Future Care Canton Harbor

Based on observations, interviews with facility staff and review of facility records it was determined that the facility failed to: 1) store food in accordance with professional standards for food service and safety, and 2) keep complete kitchen records. This was found evident of 1 of 4 kitchen observation and 2 of 3 kitchen record reviews during the annual survey. The findings include: 1) On 8/28/23 at 8:35 AM, the surveyor conducted an initial tour of the facility's kitchen. The surveyor observed the facility's Certified Dietary Manager (CDM) Staff #10 walk into the kitchen's walk-in refrigerator. The surveyor conducted an interview at this time. Staff #10 stated she usually comes to the kitchen in the morning to check the dates labeled on the food. The surveyor asked Staff #10 what was in the square clear container on the shelf. Staff #10 stated it was pudding and that it was just made but agreed it had no label to indicate what it was or when it was made. Staff #10 explained that different items have different discard dates depending on the product. The date that it was received…

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

Based on interviews and record reviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs. This finding was evident for 2 of 4 residents (#103 and #146) review for care plan. The findings include: 1) During an interview conducted on 8/29/23 at 10:45 AM, Resident #103 stated that he/she was upset because the staff did not provide continent care when needed and had been left soiled for long periods of time. The resident further stated that when my son came to visit he would change my soiled diaper routinely. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strength and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 9/11/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review it was determined that facility staff failed to provide an explanation in the resident's medical record to demonstrate the absence of the resident from their care plan meetings and 2) update a resident's care plan to reflect a new diagnosis with recommended treatments. This was evident for 1 (Resident #99) out of 3 residents reviewed for care planning during the investigation portion of the survey. The findings include: A care plan is a guide that addresses the needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. In a care plan meeting, staff and residents/families talk about life in the facility-meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents/families can bring up problems, ask questions, or offer information to help staff provide care. The Brief Interview for Mental Status (BIMS) assessment is a 15-point cognitive screening used to screen and identify the…

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

Based on interviews and resident record reviews, it was determined that the facility failed to provide scheduled showers to residents. This was evident of 2 of 2 residents (Resident #398 and #108) reviewed for Activities of Daily Life (ADL) care on an annual and complaint survey. The finding include: Activities of Daily Living (ADLs) are everyday routine activities that are done to take care of oneself. 1a) On 8/28/23 at 12:13 PM, the surveyor conducted an interview with Resident #398. During this interview Resident #398 stated that they had been here over a week and hadn't gotten a shower. On 9/5/23 at 10:58 AM, the surveyor reviewed Resident #398's electronic medical record. This review revealed that Resident #389 had been admitted to the facility in the middle of August 2023 and had a past medical history that included, difficulty in walking, weakness, history of falling, and cerebral infarction (disruption of blood flow to the brain). On 9/6/23 at 10:52 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) Staff #22. During this interview Staff # 22 stated the GNA's are…

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 staff interview, it was determined that the facility staff failed to ensure skin alterations were documented in the medical record. This was evident for 1 (#451) of 65 residents reviewed during the recertification survey. It was determined that the facility's failure to document the skin alterations resulted in past non-compliance which existed from 01/12/2023 until 01/29/2023. The findings include: On 09/12/2023 at 9:00 AM, a record review revealed that on 01/18/2023 the facility received a complaint from Resident #451's son alleging that the resident had obtained a wound on [his/her] right hip where a previous wound had been healed. When investigating the concern, facility staff members were interviewed. Staff #59 recalled that Resident #451's right hip had a dark spot, like a bruise. Staff #61 also remembered a dark area on the right hip. Staff #61 stated that it wasn't new and that it was darker but was there before. Staff #60, a nurse that cared for Resident #451 on the day 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 interviews and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 out of 5 (Resident #128) residents reviewed for respiratory care during an annual and complaint survey. The findings include: Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen in the red blood cells, referred to as a pulse ox. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. On 8/30/23 at 10:25 AM, the surveyor observed Resident #41 resting in bed noted to have oxygen being delivered via nasal cannula. On 9/6/23 at 8:58 AM, the surveyor reviewed Resident #128's medical records. The review revealed that Resident #128 was admitted to the facility in early 2022 and had a past medical history of, acute pulmonary edema (fluid on the lungs), Chronic Obstructive Pulmonary Disorder (COPD), and lung cancer. Further review revealed…

