Eastport Memorial Nursing Home

Based on observation and interview, the facility failed to ensure that the environment was free from potential risk of accidents by allowing 2 of 3 egresses on the resident's ground floor to be blocked by snow and not easily passable.Findings:On 1/27/26 at 9:00 a.m., during entrance to the facility, observed the walkways to the two front entrance/egress doors hindered with snow that was approximately 15 inches at the street and approximately 4 to 6 inches on the walkways and ramps leading up to the egress doors. The one walkway and door shoveled free of snow was the employee entrance that is at the left side of the building. To go from the inside of the building out through the only egress that wasn't hindered with snow (employee entrance), the 25 current residents would have to be taken through one of two locked doors and navigated through narrow corridors and out the side of the building or out through the front egresses hindered by snow. Two maintenance staff were observed in the building doing other tasks.On 1/27/26 at a little after 9:00 a.m., in an interview 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.

Based on interview, the facility failed to conduct regular inspections of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattress and bed frame are compatible and identify areas of entrapment for 1 of 5 beds reviewed. (Resident #1) Finding:On 1/27/26 at 12:05 p.m., along with the Director of Nursing (DON), an observation of Resident #1's bed was done. The mattress fit well with the bed frame and there were no unsafe gaps observed in regards to the quarter bedrails. The DON stated there were four other residents with air mattresses and side rails. These beds were observed and no entrapment or safety issues were observed.On 1/27/26 at 12:45 p.m., in an interview with the Maintenance Supervisor, he stated he measures the bed mattress and bed frame to ensure a proper fit. He stated he assesses the bed mattress, frame, and bed rails to ensure that there are no gaps or entrapment hazards. He stated he does not document his assessments for when he initially places a new mattress in a bed frame and does not have a regular maintenance program for…

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 interviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's representative status and a change in the resident's medical plan of care for 1 of 1 resident representative not notified of resident changes. (Resident #1 [R1]) Finding: On 7/1/25, a review of R1's clinical record was completed. An advanced directive indicted that family member #1 (FM1) was designated by R1 in 2017 to be his/her legal representative. On 6/10/25, R1's primary physician made a medical visit. At that time, family member #2 (FM2) was visiting and requested that R1 be transitioned to end of life care. FM2 delivered a copy of a legal document indicating that FM2 is the Power of Attorney (POA). There is no evidence in R1's clinical record that the facility contacted FM1 to discuss the conflict of who is R1's legal representative and if FM1 wanted medical care changes. On 6/25/25, the primary physician documented in R1's progress note that they had discovered in the physician's office file a legal document that revoked…

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 reported incident and investigation reviews, and interviews, the facility failed to implement a comprehensive care plan for Resident #1 (R1) for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25). Findings: On 6/23/25, R1's clinical record was reviewed. R1 had been identified as an elopement risk and wore a wander guard bracelet on his/her ankle which should trigger a secured exit (doors with alarms, security codes, and other locking mechanisms to prevent unauthorized exit) to activate. R1's care plan, dated 11/26/24 and last reviewed on 5/21/25, under the care area of I am at risk for elopement, directed staff to redirect me from exits and at times when I am really upset and trying to leave have available staff sit with me. 1. On 5/13/25, the State Agency received a facility reported incident that indicated R1 was found outside after he/she exited the building unwitnessed. A review of the facility's investigation, dated 5/18/25, indicated that R1 had been redirected from the Sunroom exit door at least 3 times before…

