Hibbard Skilled Nursing & Rehabilitation Center

Based on Smoking Policy review, record review and interviews, the facility failed to complete a Safe Smoking Evaluation for 1 of 1 sampled resident that actively smokes cigarettes (Resident #383 [R383]). Finding: On 6/5/25, a review of the facility's Smoking Policy indicated under Number 6-Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: 6d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). On 6/5/25, a review of R383's clinical record was completed. In a Provider assessment note dated 5/21/25, the resident declines smoking cessation given his/her diagnosis of Amyotrophic Lateral Sclerosis (ALS) and being on Hospice for palliative care. There was no evidence that a Safe Smoker Evaluation had been completed. On 6/5/25 at 10:30 a.m., in an interview with the surveyor, the resident stated they are currently smoking when able. On 6/5/25 at 11:25 a.m., in an interview with the surveyor, the Skilled Nursing Manager confirmed that a Safe Smoker Evaluation was not completed.

Based on record reviews and interview, the facility failed to notify the physician of a suspected Urinary Tract Infection (UTI) for 1 of 4 Residents (Resident #71) reviewed for indwelling urinary catheters. Resident #71 was admitted in December 2024 with diagnoses to include Benign Prostatic Hyperplasia (enlarged prostate), retention of urine, obstructive uropathy (a blockage in the urinary tract that causes difficulty urinating), and indwelling urinary catheter (Foley catheter). Review of Resident #71's clinical record revealed a nursing progress note dated 6/1/25 states, Flushed resident's foley with acetic acid solution, replaced bag and tubing as it was full of sediment and smelled badly. Resident may have a UTI, recommend a UA [urinalysis] to r/o [rule out]. Further review of Resident #71's clinical record lacked evidence that the physician was notified of the above urinary concerns and that a urinalysis was done. On 6/2/25 at 12:13 p.m., during an interview, Resident #71's representative stated over the weekend, the staff told him/her they were going to check for a UTI because…

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 and interviews, the facility failed to implement, monitor and/or revise as necessary interventions to prevent or manage a resident's pain for 2 of 4 residents reviewed for pain (Resident #52 (R52) and R333) Findings: 1. On 6/3/25, review of R52's clinical record revealed the following: -R52's Care Plan identifies Potential for Acute Pain / Chronic Pain, [R52] is on pain/OPIOD medication therapy [related to (r/t)] chronic pain, and [R52] has chronic pain r/t end stage liver failure with ascites. - On 4/7/25 at 10:45 a.m., the provider note indicated R52 had an existing order for 5 milligrams (mg) oxycodone for pain, and a new order for buprenorphine 5 micrograms (MCG) / hour (HR) transdermal (application of medicine through the skin) patch to be applied weekly. At 1:35 p.m., Order notes indicated, The order you have entered Buprenorphine Transdermal Patch Weekly 5 MCG/HR (Buprenorphine) *Controlled Drug* Apply 1 patch transdermally one time a day every [Tuesday (Tue)] for pain and remove per schedule Has triggered the following drug protocol alerts/…

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 interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 1of 3 Medication storage Carts reviewed (Treatment Cart). Finding: On 6/3/25 at 7:33 a.m., during review of the treatment cart a surveyor observed and confirmed the following were on the cart and available for use with the Licensed Practice Nurse (LPN2): -1 used bottle (less than half full of fluid) 100 milliliters (ml) Normal Saline irrigation fluid, open, unlabeled, and undated. -1 Tube of Hydrophilic Wound Dressing (Triad) open, unlabeled, with an expiration date of 3/31/25. -1 sealed multi-use vial containing 10ml of Insulin glargine 100units (u)/10ml, labeled with a yellow sticker stating refrigerate. LPN2 stated it should be in the refrigerator until it is opened. LPN2 was unable to determine how long the vial had been out of the refrigerator. -1 sealed multi-use vial containing 10ml of Insulin Lispro 100u /10ml, labeled with a yellow sticker stating refrigerate. LPN2 stated it should be in the refrigerator until it is opened. LPN2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and policy review, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 26 sampled residents reviewed. (Resident #46 [R46], R7, R52, R71, R333). Findings: Review of facility Abuse & Neglect - Clinical Protocol dated 10/22 states :Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse The nurse will assess the individual and document related findings> Assessment data will include: injury assessment (bleeding, bruising deformity, swelling etc.); pain assessment; current behavior; patients age and sex.; all current medications, especially anticoagulants, NSAIDS, salicylate; other plate inhibitors; vital signs; behavior over last 24 hours 9 bruise could be related to movement disorder or aggressive behavior); history of any tendency…

