Lanessa Extended Care

Based on interview, and record review, the facility failed to assess one Resident (#79) out of a total sample of 18 residents, for the clinical appropriateness to self-administer medications. Specifically, for Resident #79, the facility failed to complete an assessment for the appropriateness and safety of self-administration of medications when an order was received to leave a Benadryl cream at the Resident's bedside. Findings include: Review of the facility's policy titled Self-Administration of Medications, dated July 2015 indicated: -Evaluate the resident's cognitive, physical, and visual ability to self-administer medications. -Complete the Self Administration Evaluation and document whether the resident can safely self-medicate or is unable to safely self-medicate. If the resident can't safely self-medicate, document the reason why. -Inform the resident/responsible party of the decision. -Update the care plan for self-medication to include where the medication will be stored, documentation of self-administration, and location of the drug administration. -Perform resident…

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

Based on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to: A) address grievances related to staffing levels on the 11:00 P.M.- 7:00 A.M. shift when reported in Resident Council Meeting on 12/18/24. B) document response and rationale when concerns with staffing levels on 11:00 P.M.- 7:00 A.M. shift were reported in Resident Council Meeting on 1/21/25. Findings include: Review of the facility Grievance Policy, undated, indicated the following: -The facility will make prompt efforts to resolve any grievances . -The facility will appoint a grievance officer who will be responsible for overseeing the grievance process including: >Receiving and tracking grievances to conclusion >Conducting any necessary investigations >Issuing written grievance decisions to the resident if requested Residents will be notified individually or through postings in prominent locations…

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

Based on record review, and interview, the facility failed to accurately execute Advance Directives for two Residents (#41 and #234) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident # 41, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #41's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) after the Physician had determined that the Resident lacked the capacity for informed medical decision making. 2. For Resident #234, ensure that the MOLST form was valid and reflected the signature of the Resident who maintained his/her capacity for informed medical decision making. Findings include: Review of the facility policy for MOLST, dated August 2015, indicated: -the admitting nurse will note the existence of the MOLST form on the admissions assessment and review the form for completeness (e.g. signed by the resident/patient or legally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and/or Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were accurately issued for three Residents (#483, #63, #34) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #483: >issue a NOMNC with Provider contact information inserted above the title of form. >provide the NOMNC two days prior to discharge. 2. For Resident #63: >provide a NOMNC with Provider contact information inserted above the title of form. >provide paper copies of NOMNC to responsible party. >obtain signature on the SNF ABN form, indicating the responsible party…

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 a clean, comfortable, and homelike environment for one Resident (#54) out of a total sample size of 18 residents. Specifically, the facility failed to maintain Resident's #54 wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair for mobility and the wheelchair was visibly soiled. Findings include: Resident #54 was admitted to the facility in October 2023 with diagnoses including Unspecified Abnormalities of Gait, Mobility and Weakness. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of a total possible score of 15. -was dependent for wheelchair mobility. Review of the Comprehensive Person-Centered Care Plan for Resident #54 indicated: -Resident #54 had impaired mobility and required intervention of a wheelchair for a mobility device. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide care and services that met professional standards of practice for two Residents (#56 and #51) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #56, schedule a urology appointment when the Resident had been discharged back to the facility from the hospital with a kidney stone and related infection. 2. For Resident #51, implement a Physician order for a Pulmonary Consultation to evaluate the Resident for clinical symptoms and Chronic Obstructive Pulmonary Disease (COPD). 3. For Resident #51, implement the Physician's orders for weekly weight monitoring. Findings include: Review of the facilty Policy and Procedure for Consultant Services dated April 2015, indicated: >The organization will identify and facilitate consultant services to meet the Resident's needs, to ensure optimum care for each resident/patient through their consultant services. >The licensed charge nurse will obtain an order 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 observation, record review, and interview, the facility failed to provide a smoking environment that was free of accidental hazards for one Resident (#62), out of a total sample size of 18 residents. Specifically, the facility failed to ensure that Resident #62 was appropriately supervised during smoking activity when the Resident was assessed as needing supervision, placing the Resident at risk of accident and/or injury. Findings include: Review of the facility policy titled Smoking; revised November 2020 indicated but was not limited to the following: -It is the policy of the facility to provide a healthy and safe environment for residents, staff, and visitors by limiting the use of tobacco smoking materials on its campus. -Purpose is to afford residents the privilege of smoking while maintain a safe and clean environment within the policy of this facility, that also is respectful to the non-smoker. <Residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly, and as dictated by any significant change in condition, to ensure that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment in accordance with professional standards of practice relative to an indwelling urinary catheter for one Resident (#34) out of a total sample of 18 residents. Specifically, the facility failed to: -reassess Resident #34's indwelling catheter status upon re-admission when the Resident was hospitalized with indwelling urinary catheter associated complications. -obtain a Physician order to include the current indwelling urinary catheter size required for the Resident. -update the Resident's Indwelling Catheter Care Plan to reflect the Resident's current indwelling catheter status. Findings include: Review of the facility's policy titled Urinary Catheter Insertion (Indwelling), dated April 2015, indicated an indwelling urinary catheter would be inserted when the resident's clinical condition demonstrates necessity by a licensed nurse, as ordered by the physician. Resident #34 was admitted to the facility in February 2023…

