Sandy River Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure that 3 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #48, #66 and #68). Findings: 1. Resident #48 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder. Resident #48's clinical record contained a PASRR Level I determination letter dated 6/24/24 that stated further PASRR evaluation was not required due to Resident #48 met the criteria for a short-term convalescence admission. Resident #48 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #69 was admitted on [DATE] with a diagnosis of COPD and Congestive Heart Failure (CHF). A review of Resident #69's July 2024 Medication Administration Records (MAR) indicates that the resident received Oxygen at 2 liters per nasal cannula continuously from 5/1/24 - 7/29/24. A review of Resident #69's care plan did not include a focus, goals or interventions in the area of oxygen therapy. On 8/7/24 at 1:46 p.m., a surveyor confirmed the above finding during an interview with the Market Clinical Advisor. Based on record reviews and interviews the facility failed to update and/or implement goals and interventions for 2 of 23 care plans reviewed for respiratory care, and 1 of 1 careplans reviewed for Post-Traumatic Stress Disorder (PTSD). (Resident's #28, #69, #26). Findings: 1. Resident #28 was admitted on [DATE] and has diagnoses to include obstructive sleep apnea, morbid obesity and chronic obstructive pulmonary disease (COPD). Review of Resident #28's care plan updated 5/6/24 states [Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents' care plans were reviewed and revised by the interdisciplinary team (IDT) within 7 days after each comprehensive assessment for 4 of 4 residents reviewed for IDT meetings (Resident's #7, #32, #33 and #65). In addition, the facility failed to ensure a a resident's care plan was revised to address nutrition and weight loss (#42). Findings: 1.Review of Resident #7's clinical record revealed quarterly Minimum Data Set (MDS) dated [DATE]. Further review of Resident #7's clinical record revealed an Interdisciplinary Team Meeting (IDT) was held on 7/19/24 (30 days after MDS date). 2.Review of Resident #32's clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #32's clinical record revealed an IDT meeting was held on 5/1/24 (19 days before the MDS date). 3. Review of Resident #33's clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #33's clinical record revealed an IDT meeting was held…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was replaced for 1 of 1 resident (Resident #28) and failed to change oxygen tubing for 1 of 2 residents reviewed (Resident #69). Findings: 1. Resident #28 was admitted on [DATE] and has diagnoses to include severe morbid obesity, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, requiring a CPAP machine (a machine that uses mild air pressure to keep breathing airways open while you sleep). Review of Resident #28's clinical record reviewed Hospital Discharge Summary dated 2/12/24 states Special Instructions: Make sure you use your CPAP for any sleep, including daytime napping . Review of Resident #28's active orders dated August 2024 revealed the following: 1.Order with start date of 10/26/24 states CPAP [a machine that uses mild air pressure to keep breathing airways open while you sleep] mask…

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 medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications, on 1 of 4 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication storage rooms and 1 of 3 medication carts reviewed. Findings: 1. On 8/5/24 at 9:01 a.m. two surveyors observed an unlocked and unattended medication cart in the hallway of the Sugarloaf unit for approximately 2 minutes. During this time, one resident was observed in the hallway. Upon return to the medication cart at 9:03 a.m., the Unit Manager confirmed she had left the medication cart unlocked and unattended. 2. On 8/6/24 at 12:15 p.m., during review of the lower level Medication Storage room with LPN #1, a surveyor observed 1 open/undated 8 ounce bottle of Geri Care Senna liquid with an expiration date of 4/24, and 1 unopened 8 ounce bottle of Geri Care Senna liquid with an expiration date of 4/24. 3. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to offer nourishing snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times on 6 of 6 units (Mt. [NAME], Mt. Blue, Sugarloaf, [NAME], Rangeley and Porter), for 2 of 4 days of survey. Findings: On 8/5/24 at 10:37 a.m., in an interview, Resident #181 stated They don't have a snack cart and we don't get offered snacks. I was told there's a bag in the cupboard if you want something. No yogurt or puddings. No hydration cups. On 8/5/24 at 11:08 a.m., a surveyor checked and confirmed the Sugarloaf Unit cupboard contained only white bread and Ensure. No sandwich fillings, peanut butter, etc. On 8/5/24 at 12:36 p.m., a surveyor checked the Mt. Blue cupboards and refrigerator and found there was only a few small cracker packages, 2 small snack oatmeal pies, 1 very small container of tuna salad in the fridge and 1 loaf of bread. On 8/6/24 at 9:15 a.m., Resident #73 said to a surveyor that he/she is never offered snacks…