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 it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 of 5 (Resident # 41) residents reviewed for pain management during the annual survey. The findings include: On 8/31/23 at 12:41 PM, the surveyor reviewed Resident #41's medical record. The review revealed Resident #41 had a past medical history of polyneuropathy (multiple nerves damaged causing pain in different areas of the body), surgical amputation, diabetes type 2 with foot ulcer and muscle weakness. A care plan is a guide that addresses the needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Further review of the record revealed Resident #41 had a care plan for chronic pain related to diabetic neuropathy (damaged nerves that cause pain) and arthritis. On 9/5/23 at 9:54 AM, the surveyor reviewed Resident #41's hospital discharge summaries. The review revealed a hospital discharge summary from a hospital stay Resident #41 had in early July 2023. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 2 of 2 random observations. The findings include: 1) This surveyor observed on the second floor an unlocked medication cart on 9/6/23 at 10:42 AM. The cart was located by room [ROOM NUMBER] and across from room [ROOM NUMBER]. Five different staff members, including nursing staff, walked past the cart without securing it. They continued down the hallway without maintaining eye contact with the medication cart. Staff at the nursing station were not looking at the cart. There were no residents in the vicinity. This surveyor checked the drawers at 10:57 AM. Every medication except the controlled substances which were in a locked drawer within the cart were accessible. A nurse (Staff #37) walked up to the cart at 10:58 AM and locked it. This surveyor approached and informed her that the cart has been under observation. I asked if it was her assigned…

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 with facility staff, it was determined that the facility failed to ensure that infection control practices and guidelines were followed. This was found to be evident for 3 (resident #474, 475 and #110) out of 65 residents reviewed for infection control. The findings include: 1) On 08/31/23 at 09:28 AM, an observation was conducted in Resident #475's room. The Surveyor observed Geriatric Nursing Assistant (GNA) #8 obtain Resident #474's blood pressure. She (#8) did not disinfect the shared blood pressure cuff prior to taking Resident #475's blood pressure. During an interview conducted on 08/31/23 at 09:35 AM, the surveyor asked GNA #8 how she provided infection control when using a shared blood pressure cuff. The GNA admitted that she did not apply the infection control practices properly in terms of disinfecting the shared blood pressure cuff. An interview with the Regional Clinical Service Manager (RCSM, Staff #5) on 08/31/23 at 11:18 AM confirmed that the expectation was for all staff to consistently apply the infection control practices 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 resident and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 12 (#38, #51, #53, #81, #127, #132, #6, #90, #130, #25, #59, #31) of 40 residents reviewed. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Upon introduction and interview on 1/25/19 at 8:30 AM, resident #38 indicated that he/she was waiting for glasses. At the time, resident #38 was not wearing glasses and indicated that the television was blurry. Review of the resident's medical record on 1/29/19 revealed that resident #38 was seen by an ophthalmologist on 3/21/18. The consultant ophthalmology report indicated issues with the resident's left eye and prescribed medicated drops with follow-up in 6-months. Review of resident #38's care plans revealed a care plan related to impaired visual function, dated 3/13/18. One 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 observation and review of medical records, it was determined that the facility failed to perform appropriate revision to care plan goals and interventions as resident care needs became apparent or changed over time. This was evident for 6 (# 48, #53, #27, #110, #25, #437) of 40 residents reviewed. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 1/25/19 at 12:57 AM, an observation of Resident #48 revealed that the resident had a contracture (shortening of a muscle or joint) of both hands. Review of Resident #48's physician orders revealed that a 9/16/18 order for bilateral hand splints was discontinued on 11/28/18. On 1/30/19 at 3:51 PM, during an interview, Staff #34 stated that Resident #48 recently received OT and it was determined that hand splints were no longer needed. Review of Resident #48's care plans revealed a care plan Alteration in musculoskeletal status r/t (related to) contracture of bilateral upper extremities which included…

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 staff interview, observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance (QAA) program based on repeat deficiencies related to ensuring a resident's dignity, accurate comprehensive assessments and the facilities ineffective QAA program. The findings include: On 2/1/19 at 3:01 PM, review of the Quality Assurance Program with Staff #13 revealed that effective processes had not been put in place regarding repeat deficiencies. The facility's action plans did not resolve quality deficiencies identified during the last recertification survey, which was concluded on 9/22/17, with a plan of correction date of 11/6/17. Dignity and respect of individuality, comprehensive assessments and having an effective quality assurance program were cited during the annual survey on 9/22/19. Effective processes were not put in place to correct the deficiencies. Cross Reference F557, F636. During an interview, when asked about the QA process put into place following the prior deficiencies, Staff #13…