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

Based on interview and record review, the facility failed to maintain sufficient nursing staff to provide care to residents on one unit (Elmwood) out of two sampled nursing units, when no staffing waivers were in place. Specifically, the facility failed to: -ensure sufficient qualified nursing staff were available to provide care and respond to resident's basic needs on the 11:00 P.M. to 7:00 A.M. (night) shift. -ensure that positions are filled timely when there are staff call outs. -schedule the type and level of staff that reflect the expectations described in the facility assessment. Findings include: Review of the Facility Assessment, dated July 2024, indicated: -Total Number of beds: 96 -Windsor Unit: >Short term rehab unit/long term care with 49 Beds. >Residents on the unit are short term rehab services, medication management. >Some residents do transition to long term care and are at a higher functioning level. -Elmwood Unit: >Secure long term care unit with 47 beds. >Residents often transition to this unit for long term care. >Most residents have advanced cognitive loss…

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

Based on interview, and record review, the facility failed to ensure that competency in skills and techniques necessary to provide resident care were demonstrated for one Certified Nurses Aide (CNA [#3]), out of a total of five staff reviewed. Specifically, for CNA #3, the facility failed to ensure that annual competency training with demonstrated competency in the skills and techniques necessary to care for residents' needs was completed for 2024 as required. Findings include: Review of the Facility Assessment Tool, dated July 2024, indicated but was not limited to the following: -Staff training/education and competencies: Required in-service training for nurses' aides. In-service training must: >Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. >Include dementia management training and resident abuse prevention training >Address areas of weakness as determined in nurses' aides performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. >For nurses' aides…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#51 and #23) out of a total sample size of 18 residents. Specifically, the facility failed to ensure that the Residents (#51 and #23) received follow-up Behavioral Health Services after recommendations for continued follow-up visits were made by the Provider. Findings include: Review of the facilities policy on consultant services dated April 2015 indicated: >The facility will identify and facilitate consultant services to meet the resident's need, to ensure optimum care for each resident/patient consultant services. 1. Resident #51 was admitted to the facility in July 2021 with diagnoses including Cerebral Vascular Accident (CVA), Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated: -The Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that psychotropic medications (medication that affect the mind, emotions and behavior) administered were necessary for one Resident (#27) out of five applicable residents reviewed, out of a total sample of 18 residents. Specifically, the facility failed to ensure: -For Resident #27, that the obtained consent from the Resident's Health Care Proxy (HCP) for the use of psychotropic medications was necessary when the Informed Consent for Psychotropic Administration was obtained from and signed by another residents' HCP. Findings include: Review of the facility policy titled Psychotropic Medication Management, dated April 2015, indicated: -Each resident's drug regimen will be free from unnecessary drugs. Administration of psychoactive medications will focus on the individual needs of the resident and will be prescribed only when necessary and clinically indicated to treat specific conditions and symptoms as diagnosed and documented. -Notify resident…

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

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for one Resident (#24) out of a total sample of 18 residents. Specifically, the facility failed to maintain accurate documentation of meal intake percentages by Certified Nurse Aides (CNAs) when Resident #24 was identified as being at risk for weight loss. Findings include: Review of the facility policy titled, Nursing Documentation, dated 2/2016 indicated: -The nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. Resident #24 was admitted to the facility in April 2023 with diagnoses including Alcohol Dependence, Traumatic Fracture, COPD and Muscle Weakness. Review of Resident #24's Clinical Progress notes indicated: -11/27/24 - Dietary Risk Meeting: >Resident admitted to risk on 11/20/24 .weight 153.6, weight loss 8.5% over 30 days and 10.9% over 90 days, >Resident re-weight 11/20/24: 159.4, weight loss 5% over 30 days . -12/11/24 - Dietary Risk Meeting: >Resident admitted to risk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to maintain infection control practices per professional standards for three Residents (#7, #47 and #11) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #7, appropriately provide care for a urinary drainage bag that was not in use when the Resident interchanged the urinary drainage bags for daytime and nighttime use, placing him/her at risk for contamination and infection. 2. For Resident #47, assist with hand hygiene prior to eating, following the Resident's participation in a group activity when his/her hands were visibly soiled, placing the Resident at risk for contamination and infection. 3. For Resident #11, maintain Enhanced Barrier Precautions (EBP) while providing high contact care during a bolus feeding (administering a dose of formula through a feeding tube using a catheter syringe [syringe without a needle]) procedure, placing the Resident at risk for transmission of organisms.…

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

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 who had a history of exit seeking and routinely wandered the unit during the evening shift and Resident #4, his/her roommate who was also ambulatory) the Facility failed to ensure that they were free from involuntary seclusion by being confined to their room by staff, when on 01/12/24 from approximately 9:30 P.M. to 11:30 P.M., a plastic bag was tied from the door handle of Resident #1 and Resident #4's room to the handrail in the hallway outside their room, by Certified Nurse Aide (CNA) #1 who admitted to doing it in order to prevent Resident #1 from exiting his/her room to wander the unit and exit seek. Findings include: Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the Facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Further review of the policy indicated it included the following definition of involuntary seclusion:…

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

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of involuntary seclusion to the Administrator or designee, when on 01/13/24, Nurse #1 and Nurse #2 became aware during the overnight shift, that the door to a bedroom occupied by two ambulatory residents was tied shut, preventing them from exiting the room at will. However, although both Nurse #1 and Nurse #2 were both aware of the incident, the Facility Administration was not made aware of the incident until 01/15/23 (two days later), when Director of Nurses (DON) #1 spoke with Nurse #1 and Nurse #2 after discovering a progress note about the incident. Findings include: Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the Facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.…

