Moran Nursing And Rehabilitation Center

Based on interviews, observations, and record review, the facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program for its water management and Legionella mitigation processes. These failures could affect all residents of the facility who may be exposed to the facility's water system.The findings include:Legionella is a waterborne bacteria associated with respiratory illness and pneumonia-like infections, particularly in vulnerable populations residing in healthcare facilities.On 5/13/26 at 11:40 AM, an interview was conducted with Staff #14, the Maintenance Director, regarding the facility's water management and Legionella prevention processes. Staff #14 stated that maintenance requests are primarily verbal, acknowledged that only limited staff utilize the facility's electronic tracking system, and confirmed that routine shower flushing was not consistently performed or documented. Staff #14 stated that resident room showers were generally not utilized and reported that no routine flushing log was maintained for those…

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 proper airflow in the soiled laundry rooms. This was evident from the tours of the soiled laundry rooms conducted during the annual survey.The findings include:Airborne transmission occurs when pathogens are so small that they can be easily spread in the air, and because of this, there is a risk of transmitting the disease through inhalation. These small particles containing infectious agents may be spread over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individuals. According to the Centers for Disease Control and Prevention (CDC), preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems. On 05/12/2026 at 11:00 AM, the surveyor conducted a tour of the clean and soiled laundry rooms alongside the Healthcare Services Group Environmental Services Director. During the tour, a strong…

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

Based on record reviews, interviews, and observations, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) received education based on annual performance evaluations and that GNAs received the federally required 12 hours of annual education and in-service training. This was evident for 2 (GNA #17 and GNA #18) of 2 reviewed for annual education while performing the staffing task.The findings include:On 5/13/26 at 6:18 PM, the surveyor reviewed employee records and identified that the most recent performance evaluation for GNA #17 was completed on 7/12/24 and the most recent performance evaluation for GNA #18 was completed on 10/9/24. Both evaluations had exceeded one year since completion.Further review of GNA #18's education training record revealed that GNA #18 had only completed 9.5 hours of training over the past year. Additionally, because a performance evaluation had not been completed, the GNA's (#17 and #18) had not received training assignments based on identified performance needs.On 5/14/26 at 9:28 AM, the surveyor interviewed 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, interviews, and record review, the facility failed to give clean and safe incontinence care for 1 resident (Resident #12) out of a universe of 1 resident reviewed for incontinence care. The staff did not keep clean and dirty items separate, did not change gloves when needed, did not follow hand hygiene steps, and did not follow enhanced barrier precaution rules. This failure placed the resident at risk for infection.Review of facility nursing policy and procedures titled, Perineal and Incontinence Care dated 5/5/23 documented, Using gentle downward strokes, clean from the front to the back of the perineum to prevent intestinal organisms from contaminating the urethra or vagina. Avoid the area around the anus and use a clean section of wash cloth for each stroke by folding each used section inward .If you're using soap and water, wet a clean washcloth and rinse the perineum thoroughly from front to back, because soap residue can cause skin irritation. Pat the area dry with a bath towel .Clean, rinse, and dry the anal area, starting at the posterior vaginal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow infection control practices for 3 residents (Residents #12, #2, and #7) out of a universe of 3 residents reviewed for infection control. Staff did not perform hand hygiene, did not change gloves when required, did not keep clean and dirty items separate, did not follow safe medication administration practices, and did not follow safe catheterization procedures. These failures placed residents at risk for infection, cross contamination, and harm.Review of facility policy, titled Hand Hygiene/Handwashing dated 2022 documented, Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff .Procedures: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .After: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After…

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

Based on interview, record review, and facility document and policy review, the facility failed to revise the care plan for 1 (Resident #14) of 9 residents reviewed for care plans. Specifically, the facility failed to revise Resident #14's care plan to include a history of drug abuse and an incident when the resident was found unresponsive and positive for fentanyl (a potent opioid drug), which was not prescribed for the resident.Findings included:A facility policy titled, Care Plan Process, Person-Centered Care, revised 05/05/2023, indicated, 6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. The policy also revealed, 9. Thru [sic] ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change in condition dictates the need such as but not limited to falls and pressure ulcer development. A Resident Face Sheet indicated the facility admitted Resident #14 in April 2023. According to the…