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 resident interview, observation and medical record review, it was determined that the facility staff 1) failed to ensure access to the nurse call bell for a resident who was dependent on nursing staff due to impaired mobility and 2) failed to ensure access to be able to turn the over the bed light on and off. This was evident for 5 (#51, #127, #6, #90, #388) of 32 residents observed in the initial resident pool. The findings include: 1) An interview was conducted with Resident #51 on 1/25/19 at 9:28 AM. During the interview, the resident was asked to activate the call light, so the surveyor could make sure the call light worked. Resident #51 looked around and saw the call bell cord clipped to the privacy curtain on the left side of the bed and stated that he/she could not reach the call bell cord. The surveyor advised Staff #28. Review of Resident #51's care plan, ADL (activities of daily living) self-care performance deficit r/t impaired balance had the approach encourage the use of bell to call for assistance. The care plan at risk for falls r/t gait/balance problems had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 15 of 35 resident rooms observed during the survey. The findings include: 1) Surveyor observed two stained ceiling tiles above the window in room [ROOM NUMBER], on 1/24/19 at 10:02 AM. Additionally, there was a separation between the wood molding by the window, with exposure of rough wood along the separation. The filter of the heating /air conditioning unit was exposed and hanging down to the floor, with noted dust accumulations. 2) On 1/24/19 at 11:09 AM in room [ROOM NUMBER], observation revealed that the window ledge above the b-bed was separating from the wall, with additional wall damage noted behind the bed. 3) On 1/24/19 at 11:09 AM in room [ROOM NUMBER], observation revealed that the cover of the heating/AC unit was off the unit and sitting on the floor, exposing the insides 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 medical record review and staff interview, it was determined the facility staff failed to conduct an accurate, comprehensive assessment by failing to assess a resident's cognition and mood on comprehensive MDS assessments and failing to accurately code a resident's dental status. This was evident for 7 (#6, #130, #110, #31, #42, #51, #53) of 40 residents reviewed. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) On 1/25/19 at 9:28 AM, observation of Resident #6 revealed the resident did not have any teeth. Review of Resident #6's annual comprehensive assessment with and assessment reference date (ARD) of 8/20/18 revealed Section L0200. Dental was coded…

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 medical record review and staff interview, it was determined that the facility staff failed to conduct an accurate assessment by failing to assess a resident's cognition and mood on quarterly MDS assessments. This was evident for 5 (#110, #31, #42, #51, #26) of 40 residents reviewed. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of the medical record for resident #110 on 1/28/19, revealed an incomplete MDS assessment. Review of the quarterly MDS with an assessment reference date (ARD) of 11/1/18 failed to assess the resident in Cognition and Mood, Sections C & D. 2) Review of the medical record for Resident #31 on 1/28/19 revealed…

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 resident interview, medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#38) of 4 residents reviewed for dental status, 2 (#51, #53) of 9 residents reviewed for hospitalizations, 1 (#132) of 5 residents reviewed for accidents and 1 (#25) of 5 residents reviewed for unnecessary medications. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop…

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, the facility failed to ensure that resident's pain was managed for 1 ( #131) of 3 residents reviewed for pain. The findings include: A record review for Resident #131, on 1/29/19 at 8:14 AM, revealed a care plan, initiated 1/27/19; for pain related to healing fractures with the goal; Resident #131 will not have an interruption in normal activities due to pain through the review date with the following interventions; Administer analgesia (Tylenol) as per orders, initiate non-pharmacological interventions (like relaxation, guided imagery, music distraction and massage) before, after and if possible, during painful activities or before pain occurs., Orders included to notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain., PT/OT (physical therapy/occupational therapy) treatment as ordered. Review of medical records, for resident #131, revealed that this resident's medication administration record (MAR) did not have a pain medication order. On 1/30/19 at 1:35 PM, record 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.

