents were provided education on the pneumococcal vaccine, were assessed for the eligibility for the administration of a pneumococcal vaccine and that the medical record for 2 out of 5 residents had documentation of the administration of the pneumococcal vaccine. Findings include: Review of the facility's policy, entitled, Resident and Staff Pneumococcal Immunizations, not dated, indicated the following: Purpose: To decrease the risk of transmission of the pneumococcal virus and provide a safe environment for our residents. Policy: It is the policy of Covenant long term care facilities to offer eligible staff members, and residents or their responsible party upon admission if they have previously had the appropriate pneumococcal vaccination and their age at the time of the vaccination. The record that accompany the resident also will be used to determine immunization status. Procedure: Before offering the pneumococcal immunization, each resident or the resident's legal representative 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.