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

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure that an allegation of involuntarily seclusion, was reported to the Department of Public Health (DPH) within two hours, as required, per Federal Regulations and Facility policy. When on 01/15/24 at approximately 7:30 A.M., Director of Nurses (DON) #1 became aware of an incident that occurred on 01/12/24, where the door to the bedroom occupied by Resident #1 and Resident #4 was found to be tied shut, however the incident was not reported that day to DPH until 6:07 P.M., more than ten hours later. Findings include: Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the Facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The Policy indicated the following definition of Involuntary Seclusion: the separation of a resident from other residents or from his/her room or confinement to…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had dementia and was known by staff to wander the hallways and exhibited exit seeking behaviors, the Facility failed to ensure that Resident #2 was provided with an adequate level of staff supervision, in an effort to maintain his/her safety to prevent an elopement. On 03/11/2024, at some point during the day shift, unbeknownst to staff, Resident #2 exited the Facility, unit staff only became aware of the elopement after Resident #2's lunch tray was left untouched, and staff could not locate him/her. Resident #2 was found later that same day by the police, seated on the side of a road, four miles from the Facility. Findings include: Review of the Facility's policy titled Elopement, dated July 2015, indicated the Facility would maintain a process to screen all residents for risk of elopement, implement preventative strategies for those identified at risk, institute measures for resident identification at the time of admission, and conduct missing resident procedures, as warranted. Resident…

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

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2) the Facility failed to ensure they provided sufficient nursing staff so that the care and safety needs of the residents were adequately met, when on 01/12/24 during the evening shift, Resident #2 was able to wander off the locked unit he/she resided on, and that same night, Certified Nurse Aide (CNA) #1 admitted to securing the door to Resident #1's room to prevent him/her from exiting his/her room to wander and exit seek while she attended to another resident, because the unit was short staffed. Findings include: Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the following: - Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure that the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure that sufficient nursing staff were available to provide care and services to the meet the needs of four Residents (#40, #39, #47 and #78) on two Units (Windsor and Elmwood), out of two units observed. Specially, the facility failed to ensure that: 1) For Resident #40, scheduled medications were provided within the required timeframe. 2) For Resident #39, nursing staff were available to assess and medicate for pain as needed. 3) For Resident's #47 and #78, adequate staff were available to assist with the toileting needs. 4) adequate staff were available to assist with meals and dining. Findings include: Review of the Payroll -Based Journal data for Quarter Three (April 1 - June 30, 2023) indicated excessively low weekend staffing. Review of the Facility Assessment Tool dated 10/27/23, indicated the facility capacity was 96 total residents on two units. The Windsor Unit capacity was 49 residents and the Elmwood Unit capacity was 47…

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

Based on interview and record review, the facility failed to ensure that the nursing staff completed training as outlined in the Facility Assessment Tool. Specifically, -the facility failed to provide documentation that staff competencies were completed for six (Nurse's #2, #5, #6, #7, #8 and #10) out of seven staff training records reviewed. -the facility could not verify that current licensed nursing staff (Nurse's #4, #2, #5, #6, #7, #8 and #10) had completed their required annual competencies. Findings include: Review of the Facility Assessment Tool, most recent revision undated, indicated but was not limited to the following: Staff training/education and competencies: -Orientation includes conducting separate competencies for our Nurses and Certified Nurses Aides (CNAs) -All mandatory training and competencies are completed annually and/or PRN (as needed). -Competency requirements met at time of Orientation and Yearly for Nurses include glucose, pulse oximetry, occult blood testing, injection safety, insulin pen, IV, pump, pain assessment, wound dressing for Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policies reviewed, the facility failed to ensure care and services were provided for one Resident (#79) of two applicable residents with catheters, out of a total sample of 19 residents, who had an indwelling urinary catheter (flexible tube inserted into the bladder to allow for urine flow). Specifically, the facility failed to: -obtain Physician's orders for the care of the Resident's catheter, including irrigation orders and changing the urinary drainage bag. -accurately monitor urinary output. -ensure that an assessment was completed to determine rationale for continued use of the urinary catheter. Findings include: Review of the facility policy titled Urinary Catheter Care, dated April 2015, included the following: -Ensure the catheter tubing was secured . to prevent urinary tract infections caused by urinary reflux, always keep the drainage bag below the level of the resident's bladder. -Position the tubing for straight drainage. Review of the facility policy…

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

Based on observations, interviews, record and policy reviews, the facility failed to adhere to infection control practices to reduce the potential transmission of infection for one Resident (#25), out of a total sample of 19 residents, and for one unit out of two units observed. Specifically, the facility failed to ensure that: 1) the appropriate personal protective equipment (PPE) was worn by staff for Resident #25, who was identified as requiring Enhanced Barrier Precautions (EBP-used in addition to standard precautions to prevent the transmission of multi-drug resistant organisms [MDROs]) 2) facility staff appropriately cleaned and disinfected medical equipment after resident use, specifically a glucose monitoring device (meter used to test the concentration of glucose in the blood and is performed by piercing the skin to draw blood and then applying the blood to a test strip) on the Elmwood Unit. Findings include: 1) Review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated the following: -It is the policy of this facility to implement enhanced…