Based on medical record review and staff Interview, it was determined that the facility failed to ensure that a physician or nurse practitioner supervised the immediate care and needs for a resident with a pressure ulcer. This was evident for 1 (#29) of 5 residents reviewed for pressure ulcers. The findings include: Upon entering the facility on 1/24/19 for the recertification survey, review of the facility matrix revealed that Resident # 29 had a facility acquired pressure ulcer, stage 3 (a stage 3 pressure ulcer has full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling). During record review of Resident # 29's chart on 1/31/19 at 11:06 AM, the progress notes written on 10/8/18, 11/15/18, 11/21/18, 12/5/18, and 12/26/18 failed to reveal that the pressure ulcer was being followed by the physician and/or certified nurse practitioner. On 01/31/19 at 12:06 PM, an interview was conducted with the CRNP (certified register 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.

2) Review of the medical record for Resident #132 on 1/30/19 revealed a physician's History and Physical note dated 12/3/18. The note was printed on 12/11/18. An 11/16/18 physician's History and Physical note was printed on 11/21/18. Further review of the medical record revealed a physician's progress note dated 12/20/18 was printed on 12/26/18, a 12/25/18 physician's progress note that was printed on 1/23/19 and a 1/2/19 physician's progress note that was printed on 1/23/19. The physician's progress notes were not in the medical record the day of the visit. The medical records clerk stated during an interview on 1/30/19 at 2:43 PM, the physician dictates the note and then it is sent over through a secure email. Every morning when I come in I print the physician's notes and give it to the charge nurse to file. The medical records clerk acknowledged that some of the physician notes took 3 to 4 weeks to arrive at the facility via email. Discussed with the Corporate Nurse on 2/1/19 at 8:36 AM. 3) On 1/25/19, a review of Resident #130's medical record revealed that physician notes were…

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 on [DATE] at 09:25 AM, it was determined the facility failed to properly store medications as evidenced by 1) failing to label and date medications when opened and 2) failing to discard a medication after the expiration date. This was evident in 4 of 4 medication carts observed. The findings include: 1) Inspection of medication cart on 2nd floor revealed that the facility failed to ensure that the medications were labeled appropriately and not expired. [DATE] 09:25 AM 2nd floor Medication Cart: Resident #4; Humalog Kwik Pen dispensed on [DATE] did not have an open date. Resident #6; Novolog flexpen dispensed on [DATE], did not have an open date. Resident #87; Humalog Qwik pen dispensed on [DATE], did not have an open date. Resident #6; novolog flex pen, dispensed on [DATE], was opened on [DATE] and was expired Resident #92; Levemir flex touch did not have an open date. Resident #83; Novolog injection opened on [DATE], had expired Resident # 99; Lantus injection opened on [DATE] expired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines by 1) failing to label and store resident care equipment in a manner to prevent the development and transmission of disease 2) and failing to ensure that medications were administered in a hygienic manner. This was evident for 1 of 5 observed medication passes during medication administration and 3 of 15 resident room observed on Unit 3. The findings include: 1) During observation of the bathroom in room [ROOM NUMBER], a bed pan was laying inside of a basin on top of the trash can. 2) Observation conducted in the bathroom of room [ROOM NUMBER], on 01/24/19 at 9:42 AM, revealed soiled linen lying on top of the trash can, a bed pan sitting on top of 2 basins, and a toilet hat (to collect urine) sitting on top of the grab rail. 3) Observation conducted in the bathroom of room [ROOM NUMBER], on 1/25/19 at 11:42 AM, revealed that a bed pan was sitting inside basins on top 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 observationt it was determined that the facility staff failed to treat a resident with respect and dignity by standing to feed a resident and not being at eye level. This was evident for 1 (#89) random observation. The findings include: Observation was made, on 1/25/19 at 9:12 AM, of Geriatric Nursing Assistant #24 standing to feed breakfast to Resident #89. There was a fold up chair next to the bed. According to Resident #89's care plan, the resident was totally dependent on staff for all care needs. The Corporate Nurse was made aware of the observation on 2/1/19 at 8:36 AM.

