Russell Park Rehabilitation & Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 3 medication carts observed for medication storage. Finding: On [DATE] at 7:33 a.m., observation of the Nurse Treatment cart with the Licensed Practical Nurse (LPN) the following was observed; one opened and unlabeled Basaglar (insulin) Kwik Pen with the manufacturer's instructions of, after first use .discard after 28 days and a Epinephrine injection with manufactures exp date of 4/2025. At this time, the LPN confirmed they were either undated and/or expired. On [DATE] at 7:48 a.m., the above was discussed with the Director of Nursing Services

Based on observation and interview, the facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 days of survey. (5/19/25) Findings: On 5/19/25 at 8:30 a.m., 2 surveyors and the Food Service Director (FSD) observed a heavily soiled garbage storage area containing 3 trash dumpsters, in which food and trash debris were noted behind all 3 trash dumpsters. At this time the above information was confirmed.

Based on record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 5/21/25, was effective. The Federal citation F695 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 7/15/25.During the follow-up survey on 7/15/25, it was determined that F695 for failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care. (see F695). On 7/15/25 at 3:45 p.m., during an interview, the above was confirmed with the Administrator and the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed during a complaint investigation (Resident #3), in addition, the facility failed to ensure psychotropic medication orders included an appropriate diagnosis for 1 of 1 residents reviewed for medications (Resident #2). Findings: 1. Resident #3 was admitted on [DATE] and has diagnoses to include state 4 pressure ulcer on his/her coccyx. Review of signed provider orders active August 2024 reveled order with start date of 10/18/23 Resident information every two hours. Turn patient every 2 hours, waffle heel protectors at all times while in bed May remove for ADL's. Review of Resident #3's Treatment Administration Record dated August 2024 revealed nursing documentation indicating Resident #3 was repositioned every two hours from August 1st through 13th. Review of Resident #3's clinical record revealed positioning sheets between 7/11/24 through…

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, observations, interviews, Center for Medicare and Medicaid (CMS) guidance, and Center for Disease Control (CDC) guidance, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of infectious disease for 3 of 3 residents reviewed for foley catheters (Residents #1, #2, and #3). Findings: Review of CMS guidance dated 3/20/24 states .Enhanced Barrier Precautions (EBP) recommendations now include use of EBP for residents with .indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. Contact precautions until the organism is identified; EBP if they do not meet criteria for contact precautions . Review of CDC guidance dated 4/2/24 states .EBP may be indicated (when Contact Precautions do not…

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

Based on observations and interviews, the facility failed to make reasonable accommodations to maintain the call system within reach for 2 of 3 residents (Resident #2) observed for call bells. Findings: 1. Observations of Resident #2 on 8/13/24 at 12:30 p.m., and 1:56 p.m., revealed call bell handing from wall and attached to a wiffleball lying the end of his/her bed and not in reach. 2. Observation of Resident #1 on 8/13/24 at 1:56 p.m. revealed call bell tucked under Resident #1 and not in reach. During interview on 8/13/24 at 1:57 p.m., Certified Nursing Assistant (CNA) #1 indicated that Resident #2 rarely uses the call bell, but the resident's roommate, Resident #1, will use call bell for him/her. During interview on 8/13/24 at 2:03 p.m., CNA #2 indicated Resident #1 typically rings for Resident #2. CNA #2 further indicated that all staff should be ensuring that call bells are in reach for all residents.

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to the end of Skilled services for 2 of 3 residents whose Medicare Part A Skilled services were discontinued (Residents #302, 303). Findings: 1. On 10/6/23, Resident #302 was admitted from a hospital to receive skilled services. On 11/3/23, Resident #302 was discharged to the community with benefit days remaining. The medical record lacked evidence that Resident #302 or his/her legal representative received a NOMNC. 2. On 9/11/23, Resident #303 was admitted from a hospital to received skilled services. On 10/13/23, Resident #303 was discharged to the assisted living unit within the facility with benefit days remaining. The medical record lacked evidence that Resident #303 or his/her legal representative received a NOMNC. On 3/13/24 at 2:58 p.m., the Director of Nursing stated to 3 surveyors that the facility did not have the beneficiary notices as requested for Residents #302 and #303.