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

Based on observations, interviews, the facility's Refrigerated/Frozen Storage policy revision date 6/15/18, the facility's Environment: policy HCSG 028 revised 9/2017, the facility's Warewashing policy HCSG 022 revised 2/2023, the facility's Food Storage: Cold Storage revised 2/2023, the facility's Food Storage: Dry Goods revised 9/2017, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling tiles, ceiling lights, he hood system, the food slicer, the food mixer, and cement blocks. Additionally, the facility failed to ensure that foods in the dry storage room, the reach-in refrigerator and the walk-in refrigerator were labeled and/or dated. Further, the facility failed to ensure refrigerator temperatures were monitored for an area refrigerator. Findings: A surveyor completed Initial Kitchen Tour on 8/5/24 from 9:15 a.m. to 10:00 a.m. with the Food Service Director in which the following findings were observed: 1. > There were 3 ceiling vents, 2 ceiling lights and the 4 surrounding ceiling tiles, in the dish room, that were…

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

Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 2 trash collection container for 4 of 4 days of survey. (8/5/24, 8/6/24, 8/7/24 and 8/8/24) Findings: 1. On 8/5/24 at 9:05 a.m., a surveyor observed trash bags stored in an open container outside the building by a lower level exit. 2. On 8/6/24 at 7:30 a.m., a surveyor observed trash bags stored in an open container outside the building by a lower level exit. On 8/6/24 at 7:40 a.m., in an interview, the Administrator confirmed the findings. 3. On 8/7/24 at 9:05 a.m., a surveyor and the Administrator observed trash bags stored in an open container outside the building by a lower level exit. At this time, in an interview, the Administrator confirmed the findings. 4. On 8/8/24 at 8:30 a.m., a surveyor and the Maintenance Director observed trash stored in an open container outside the kitchen. At this time, the Maintenance Director confirmed the finding.

Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 residents reviewed for activities of daily living (#183), and 1 of 2 residents reviewed for oxygen use (#69). Findings: 1. A review of Resident #183's clinical record noted an admission date of 7/26/24. Certified Nursing Assistant (CNA) documentation of activities of daily living (ADLs) for 7/26/24 through 8/5/24 revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 7 out of 11 days Eating: 3 out of 11 days Bathing: 6 out of 11 days Dressing: 6 out of 11 days Drinks/snacks other than meals: 7 out of 11 days Hygiene: 7 out of 11 days Toileting: 7 out of 11 days Transfers: 7 out of 11 days Wheelchair mobility - 7 out of 11 days Walking - 7 out of 11 days On 8/6/24 at 2:45 p.m., in an interview with a surveyor, the Director of Nursing confirmed CNA documentation lacked evidence Resident #183 had received a shower or tub bath since admission, and that multiple shifts were lacking documentation of the…

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

Based on review of the quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionist attended 4 of 4 quarterly meetings. Finding: A review of the quarterly QAPI/QAA meeting attendance sheets indicate that the Infection Preventionist did not attend the 10/31/23, 1/26/24, and 7/29/24 quarterly meetings. A review of the facility's policy, Center Quality Assurance Performance Improvement process, with a revision date of 10/24/22, stated, Process. 2. The QAA Committee: 2.1. Functions under the authority of the Administrator and the governing Body and is composed of 2.1.1 Administrator, 2.1.2 Director of Nursing, 2.1.3 Medical Director, 2.1.4 Infection Preventionist, or designee, 2.1.5 Consultant Pharmacist (recommended), 2.1.6 Patient and/or family representatives (if appropriate), 2.1.7 Three (3) additional staff representatives, including, but not limited to department heads, certified nursing assistants, rehabilitation services, hospice, home…