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, policy and record review, the facility failed to ensure the Physician was notified of a significant weight change and recommendations for scheduled appointments for one Resident (#79), out of a total sample of 19 residents. Specifically, the facility failed to notify the Physician when Resident #79 had: A) recommendations for a Computerized Tomography scan (CT: X-ray images taken from different angles of the body to create a cross sectional image of the bones, blood vessels, and soft tissue). B) an appointment to replace his/her gastrostomy tube (G-tube: tube inserted through the belly that brings nutrition directly to the stomach). C) a significant weight loss (weight change of 5 percent (%) or more in one month, 7.5% or more in three months or 10% or more in six months). Findings include: Resident #79 was admitted to the facility in October 2023 with diagnoses including Traumatic Brain Injury (TBI: TBI: brain dysfunction resulting from a sudden, external, physical injury to the head), G-tube status, and Dysphagia (difficulty swallowing). 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, interviews, records and policy review, the facility failed to ensure that Physician orders were implemented for three Residents (#51, #79 and #43), out of a total sample of 19 residents. Specifically, the facility failed to: 1. ensure that weights were obtained as ordered by the Physician for Resident's #51 and #79 2. ensure a Dermatology Consult was obtained as ordered by the Physician for Resident #43 Findings include: Review of the facility policy titled Weights, dated August 2015, included the following: -Residents will be weighed at the discretion of the Interdisciplinary Team -Residents will be weighed monthly, unless clinically indicated -Weights are documented in the resident's medical record . 1a. Resident #51 was admitted to the facility in November 2019, with diagnoses including Dementia (progressive and persistent loss of intellectual functioning, especially with impairment of memory) and Dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) Assessment, dated…

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

Based on record review and interview, the facility failed to ensure that annual performance reviews were completed as required for two out of four Certified Nurses Aides (CNAs). Specifically, the facility failed to ensure that expectations, individual performance and training requirements were communicated to two CNAs through the annual performance appraisal process. Findings include: Review of the policy, titled Employee Performance Appraisals, dated February 2010, indicated: -Properly done performance appraisals demonstrate that this facility is seriously committed to helping its employees develop their full potential. It is a time when Supervisors/Department Heads can communicate essential information to employees about their jobs, their future, and employees can express their hopes, aspirations, and needs to their supervisors. -Accuracy in deriving a decision regarding employee appraisals can only be achieved through regular documentation. By directly observing the performance of your staff on a day-to-day basis, you will be able to record specific examples of behavior. Keep…

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, policy reviews, and interviews, the facility failed to ensure that Pharmacy recommendations were addressed by the attending Physician for two Residents (#33 and #53), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #33, to report the Pharmacy recommendations to the attending Physician pertaining to orders needed for a psychotropic (medication that affects a person's mental state) medication. 2. For Resident #53, to report the Pharmacy recommendations to the attending Physician pertaining to an anti-nausea medication. Findings include: Review of the facility's policy, titled Consultant Services, dated 4/2015, indicated the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident/patient at the request of the MD or the family. The Consultant should document findings and recommendations on this form. -The charge Nurse will then notify the attending Physician of the findings and he/she can then order the specific treatments as outlined by the consultant. -A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure that the use of as needed (PRN) medications were appropriately evaluated for two Residents (#58 and #79) out of a total sample of 19 residents. Specifically, 1) For Resident #58, that an as needed (PRN) psychotropic medication (medications that are used to treat a variety of conditions and affect mood, behavior and perceptions) was limited to 14 days and was re-evaluated for continued use by the Provider. 2) For Resident #79, that a PRN antipsychotic medication (class of medications that are used to manage psychosis [a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality]) was limited to 14 days. Findings include: 1) Resident #58 was admitted to the facility in March 2022 with diagnoses including Dementia (a type of cognitive decline that leads to a decline in thinking, reasoning, and independent function), Major Depression, Anxiety, and mixed obsessional thoughts and acts. Review of…

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

Based on observation, record review and interview, the facility staff failed to ensure a medication error rate of less than five percent (%) for one Resident (#60), out of four residents, out of 34 opportunities. Specifically, the medication error rate was observed to be 11.76%, when four scheduled medications were administered beyond the required timeframe of one hour after the scheduled time. Findings include: Review of the policy titled, Medication Administration-General Guidelines, dated 2017, included, but not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices and only administered by persons legally authorized to do so. 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). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications with unnecessary interruptions. -Five Rights- Right resident, right drug,…

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 maintain accurate medical records for one Resident (#37), out of a total sample of 19 residents. Specifically, the facility failed to maintain accurate records related to activities participation and refusals of participation. Findings include: Resident #37 was admitted to the facility in August 2020 with diagnoses including unspecified Dementia (a type of cognitive decline that leads to a decline in thinking, reasoning, and independent function), Psychotic Disturbance (a mental disorder characterized by a disconnection from reality), and mood disturbance with anxiety. Review of the MDS assessment dated [DATE], indicated that Resident #37 was able to make his/herself usually understood and could usually understand during communication with others. During an interview on 11/5/23 at 12:49 P.M., Family Member #2 said when they visited the facility, Resident #37 was always in his/her room and never in the day room or participating in group activities. The…