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 a sanitary, orderly, and comfortable interior for the 2 of 3 units (A unit and B unit) and hallways for 4 of 4 facility tours (3/11/24, 3/12/24, 3/13/24 and 3/14/24). Findings: On 3/11/24, 3/12/24, and 3/13/24, a surveyor made the following observations throughtout the facility and on 3/14/24 from 9:20 a.m. to 9:40 a.m., an environmental tour was conducted with a Maintenance worker and the Administrator in which the following findings were observed. Hallways: > The ceiling vent in the hallway by the administration offices, was heavily soiled with dust/dirt. > The ceiling vent in the A Unit hallway by resident room [ROOM NUMBER], was heavily soiled with dust/dirt. > The wall mounted air conditioning unit on the B Unit was dusty/dirty and the cover was held on with tape. A Unit > Resident room [ROOM NUMBER] - The standing fan was heavily soiled with dust. The…

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

Based on interviews and record review, the facility failed update a care plan with interventions for the problem area of safety for 1 of 2 residents reviewed for falls (Resident #22). In addition, the failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment (Resident #41, # Resident #46). Findings: The facilities Falls Management Policy, revised 7/19 states under Procedure: A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. Residents' care plan will be updated with all new interventions. 1. On 3/12/24, a surveyor reviewed Resident #22's medical record which stated he/she had fallen twice on 2/25/24, one fall at approximtely 6:00 a.m., and the second fall at approximately at1:00 p.m. The medical record lacked evidence of a fall incident report being completed for the 6:00 a.m. fall. Secondly, Resident #22 had additional falls on 2/27/24 and 3/10/24. As of 3/12/24 Resident #22 care plan had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview the facility failed to ensure weights were obtained and monitored as per the facilities policy for 3 of 7 residents reviewed for weights ( Resident #7, #15, #30). In addition, the facility failed to ensure mouth care was provided daily for 1 of 1 resident reviewed for dental ( Resident #30), and failed to monitor pain for 1 of 1 resident reviewed for hospice services (Resident #35). Findings: 1. On 3/12/24, Resident #7's clinical record was reviewed by a surveyor. Weights documented by staff showed the following: 12/20/23 - 101.40 pounds(lbs.) 12/27/23 - 114.20 lbs. (a 12.8 lbs. weight gain) 1/29/24 - 90.00 lbs. (a 24.2 lbs. weight loss) 2/6/24 - 93.40 lbs. (a 3.40 lbs. weight gain) 3/6/24 - 85.40 lbs. (an 8 lbs. weight loss) 2. On 3/12/24, Resident #15's clinical record was reviewed by a surveyor. Weights documented by staff showed the following: 5/19/23 - 172.40 pounds (lbs.) 6/2/23 - 163.40 lbs. (a 9 lbs. weight loss) 6/9/23 - 167.30 lbs. (a 3.9 lbs. weight…

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, observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use in 2 of 2 medications rooms and 2 of 2 medications carts observed. (A wing and B/C wing carts) Findings: 1. On 3/11/24 at 9:57 a.m., observation of the medication room with the Licensed Practical Nurse (LPN) #1, the surveyor noted a bottle of Tuberculin Purified Protein unlabeled without an opened date with manufactures instructions, once entered vial should be discarded after 30 days. 2. On 3/12/24 at 8:58 a.m., observation of A wing medication cart with Certified Medication Technician (CNA-M) #1 the following was observed: one opened bottle of milk of magnesium with expiration date of 2/24, an opened bottle of nasal moisturizing spray not labeled with the resident's name of whom it belonged. At this time, a review of the medication storage containing over the counter medications revealed 2 additional bottles of milk of…

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

Based on observation, interview, and the facility's Daily Cleaning Schedule, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to ensure dishes were stored in a sanitary manner, failed to ensure foods were dated and labeled for 2 of 2 kitchen tours on 2 of 4 days of survey (3/11/24 and 3/12/24), and failed to remove dented cans from use for 1 of 2 days observed (3/11/24). This has the potential to affect all residents. Findings: Review of the facilities Daily Cleaning Schedule states, Dish room floor/Walls and Air Conditioning Units should be cleaned daily. 1. On 3/11/24 at 9:20 a.m., during initial tour of the kitchen two surveyors observed: - The dry storage area contained two dented #10 cans of pumpkin, a large plastic bin 1/3 full and label as quick oats with no date and a bag of pasta wrapped in plastic wrap undated. - The kitchen contained a shelving unit with a tray of bowls stored upright, an air conditioner above the prep sink coated with dust on top, two light fixtures with fluorescent light bulbs with no protection, multiple…