Based on observation and interview with residents, it was determined that the facility failed to ensure that residents were treated with respect and dignity as evidenced by the failure of staff to knock on resident doors and request permission to enter prior to entry. This was evident for 1 of 5 observed medication passes during medication administration observation. The findings include: Registered Nurse (RN) #17 was observed while performing medication administration for Resident #91 on 1/31/19 at 8:24 AM. During the medication administration, RN #17 entered the room a total of 4 different times. Resident #91 was in the bed closer to the window and Resident #389 was in the bed closer to the door. The first time that RN #17 entered the room (approximately 8:26 AM), s/he walked past the open door and into the room a short way without knocking, then turned around and returned to the door. S/he then knocked loudly on the door and called out, It's time for your medicines. RN #17 then exited the room at 8:27 AM and returned to the room quickly with more supplies. RN #17 did not knock…

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 medical record review and interview with facility staff, it was determined that the facility staff failed to provide written notification of room/roommate change. This was evident for 1 (#437) of 5 residents reviewed for abuse. The findings include: Resident #437's medical record was reviewed on 1/31/19 at 1:45 PM. A progress note, dated 11/4/18 16:00, revealed that the resident was involved in a verbal altercation with his/her roommate. The roommate alleged that the altercation turned physical. A progress note, dated 11/5/18 02:59, indicated that Resident #437's room was changed for arguing with his/her roommate. The record failed to reveal that Resident #437 was provided with written notification of the room change. During an interview on 1/31/19 at 2:15 PM, Staff #1 confirmed that the resident was not provided with a written notification for the room change. Staff #3 was made aware of these findings on 2/1/19 at 8:40 AM. Cross reference F 600.

Based on observation, it was determined that facility staff failed to assure that resident medical records remained private and confidential as evidenced by resident information being left visible on the medication administration computer while the nurse entered the resident's room to administer medications. This was evident for 1 of 5 observed medication passes during medication administration observation. The findings include: Staff #17 was observed while performing medication administration for Resident #91 on 1/31/19 at 8:24 AM. When Staff #17 first entered Resident #91's room at 8:26 AM, the surveyor noted that the medication administration computer was left still displaying Resident #91's medical information, including name, date of birth , allergies, diagnoses, prescribed medications, and other information.

Based on review of resident and facility records and interviews with staff, it was determined that the facility staff failed to provide a safe resident environment free from abuse by failing to address a resident to resident altercation resulting in a second altercation. This was evident for 1 (#25) of 5 residents reviewed for abuse. The findings include: On 1/31/19 at 10:00 AM, the surveyor reviewed facility incident reports for 2 alleged physical altercations between Resident #25 and #437, who were roommates. The incidents occurred on 10/27/18 and 11/4/18. The report from the incident dated 10/27/18 alleged that Resident #437 struck Resident #25. The report from 11/4/18 alleged that Resident #437 attempted to strike Resident #25 causing Resident #25 to fall from his/her wheelchair. A nursing progress note, dated 11/4/18 16:00, in Resident #437's record indicated Patient had verbal altercation with his/her roommate. Reported by the roommate that the altercation turned physical. The surveyor requested the facility's record of the report to the state agency, investigation follow up…

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 review of resident and facility records and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administrator and state agency. This was evident for 1 (#25) of 5 residents reviewed for abuse. The findings include: On 1/29/19, the surveyor requested and received the facility's incident reports related to 2 alleged physical altercations between Resident's #25 and #437. On 1/31/19 at 10:00 AM, the surveyor requested the facility's documentation that the initial report and investigation follow up report had been sent to the state regulatory agency for each incident. At 12:20 PM on 1/31/19, Staff #1 informed the surveyor that he/she was unable to find that the reports had been sent to the state agency for either incident and stated, I don't know why it wasn't done. Staff #3 was made aware of these findings on 2/1/19 at 8:40 AM. On 2/1/19 at 8:47 AM, Staff #2 informed the surveyor that a nurse reported the incident on 10/27/18 to the supervisor, but the supervisor did not report the incident. Cross…

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 review of resident and facility records and staff interviews, it was determined that the facility staff failed to investigate alleged abuse and prevent further potential abuse by failing to address an alleged resident to resident altercation resulting in a second allegation of assault. This was evident for 1 (#25) of 5 residents reviewed for abuse. The findings include: On 1/31/19 at 10:00 AM, the surveyor reviewed facility incident reports for 2 physical altercations between Resident #25 and #437 who were roommates. The incidents occurred on 10/27/18 and 11/4/18. The report from the incident dated 10/27/18 alleged that Resident #437 struck Resident #25. The report from 11/4/18 alleged that Resident #437 attempted to strike Resident #25 causing Resident #25 to fall from his/her wheelchair. The surveyor requested the facility's investigation documentation for both incidents. At 12:20 PM, Staff #1 informed the surveyor that he/she was unable to find that either incident had been investigated. Staff #1 stated I don't know why it wasn't done. Review of Resident #437's record…