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 interviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to a dressing change and the processing of linens for 1 of 2 observations during the survey. Findings: 1. On 6/4/25 at 9:59 a.m., a surveyor entered Resident #333's room with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 to observe Resident #333's wound dressing change. Upon entering the room, a surveyor observed an unbagged, soiled gown and an open, clear plastic trash bag containing soiled linen lying on the floor under the sink. RN #1 walked from Resident #333's bed to the sink and stepped on the soiled gown as she washed her hands. RN #1 then returned to Resident #333's bedside and began the dressing change. Resident #333 requested help supporting his/her left leg during the dressing change, and RN #1 proceeded to remove a pillow from the top of the bed and placed it under Resident #333's left knee. A surveyor observed dried blood on the…

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

Based on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Pneumococcal Conjugate Vaccination (PCV) 20 to 2 of 5 residents (Resident #47 [R47] and R72). Findings: 1. The facility's policy, Pneumococcal Vaccine, revised 06/2022, indicated prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal Vaccine series and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessments of Pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Administration of the Pneumococcal vaccines are made in accordance with current CDC recommendations at the time of the vaccination. 1. The documentation in R72's clinical record indicated that R72 received the PCV13 in 2016, and Pneumococcal Polysaccharide Vaccine (PPSV)…

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

Based on record review and interview, the facility failed to update and revise a resident's care plan to reflect a new safety concern with the resident handling of hot fluids for 1 of 1 resident reviewed (Resident #1 [R1]). Finding: On 5/13/25, a review of R1's clinical record indicated that on 3/26/25 the resident accidentally spilled hot coffee on his/her right lateral thigh sustaining a second degree burn. R1 is diagnosed as a functional quadriplegic and has been able to independently handled his/her own coffee cup. A review of R1's current care plan does not address the new potential safety risk for the resident safely handling hot coffee or any hot beverage independently. On 5/13/25 at 2:15 p.m., in an interview with the Director of Nursing Services, he stated the resident's care plan was not updated to address safety issues with the resident's use of hot coffee.

Based on record review and interview, the facility failed to update a care plan for the area of constipation/fecal impaction for 1 of 3 residents reviewed for bowel management. (Resident #1 [R1]). Finding: On 1/6/25 a review of R1's clinical record indicated R1 has a diagnoses of dementia and a history of chronic constipation. A review of R1's physician orders for bowel management during December 2024 indicated that R1 had orders for a High fiber diet, Lactulose (osmotic laxative) solution 10 Milligrams (GM)/15 milliliters (ml) give 15 ml by mouth twice a day for constipation, Senna Plus (stimulant laxative) 8.6-50 mg, give 2 tablets by mouth daily for constipation, Milk of Magnesia (laxative) oral suspension give 30 ml by mouth as needed for constipation every day, Bisacodyl Laxative 10 mg rectally suppository, insert one rectally as needed for bowel management every 3 days, Fleet oil rectal enema (mineral oil) insert one applicator rectally as needed for constipation every 3 days, Senna 8.6 mg give 2 tabs as needed for bowel management daily take with water. Docosate Sodium 100…

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, facility policies review, and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 1 of 1 residents reviewed for a skin tear incident (Resident #1 [R1]). Finding: The facility's policy, Accidents & Incidents - Investigation and Reporting, revised 2/2022, indicated that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/ Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident Form: - the date and time the accident or incident took place; - the nature of the injury/illness (bruise, fall, nausea, etc.); - the circumstances surrounding the accident or incident; - where the accident or incident took place; - the name(s) of witnesses and their accounts of the accident or incident; - the injured person's…