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

Based on observation, interview, and facility policy review, the facility failed to ensure staff donned all required personal protective equipment (PPE) prior to providing incontinence care and failed to ensure staff followed the facility's hand hygiene policy/procedure for 1 (Resident #8) of 1 resident reviewed for infection control.Findings included:A facility policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), revised 05/15/2023, revealed, B. EBP will be implemented during the following high-contact resident care activities: 1) Dressing, 2) Bathing/showering, 3) Transferring, 4) Providing hygiene, 5) Changing linens, 6) Changing briefs or assisting with toilet, 7) Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. The policy further revealed, C. EBP requires the following PPE: 1) Gloves, 2) Gown, and 4) All PPE is donned and doffed with appropriate hand hygiene and disposable [sic] after individual use or when visibly soiled.A Resident Face Sheet revealed the facility admitted Resident #8 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 reviews and interviews it was determined the facility staff failed to ensure that licensed nurse coverage was present the entire night shift on 2/21/25. This was evident for 1 (#MD00214955) of 12 complaints reviewed during the survey. The findings include: During an interview on 3/5/25 at 2:26 PM, Resident #2 indicated to a surveyor that s/he felt unsafe. When asked to explain, s/he reported that agency staff who worked overnight 2 weekends ago left the building unattended, to get food. The resident added that no medications were given that evening. s/he was uncertain of the credentials of the staff involved. Review of an anonymous complaint on 3/6/25 alleged that 2 agency LPN's (Licensed Practical Nurses) left the facility for approximately 1-2 hours during the night shift on 2/21/25 to purchase food from a convenience store. The agency LPNs were the only licensed nurses in the facility that night. The absence of the Agency LPNs left the facility resident's and GNAs (Geriatric Nursing…

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 review and interviews, it was determined that the facility failed to ensure allegations of abuse were reported within the mandated time frame. This was evident for 3 (Resident #38, #25, #64) of 6 residents reviewed for abuse. The findings include: 1.)On 3/06/25 at 11:56 AM a review of the facility reported incident (FRI) #MD00214156 was conducted. The report described an allegation that a Geriatric Nursing Assistant (GNA #3) was observed to have forcefully pushed Resident #25 into his/her wheelchair. Further review revealed that the incident was witnessed by the facility social worker (SW #18) and that the incident occurred in the resident dining room on 1/30/25 at 12:15 PM. A review of the facility investigation file revealed that the Nursing Home Administrator (NHA) first reported the incident to the Office of Health Care Quality on 1/30/25 at 4:48 PM. On 3/10/25 at 9:34 AM an interview with the NHA and the Director of Nursing was conducted. The NHA acknowledged that the incident was reported more than 4 hours after it occurred and confirmed the deficiency 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 records review and interviews, it was determined that the facility failed to ensure allegations of abuse are thoroughly investigated. This was evident for 3 (Resident #38, #25, #64) of 6 residents reviewed for abuse. The findings include: 1.)A review of Facility Reported Incident (FRI) #00209595 revealed that on 9/08/24 at 10:00 PM, Resident #64's representative informed facility Nurse #40 of an abuse allegation. The representative reported that on 9/07/24, the Geriatric Nursing Assistant (GNA) was fast and rough when applying a cream and slapped the resident's hand when the resident grabbed the handrail. Nurse #40 notified the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at 10:45 PM on 9/08/2024. Further review of the FRI documentation revealed that the facility had identified the alleged abuser as Geriatric Nursing Assistant (GNA #39) as evidenced by a hand-written letter which explained his/her account of the events on 9/07/24. The letter was signed and dated by GNA #39 on 9/08/24. A review of the facility policy and procedure titled Abuse, Neglect,…