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

Based on record review and interview, the facility failed to ensure that all required staff members attended the scheduled Quality Assurance Performance Improvement (QAPI) meeting, as required. Specifically, the facility Infection Preventionist (IP) failed to attend two of the last five quarterly QAPI meetings. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement (QAPI) Plan, dated 2019, indicated the following: -The Quality Assurance committee members are the Medical Director or his/her designee, the Director of Nursing (DON), the Infection Preventionist (IP), and at least three other staff members, one whom is the Administrator, Owner, or Board Member. -Committee meetings are held on a monthly basis at a minimum. The committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress reports. Review of the attendance sheets from 10/31/22 and 4/24/23 did not indicate the Infection Preventionist was in attendance during the scheduled quarterly meetings held on those dates. During an interview on 11/8/23…

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

Based on policy review, record review, and interview, the facility failed to ensure that its staff administered the Influenza Vaccine as required, after obtaining consent for one Resident (#12), out of five applicable residents. Findings include: Review of the facility policy titled Immunization of Residents, undated, indicated the following: -The resident or the resident's legal representative will be provided education regarding the pros and cons of the vaccine prior to administration. -Administer Influenza Vaccine (0.5 milliliter) in the deltoid muscle and document vaccination in the Medication Administration Record (MAR). If the vaccine was not given, record the reason(s) for non-receipt of the vaccine (i.e., medical contraindication, resident refusal). Resident #12 was admitted to the facility in December 2019 with a diagnosis of Cerebral Palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth). Review of the Resident Annual Influenza Education form dated 10/23/23,…

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

Based on records reviewed and interviews, the Facility failed to ensure that staffing included the services of a Registered Nurse (RN) for a minimum of 8 consecutive hours a day, 7 days a week as required, when during June 15, 2023 through July 15, 2023, the facility had no RN coverage for several days, for an entire 24 hour period. Findings include: Review of the Facility's nursing schedules dated Thursday, June 15, 2023 through Saturday, July 15, 2023 indicated there was no Register Nurse coverage during the day, evening or night shift for the following days: - Saturday, June 17, 2023. - Sunday, June 18, 2023. - Saturday, June 24, 2023. - Sunday, June 25, 2023. - Saturday, July 1, 2023. - Sunday, July 2, 2023. - Tuesday, July 4, 2023. - Saturday, July 8, 2023. - Sunday, July 9, 2023. - Saturday, July 15, 2023. During interview on 9/25/23 at 2:54 P.M., the Director of Nursing said she was aware of the Registered Nurse (RN) requirement of one RN for 8 consecutive hours, for each 24 hour period and said the facility had not met that requirement for the dates identified by 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 its staff provided sufficient licensed Nurse staffing levels on two out of two resident units, based on the facility census, resident daily needs, and in accordance with the Facility Assessment Tool. Specifically, lack of appropriate staffing levels reported by Resident #23 and Resident #35. Findings include: On 8/31/22 at 8:31 A.M., the surveyor observed one licensed Nurse working on the Windsor Unit on the 7:00 AM to 3:00 PM (day) shift. Review of the facility Detailed Census Report, dated 9/1/22, indicated that the facility housed 91 residents and that the facility capacity for residents was 96. During an interview on 8/31/22 at 8:40 A.M., Nurse #3 said that she worked by herself the previous weekend on the Windsor Unit and that she typically worked alone once to twice a week. Nurse #3 said that when this occurred, resident treatments, doctors' recommendations, and completion of medication and treatment administration records were missed. During an interview on 8/31/22 at 8:50 A.M., Resident #23…

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

Based on record review and interview, the facility failed to ensure that its staff assessed residents and individuals entering the facility for signs and symptoms of COVID-19 (a virus that causes a respiratory disease) each shift during an outbreak as required. The facility also failed to ensure that their Legionella management program was updated as required. Specifically, 1) During outbreak testing on the Elmwood Unit, the staff failed to assess for COVID-19 symptoms each shift for two Residents (#46 and #47) out of a total of three residents sampled. 2) The facility also failed to ensure that two Hospice staff entering the facility were screened for symptoms of COVID-19 and exposure to others with suspected or confirmed COVID-19 infection as required, and 3) The facility failed to update their Legionella program as required. Findings include: Review of the Massachusetts Department of Public Health (DPH) guidance titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, 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.

Based on observation and interview, the facility failed to ensure that its staff maintained a clean, homelike environment in the two out of two resident shower rooms, located on each unit. Specifically, the tile, grout and caulk in both resident showers were covered with a black mold/mildew like substance, impacting the care of one Resident (#41). During an interview on 8/31/22 at 9:10 A.M., Resident #41 said he/she refused to use the shower on the Windsor Unit because it had black mold in it. The Resident said staff offered to take him/her to the shower on the Elmwood Unit but the Resident said it was not clean and it smelled bad. Resident #41 further said there was usually one housekeeper to clean both units (census of 91) five days a week and no one to cover the remaining two days. On 8/31/22 at 4:27 P.M., the surveyor observed there was a black mildew-like substance on the tile, grout and caulk in the Windsor Unit shower. The black substance was in the seam where the floor met the wall and between the tiles extending up from the floor. On 8/31/22 at 4:32 P.M., the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that its staff followed the plan of care for four Residents (#83, #78, #35 and #23) out of 19 sampled residents. Specifically, 1) Implementation to monitor blood glucose levels for one Resident (#83), 2) Implementation to monitor weekly weights for one Resident (#78), and 3) Administration of a Physician ordered medication for two Residents (#35), and 4) Resident (#23). Findings include: 1. For Resident #83 the facility failed to ensure that its staff monitored finger stick blood sugars (FSBS- used to determine blood glucose levels) as ordered. Resident #83 was admitted to the facility in August 2022 with diagnosis including Diabetes Mellitus (DM). Review of the August 2022 Physician's orders indicated to check the FSBS four times per day. Review of the August 2022 Medication Administration Record (MAR) indicated that the FSBS was not checked 33 out of 110 times that it was scheduled to be checked. During an interview on 9/06/22 at 10:08 A.M.,…