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 the facility's incident report forms and investigations, facility policy review, and interviews, the facility failed to provide adequate supervision to a resident who was actively exit seeking and was able to leave the facility unwitnessed and/or failed to follow it's own Elopement and Wandering Policy by ensuring secured exits were in working order for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25) for Resident #1 (R1). Findings: The facility's Elopement and Wandering Policy, reviewed 3/12/25, indicated the following: Environmental Modifications: Secure exits: Doors with alarms, security codes, and other locking mechanisms to prevent unauthorized exit. Door alarms should continue alarming after the door is closed and the alarm should be deactivated by staff entering the code to end the alarm. At any time staff finds that door alarms are not functioning properly, it must be reported immediately to maintenance staff or the Administrator and/or the Director of Nursing. Facility Notification: In the event of a resident's elopement, staff need 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 interviews, the facility failed to employ a qualified Activity Director (AD) to manage resident centered activities for all residents (24 residents). Finding: On 1/27/25 at 10:45 a.m. in an interview with a surveyor, the Administrator stated that the AD has not completed a State-approved program to become qualified as an AD. On 1/29/25 at 11:02 a.m., in an interview with a surveyor, the AD stated she hasn't completed the State-approved program to take the exam to become an Activity Professional, and does not have other requirements to ensure the activities program is directed by a qualified professional. The surveyor confirmed at this time that the AD has not completed the State-approved program and is not qualified to be the AD. The Administrator and AD state the AD is enrolled in the program and is in the process of completing a State-approved program to become qualified as an AD.

Based on observations, record review, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 1/29/25, were implemented / effective. The facility lacked evidence that the PoC for deficiencies F636 (Comprehensive Assessments & Timing), F637 (Comprehensive Assessments After Significant Change), F656 (Develop/Implement Comprehensive Care Plan), F684 (Quality of Care), and F689 (Free of Accident Hazards/Supervision/Devices) was implemented in order to prevent repeat deficient practice. The deficiencies F695 (Respiratory Care), and F761 (Label/Store Drugs and Biologicals) were again identified during the re-visit survey on 3/18/25. Findings: 1. The facility's accepted PoC for F636, signed on 2/14/25, indicated the facility would print weekly MDS reports to identify residents needing assessments, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents have a Comprehensive Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete an annual Comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment timely for 1 of 1 residents reviewed for hospice (Resident #23 [R23]) Finding: On 1/28/25, a review of R23's clinical record was completed. R23 was admitted on [DATE]. An admission Comprehensive MDS assessment was completed and submitted on 6/17/23. Quarterly MDS assessments were completed on 9/15/23, 12/14/23, 3/15/24, 6/16/24, 9/15/24 and 12/16/24. The record lacked evidence that an annual Comprehensive MDS assessment was completed. On 1/29/25 at 10:05 a.m., during an interview with a surveyor, The Interim Director of Nursing reviewed her records and stated the MDS completed on 6/16/24 should have been an annual Comprehensive MDS assessment. At the time of the interview, it was 592 days since R23's last Comprehensive assessment. At this time a surveyor confirmed the above finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 1 of 1 sampled residents (Resident #23 [R23]). Finding: On 1/28/25, a review of R23's clinical record was completed. R23 was admitted on [DATE]. An admission MDS was completed and submitted on 6/17/23. On 7/29/24, R23 transitioned to hospice level of care. The record lacked evidence that a significant change in status MDS was completed after R23 transitioned to hospice level of care. On 1/29/25 at 10:05 a.m., during an interview with a surveyor, The Interim Director of Nursing reviewed her records and stated she had not completed a change in condition when R23 transitioned to hospice. At this time a surveyor confirmed the above finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a care plan to address the physical needs of a resident for 1 of 5 residents reviewed for unnecessary medication (Resident #9 [R9]). Finding: On 1/28/25, a record review of R9's clinical record was completed. R9 was admitted on [DATE] with diagnoses including heart failure and atrial fibrillation (afib). The care plan did not address the management of heart failure, afib or the use of an anticoagulant medication (a medication used to prevent blood clots). On 1/28/25 at 2:12 p.m., during an interview with the Interim Director of Nursing, a surveyor confirmed the care plan did not address monitoring and management of heart failure including daily weight monitoring as ordered by the provider, and/or the monitoring and management of afib including the use of anticoagulant medication.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to follow a doctors order for daily weights for a resident with heart failure for 1 of 5 residents reviewed for unnecessary medications [Resident #9 (R9]. and the facility failed to have a provider appropriately addresss a pharmacist reocmmendation regarding a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (R1). Finding: 1. On 1/28/25, clinical record review indicated R9 was admitted on [DATE] with a diagnosis of heart failure. A provider order dated 1/16/25 stated, Start Daily weight checks. Notify provider of weight gain greater than 3 pounds in one day or 5 pounds in one Week. The record lacked evidence that daily weights were obtained as ordered. On 1/28/25 at 1:54 p.m., during an interview, provider orders and daily weight documentation were reviewed by the Interim Director of Nursing and a surveyor. At this time the surveyor confirmed the provider order for daily weights were not followed. 2. Review of pharmacist…