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 it was determined the facility staff failed to 1.) ensure resident care was supervised 24 hours per day by licensed nursing staff and failing to ensure medications were administered as ordered by the physician and 2.) ensure physician order for weekly blood sugar check was performed. This was evident for 1 (#MD00214955) of 12 complaints and 1 of 5 (#8) residents reviewed for unnecessary medications reviewed during the survey. The findings included: 1a. Review of the medical record for Resident #68 on 3/07/25 at 7:36 AM revealed admission to the facility for care and treatment related to alcohol dependence with alcohol induced persistent dementia, heart failure, history of traumatic brain injury and depression. A review of the medication administration record (MAR) revealed that on 2/21/25 Resident #68 was ordered Ativan for generalized anxiety disorder to be administered at 8:00 PM, in addition to; Eliquis for atrial fibrillation, Imodium, an antidiarrheal, Lopressor, blood…

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 interviews, it was determined that the facility failed to offer the current COVID-19 vaccination or document the refusal for the current COVID vaccine for residents. This was evident in four (Resident #63, # 20, #11, #18) out of five residents reviewed for immunization status. The findings include: On 3/04/25 at 9:00AM a review of immunization records failed to reveal a record that Resident #63, # 20, #11 and #18 had been offered or was educated about the current COVID-19 immunization. In addition, the review failed to reveal documentation that the resident refused the current COVID vaccine On 3/04/25 at 3:39 PM the Infections Preventionist (Staff #2) was interviewed. During the interview she confirmed that Residents #63, #20, #11 and #18 had not been administered the COVID vaccine and there was no documentation that they received COVID vaccine education or declined the vaccine. She confirmed that the residents should be offered the COVID vaccine, and that the facility will start offering the COVID vaccine when they offer the flu vaccine in the…

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

Based on observations and interview it was determined that the facility failed to maintain a clean and sanitary environment as evidenced by ceiling tile discolored with black and fuzzy white substance. This was evident for 1 combination shower/bathrooms of 2 observed during a survey. The findings include: On 3/04/25 at 2:47 PM an observation of the 3rd floor shower/bathroom was made with Nurse Staff #5. An observation of one ceiling tile in stall #1 revealed that 1/4 of that tile's surface was covered with a black and fuzzy white substance. On 3/04/25 at 2:55 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the above observation. The NHA reported that there had been recent repairs for a leaking pipe in stall #1 and maybe the tile had not been replaced after the repair. On 3/04/25 at 2:58 PM the Maintenance Director joined the observation in the 3rd floor shower/bathroom. He reported that the ceiling title had been replaced after the repair of the pipe leak. He reported that the current concern with the black and fuzzy white substance on the tile 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.

Based on observation, interview, review of facility reported incidents and facility policy, it was determined that the facility failed to treat a vulnerable resident with respect and free from verbal and physical abuse. This was evident during a recert/complaint survey and investigation review of 2 of 11 facility reported incidents involving alleged abuse (R #407 ). The findings include: 1. Review of the facility reported incident documented as occurring on 9/05/23 between Resident #407 and GNA #17 revealed an allegation where Resident #407 reported to the day shift on 9/06/23 that during care on the night of 9/05/23, GNA #17 was rough while providing care and felt like GNA #17 was not listening to the residents' needs. The nurse immediately reported the allegation to the then Administrator and an investigation was initiated. According to the facility investigation it was not reported that Resident #407 verbalized to the day nurse that she felt that she was abused the night before. However, according to a statement acquired from the nightshift nurse during the facilities…

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 review and interviews, it was determined that the facility failed to ensure comprehensive assessments were coded accurately. This was evident for 1 (Resident #8) of 7 residents reviewed for accidents. The findings include: Resident #8 had been residing in the facility since 2022. A quick look into the resident's medical record indicated that a Facility Reported Incident (FRI) related to MD00210606 for unwitnessed fall with fracture was submitted in October of 2024. Resident #8 was interviewed on 3/3/25 at 11:07 AM. During the interview, the resident reported the most recent fall had resulted in an injury and had to wear a shoulder sling for a while. On 3/7/25 at 10:01 AM, Resident #8's medical record was reviewed. The review revealed care plans related to falls and indicated that Resident #8 also had a fall on February 15 of 2024. Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need…