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

Based on policy review, record review, and interview the facility failed to ensure that its staff provided professional standards of quality care for one Resident (#83) out of 19 sampled residents. Specifically, staff failed to rotate subcutaneous (SC-layer of skin directly below the dermis) injection sites for the administration of insulin. Failure to do so could result in hard lumps of extra fatty deposits at the injection sites. Findings include: Review of the American Diabetes Association website indicated the following: Don't inject insulin in the exact same place each time .if insulin is injected near the same place each time, hard lumps of extra fatty deposits may develop. Review of the facility's policy for Medication Administration of SC Injections, dated March 2017, indicated the following: -Insulin injection sites rotated within the same anatomic region for consistent absorption. -Document site and rotate site. 1. Resident #83 was admitted to the facility in August 2022 with diagnosis including Diabetes Mellitus (DM). Review of the August 2022 Physician's orders 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 observation, record review and interview the facility failed to ensure that its staff offered the necessary care and services to get out of bed to the wheelchair on a daily basis for one Resident (#55) out of a total of 19 sampled residents. Specifically, there was no evidence that Resident #55 was offered the opportunity to get out of bed on 26 days in July 2022 and 21 days in August 2022. Findings include: Resident #55 was admitted to the facility in March 2018 with diagnoses including Cerebral Infarction (Stroke), unspecified Dementia without behavioral disturbance and legal blindness. Review of a Minimum Data Set (MDS) assessment, dated 7/13/22, indicated Resident #55 had severe cognitive impairment as evidenced by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the following for the seven day look back period: -Transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) was coded as Activity did not occur. -Surface to surface transfers (transfer…

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 policy review, record review and interview, the facility failed to ensure that its staff provided diabetic foot care, to prevent complications of the feet related to Diabetes Mellitus, for two Residents (#44 and #68) out of 19 sampled residents. Findings include: Review of the facility's policy for Diabetic Foot Care, dated June 2015, indicated the policy was to provide diabetic foot care by a qualified nursing staff and foot condition is noted, and changes reported, as warranted. 1. Resident #44 was admitted to the facility in June 2021 with diagnosis including Diabetes Mellitus and diabetic neuropathy (nerve damage that most often affects the legs and feet). Review of the July 2022 and August 2022 Physician's orders did not indicate an order to provide diabetic foot care. Review of the July 2022 and August 2022 Treatment Administration Records (TARs) did not indicate diabetic foot care was provided. During an interview on 9/1/22 at 7:04 A.M., the Director of Nurses (DON) reviewed the July 2022 and August 2022 Physician's orders and said there should have been an order 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, record review and interview, the facility failed to ensure that its staff provided care and services of a midline (a long catheter inserted into the upper arm with tip located just below the axilla, used for administration of intravenous (IV) medications), specifically related to flushing the midline before and after IV medication administration, for one Resident (#68) out of 19 sampled residents. Findings include: Resident #68 was admitted to the facility in July 2022. Review of the clinical record indicated the Resident was started on two IV antibiotics, Ceftriaxone and Flagyl, on 8/24/22 for the treatment of osteomyelitis (bone infection). Review of the August 2022 Infusion Medication Administration Record (MAR) indicated the following orders: -Ceftriaxone one gram (gm) IV every 24 hours -Metronidazole one gm IV every 8 hours -Flush midline before medication administration with 10 milliliters (ml) of normal saline (NS) -Flush midline after medication administration with 10 ml of NS and 5 ml (10 units/ml) of Heparin (to prevent blood clots). Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to ensure that Physician visits were complete. Specifically, that orders were signed and dated, for four Residents (#19, #44, #55, and #25) out of four applicable sampled residents. Findings include: 1. Resident #19 was admitted to the facility in June 2022. Review of the clinical record indicated the Resident was seen by the Nurse Practitioner (NP) on 6/10/22 and by the Physician on 6/21/22. Review of the Physician's orders indicated the last signed orders were June 2022. Further review indicated the Physician or NP had not signed the Resident's orders for July 2022 or August 2022, as required. During an interview on 9/6/22 at 3:59 P.M., the Regional Clinical Specialist said Resident #19 should have been seen by a Physician or NP every 30 days since admission [DATE]) and orders should have been signed with each required visit. 2. Resident #44 was admitted to the facility in June 2021. Review of the clinical record indicated the Physician orders…