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 interview, the facility failed to ensure that the clinical records contained accurate documentation for 2 of 8 residents reviewed for Activities of Daily Living (ADLs) (#5 and #148). Findings: 1. On 6/9/23 at 1:15 p.m., the state agency received a complaint which included a concern of lack of care for an extended period of time after admission for a Resident #148. On 3/13/24 at 11:30 a.m., a review of the clinical record for Resident #148 showed an admission to the facility on 3/7/23 and discharge on [DATE]. The surveyor could not locate documentation for ADL care from 3/7/23 to 3/22/23. On 3/13/24 at 12:20 p.m., in an interview, the Director of Nursing(DON) and the Quality Improvement Specialist reviewed Resident #148's clinical record with a surveyor and confirmed that Resident #148's clinical records contained no documentation for ADLs from 3/7/23 to 3/22/23. 2. On 3/12/24 at 10:55 a.m a surveyor observed the treatment nurse for the entirety of the wound care for Resident #5.…

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

Based on observations and interviews, the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to linen handling for 2 of 4 days of survey (3/11/24 and 3/13/24) on 1 of 3 units (A Unit), and for catheter care for 1 of 1 residents observed with an indwelling urinary catheter (#7). Findings: 1. On 3/11/24 at 10:00 a.m., a surveyor observed laundry worker #1 delivering clean laundry on an uncovered cart to resident rooms on the A Unit. At this time, laundry worker #1 confirmed she was delivering clean laundry to resident rooms and stated she did not know clean laundry had to be covered when delivered. 2. On 3/11/24 at 10:50 a.m., a surveyor observed on A Unit CNA #5 carrying an large ball of visibly soiled linen, unbagged, against his body down the hallway to the spa room where the soiled linen hamper was. The surveyor discussed the finding with CNA #5 and he denied the ball of visibly soiled unbagged linen was soiled and that he was carrying it in his…