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

Based on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 3 (#51, #132, #130) of 9 residents reviewed for hospitalization. The findings include: 1) Review of Resident #51's medical record on 1/29/19 revealed the resident had a fall on 7/15/18. Nursing documentation on 7/16/18 revealed, swelling, bruising, painful left hip. The 7/16/18 22:20 nurse's note documented, resident was transported to ER via 911 for left acute femoral fracture. There was no further documentation that the resident was prepared and oriented to the transfer. On 1/29/19 at 1:35 PM, an interview was conducted with the charge nurse, Staff #33. Staff #33 went through the medical record with the surveyor and confirmed there was no documentation that the resident was prepared for transfer to the hospital. 2) Review of the medical record for Resident #132 on 1/30/19 revealed a 11/17/18 change in condition nursing note which documented 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, family and staff interview and medical record review, it was determined that the facility staff failed to provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 1 (#48) of 2 residents reviewed for activities of daily living. The findings include: On 1/28/19 at 9:16 AM, during an interview, when asked if Resident #48 got the help needed to clean his/her teeth, the resident's representative (RP) stated that they could do better oral care because sometimes when he/she visited, the resident's breath smelled bad. The RP also stated that the resident has had infections of his/her finger nails and toes. On 1/30/19, Resident #48's medical record was reviewed and documented that the resident was totally dependent on staff for all activities of daily living (ADL). On 1/30/19 at 3:31 PM, an observation of Resident #48 revealed that the resident's finger nails were long and dirty on both of the resident's hands. On 1/31/19, at 10:23 AM, during an observation of Resident #48,…

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 review of residents' medical records and interview with facility staff, it was determined that the facility failed to ensure that a physician's order for twice-daily blood glucose checks was performed for the first 7 days of the order. This was evident for 1 of 40 residents (Resident #7) reviewed during the investigation phase of the survey. The findings include: Resident #7's medical record was reviewed on 1/28/19 at 11:16 AM. During the review, a note was found written by the resident's primary physician on 1/6/19 that stated, The patient's fingersticks are running significantly elevated. We need to check his/her fingersticks. They are now being checked at this current time at least twice a day. Further review of the medical record did not reveal that the resident was receiving twice-daily fingersticks prior to 1/6/19, however. A physician's order, dated 1/6/19, was also found that ordered twice daily fingersticks to check for blood glucose. In reviewing Resident #7's January treatment administration record (TAR), a treatment was found that stated check finger sticks bid…

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 resident and staff interview and medical record review, it was determined the facility failed to arrange follow-up consultation with eye care practitioner to ensure that the resident received proper treatment. This was evident for 1 (#38) of 3 residents reviewed with sensory problems related to vision and/or hearing problems. The findings include: Upon introduction and interview on 1/25/19 at 8:30 AM, resident #38 indicated that he/she was waiting for glasses. At the time, resident #38 was not wearing glasses and indicated that the television was blurry. Review of the resident's medical record on 1/29/19 revealed that resident #38 was seen by an ophthalmologist on 3/21/18. The consultant ophthalmology report indicated issues with the resident's left eye and prescribed medicated drops with follow-up in 6-months. Review of resident #38's care plans revealed developed care plan related to impaired visual function dated 3/13/18. One of the care plan interventions was written as Arrange consultation with eye care practitioner as required. Further review of the medical record did…

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, medical record review and staff interview, it was determined the facility failed to ensure a resident with urinary incontinence received the appropriate services to achieve or maintain as much normal bladder function as possible. This was evident for 1 (#81) of 1 resident reviewed for bladder incontinence. The findings include: Observation was made of Resident #81, on 1/25/19 at 9:48 AM, lying in bed asleep. There was a urinal sitting on the window sill adjacent to the bottom of the bed. Review of Resident #81's medical record revealed a 12/1/18 quarterly MDS which documented that the resident was frequently incontinent. On 1/31/19 at 2:22 PM, Staff #7 was asked if the resident was able to use the urinal. Staff #7 stated, he has come a long way. We discussed this in care plan meeting. The resident will let you know after he urinates. We have worked hard with him to try to get him to go in the urinal, but it has not been successful. The family wants us to continue to offer him the urinal and we do without success. Review of the ADL (activities of daily living)…