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 staff failed to ensure Physician visits were done in the required intervals for four Residents (#19, #44, #55 and #25), out of four applicable sampled residents. Findings include: 1. Resident #19 was admitted to the facility in June 2022. Review of the clinical record indicated the Resident was seen by the Nurse Practitioner (NP) on 6/10/22 and by the Physician on 6/21/22. Further review indicated no Physician or NP visits were done in July 2022 or August 2022, as required. During an interview on 9/6/22 at 3:59 P.M., the Regional Clinical Specialist said Resident #19 should have been seen by a Physician or NP every 30 days since admission [DATE]). 2. Resident #44 was admitted to the facility in June 2021. Review of the clinical record indicated the Resident was seen by the Physician on 3/23/22 and by the Physician's Assistant (PA) on 8/17/22. There were no visits between March 2022 and August 2022. During an interview on 9/6/22 at 3:59 P.M., the Regional…

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

Based on record review and interview, the facility failed to ensure that its staffing included a Registered Nurse (RN) for a minimum of 8 hours a day, 7 days a week, as required. Specifically, the facility had no RN coverage over three days between 7/28/22 and 8/31/22. Findings include: Review of the facility's nursing schedule from 7/28/22 to 8/31/22 indicated that there was no RN coverage on 8/6/22, 8/20/22 and 8/21/22. During an interview on 8/31/22 at 3:47 P.M., the Director of Nurses said that the requirement for RN coverage in the facility is one RN for 8 hours, for each 24-hour period, but there was no RN coverage for the 8/6/22, 8/20/22 and 8/21/22, dates as required.

Based on record review and interview the facility failed to ensure that its staff kept one Resident (#35), out of a total of 19 sampled residents, free from significant medication errors. Specifically, the facility did not request a refill for Caplyta (antipsychotic medication) in a timely manner on two different occasions resulting in the medication not being available to be administered to the Resident as ordered for four consecutive days in July 2022 and 17 consecutive days in August 2022. Findings include: Resident #35 was admitted to the facility in June 2022 with diagnoses including Bipolar Disorder and a personal history of suicidal behavior. Review of the medication insert for Caplyta 42 milligrams (mg) included, but was not limited to the following: -Monitor all antidepressant-treated patients for any indication for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes. Review of the Physician's orders indicated the following orders: -Caplyta 42 mg, one capsule by mouth…

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

Based on record review and interview the facility failed to ensure that its staff maintained complete and accurate medical records for medication administration for one sampled Resident (#35) out of a total of 19 sampled Residents. Specifically, the facility staff failed to document the administration of an antipsychotic medication, and inaccurately documented that another routine medication was administered, when the medication was not available in the facility during the documented administration time period. Findings include: Resident #35 was admitted to the facility in June 2022 with diagnoses including Bipolar Disorder and a personal history of suicidal behavior. Review of the Physician's orders indicated the following orders: -Caplyta 42 milligrams (mg), one capsule by mouth at bedtime (initiated 7/8/22). -Atvorstatin 10 mg, one tablet by mouth at bedtime (initiated 6/27/22). Review of the July 2022 Medication Administration Record (MAR) showed: -There were no entries for the administration of Caplyta at 8:00 P.M., on 7/9/22, 7/12/22 and 7/28/22. -There were no comments on 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 interview and document review the facility staff failed to ensure that its Quality Assessment and Performance Improvement (QAPI) committee was composed of the required members. Specifically, there was no evidence the Medical Director or his/her designee was at the quarterly QAPI meetings held on 10/15/2021 and 1/26/22, and there was no evidence the Director of Nurses (DON) was at the quarterly QAPI meetings held on 10/15/21, 1/26/22 and 4/26/22. Review of the attendance sheet for the quarterly QAPI meeting held on 10/15/21 showed there was no evidence the DON and the Medical Director or his/her designee participated in the meeting. Review of the attendance sheet for the quarterly QAPI meeting held on 1/26/22 showed there was no evidence the DON and the Medical Director or his/her designee participated in the meeting. Review of the attendance sheet for the quarterly QAPI meeting held on 4/26/22 showed there was no evidence the DON participated in the meeting. During an interview on 9/7/22 at 10:15 A.M. the Administrator reviewed the attendance sheets with the surveyor 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 policy review, document review and interview, the facility failed to ensure that all of its staff participated in mandatory training on abuse, neglect, and exploitation prevention for five out of five sampled current employees. Specifically, the facility had no process in place to track attendance, and ensure all staff participated in the required training and no evidence that those who had participated were assessed to determine if the training had been effective. Findings include: Review of the facility Abuse Prohibition Policy, dated September 2020, indicated the following: -All employees will be provided an educational program regarding abuse prohibition practices. -Educational programs shall include the following information: Definition of abuse, definition of exploitation, definition of misappropriation of resident property, definition of neglect, appropriate methods to manage residents with behavioral symptoms, and mechanisms for staff to report allegations of abuse without reprisal. -The initial education/training of personnel will be provided during general…