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 immunization record review, review of the facility's immunization policy and interview, the facility failed to implement its own immunization policy for 2 of 5 residents whose immunization records were reviewed for influenza and pneumococcal vaccinations. (Resident #2 and Resident #248). Finding: On 3/12/24 at 10:30 a.m. a surveyor reviewed Resident #2's Electronic Medical Record (EMR) under Immunizations and found no record of Resident #2 receiving an influenza or pneumococcal vaccination. Resident #2 was admitted to the facility on [DATE]. A Review of the Paper Medical Record found documentation that an influenza vaccination was given on 3/8/24. This was not documented in the EMR under Immunizations. No documentation was found that Resident #2 received educational materials for the influenza vaccination. No documentation was found of the pneumococcal vaccination being offered, or educational materials provided. On 3/12/24 at 10:40 a.m. a surveyor reviewed Resident #248's EMR under immunizations 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 on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement its Immunization Policy for 1 of 5 residents whose immunization records were reviewed for COVID -19 vaccination (#248). Finding: During a review of sampled residents for Immunizations, the surveyor noted that Resident #248 had not received a COVID-19 vaccine. The medical record also lacked documentation of a refusal or education provided for the COVID-19 vaccination. Facility Policy Titled - COVID-19 (SARS-CoV-2) Vaccine Policy, dated 5/2/23, says: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications of COVID-19 by offering residents and employee(s) COVID-19 vaccines. And, If a resident and/or resident representatives' does not consent to the vaccine, the facility will document a clinical note in the resident's medical record and include date, time, and the name of the individual they spoke with. On 3/12/24 at 11:40 a.m., the above finding was brought to the attention of the Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and the facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in the area of bathing for 1 of 1 residents reviewed for bathing. (Resident #148) Findings: On 6/9/23 at 1:15 p.m., the state agency received a complaint that Resident #148 was not receiving a bath for an extended period of time after admission. A review of the admission record for Resident #148 showed an admission to the facility on 3/7/23 and discharge on [DATE]. On 3/13/24 at 11:30 a.m., in an interview with the Director of Nursing (DON), she stated that the facility gives residents a shower/tub bath once a week. On 3/13/24 at 12:20 p.m., a surveyor and the DON reviewed the facility's bathing documentation for Resident #148. Resident #148 received one shower on 3/24/23. At this time, in an interview, the Director of Nursing stated that the facility had no other bathing documentation and confirmed that Resident #148 had only one shower during his/her stay at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's right to formulate an advance directive regarding cardiopulmonary resuscitation (code status) was accurate in the clinical record for 1 of 19 sampled residents reviewed for advanced directives (Resident #7). Findings: 1. On 3/11/24, Resident #7's electronic medical record (EMR) and paper records were reviewed by the surveyor for cardiopulmonary resuscitation (code status). Resident #7's records show he/she was admitted to the facility on [DATE]. Both the EMR and paper records(face sheet) lacked the code status for the resident. On 3/11/24 at 1:35 p.m., in an interview, Licensed Practical Nurse (LPN #1) confirmed that Resident #7's electronic medical record and face sheet did not contain the current code status for the resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and clinical record review, the facility neglected to identify and complete an assessment of a change in condition for 1 of 3 residents reviewed for neglect (#298). Findings: On 3/8/24 at 5:06 p.m., in a telephone interview with a surveyor, a complainant stated that on 8/24/23, two family members found Resident #298 in his/her room talking to him/herself and acting delirious. The complainant stated concerns were brought to the attention of the nurse who stated staff were waiting for the doctor to visit the next day. The complainant stated the nurse was told the family wanted Resident #298 sent to the hospital. The complainant stated he/she spoke with another nurse at the facility later in the evening. The second nurse stated the doctor would be in the next day to see Resident #298. The complainant stated he/she voiced concerns that Resident #298 was septic. Within the hour, the second nurse called the complainant and stated Resident #298 was being sent to the hospital. A review 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 record review, observations, and interview, the facility failed to implement a care plan in the area of grooming for 1 of 1 resident reviewed for Dental. (Resident#30) Finding: Review of Resident #30's care plan, initiated 6/7/23, last revised 12/18/23 for Grooming has an nursing intervention of, [Resident #30] will brush his/her teeth, wash his/her face and comb his/her hair daily to maintain current level of function. On 3/11/24 at 12:48 p.m. and on 3/12/24 at 8:30 a.m., and 1:01 p.m., Resident #30's teeth were observed to be coated with a thick yellow substance at gum line. On 3/11/24 at 1:05 p.m., the surveyor and the Quality Improvement Specialists (QIS) observed resident #30's teeth coated with a thick yellow substance confirming mouth care/brushing teeth has not been completed.

Based on interviews and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all the resident's pre- and post-discharge medications for 1 of 1 residents reviewed for discharge to the community (Resident #9). Finding: On review of Resident #9's clinical record, a surveyor noted an admission date of 12/19/23 to the skilled unit. On 2/29/24, Resident #9 was discharged back to his/her bed in the residential care unit. The surveyor located an incomplete recapitulation of stay in the clinical record dated 2/29/24. On 3/13/24 at 4:15 p.m., in an interview with a surveyor, the Director of Nursing and the Quality Improvement Specialist confirmed the recapitulation of stay was not completed and did not include the necessary information required at the time of the Resident #9's discharge.

Based on clinical record review, facility policy review, and interviews, the facility failed to follow its own policy for completing pressure ulcer wound assessment documentation for 2 of 2 residents reviewed with pressure ulcers (Resident #2 and Resident #5). Findings: On 3/13/24 at 11:00 a.m. a surveyor reviewed the facility policy titled: Skin Management Program Policy, last reviewed 8/2023, which stated Daily documentation of: a. the site b. dressing status and/or surrounding skin areas if the site is covered c. weekly wound measurements by a registered nurse. On 03/13/24 at 10:09 AM a surveyor reviewed the Electronic Medical Record (EMR) for Resident #5 and located the following wound care orders: Wound #3 - Change dressing twice a day beginning 2/29/24 for 30 days. Wound #4 -change dressing every shift and as needed. A surveyor reviewed the wound assessment documentation in the EMR for Resident #5 and found only one entry documenting the condition of the wound since 2/29/24. On 3/13/24 at 10:18 a.m., a surveyor reviewed the EMR for Resident #2 and located a wound care order,…