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, review of the facility incident report, and interviews, the facility failed to monitor an unlocked and/or non-alarmed door to prevent a resident identified as an elopement risk from leaving the building unnoticed. A staff member, who was on the third floor, looked out the window and saw a resident outside, unattended. The failure to have monitoring of unlocked, and/or non-alarmed doors, resulted in an avoidable elopement for 1 of 1 resident reviewed for elopement risk (Resident # 15 [R15]). Finding: R15 was admitted to the facility on [DATE] with diagnoses to include Schizophrenia, Major Depressive Disorder, and Alzheimer's disease. R15 was identified as an elopement risk and wears a wander guard alert (a safety device that alarms if resident wanders too close to a door). Review of R15's Reportable Incident Form dated 12/10/24 indicates that on 12/10/24 at approximately 10:25 a.m., R15 was outside for three minutes and he/she was standing at the edge of our property near the sidewalk. Our…

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

Based on observations, record reviews, and interviews, the facility failed to maintain a physician ordered oxygen setting on an air concentrator, and failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care (Resident #20 [R20], and R8). Findings: 1. On 1/27/25 at 11:00 a.m., during an intial tour, a surveyor observed that the oxygen regulator on R20's oxygen concentrator was set at 3.5 milliliters per minute (LPM). Also observed that the concentrator was soiled with dried liquid and dust and the oxygen concentrator air intake filter located on the back on the concentrator was heavily soiled with dust. On 1/28/25, a review of R20's clinical record was completed. R20 had a physician order for continuous oxygen at 2 LPM. On 1/28/25 between 10:15 a.m. and 11:15 a.m., in an interview with the Licensed Practical Nurse (LPN)-Charge Nurse, she confirmed that the oxygen concentrator and air filter were soiled/dusty and that the oxygen…

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 remove an expired medication from the supply available for use in 1 of 2 locations where medications are stored (medication storage room). Findings: On [DATE] at 7:30 a.m., a surveyor and a Licensed Practical Nurse (LPN) observed an opened vial (bottle) of Novolog (insulin, medication used to treat diabetes, high blood sugar) for Resident #9 (R9) that was in the medication storage room with an open date of [DATE]. The LPN states the Novolog is good for 28 days once opened according to manufacturers directions. In an interview with the LPN, a surveyor confirmed that the Novolog vial was labeled with an opened date of [DATE] and is still being used 16 days after the insulin should have been discarded. The LPN discarded the Novolog vial for R9 at time of finding and replaced it with a new Novolog vial.

Based on review of the facility's Water Management Program/Legionella and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens in the area of testing protocols. Finding: On 1/28/25, a review of the facility's Water Management Program/Legionella (revised on 5/24/22) was completed. There was no evidence of testing protocols in the Water Management Program if water testing was necessary. There was no evidence of testing protocols for control measures, acceptable ranges, how this would be monitored and what interventions would be used if water tests positive for Legionella or other opportunistic waterborne pathogens. On 1/28/25 at 1:57 p.m., in an interview with a surveyor, the Maintenance Supervisor stated he could not show evidence of a plan or protocol in place for Legionella/water pathogen testing, acceptable test ranges or monitoring of the water for potential Legionella or other opportunistic waterborne pathogens.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that a resident was provided a hearing aid device daily for 1 of 1 resident that required a hearing aid (Resident #1 [R1]). Finding: On 10/7/24, a review of R1's clinical record was completed. R1 was admitted on [DATE] with a diagnosis of bilateral sensorineural hearing loss. On R1's current physician orders dated 9/19/24, there is an order to install 1 device (hearing aid) in each ear in the morning and remove devices at bedtime. Documentation on a nurse's note dated 8/13/24, written by the Director of Nursing, indicated staff were educated about hearing aids and reminded that it is in his/her plan of care. R1's current care plan indicates R1 has the potential to have problems communicating. The intervention indicates to make sure R1 has his/her hearing aids, and that they are functioning appropriately. In addition, under the care plan problem of anxiety and agitation, the intervention is to evaluate R1 for situational stressors such as 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 reviews and interviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care 2 of 3 newly admitted sampled residents (Resident [R] 176 and R8). Findings: 1. On 1/3/24, R176 was admitted to the facility. A review of R176's clinical record included a diagnosis of Chronic Obstructive Pulmonary Disease (a disease which limits airflow in and out of your lungs) and dependence on supplemental Oxygen. R176's baseline oxygen use was 3 liters of oxygen per minute continuously. R176's baseline care plan, initiated 1/3/24, did not include interventions to monitor and maintain R176's respiratory health. On 1/9/24 at 3:40 p.m., in an interview the Assistant Director of Nursing (ADON), two surveyors confirmed the resident's baseline care plan did not reflect the resident's need for oxygen. 2. On 1/9/24, R8's clinical record was reviewed…