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 policy review, record review and interview, the facility failed to ensure that its staff obtained written consent, including education on the risk and benefits of proposed care related to the use of an anti-psychotic medication, for one Resident (#19), out of 19 sampled residents. Findings include: Review of the facility's policy for Psychotropic Medication Informed Consent, dated February 2016, indicated that prior to administering a psychotropic medication, the facility shall obtain the informed written consent of the Resident, the Resident's Health Care Proxy (HCP) or the Resident's guardian. The written consent form shall be kept in the Resident's medical record. Resident #19 was admitted to the facility in June 2022 with diagnosis including Traumatic Brain Injury (TBI). Review of the September 2022 Physician's orders indicated to administer Risperidone (anti-psychotic) one milligram (mg) by mouth daily, initiated on 6/9/22. Review of the clinical record indicated no written consent, including education on the risk and benefits, for the use of Risperidone. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure its staff notified the Physician about missed medications for one Resident (#35) and a fall for one Resident (#5) out of a total of 19 sampled residents. Specifically, 1) The facility failed to notify the Physician that: a) Resident #35 missed four consecutive administrations of an antipsychotic in July 2022, and b) 17 consecutive administrations of an antipsychotic and 15 consecutive administrations of a statin (cholesterol lowering medication) in August 2022. 2) The facility also failed to notify the Physician when Resident #5 had a fall on 8/29/22. Findings include: 1. For Resident #35 the facility failed to ensure that its staff notified the Physician of medication omissions in July and August of 2022. Resident #35 was admitted in June 2022 with diagnoses including Bipolar Disorder and a personal history of suicidal behavior. Review of the Physician's orders indicated the following orders: -Caplyta 42 milligrams (mg), one capsule by mouth…

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

Based on record review and interview, the facility failed to ensure that its staff followed the facility grievance policy and made prompt efforts to resolve a grievance for one Resident (#35), out of a total of 19 sampled Residents. Specifically, the facility staff failed to notify the grievance officer of a grievance form filed by a family member on 7/8/22, and there was no evidence an attempt had been made to resolve the grievance. Findings include: Review of the facility grievance policy, revised November 2016, included but was not limited to the following: -Residents have the right to voice grievances without discrimination or reprisal or fear of discrimination or reprisal. Such grievances may include issues with care or treatment that has been received or not received, the behavior of staff or other residents and other concerns regarding the resident's stay at the facility. -Upon receipt of the grievance, the staff person receiving the grievance shall immediately notify the grievance officer. -The grievance officer shall begin the grievance process by logging a summary of the…

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

Based on record review and interview, the facility failed to ensure that its staff completed a Preadmission Screening and Resident Review (PASRR- a federal and state required process that is used to identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities in all individuals seeking admission to a nursing facility), in a timely manner, for one Resident (#44) with a SMI, out of 19 sampled residents. Findings include: Resident #44 was admitted to the facility in June 2021 with diagnoses including Bipolar Disorder, Borderline Personality Disorder, and Post Traumatic Stress Disorder (PTSD). Review of the PASRR Level I Screening, dated 6/29/21, indicated the Resident had a positive SMI screen, but a Level II PASRR Evaluation (used to confirm if the individual has SMI and, if so, whether the individual requires a nursing facility level of care and specialized services) was not indicated at that time due to Exempted Hospital Discharge (maximum 30 calendar days). Further review indicated if the nursing facility determined that the Resident's stay…

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, and policy review the facility failed to ensure that its staff provided care consistent with professional standards for one Resident (#52) out of a total sample of 19 residents. Specifically, the facility staff failed to change the oxygen tubing as ordered for Resident #52. Findings include: Review of the facility policy titled, Oxygen Administration Nasal Cannula, dated November 2020, indicated to replace, and date cannula tubing weekly or when visibly soiled or damaged. Resident #52 was admitted to the facility in October 2021, with diagnosis including Chronic Obstructive Pulmonary Disease, (COPD) and Emphysema (a condition affecting the alveoli (air sacs) of the lungs, where they are abnormally inflated with air, making it harder to breathe). On 8/31/22 at 8:05 A.M., the Surveyor observed Resident #52 lying in bed with oxygen at 2.5 liters per minute (l/min) administered via nasal cannula (N/C). The oxygen tubing had a date of 3/9 marked on a piece of secured tape. Review of the August 2022 Physician Orders indicated: - Oxygen 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, record review and interview, the facility failed to ensure that its staff monitored pain and assessed the effectiveness of pain interventions for one Resident (#35) out of a total sample of 19 residents. Specifically, the facility staff did not assess Resident #35's pain every shift as ordered and did not have documented evidence they assessed the effectiveness of pain interventions after each occurrence as indicated on the care plan. Findings include: Resident #35 was admitted to the facility in June 2022 with diagnoses including low back pain unspecified, bilateral primary Arthritis of the hips, pain in the left knee, displaced transverse fracture of the left patella (knee cap), subsequent encounter for closed fracture with delayed healing, and Fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances). Review of a Minimum Data Set (MDS) assessment, dated 7/3/22, indicated Resident #35 was cognitively intact as evidenced by a score of 14 out of 15 on a Brief Interview for Mental…

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

Based on record review and interview, the facility failed to ensure that its staff did not administer a psychotropic medication, specifically an anti-psychotic medication, without an appropriate diagnosis, for one Resident (#78) out of 19 sampled residents. Findings include: Resident #78 was admitted to the facility in July 2022 with diagnoses including unspecified Dementia with behavioral disorder, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 8/4/22, indicated the Resident had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS). Review of a Physician's Assistant (PA) note, dated 8/1/22, indicated there were no new concerns other than the Resident was impulsive and attempted to leave the facility. -The Resident would be started on Seroquel (anti-psychotic) 12.5 milligrams (mg) three times a day due to impulsivity. -Further review indicated no documentation that the addition of the medication was reviewed with the Resident's Representative. Review of the Informed Consent for Pyschotropic…

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.