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

Based on record review and staff interview, it was determined facility staff failed to provide adequate supervision for residents during care to prevent accidents. This was evident for 1(404) of 6 residents reviewed for accidents/hazards. 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. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A record review for Resident (R)404 on 3/6/25 at 1:16 PM revealed a care plan initiated on 3/22/19, for the potential of skin breakdown related to vitamin deficiency, weakness, incontinence, and a history of pressure ulcers. A low air loss mattress was included as an intervention. A low air loss mattress is a mattress that fluctuates pressure by intermittently inflating and deflating certain areas of the mattress…

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 it was determined that the facility failed to have an effective system in place to be sure policies and procedures were in place and physician orders were followed for residents who required chest tube care. This was evident for 1 complaint (#MD00200327) of 12 complaints investigated during the recertification survey. The findings include: A chest tube, also called a thoracostomy tube, is a flexible tube surgically inserted through the chest wall between the ribs into the pleural space (the space between the membrane lining the lungs and the membrane lining the chest wall). Chest tubes are commonly made from PVC or silicone. Physicians use a chest tube to create negative pressure in the chest cavity and allow lung re-expansion. It helps remove air, blood, fluid, or pus from the chest cavity. On 3/07/25 10:09 AM a review of the confidential complaint #MD00200327 revealed an allegation that the facility failed to drain Resident #377's chest tube as ordered and needed. A 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 observations and staff interviews, it was determined that the facility failed to ensure the maintenance of essential kitchen equipment, as evidenced by failure to ensure that the walk-in refrigerator door would routinely close. This was evident for one out of one walk-in refrigerator observed in the kitchen. The findings include: On 3/03/25 at 10:17 AM, during a kitchen tour, the surveyor observed the facility's walk-in refrigerator door was not fully closed, and observed a sign on the door reminding staff to ensure that the door closed completely. The surveyor then interviewed the Certified Dietary Manager (CDM #32) and asked questions about how temperatures are monitored for each of the refrigerators and freezers. She notified the surveyor that the facility staff check the temperatures twice daily, but because the walk-in refrigerator door doesn't always close, they check it more often. While observing the inside of the walk-in refrigerator, with the CDM, the surveyor noted that the door didn't fully close behind them. The CDM (#32) acknowledged that the door didn't…

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, but not limited, for 3 (#35, #57, #72) of 5 residents reviewed for hospitalization and 1 (#20) of 8 residents reviewed for accidents. The findings include: 1)Review of the medical record for resident #72 on 11/5/19 documented that, on 4/2/19, resident #72 was found on the floor, was evaluated and transferred out to an acute care facility at 1:50 AM. 2) Review of the medical record for resident #35 on 11/8/19 revealeddocumentation that, on 9/6/19, the resident was evaluated for respiratory concerns and was sent to the emergency room at approximately 1 PM. There was no written documentation found in the medical records that Resident #72 and resident 35, were oriented and prepared for the transfer in a manner that each resident could understand, nor was there documentation of the resident's understanding of the transfer. An interview was conducted with 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 review of employee files and interviews, it was determined that the facility failed to have a system in place to ensure that newly hired nursing and geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to work independantly with residents and failed to ensure that nurses were only allowed to work with active current nursing licenses. This was found to be evident for 3 out of 3 GNAs (Staff #11, #12, and #10) and 2 out of 3 nurses (Staff #13 and #15) hired in the past year and chosen for review. The findings include: On [DATE] at 12:05 PM, the Director of Nursing (DON) reported that there was a skills check list for newly hired nurses and GNAs. Review of GNA #11, #12 and #10's employee files revealed that all three had been hired during calendar year 2019. Review of the staffing sheets noted that all three of the GNAs were working in [DATE] with full independant assignments. Further review of the employee files failed to reveal documentation of skills assessments. 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 medical record review and staff interview, it was determined that facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#71) of 5 residents reviewed for unnecessary medications and for 1 (#57) of 3 residents reviewed for dental concerns. The findings include: The MDS (minimal 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. 1) On 11/5/19 at 10:14 AM, an observation of Resident #71 revealed the resident did not have any teeth. At that time, in an interview, Resident #71 stated that he/she did not currently have any teeth. Resident #71 stated that…