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

Based on observations, record reviews, and interviews, the facility failed to ensure that care plans were developed to reflect a resident's current needs for 4 of 14 residents reviewed (Resident [R6], [R23], [R2], [R8], and [R12]). Findings: 1. On 1/8/24 at 3:15 p.m., a surveyor observed R6 wearing oxygen being administered by nasal cannula. On 1/9/24, R6's clinical record was reviewed and included a physician order, dated 11/1/23, to administer oxygen 3.0 liter per minute per nasal cannula. A review of R6's current care plan, last reviewed on 11/14/23, did not include a care area or interventions that identified that R6 used oxygen. On 1/9/24 at 3:14 p.m., a surveyor confirmed this finding with the Assistant Director of Nursing (ADON). 2. On 1/9/24 at 3:15 p.m., R23 clinical record was reviewed. The admission Minimum data set (MDS) 3.0 DATED 6/17/23, under section I6100 indicated R23 had a diagnosis of Post Traumatic Stress Disorder (PTSD). Review of R23's care plan there is no evidence that his/her PTSD had been addressed identifying any triggers or interventions for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy reviews, record reviews, and interviews, the facility failed to ensure that physician's orders were obtained for treatment of pressure ulcers for 2 of 5 residents reviewed for pressure ulcer care (Resident #11 [R11], Resident#18 [R18]). and failed to ensure that weekly pressure ulcer assessment documentation, used to monitor the healing progress of the wounds, included all of the required documentation for 3 of 5 residents reviewed with a pressure ulcer (R18, R8, R12). Findings: The facility's policy, Wound Care, revised 10/10, directs staff to verify that there is a physician order for this procedure. The facility's policy, Weekly Wound Documentation:, revised 7/22, directs staff to complete weekly. The weekly evaluation must include: type of wound, wound(s) location, wound size (length, width, and depth), amount of drainage, and any other relevant wound status information. 1. On 1/8/24 at 1:43 p.m. during a review of the clinical record for R11, indicated that on 12/28/23 R11 developed…

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 ensure that wooden doors were maintained in a manner to prevent possible injury to residents on 3 of 3 days of survey (1/8, 1/9, and 1/11/24) and failed to ensure that electrical outlet adapter was used in accordance with current fire prevention codes for 1 of 3 days of survey (1/8/24). Findings: 1. On 1/8/24 at 12:15 p.m., two surveyors observed the corners of the wooden bedroom doors in room [ROOM NUMBER] and 3 were chipped, creating sharp edges. On 1/8/24 at 12:25 p.m., a surveyor and fire marshall observed Resident # [R] 21's television plugged in to an improper outlet adapter. On 1/08/24 at 12:44 p.m., during a brief tour with the Administrator, a surveyor confirmed that the wooden doors for room [ROOM NUMBER] and room [ROOM NUMBER] had sharp edges and that the electrical outlet adapter was not a proper one to use for R21. 2. On 1/9/24 at 8:55 a.m., a surveyor observed the corners of the wooden bedroom doors in room [ROOM NUMBER] and 3 were still…