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 interviews, the facility failed to maintain a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections in 3 of 16 residents diagnosed with Coronavirus (COVID-19). Findings: According to the Centers for Disease Control (CDC) website, About COVID-19 | COVID-19 | CDC, revised June 13, 2024, Coronavirus (COVID 19) spreads when an infected person breathes out droplets and very small particles that contain the virus. Other people can breathe in these droplets and particles, or these droplets and particles can land on others' eyes, nose, or mouth. In some circumstances, these droplets may contaminate the surfaces they touch. On 8/26/24 at 10:50 a.m., a list was provided to a surveyor by the Administrator that identified resident's that currently tested positive for COVID-19. Further review indicated that R2 tested positive on 8/25/24, R3 tested positive on 8/23/24, R4 tested positive on 8/21/24 and 8/25/24. On 8/26/24 between 2:40 p.m. - 2:50 p.m., a tour of the facility was completed 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 observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 environmental tours. On 7/22/24 at 8:01 a.m. through to 8:35 a.m., environmental tours were completed with the Administrator and surveyors with the following findings at the time of the observations. 1. room [ROOM NUMBER]a - the veneer/stain on the bedside table and dresser drawer was chipped and missing creating an uncleanable surface. room [ROOM NUMBER]a - the Lansko fan was soiled with dust. room [ROOM NUMBER]a - the veneer/stain on the bedside table and dresser drawer was chipped and missing creating an uncleanable surface. room [ROOM NUMBER]a - the covers on the fall safety floor mats are soiled and cracked creating an uncleanable surface. The cove base on the floor, left of the bathroom door was pulled away from the wall. The room divider curtain was soiled. room [ROOM NUMBER]a - the veneer/stain on the…

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

Based on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 8 Residents reviewed for unnecessary medications and/or treatments (Resident #39 [R39]), R22, R77, R55, R49, and R50). Findings: 1. On 7/10/24, R39's clinical record/medication orders were reviewed. R39 had a medication order for Prazosin Hydrochloric acid (HCL) 1 milligram (mg) by mouth every day for Post Traumatic Stress Disorder (PTSD). Prazosin is an antihypertensive drug also used to manage nightmares and sleep disturbances associated with PTSD. R39's May and June 2024 Medication Administration Record (MAR) and medication exception report indicated that from 6/13/24 through to 7/6/24 (25 days), R39's Prazosin was held (not administered to the resident). On 7/10/24 at 2:22 p.m., in an interview with the surveyor, the Long Term Care Manager (LTC) stated the medication was held because the facility was unable to get the correct dose from the pharmacy. She stated she made several calls to the pharmacy but was told the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately on an admission and annual MDS assessment to indicate that a resident had a state Level II Preadmission Screening and Resident Review (PASRR) and Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled residents reviewed for PASRR (Resident #61 [R61]). Finding: On 7/9/24, R61's clinical record was reviewed and included a PASSR, dated 5/2/23, that indicated that R61 qualified for Level II services. Review of R61's admission MDS, dated [DATE], and annual MDS, dated [DATE], Section: A1500 were coded to indicate that R61 did not have a Level II PASRR. During review of R61's clinical record, the PASSR Level II, dated 5/2/23, indicated that the resident had a diagnosis of PTSD and physician progress notes repeatedly included documentation that PTSD was well managed considering his/her diagnosis. Review of R61's admission MDS, dated [DATE], and annual MDS, dated [DATE], Section: I6100 were 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 record review and interview, the facility failed to ensure that a care plan was developed for a resident with the diagnosis of Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled residents reviewed for PASRR (Resident #61 [R61]). Finding: On 7/9/24, Resident #61's clinical record was reviewed which included documentation on the Level II PASRR and physician progress notes that R61 had a diagnosis of PTSD and a trauma assessment, dated 7/9/23, had been completed that indicated R61 had an traumatic experience in the past. On 7/10/24 at 10:00 a.m., during an interview with a surveyor, the Long Term Care (LTC) Manager reviewed R61's care plan and was unable to find a care plan that addressed R61's possible triggers of PTSD and no evidence of interventions of what staff should do if R61 displayed signs of re-traumatization or should not do that may cause re-traumatization to the resident. The surveyor confirmed this finding during this interview.

Based on interviews and observations, the facility failed to follow physician orders for use a equipment (wedge pillow) to maintain and/or improve residents' highest level of bed mobility for 1 of 1 resident reviewed for positioning and mobility. (Resident #50 [R50]) Finding: On 7/09/24 at 10:55 a.m., a surveyor observed R50's position to be slouched in bed on R50's right side. In an interview with the surveyor, R50 stated the need for a wedge pillow to maintain positioning, without the wedge pillow he/she often ends up lying on their right side. R50 stated it also is hard to reach items at meal times without extra support, and the wedge pillow has been missing for a while. No wedge pillow or other support pillows were observed in use at the time of the interview. On 7/10/24 at 7:29 a.m., a surveyor observed R50 lying in bed waiting for breakfast. No wedge pillow or other support pillows were observed in use at the time of the observation. On 7/10/24 at 10:00 a.m., clinical record review for R50 included a doctor's order dated 6/17/24 to use wedge daily, the Plan of Care Summary…