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

Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a desk wall laminate covering for 1 of 3 days of survey. (8/5/24) Finding: On 8/5/24 at 11:15 a.m., a surveyor observed the nursing station laminate wall covering to be chipped/gouged and missing pieces along the bottom edge. This created sharp edges which were accessible to residents, staff and visitors creating an accident hazard. On 8/5/24 at 11:29 a.m., in an interview, the Market Clinical Advisor observed and confirmed the nursing station laminate wall covering was chipped/gouged and missing pieces and was an accident hazard to passersby.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide documentation of monitoring of psychotropic medication side effects for 1 of 5 residents reviewed for unnecessary drug use (#7). Findings: Resident #7 was originally admitted on [DATE] and has diagnoses to include anxiety and depression. Review of Resident #7's active physician orders as of August 2024 revealed the following medications: -Order with start date of 6/4/24 for Abilify Oral Tablet 15 mg (milligram) (Aripiprazole) Give 15 mg by mouth one time a day for depression. -Order with start date of 6/4/25 for Buspirone HCL Oral Tablet 10 mg (Buspirone HCL) Give 1 tablet by mouth in the afternoon for anxiety -Order with start date of 6/4/24 for Buspirone HCL Oral Tablet 10 mg (Buspirone HCL) Give 1 tablet by mouth one time a day for anxiety. -Order with start date of 6/4/24 for Buspirone HCL Oral Tablet 10 mg (Buspirone HCL) Give 2 [tablet] by mouth at bedtime for anxiety dose equals 20 mg. -Order with start date of 4/22/24 for Trazodone HCl…

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

Based on observation and interview, the facility failed to ensure appropriate infection control procedures were followed related to hand sanitizing during the medication pass task for 1 of 2 medication passes observed. Finding: On 8/8/24 at 8:34 a.m., during a medication administration observation, a surveyor observed a Certified Nursing Assistant Med Technician (CNA-M) administering medications to (Resident #49) in a plastic medication cup. The CNA-M was then observed discarding the medication cup into the trash can and walked by a hand sanitizer located on the wall in Resident #49's room. The CNA-M was then observed to walk back to the medication cart, unlocked the cart and began to prepare medications for Resident #66. At this time a surveyor intervened and asked CNA-M if she had washed or sanitized her hands. CNA-M stated No. and acknowledged that she should sanitize her hands between residents. On 8/8/24 9:53 a.m., a surveyor discussed the lack of handwashing/sanitizing between residents during the medication pass with the Market Clinical Advisor.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately maintain housekeeping and maintenance services necessary to maintain in good repair and sanitary condition unit refrigerators, kitchenette cabinet doors, dining tables, microwave ovens on 7 of 7 kitchenettes. (Mount Blue, Sugarloaf, Mount [NAME], Rangely Lake, [NAME] & [NAME], First floor recreation) Findings: On 4/29/24 between 11:10 a.m. to 12:15 p.m., surveyor conducted a tour of the facility dining areas and kitchenettes and observed the following in - The refrigerator shelves and door shelves on the Mount Blue, Sugarloaf, Mount [NAME], Rangely Lake, Porter, [NAME] units and first floor recreation area were soiled with yellow/pink/white dried liquid - The upper and lower kitchenette cabinet doors on the [NAME] unit had chipped paint creating an uncleanable surface creating an uncleanable surface. - The microwaves on Mount [NAME], Rangely Lake and [NAME] units were soiled with dried food debris. - The Mount Blue unit kitchenette cabinets…

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 properly store, label and date food in the walk-in refrigerator and unit refrigerators for 6 units, first floor recreation area and kitchen 1 of 1 days of survey (4/29/24). Findings: On 4/29/24 between 11:10 a.m. to 12:15 p.m., the unit kitchenettes were observed to contain unlabeled, expired, and/or out of date food items which were available for resident use. Mount Blue: - A gallon sized zip lock bag with a crumbled chocolate chip cookie - 1 plain muffin covered with plastic on a plate. - 1 package of Ball Park franks, undated - 1 small plastic container of Philadelphia Garden Vegetable dip - 1 12-ounce bottle of [NAME] Hot sauce, undated - 1 12-ounce bottle of Brianna's, Raspberry Poppy Seed Dressing - 1 10-ounce jar of Cinnamon Apple Jelly - 2 small containers of tuna, date expired 4/28 - 1 sandwich covered in plastic wrap. - 1 10-ounce container of Dark Chocolate Hummus - 1 1.5-quart container of Breyers mint chocolate chip ice cream - 1 1.44…