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

Based on surveyor observation, medical record review, and resident and staff interview, it was determined that the facility staff failed to develop and implement a resident centered care plans. This was evident for 2 (#71, #57) of 3 residents reviewed for dental, and for 1 (#35) of 8 residents reviewed for accidents. 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 11/5/19 at 10:14 AM, an observation of Resident #71 revealed that the resident did not have any teeth. At that time, in an interview, Resident #71 stated that they did not currently have any teeth and indicated that they were in the process of getting dentures prior to the resident's admission to the hospital and subsequent stay at the facility. On 11/7/19 at 12:45 PM, Resident #71's medical record was reviewed. Review of Resident #71's care plans failed to reveal that a comprehensive care plan with measurable, resident centered goals had been developed to address Resident #71 oral status…

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, it was determined that the facility failed to ensure that the discharge care plan was updated to reflect a change in the discharge goal. This was found to be evident for one out of three (Resident #73) closed record reviews. The findings include: On 11/7/19, review of Resident #73's medical record revealed the resident had been discharged to another skilled nursing facility in August 2019. A review of the care plan addressing discharge planning revealed a short term goal that the resident and or the responsible party will express satisfaction with [his/her] stay in the facility. This goal had a target date of 8/1/19. The care plan had been updated by the social worker on 6/6/19. Review of the evaluation note written on 6/6/19 revealed that the resident frequently asked to return to previous county but no documentation was found in the care plan that a transfer to another facility was being pursued. Review of the progress notes revealed that, on 7/12/19, the resident was accepted by another skilled nursing facility that was closer 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 medical record review, observation and interview, it was determined that the facility failed to ensure that the functionality of a wanderguard was checked on a regular basis. This was found to be evident for 2 out of 3 residents (Resident #33 and #74) reviewed for documentation of wanderguard presence and functionality. A wanderguard is an electronic device that is either worn by the resident or is attached to the resident's wheelchair that alerts staff when the resident approaches an alarmed exit. The findings include: 1) On 11/7/19, review of Resident #33's medical record revealed a diagnosis of dementia and a care plan addressing elopement risk. The resident also had a current order for a wanderguard to be in place at all times. The resident had been observed by surveyor ambulating without assistance on several occasions during the survey. On 11/7/19 at 11:16 AM, surveyor noted the presence of a wanderguard on the resident's ankle. On 11/7/19, review of the November treatment administration record (TAR) revealed documentation of the presence of the wanderguard, but no…

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, it was determined that the facility failed to provide a physician ordered dietary supplement as ordered. This was found to be evident for 1 out of 3 residents (Resident #33) reviewed for nutrition/hydration. The findings include: On 11/7/19, review of Resident #33's medical record revealed that the resident was admitted to the facility in 2018 with diagnoses that included, but were not limited to, cancer, dementia and weight loss. On 3/13/19, the registered dietitian wrote a note that the Med Pass supplement would be discontinued due to poor acceptance. Further review of the medical record revealed that, on 6/5/19, the interdisciplinary team reviewed the resident due to a significant weight loss over the past 6 months. The registered dietitian's (RD) note revealed the following: .we feel it is time to try another supplement and see if [resident] will eat it. Magic cup once a day in the afternoon was suggested by the RN [registered nurse] unit mgr [manager] and writer agrees. If [resident] will eat this it will add 290 cal and 9 g…