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, manufacturer's manual review, and interview, the facility failed to ensure that an oxygen concentrator was operated and maintained per manufacturer's directions for 1 of 1 residents reviewed with oxygen (Resident #22 [R22]). Finding: On 7/8/24, a review of R22's physician order's indicated that R22 used oxygen at night and there was a weekly treatment to clean the filter and change the tubing on Sunday nights (7/7/24). On 7/8/24 at 12:17 p.m., a surveyor observed the oxygen concentrator in R22's room noting that it was missing the cabinet filter compartment which snaps on the back of the concentrator. Review of the manufacturer's manual for the Invacare Perfecto2 reads on page 24, do not operate the concentrator without the filter installed. On 7/9/24 at 10:35 a.m., a surveyor observed the oxygen concentrator again without the cabinet filter compartment attached to the concentrator. On 7/10/24 at 10:08 a.m., a surveyor showed the Long Term Care (LTC) Manager the diagram that outlined the oxygen concentrator parts in the manufacturer's manual and then went 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Physician ordered lab was completed for a urine test for 1 of 2 urinalysis ordered for Resident #35 (R35). Finding: On 7/9/24, R35's clinical record was reviewed and included a physician order, dated 6/17/24, for a urinalysis as the physician thought that symptoms R35 was having was being caused by an infection. The order was entered into the computer to be completed on 6/18/24. The clinical record lacked evidence that a urine was collected for testing until another order was received and collected on July 7th. On 7/11/24 at 11:25 a.m., during an interview with a surveyor, the Long Term Care Manager stated she was unable to find evidence that a urine as collected and tested on [DATE].

Based on record reviews and interviews, the facility failed to accurately document resident weights for 2 of 3 resident reviewed for weight loss concerns (Resident #39 [R39] and R14). Findings: 1. On 7/10/24, R39's clinical record was reviewed. A Registered Dietician's (RD) note, dated 6/18/24, indicated a follow up was done due to a weight loss of 51% over the past 30 days. The RD indicated from 4/9/24 to 6/13/24, weights ranged from 148.4 pounds (#) to 216# making it difficult to fully access trends. The following weights were documented: 4/9/24 - 216#, 4/18/24 - 167.3#, 5/7/24 - 156.4#, 6/4/24 - 190.6#, 6/13/24 - 148#. On 7/10/24 at 9:33 a.m., in an interview with the surveyor, the Long Term Care Manager (LTC Manager) confirmed that several of the weights were inaccurate and a re-weigh should have been done.2. On 7/8/24, R14's clinical record was reviewed and included a RD note, dated 5/19/24, that indicated this was a follow up due to significant weight loss in April of 13.7% over 30 days and 14.8% over 90 days. RD does question this weight as it is 17.2 lbs less than prior…

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

Based on record review and interview, the facility failed to inform a resident representative that two new Stage II pressure ulcers were observed (Resident # 39 [R39]). Finding: On 7/9/24, R39's clinical record was reviewed. On 10/18/23, a nurses note indicated that there were two new open skin areas (Stage II pressure ulcers): one on R39's right buttocks/leg crease and one on the upper back side of the right leg. There was no evidence in the clinical record that R39's representative (son) was notified of the new pressure ulcer areas. On 07/10/24 at 7:42 a.m., in an interview with the surveyor, the Administrator confirmed that the son was never notified of the new two pressure ulcer.

Based on facility's investigation, written statements, record review and interviews, the facility failed to complete a resident assessment and notify a physician regarding a resident's complaint of increased pain with signs and symptoms of a hip/leg injury including a bump and bruising to residents left leg/hip area, causing a delay in medical treatment for 1 of 1 residents (Resident #1[R1]) for 4 days (7/8/23, 7/9/23, 7/10/23, and 7/11/23). Finding: On 7/11/23 the facility investigated an injury of unknown origin, during this investigation staff's written statements were obtained. On 1/23/24 during review of CNA#1's written statement, the statement for 7/8/23 reflects that [R1] reported to Certified Nursing Assistant (CNA#1) he/she was unable to bring his/her legs to the side of the bed or stand up. R1 was asked to roll on his/her left side to assist with incontinence care, R1 then reported increased pain to left hip area. R1 then stated to CNA #1 that resident broke his/her hip. The statement reflects the charge nurse was made aware. In addition, CNA #1's written statement…