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 6. On 1/8/24 at 2:20 p.m., a surveyor observed R6's oxygen concentrator was covered in a white substance and the vent on the back of the concentrator was covered with dust. On 1/9/24 at 3:27 p.m., a second surveyor observed that the oxygen concentrator was covered in a white substance and that the vent on the back of the concentrator was still covered with dust. On 1/9/24 at 3:27 p.m. a surveyor confirmed the above finding with the Assistant Director of Nursing (ADON). Based on observations, record reviews, and interviews, the facility failed to provide physician ordered respiratory services for 1 of 1 residents (Resident [R] 20} reviewed with a bilevel positive airway pressure (BiPap) machine when the facility failed to obtain services in the form a of rental BiPap machine while R20's machine was broken and needing repair. The facility also failed to recognize that nebulizer treatments could be used in the facility after the Public Health Emergency (PHE) ended on 5/11/23 when hospital discharge orders for the…

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

Based on facility policy review, record reviews and interviews, the facility failed to ensure that a resident's pressure ulcer care was supervised by a physician when the physician did not document the evaluation or assessment of the pressure ulcers for 3 of 4 residents reviewed (Resident [R] 11, R18, and R12). Findings: The facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last updated April 2018, indicated under the section Monitoring: During resident visits, the physician will evaluate and document progress of wound healing - especially for those with complicated, extensive, or poorly-healing wound. 1.On 1/8/24 at 1:43 p.m. during a review of the clinical record for R11, indicated that on 12/28/23 R11 developed open areas on his/her coccyx and upper leg/buttocks. The electronic treatment administration record (eTAR) documents that on 12/28/23 a treatment was initiated to cleanse area in left lower buttock, apply derma gran and foam pad every shift AM PM on (night) NOC as needed with incontinence episodes. On 1/5/24 nursing orders were initiated to cleanse wound…

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 the resident's physician was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents (Resident #25(R25)) chosen for closed record review. Findings: The standing orders, signed on 10/27/23, state for Shortness of Breath: Apply [oxygen] at 2 Liters (L) per minute via nasal cannula PRN (as needed). Check pulse ox (oxygen saturation) on oxygen if not greater than 90% call MD. On 11/5/23 at 4:19 p.m., documentation shows R25's breathing pattern is normal, oxygen saturation is 93% on 3L of oxygen. There is no documentation to support the physician was notified of the need for oxygen exceeding the standing orders. On 11/7/23 at 6:49 a.m., vital signs documented shows, pulse: 104, respiratory rate: 141, and oxygen saturation 92% on 2L of oxygen. At 1:49 p.m., documentation shows, pulse: 43, oxygen saturation 72% on 2L of oxygen, oxygen saturation 88-92% on 3L of oxygen, respiratory rate 20. There is no documentation to support the physician was notified of change in…

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 1 of 1 environmental tours (1/11/24). Findings: On 1/11/24 at 8:47 a.m., the Maintenance/Housekeeping Supervisor and surveyor toured 4 rooms with the following observed and confirmed at the time of tour: room [ROOM NUMBER] - The floor area around bed 2, including the fireplace indent and yellow wall tile was dirty, the paint on the window sills were cracked, water stained, and the paint was peeling. The protector attached to the doors were not secure to the door, the outlet box by bed 2 has open areas around it, and the wall above bed 1's night stand was gouged with peeling paint. room [ROOM NUMBER] - The two fans in the room were dusty and the floor was dirty, The protector attached to the doors was not secure to the door. The paint on the window sill was cracked, water stained, and the paint was peeling. 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 reviews the facility failed to report suspected abuse to the State Agency in a timely manner after it was brought to their attention that it was suspected that a resident was abused physically (Resident #16 [R16]). Finding: Review of facility policy titled Abuse, Neglect and Exploitation Prevention Policy dated June 2022 states It is the policy of this facility to provide quality care to all of our residents. Reporting: reporting requirement timeframes: 1) immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. On 5/16/23 at 2:17 p.m., the Department of Licensing and Certification (State Agency) received a report from Adult Protective Services (APS) indicating that R16 was physically abused by staff working at this facility during a shower with the allegation that they were rough and hurt him/her. During the facility's recertification survey and this investigation, the facility was not able to provide evidence that this allegation of abuse was reported to the Division of Licensing and…