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 clinical records were complete and contained accurate information for 2 of 3 residents reviewed for pressure ulcer care (#1, #2). Findings: 1. A review of medication and treatment administration records (MAR/TARs) for Resident #1 noted multiple days of incomplete, and/or lack of documentation, in August and September, 2023, as follows: August 2023: Documentation of Pain Assessment - Day shift: 8/17/23, 8/22/23, 8/27/23 Hydromorphone 2 milligrams by mouth every 8 hours for pain - midnight dose: 8/18/23 Nonpharmacological interventions for pain - Day shift: 8/17/23, 8/22/23, 8/27/23 Nystatin Suspension 100,000 units/ml (milliliter) give 5 ml po 4 times daily for thrush - 5:00 p.m. dose: 8/17/23, 8/22/23, 8/24/23 Protein liquid twice daily for impaired skin - 5:00 p.m. dose: 8/22/23, 8/24/23 Daily vital signs - Day shift: 8/17/23, 8/22/23, 8/24/23, 8/27/23 Weekly weight - Day shift: 8/21/23 Left dorsal foot wound: Cleanse with wound wash. Pat dry. Apply sure prep to periwound. Paint wounds with betadine, cover…

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 a resident with care and services (incontinence care/mobility assistance) to promote physical, mental health, and well-being in a timely manner for 1 of 3 residents sampled (Resident #2). Finding: On 10/3/23 at 11:20 a.m., in an interview with a surveyor, Resident #2 stated I had to wait for 2 and a half hours in my own mess this morning. They said they had to get breakfast over with before they could clean me up. Resident #2 stated this happened at 7:30 a.m. and he/she waited until 10:00 a.m. for assistance. Surveyor asked if this happened often, Resident #2 stated I've laid here for 3-4 hours before. He/she stated staff brought in the breakfast tray and left it on the overbed table. Resident #2 stated I couldn't eat it because of the position I was in and eventually they took it and I didn't get anything. Resident #2 stated he/she had been slumped towards the left side and could not right him/herself in bed without staff assistance, and he/she needed to be cleaned before he/she could sit back up due 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 that physician's orders were followed for 1 of 2 residents reviewed for pressure ulcer care ( Resident #1). Findings: A review of the clinical record for Resident #1, indicated he/she was admitted to the facility on [DATE] from an acute care hospital. The hospital Discharge summary, dated [DATE], on page 6, described Resident #1's seven (7) pressure injuries. The area on Resident #1's right heel was described as a dark purple DTI (Deep Tissue Injury) with intact skin. The periwound is boggy, reddened and blanchable. The recommendations stated to offload the area, use a [NAME]-[NAME] heel boot, apply Skin Prep twice a day to clean and dry affected area and leave open to air. Physician documentation revealed Resident #1 was evaluated by the facility's provider on 8/10/23, who noted bilateral heels with DTI's. Provider order, dated 8/30/23, stated Right heel wound: Cleanse with wound wash. Pat dry. Apply Sure Prep to periwound. Apply Maxsorb AG…

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 complete a medication reconciliation to ensure that correct physician orders were implemented for 1 of 2 sampled residents (Resident #1) admitted from an acute care hospital. Findings: A review of the clinical record for Resident #1 revealed an admission date of 8/25/23 from an acute care hospital. The facility received a hospital discharge summary on 8/25/23, which noted a time of 8:06 a.m. and indicated a co-signature was required. Page 4, stated Current discharge medication list. Continue these medications which have not changed. Metoprolol tartrate 50 mg (milligrams) by mouth 2 times daily (a short acting beta blocker to treat blood pressure), and Aspirin 81 mg by mouth daily. On 8/25/23, a revised discharge summary, with a time of 1:13 p.m., noted on page 5 the following instructions: Start taking these medications - Amiodarone (an antiarrhythmic to treat ventricular tachycardia) 200 mg by mouth daily, Metoprolol succinate (an extended release beta-blocker [brand name Toprol XL]) 50 mg by mouth daily, Clopidogrel…