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 interview, the facility failed to ensure resident furniture, baseboard for a radiator, privacy curtain, chairs, tables, carpeting, wheelchair, and bathroom were maintained in a clean and sanitary manner on 1 of 1 environmental tour. (4/12/23) Findings: On 4/12/23 between 2:28 p.m. and 2:35 p.m., during an environmental tour with the Maintenance Director, a surveyor, and the Maintenance Director observed the following: -In room [ROOM NUMBER], a television stand was marred, and the baseboard by the window was scraped showing rust. -In room [ROOM NUMBER], a privacy divider curtain was soiled with brown stains. -In room [ROOM NUMBER], there were cracks in approximately 12 floor tiles creating an uncleanable surface. -In the Special Care Unit (SCU), there were 13 of 13 armchairs (some recliners) that were cracked, stained, torn, and had dried debris on them. -In the SCU, 2 of 3 dining tables had varnish worn off the edges of the tables. -In the SCU, the hallway carpet was stained in several…

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, observation of a pressure ulcer wound dressing change, interview and facility wound care policy and procedure review, the facility failed to ensure that infection control procedures and the facility's wound management policy and procedures were followed for 1 of 3 residents that require pressure ulcer wound treatments (Resident #51). Finding: 1. On 4/11/23, Resident #51's clinical record was reviewed and under the physician order section an order for the resident's Stage 3 pressure ulcer (on the coccyx) stated: Cleans the coccyx with wound cleanser, apply skin prep to peri-wound, pack with silver alginate and cover with Mepilex daily in am. On 4/11/23 at 11:10 a.m., the surveyor observed Registered Nurse #2 (RN#2) perform a dressing change on Resident #51's coccyx Stage 3 pressure ulcer. The wound was clean, no signs of infection and the resident stated it has been healing. The surveyor observed that the resident's wheelchair was placed next to his/her bed. On the seat of the wheelchair was a wash basin, and an unclean gold colored bed spread draped over the…

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

Based on record reviews and interviews, the facility failed to provide services to maintain and/or improve residents highest level of Active Range of Motion (AROM) and dressing and grooming, the facility failed to provide Restorative services as outlined in the resident's restorative therapy program care planned for 2 of 2 sampled residents (Resident #51 and Resident #48). Findings: 1. Resident #51's Nursing Rehab/Functional maintenance plan (FMP) with revision date of 4/3/23, Resident will maintain the ability to participate in Active/Active Range of Motion (A/AROM) exercises daily to maintain ROM and strength for functional mobility and participation on bed mobility and transfers with assist of one for 3 months. Interventions is resident to perform AROM to bilateral lower extremities daily 1-2 times a day. Resident to perform exercises either in supine or while seated in wheelchair or edge of bed. Provide resident with verbal cues and visual demonstration of each exercise for correct technique. Perform 15 reps of 2 sets of supine pelvic bridging exercises, hip flexion with knee…

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 reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all 60 residents that reside on [NAME]-[NAME] and Main units. This has the potential to affect all residents that need assistance with Activities of Daily Living (ADL). Findings: On 4/10/23 at 1:00 p.m. a surveyor observed 1 Certified Nursing Assistant (CNA) on the Special Care Unit (SCU) in the community area, next to the dining room. Resident #27 asked to go to the bathroom, the CNA took him/her, leaving 7 (seven) residents in the community area of the SCU unit unsupervised. A second CNA was observed walking in the hallway assisting Resident #216, at this time Resident #215 was observed unattended in the kitchen/dining area by a surveyor. He/she was opening kitchen cabinets in the dining room area, and then walked in the community area. A CNA-M was directing Resident # 216. There was not enough staff for the acuity of the resident population. 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 record review, the facility failed to provide evidence that the menus were developed and based on the residents cultural needs based on the resident population, as well as being updated to reflect residents input for 4 of 4 days of survey. (4/10/23, 4/11/23, 4/12/23 and 4/13/23) Finding: On 4/10/23 the facility menu was reviewed after residents voiced concerns/complaints that they don't like the meals and they said dietary has not taken their concerns seriously. On 4/11/23 at 9:24 a.m., during an interview with the Food Service Manager (FSM); she stated I have received many concerns brought forward by the residents and I have tried and tried to get them to let me change the menu. I have reached out to our corporate Food Nutrition Service (FNS) Administrator and when I told him the residents don't like the menus, he told me no menu changes. I changed the wording used on the menu, so they knew what they were eating, and I was told not to change the wording on the menu. The FSM stated that the residents get baked beans and hot dogs on Saturdays and the residents…