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 interviews, the facility failed to ensure that the resident's environment was free of accident hazards relating to a patient lift for 1 of 1 facility tours, for 1 of 4 days of survey. (3/11/24) Findings: On 3/11/24 at 9:45 a.m., a surveyor observed a Hoyer HPL500 patient lift on the A Unit that was missing 1 of 4 springs on the sling bar safety clips that would prevent the sling strap from potentially coming off during a lift/transfer. On 3/11/24 at 9:50 a.m., in an interview, Registered Nurse #2 confirmed the patient lift was missing 1 of 4 springs on the sling bar safety clips and it was an accident hazard. On 3/11/24 at 9:55 a.m., in an interview, the Quality Improvement Specialist confirmed the patient lift was missing 1 of 4 springs on the sling bar safety clips and it was an accident hazard. The patient lift was immediately removed from the floor.

Based on observations, interviews, and record reviews, the facility failed to assure that resident care policies and procedures for respiratory care and services, are developed, according to professional standards of practice, for a resident requiring specific types of respiratory care and services in the area of oxygen and nebulizer treatments for 3 of 3 wings reviewed for respiratory. (Wing A, Wing B and Wing C) Findings: The facilities policy and procedure, Oxygen use & Storage Policy, revised 7/22 states, section V. Respiratory care. A sanitary environment must be maintained to prevent the transmission of disease and infection with nursing instructions to: Nebulizer parts should be rinced after each use and discarded every week. On 2/13/24 from 8:26 a.m., through 9:35 a.m., 2 surveyors observed the following: - Room A5 had a nebulizer tubing and connected mouth piece stored on a recliner seat underneath a Hoyer pad and a wheelchair leg rest. - Room A16 had an Oxygen concentrator with a filter that was coated with layer of dust. - Room A15 had an Oxygen concentrator 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 observations and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection, on 2 of 3 wings (Wing B and Wing C) for 1 of 1 day of survey (2/13/24). Findings: On 2/13/24 from 8:26 a.m. through 9:35 a.m., 2 surveyors observed the following: - Room B6 had 2 wedge pillows stored the floor, one behind the Oxygen concentrator and the other beside the bed. - Room B5-B6 shared bathroom had a bed pan stored on the floor next to the toilet. - Room B1-B2 shared bathroom had a urinal with yellow substance on the bottom, stored on the floor next to the toilet. - Room C7 had commode bucket stored on the floor under the sink. On 2/13/24 at 10:32 a.m., two surveyors, the Administrator, and the Quality Improvement Specialists (QIS) observed the above concerns. At this time, both Administrator and the QIS confirmed the above observations did not support good infection control practice.

Based on observation and interview's, the facility failed to promote care for a resident in a manner that maintained the resident's dignity and/or respect when staff failed to perform nail care for a resident on 2 of 4 days of survey (Resident #30). In addition, the facility failed to ensure a resident 's exposed body was appropriately covered up and was not visible from passers by in the hall (Resident #36). Findings: 1. Resident #30 was admitted to facility on 5/11/22 with diagnoses to include aphasia, [loss of ability to understand or express speech], dysphagia [difficulty swallowing foods or liquids], and hemiplegia [paralysis on one side of body]. On 6/27/22 at 6:29 p.m., Resident #30 was observed lying in bed, his/her toenails were extremely long and curling under his/her toes. In addition, his/her fingernails were overgrown with obvious dark substance under them. On 6/28/22 at 8:11 a.m. a surveyor observed Resident #30 outside, without footwear, sitting in a wheelchair in the presence of 3 other residents. His/her toenails were extremely overgrown and curling under his/her…