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 observations, the facility failed to ensure that call lights were within reach for residents that are capable of using a call bell for 2 of 5 days of survey (10/24/22, 10/25/22). Findings: 1. On 10/24/22 at 1:25 p.m., a surveyor asked Resident #66 about his/her care and he stated, sometimes the nurses are nasty, they take away my beeper (call light). At this time, the surveyor observed that the resident's call light was on his bedside table which was close the resident's bed, however when the surveyor asked the resident to press the call light, the resident could not reach the call light. 2. On 10/24/22 at approximately 4:00 p.m., a surveyor observed the call light for Resident #66 was not within his/her reach. The surveyor observed the call light to be sitting in a chair beside the resident's bed and the resident was laying down in bed. 3. On 10/27/22 at 3:15 p.m. during a a phone call with Resident #17's family member, he/she reported that during a visit on 10/24/22, Resident #17's nurse button was down behind the bed. He/She couldn't get it, it was against…

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 was unable to provide evidence that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055, which included appeal rights and liability of payment was provided at least two days prior to the resident's last covered day for 2 of 3 residents whose Medicare Part A services were discontinued, and the resident remained in the facility (#41 and #230). Findings: 1. On review of Resident #41's clinical record, he/she received Medicare Part A services that ended on 5/17/22 but the surveyor could not locate evidence that the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided to the resident so that he/she could make an informed decision to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. 2. On review of Resident #230's clinical record, he/she received Medicare Part A services that ended on 9/5/22 but the surveyor could not locate evidence that the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided…

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 notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 4 of 5 residents sampled for hospitalizations. (Residents #6, #25 #27, and #55) Findings: 1. Documentation in Resident #6's clinical record indicated that the resident was transferred to the hospital on 9/24/22. The clinical record lacked evidence that Resident #6 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. 2. Documentation in Resident's #25's clinical record indicated he/she was transferred to the hospital on 9/24/22 and subsequently admitted . The medical record lacked evidence that Resident #25 or his/her representative was provided with a written transfer/discharge notice upon transfer. 3. Documentation in Resident #27's clinical record indicated that the resident was transferred to the hospital on [DATE] and subsequently admitted . The clinical record lacked…

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 clinical record reviews, review of the electronic Medication Administration Record (MAR) and interviews, the facility failed to administer a physician ordered medication that was available for use for 2 days, for 2 of 31 residents reviewed. (Residents #27 and #173). Findings: 1. Resident #27's clinical record contained a physician order that noted Alprazolam Tablet 0.25 milligrams (mg) Give 1 tablet by mouth one time a day for Schizophrenia, start date 1/11/2022. Resident #27's MAR lacked evidence that the resident received the Alprazolam Tablet on 5/7/22 and 5/26/22. 2. Resident #173's clinical record contained a physician order that noted Lidocaine Patch 5 % Apply to lower back topically every 24 hours for back pain. Start date 5/14/2022. Resident #173's MAR lacked evidence that the resident received the Lidocaine Patch on 5/18/22 and 5/19/22. On 10/27/22 at 12:38 p.m., in an interview, the Clinical Lead confirmed that Resident #27's and Resident #173's MAR lacked evidence that the residents received the above medications on the above dates.

Based on record reviews and interviews, the facility failed to ensure an as needed anti-psychotropic medication met the requirements for continued use beyond 14 days, for 2 of 5 residents reviewed for unnecessary medication use (Resident #6 and #17). Findings: 1. On 10/27/22, Resident #6's clinical record was reviewed. A physician order was written on 4/7/22 for Risperdal 0.5 milligrams (mg) give 0.5 mg by mouth every 8 hours as needed for delirium with start date of 4/7/22. The clinical record lacked evidence of a physician progress note to include a rationale for continued use of this medication which would have been due by 4/21/22. On 10/27/22 at 3:10 p.m., in an interview, the Clinical Lead confirmed that Resident #6's clinical record did not include a rationale to continue the Risperdal beyond 14 days and it was noticed and stopped on 5/13/22. 2. On 10/27/22, Resident #17's clinical record was reviewed. A physician order was written on 8/15/22 for Lorazepam Tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed for agitation. The clinical record lacked evidence of a…