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

Based in interviews, record review and facility policy review, the facility failed to thoroughly investigate an allegation of suspected abuse for 1 of 1 abuse allegations investigated. Finding: Review of facility policy titled Abuse, Neglect and Exploitation Prevention Policy dated June 2022 states It is the policy of this facility to provide quality care to all of our residents. Investigation: a report shall be made to the Administrator, or the Director of Nursing and they will conduct an internal investigation immediately. The facility shall provide any and all information to Adult Protective Services and the Division of Licensing and Regulatory Services. On 5/16/23 at 2:17 p.m., the Department of Licensing and Certification (State Agency) received a report from Adult Protective Services (APS) indicating that R16 was physically abused by staff working at this facility during a shower with the allegation that they were rough and hurt him/her. During the facility's recertification survey and this investigation, the facility was not able to provide evidence that this allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to complete an admission Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) in a timely manner for 1 of 1 closed records reviewed for hospitalization (Resident [R] 26). Finding: On 1/9/24, a review of R26's clinical record was completed and indicated the resident was admitted to the facility on [DATE]. R26's admission MDS with CAA were due to be completed by day 14 (10/10/23) counting admission date. Resident #26's clinical record lacked evidence that the admission Comprehensive MDS with CAA's were completed. On 1/9/24 at 1:10 p.m., during an interview with the Assistant Director of Nursing (ADON), a surveyor asked about R26's MDS assessments. At 1:33 p.m., the ADON stated she was unable to find a completed MDS with CAAs for R26.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit an entry, comprehensive, and discharge Minimum Data Set 3.0 (MDS) electronically to the State MDS database for 1 of 1 closed records reviewed for hospitalization (Resident [R] 26). Finding: On 1/9/24, a review of R26's clinical record was completed and indicated the resident was admitted to the facility on [DATE]. The comprehensive assessment was due to be completed by day 14 of admission [DATE]). R26 was discharged on 10/11/23. The surveyor was unable to find evidence of any MDS that had been successfully transmitted to the State MDS database according to the facility's records. On 1/9/24 at 1:33 p.m., during an interview with a surveyor, the Assistant Director of Nursing had stated that no MDS successfully transmitted to the State database for R26.

Based on record review and interviews, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 1 resident reviewed for PASRR (Resident #5). Finding: During review of Resident #5's medical record it contained a PASRR Level I Screen dated 12/28/22. The PASRR Level I Screen in the diagnosis section, did not include a current diagnosis of psychosis. On 1/19/23 Resident #5 was ordered Risperdal 0.25 milligram by mouth twice a day for psychosis. The resident record lacked evidence that the PASRR Level I Screen was updated to include his/her new diagnosis of Psychosis and was forwarded to the State-designated authority to determine if a Level II assessment was needed. On 1/11/24 at 3:00 p.m. during an interview with the Licensed Social Worker- Conditional and the Assistant Director of Nursing the surveyor confirmed that the PASRR Level I for Resident #5 did not include a diagnosis of Psychosis and was not resubmitted to PASRR for a updated Level II.

Based on record review and interviews, the facility failed to update a care plan to reflect a resident's current needs for the use of oxygen and a gastrointestinal (GI) bleed for 2 of 14 sampled residents (Resident [R] 8 and R20). Findings: 1. On 1/8/24 at 12:54 p.m., a surveyor observed R8 wearing oxygen via nasal cannula. On 1/11/24, R8's clinical record was reviewed and contained numerous documentation that R8 was wearing oxygen, including a Medical Provider's note, dated 1/6/24, that R8 was at baseline oxygen at 2 Liters per nasal cannula. A review of the physician orders included a standing order for the use of oxygen that was added on 12/8/23 times 3 doses. On 1/11/24 at 12:07 p.m., during an interview with a surveyor, Licensed Practical Nurse (LPN) #1 stated that R8 wears oxygen as needed and we check the saturations daily. Today, R8 went to dialysis with it as sometimes he/she needs it. On 1/11/24 at 1:09 p.m., a surveyor confirmed with Registered Nurse #1 that R8's care plan had not been updated for the use of oxygen. R8's clinical record also contained information that R8…