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 interviews, the facility failed to ensure that a call bell was accessible to 1 of 33 sampled residents, (#14) Findings: On 4/10/23 at 1:33 p.m., a surveyor observed Resident #14 sitting in his/her wheelchair motioning for this surveyor to enter the room. The call bell was observed to be on the opposite side of the room, on the bed, under the sheets. The resident tried to find the call bell and stated that he/she doesn't know where it is, and he/she does and can use the call bell. Resident #14 stated that he/she needed to go to the bathroom and couldn't get to the call bell to ring for assistance. On 4/10/23 at 1:36 p.m., a surveyor confirmed the finding in an interview with Certified Nursing Assistant - Medications (CNA-M) #3 that the call bell was on the opposite side of the room, on the bed, under the sheets and not accessible to the resident and that the resident is capable of using the call bell. CNA-M #3 assisted Resident #14 at this time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, facility policy, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 2 residents reviewed for advanced directives (Resident #25 and #61). Findings: Review of facility policy titled Advanced Directives dated 2/23 states . The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment . Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Advance directives are honored in accordance with state law and facility policy .If the resident or representative indicates that he or she has not established advance directives, the facility staff will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 2 sampled residents. Findings: Review of facility policy Care Plans-Comprehensive dated 6/23 states The interdisciplinary [NAME] (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with he required quarterly MDS assessment . Resident #25 was admitted to the facility on [DATE] with diagnoses to include vascular dementia, and chronic heart failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) of 13 of 15 indicating [he/she] is cognitively intact. 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 observation and interview, the facility failed to follow Physician orders for 1 of 4 sampled Residents observed during medication administration (Resident #2). Finding: On 4/12/23 at 1:39 p.m., a medication administration observation was completed. Resident #2 had a Physician order to administer Guaifenesin 100 milligrams (mg)/5 milliliters (ml) give 20 ml/400 mg (a medication known as expectorants, it works by thinning and loosening mucus in the airways, clearing congestion, and making breathing easier) via enteral tube (a way of delivering nutrition directly to your stomach or small intestine). While a surveyor observed the medication preparation, Licensed Practical Nurse (LPN) #1 poured the medication Geri Tussin DM (a generic medication Dextromethorphan 10 mg and Guaifenesin 100 mg 10mg-100mg/5 ml liquid) (a combination medication that works to thin mucus, and the Dextromethorphan belongs to a class of drugs known as cough suppressants) into a measured clear plastic cup to administer to Resident #2. The surveyor asked if LPN #1 was going to give the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 4 sampled residents reviewed for unnecessary medications (Resident #12). Findings: Resident #12 was originally admitted to the facility on [DATE] and has diagnoses to include chronic kidney disease stage 3, major depressive disorder, insomnia, heart failure, vascular dementia, thoracic spine fx[fracture], and psychosis. Review of Resident #12's Recommendation Summary for Medical director and DON dated 2/22/23 states: This resident has been taking Trazodone 25 mg(milligrams) since 2/1/22. Please evaluate the current dose and consider a dose reduction. Review of Resident #12's complete clinical record lacked evidence that this recommendation was addressed. During an interview on 4/12/23 at 11:16 a.m., Registered Nurse (RN)1 confirmed the pharmacy recommendation dated 2/22/23 was not addressed for Resident #12. During an interview on 4/12/23 at 3:45 p.m., the above was…

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

Based on observations, clinical record review, and interviews, the facility failed to ensure that 'Contact Precautions were maintained for 1 of 1 resident (Resident #119) on contact precautions. Finding: On 4/11/23 at 10:40 a.m., observed a Transmission Based Precaution (TBP) cart outside Resident #119's room. On top of the cart was the facility's 'Contact Precaution' instructions which indicated: Visitors must report to Nursing Station before entering. Perform hand hygiene before entering and before leaving room. Wear gloves when entering room or cubicle, and when touching resident's intact skin, surfaces, or articles in close proximity. Wear gown when entering room or cubicle and whenever anticipating that clothing will touch resident items or potentially contaminated environmental surfaces. Use resident-to-resident or single-use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between residents. On 4/11/23 at 11:45 a.m., a surveyor observed a Certified Nurse Assistant (CNA) don gloves, gown, was wearing an N95 and had a face shield 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.