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

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the floor, the food disposal control box, ceiling vents, ceiling tiles, a wall mounted fan, a food slicer, ceiling lights, and window air conditioners. Additionally, the facility also failed to ensure dishes were not wet-stacked. Findings: On 10/24/22 from 8:35 a.m. to 9:00 a.m., a kitchen tour was conducted with the Acting Food Service Manager in which the following findings were observed: > The dish room had food and trash debris on the floor. The food disposal control box has chipped/missing paint. There were three ceiling vents that were heavily soiled with dust/dirt. The wall mounted fan was heavily soiled with dust/dirt. There were eight ceiling tiles that were heavily soiled with dust/dirt. > The ceiling vent, just inside the kitchen entrance door, was heavily soiled with dust/dirt. > The food slicer had dried food particles on the blade and blade shroud. > The kitchen floor had food debris and trash debris under the equipment and under the…

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

Based on observation and interview, the facility failed to maintain the dignity of 1 of 6 residents (Resident#27) reviewed for dignity related to urinary collection bags during 1 of 5 days of survey (10/24/22). Finding: On 10/24/22 at 10:49 a.m., a surveyor observed Resident #27's uncovered urinary catheter drainage bag, with dark yellow colored urine, visible from the hallway and attached to the bed frame. In an interview with Resident #27, he/she stated that he/she would prefer the bag to be covered. On 10/24/22 at 10:49 a.m., Certified Nursing Assistant (CNA #1) confirmed that the resident's uncovered urinary catheter drainage bag was visible from the hallway and was a dignity concern.

Based on interview and record review, the facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for a resident to keep a medication at bedside and self-administer the medication for 1 of 31 Residents reviewed. (Resident #172). Finding: A review of Resident #172's current physician's orders noted the following: Preparation H Cream 1 % (Hydrocortisone) Apply to affected area topically as needed for hemorrhoids Active 2/4/2022. During review of Resident #172's clinical record, the surveyor observed a care plan summary note on 2/14/22, that noted Does have hydrocortisone cream in room now. The clinical record lacked evidence that the facility's IDT determined it was clinically appropriate for Resident #172 to keep this medication at bedside and self-administer the medication. On 10/28/22 at 10:15 a.m., in an interview, the Director of Nursing confirmed that Resident #172 did not have a Medication Self-Administration assessment. The IDT did not determine if it was clinically appropriate for Resident #172 to keep this medication at bedside 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 1 of 3 residents with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASARR) evaluation and determination (Resident #27). Finding: Resident #27 was admitted to the facility on [DATE] with diagnosis of Schizophrenia. Resident #27's clinical record contained a PASARR Level I determination letter dated 2/21/20 that stated further PASARR evaluation is not required due to Resident #27 met the criteria for a short-term convalescence admission. Resident #27 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASARR Level I was forwarded again to the State Mental Health Authority to determine if a Level II evaluation and determination was needed after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to change oxygen tubing for 1 of 2 sampled residents reviewed for Respiratory Care (Resident #224). Finding: Facilities Oxygen: Nasal Cannula Policy and Procedure, revised on 6/15/22 instructs nursing to replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. On 10/24/22 at 1:35 p.m., during an interview with Resident #224, a surveyor observed the resident wearing a nasal cannula that was attached to an oxygen concentrator. Resident #224, who was admitted on [DATE], stated he/she had worn oxygen before admission to the facility. The surveyor did not observe the oxygen tubing to be labeled to identify the date it was last changed. Review of Resident #224's Treatment Administration Record, lacked evidence of the oxygen tubing being changed weekly. On 10/25/22 at 12:34 p.m., during an interview with a surveyor, the Certified Medication Technician (CNA-M) stated oxygen tubing gets changed every…

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

Based on interview and record review, the facility failed to ensure that the Consultant Licensed Pharmacist reported an identified required gradual dose reduction (GDR) for an antipsychotic medication, to the attending physician and Director of Nursing, for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #27). Additionally, the facility failed to ensure that the physician documented a GDR attempt or the reason for a contraindication of a GDR. Finding: A review of the current clinical record of Resident #27, with an admission date of 2/21/20, indicated the resident has been receiving the antipsychotic medication Risperidone 1 milligram (mg) tablet by mouth two times a day. The most recent Minimum Data Set 3.0 (MDS), Quarterly Assessment, dated 8/30/22 noted under Medications, Section N.0450. Antipsychotic Review, that the resident received antipsychotics on a routine basis and that a GDR was not attempted. Resident #27's clinical record lacked evidence that the licensed consultant pharmacist identified and recommended a GDR and lacked evidence that a GDR 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.