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 a physician order to send a urine specimen to the hospital for a urinalysis/culture for 1 of 1 residents reviewed (Resident [R] 21) and the facility failed to assess and monitor a resident for a potential allergic reaction after the administration of a medication listed as an allergy for 1 of 1 closed records reviewed for death (R25). Findings: 1. On 1/9/24, R21's clinical record was reviewed and included a telephone order for Augmentin (antibiotic). The surveyor could not find evidence that supported why the antibiotic was ordered in the clinical record. On 1/11/24 at 9:03 a.m., during an interview with a surveyor, the Assistant Director of Nursing (ADON) stated she would check on this; at 11:05 a.m., the ADON provided the surveyor with a copy of a hospital urinalysis with culture. During this time, the surveyor confirmed that there was no physician order for the urinalysis and culture in the clinical record. 2. R25 was admitted on [DATE] with…

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 identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #23 [R23]). Finding: 1. On 1/9/23, R23's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE] with a diagnosis of Post Traumatic Stress Disorder (PTSD). R23's admission minimum data set (MDS) 3.0 was dated 6/17/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. The surveyor was unable to find information in the clinical record that indicated what R23's PTSD was caused by or what events might cause re-traumatization. On 1/11/24 at 12:30 p.m , during an interview with the Assistant Director of Nursing a surveyor confirmed the finding that the facility had not obtained information regarding R23's PTSD or what triggers/events might cause…

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 interview, the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 14 residents reviewed (Resident [R] #21, R8, and R20}. Findings: 1. The facility's policy, Antibiotic Stewardship, last reviewed 4/2023, indicated the following: - When evaluating for a urinary tract infection (UTI), nurse will assess if resident meets criteria for possible UTI and initiate UTI protocol. - When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available to include signs and symptoms and when symptoms were first observed, On 1/9/24, R21's clinical record was reviewed. The Medical Provider (MP) visited R21 on 11/28/23 and there were no new orders. The clinical record included a telephone order, dated 11/29/23, for Augmentin (antibiotic) for a urinary tract infection (UTI). The surveyor was unable to find evidence of signs and symptoms of a UTI to determine why the antibiotic was ordered. On 1/11/24 at 9:03 a.m., during an interview with a surveyor, 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 facility policy reviews, the facility failed to ensure that gloves were changed, and hands washed/sanitized during a dressing change observation for 1 of 1 dressing change observations. (1/11/24) Finding: The facility's policy, Dressing changes , dated January 12, 2011, directs staff with the following phases in the procedure: There are six phases for staff to follow for dressing changes. Phase two directs staff to discard the old dressing and gloves in the plastic bag after removing the old dressing. Phase 3 directs staff to disinfect hands, Donn new gloves and cleanse the wound after wound cleansed to discard cleansing supplies and gloves into the plastic bag. Phase four directs staff to disinfect hands, Donn new gloves and dress the wound. Phase five directs staff to disinfect the scissors prior to placing them in the clean dressing kit. On 1/11/24 at 9:04 a.m. a surveyor observed a Licensed Practical Nurse (LPN#1) complete a dressing change on Resident #18. The physician orders directed staff to cleanse with normal saline, apply calcium…

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, facility policy review, and interviews, the facility failed to ensure that the Medical Provider (MP) was notified timely of a negative result of a urinalysis for a resident that was already started on an antibiotic for 1 of 1 residents reviewed for antibitoic use (Resident [R] 21). Finding: The facility's policy, Antibiotic Stewardship, last reviewed 4/23, indicated when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. ON 1/9/24, R21's clinical record was reviewed and included a telephone order, dated 11/29/23, to start an antibiotic, Augmentin. According to the Urinalysis Microscopic Report completed by the laboratory, the specimin was received on 11/30/23 at 4:45 a.m. and resulted at 11:08 p.m.; the urinalysis result was negative. The results were faxed by the laboratory to the MP's office on 11/30/23…

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