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 review of the medical record and interview with staff, it was determined that the facility's consultant pharmacist failed to identify and report irregularities in the physicians orders during the monthly drug regimen review. This was evident for 1 (#25) of 6 residents reviewed for Unnecessary Drugs. The findings include: A review of Resident #25's medical record on 2/1/19 at 11:04 AM revealed physicians orders for pain medications written on 11/13/18. One order was for Percocet 10-325 mg (milligrams) 1 tablet by mouth every 6 hours as needed for pain. The other order was for Acetaminophen 325 mg administer 1 tablet by mouth every 4 hours as needed for pain related to acute paralytic poliomyelitis (an infectious viral disease that affects the central nervous system and can cause temporary or permanent paralysis). The physicians orders were not clear as to how staff would identify if the resident was having pain related to acute paralytic poliomyelitis nor how staff were to determine which of the two pain medications to administer when the resident had pain. 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.

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to ensure the residents drug regimen was free from unnecessary drugs. This was evident for 1 (#25) of 6 residents reviewed for Unnecessary Drugs. The findings include: Resident #25's medical record was reviewed on 2/1/19 at 11:04 AM. The record revealed physicians orders for pain medications written on 11/13/18. One order was for Percocet 10-325 mg (milligrams) 1 tablet by mouth every 6 hours as needed for pain. The other order was for Acetaminophen 325 mg administer 1 tablet by mouth every 4 hours as needed for pain related to acute paralytic poliomyelitis. Poliomyelitis is an infectious viral disease that affects the central nervous system and can cause temporary or permanent paralysis. The physicians orders were not clear as to how staff would identify if the resident was having pain related to acute paralytic poliomyelitis nor how staff were to determine which of the two pain medications should have been administered when the resident had pain. 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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by failing to initiate a gradual dose reduction timely when prescribed. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications. The findings include. Resident # 38's medical record was reviewed throughout the survey. Diagnoses of resident #38 include dementia, with anxiety, mood, and depressive disorder. The resident was prescribed psychotropic medications and received ongoing outside psychiatric health consultations for evaluation of the resident's mood, behavior, and psychotropic medications. The resident had received an on sight psychiatric consultation on 1/2/19. The consultation visit recommended for the resident to have a gradual dose reduction of the anti-psychotic medication Olanzapine. The consultant practitioner recommended to reduce the dosage from 2.5 milligrams (mg) to 1.25 mg daily. A nursing progress note, dated 1/4/19, indicated that the resident…

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

Based on observations of the facility's food service operations and staff interviews, it was determined that the facility failed to properly store an ice machine dispensing scoop and failed to utilize appropriate hair restraints for employees preparing meals for residents. This was noted in the facilities kitchen during random observations. The findings include. Initial inspection of the facility's food service operation on 1/24/19 at in the kitchen revealed that the scoop to the ice machine was stored on the ice within the ice machine. The person in charge of the kitchen at the time (staff #35) was notified of the inappropriate storage of the ice scoop. It was noted that there was an ice scoop holding receptacle on the outside of the ice machine. [Appropriate ice and water handling practices prevent contamination and the potential for waterborne illness.] A random inspection of the kitchen on 1/30/19 at 10:38 AM revealed a male dietary person (Staff #11) working with open cans of food preparing individual dishes. Staff #11 was not wearing a beard restraint to cover his facial…

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 review of the medical record and interview with staff, it was determined that the facility staff failed to maintain accurate medical records by failing to ensure a resident's smoking assessment was complete and accurate, failing to ensure a medication order was transcribed accurately and failing to ensure an accurate diagnosis list in the resident record. This was evident for 1 (#6) of 5 residents reviewed for accidents and 1 (#25) of 5 residents reviewed for unnecessary medications. The findings include: 1) 1/30/19 at 1:02 PM, review of Resident #6's most recent assessment, with a reference date of 1/1/19, indicated that Resident #6 had severe cognitive impairment. Review of Resident #6's Smoking Assessment, dated 1/3/19 ,documented that the resident was not cognitively impaired, which was inaccurate, and the smoking assessment was not completed in full as a final decision of either 'safe to smoke without supervision' or 'unsafe to smoke with supervision' had not been completed. 2) On 2/1/19, a review of Resident #25's January 2019 MAR (medication administration record)…

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