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, it was determined that the facility failed to ensure pharmacist consults were addressed in a timely manner. This was found to be evident for one out of seven resident's (Resident #11) reviewed for unnecessary medications. The findings include: On 11/7/19, review of Resident #11's medical record revealed the resident had an order, in effect from 4/26/19 through 8/28/19, for Ativan 0.5 mg to be given once a day as needed. The order included the following special instructions: Only to be given prior to shower on shower days. Ativan is a medication used to relieve anxiety. Further review of the medical record revealed that the pharmacist completed a Drug Regimen Review on 4/26/19 and made the following recommendation: Resident recently had Ativan 0.5 mg added PRN [as needed] prior to shower days. The order is currently open-ended. Per the Mega Rule, please consider adding a stop date of 14 days at this time and then have the provider re-evaluate if continued use is necessary. A duration can then be put on the PRN order after the original 14…

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 medication by failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days or had a specific duration with rationale for an extended time period documented in the medical record. This was evident for 1 (#222) of 1 residents reviewed for Hospice and end of life. The findings include: On 11/8/19 at 11:28 AM, a review of Resident #222's medical record was conducted. Review of Resident #222's November 2019 MAR (medication administration record) revealed a 10/28/19 order for Lorazepam (Ativan) (anxiolytic medication) by mouth twice a day, PRN (as needed) for anxiety. The order had no discontinuation/end date, was not limited to 14 days duration, and had no documented rationale for continuing the order beyond 14 days. The Director of Nurses was made aware of this finding on 11/8/19 at 12:50 PM.

Based on observation, it was determined the facility failed to properly store medications as evidenced by 1) failing to ensure that blood glucose strip containers were dated when opened, and, 2) failing to ensure that medication was properly labeled and dated. This was evident in 1 medication room observed and 1 of 2 medication carts observed. The findings include: 2) On 11/6/19 a 9:15 AM, accompanied by the Unit Manager, Staff # 2, an observation of Unit 2's medication room revealed 2 open bottles of Evencare 50 count blood glucose strips that were not labeled with the date they were opened. Per the manufacturer, when the bottle is opened, the date opened should be recorded on the bottle and any remaining test strips should be discarded after 6 months from date of opening. 2) Review of a medication cart on Unit 2 revealed a small paper box with a manufacturer's label of Lantaprost 0.0005 % ophthalmic solution that had a pharmacy label with Resident #55's name. Inside the box was a small clear plastic bottle with a green lid that did not have any labels on it. The bottle was not…

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, resident interview, record review, and staff interview, it was determined that the facility failed to have a process in place to ensure residents received routine dental care when concerns were identified. This was evident for 1 (#57) of 3 residents reviewed for dental concerns. The findings include: On 11/4/19 at 11:50 AM, an observation of Resident #57 revealed teeth that were worn down to the gum on the lower gum. The resident was noted to have foul smelling breath. An interview with the resident on 11/4/19 at 11:50 AM, revealed that theyhad been trying to see the dentist since admission and had not heard back from staff. A record review on 11/05/19 at 1:15 PM, revealed a progress note dated 9/21/19, written by Unit Manager (UM) #3, which revealed that the resident was edentulous, meaning the resident had no teeth. Further review of the record revealed that the physician notes, dated 11/10/18 through 9/6/19, had not addressed dental issues. During an interview with Licensed Practical Nurse (LPN) #13 on 11/05/19 at 2:25 PM, she stated that, if a 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.

Based on family interview, medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records by failing to accurately document a resident's dental status. This was evident for 1 (#71) of 1 residents reviewed for dental. The findings include: On 11/5/19 at 10:14 AM, an observation of Resident #71 revealed the resident did not have any teeth. At that time, in an interview, Resident #71 stated that he/she did not currently have any teeth. Resident #71 stated that they were in the process of getting dentures but stuck here now and indicated that the Unit Manager was aware they did not have any teeth. Review of Resident #71's admission Observation Report, dated 10/10/19, revealed documentation that Resident #71 had full dentures, which was inaccurate. The Director of Nurses was made aware of these findings on 11/8/19 at 12:15 PM.