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 record review, observation and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding, for 2 of 2 residents reviewed for enteral feeding (#32 and #36). In addition the facility failed to follow the care plan for tube feedings (#36) Findings: Facility's Enteral Tube policy, revised 7/2019, under Medication Administration, Proper Preparation instructs nursing to mix crushed medications with 15 milliliters (ml) of water and Prepare medications one at a time. Under Enteral Feedings instructs nursing to: A. Obtain physician's order for the use of Enteral feeding. The physician order shall include: Frequency and amount of flushes. G. Residents with intermittent tube feeding shall have tubes flushed with 3 ml's of water prior to and following each feeding unless otherwise ordered by the physician. Residents shall have tubes flush with 30 ml's of water prior to, and following medication administration, unless otherwise ordered by the physician. J. Document of enteral feeding tube placement, residual volumes,…

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

Based on observation, interview, and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 4 medication errors out of 35 opportunities. The medication error rate was 11.43%. Findings: 1. On 6/28/22 at approximately 7:10 a.m., a surveyor observed Registered Nurse (RN) #1 prepare medications for Resident #36 via gastrostomy tube (G-tube), which included: Metoprolol tartrate 50 milligram (mg), Diltiazem 60mg and Senna 8.8 mg/5 milliliter's oral syrup. RN #1 crushed the Metoprolol tartrate and Diltiazem tablets, mixed the crushed meds with the Senna syrup and added some water to the mixture. The RN then entered the residents' room and administered the medication mixture via the g-tube. The surveyor and the RN #1 reviewed the physician orders to confirm there was no order for the medications to be crushed and mixed together prior to administration. 2. On 6/28/22 at 7:27 a.m., a surveyor observed RN #1 prepare medications for Resident #32 which included and order for Bupropion HCL 75 mg tablets, administer 2 tabs via G-tube. RN #1…

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

Based on record review, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked and failed to date biological's after opened and according to manufacturer specifications, in 1 of 2 medication rooms observed. Finding: Omnicare Pharmacy policy and procedure for Storage and Expiration Dating of Medications, Biologicals, revised 1/1/22 states: Section 3: Facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device. Section 5: Once any medication or biological package is opened, Facility should follow manufactures/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. Section 13: Controlled substance stored in the refrigerator must be in a separate container and double locked. On 6/27/22 at 7:53 p.m.,…

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 observations the facility failed to ensure staff followed facility policy and the Centers for Disease Control (CDC) recommendations for infection control practices regarding personal protective equipment (PPE) and failed to ensure that all staff members were screened for signs and symptoms of Covid-19. This failure has the potential to affect all residents in the facility. Findings: A review of CDC (Centers of Disease Control) recommendations titled Interim Infection Prevention and Control Recommendation for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic-revised 2/2/22, recommends the following for Long-Term Care Facilities: Implement Universal source Control Measures-source control refers to the use of cloth face coverings or face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures…

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, interviews and Centers for Medicare and Medicaid Services' (CMS) Corona Virus Disease-2019 (COVID-19) Long-Term Care (LTC) Facility guidelines, the facility failed to notify resident representatives of a staff member confirmed positive for COVID-19 in a timely manner. Findings: A review of the Centers for Medicare & Medicaid Services (CMS) Ref: QSO-20-29-NH Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated May 6, 2020, 483.80 Infection control section (g) COVID-19 Reporting notes the following in sub section (3): The facility must (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. During an interview on 6/28/22 at 2:11 p.m., the Director of Nursing (DON) who is also the facility Infection Preventionist…

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 a care plan was revised to reflect the resident's status for in 1 of 1 resident care plans reviewed for smoking and elopement (#30). Findings: Review of facility Comprehensive Care Plan Policy dated 1/19 states, The facility must develop and implement a comprehensive person centered care plan for each resident consistent with resident rights which includes measurable objectives and timeframes to meet a residence medical nursing mental and psychosocial needs identified in the comprehensive assessment/evaluation. In consultation with the resident and the residents representative. Reviewed and revised by the interdisciplinary team after each assessment/evaluation IDT [Interdisciplinary Team] to include a physician, licensed nurse, nursing assistant caring for resident member of food and nutrition services social services and resident/resident representative. Review of Resident Smoking Policy dated 9/18 states, smoking privilege's will be…

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 review, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection, for 1 of 1 sampled resident's reviewed for Respiratory Care (#25). Finding: On 6/27/22 at 8:24 p.m., during an interview with Resident #25, a surveyor observed the resident wearing a nasal cannula that was attached to an oxygen concentrator. The surveyor did not observe the oxygen tubing to be labeled to identify the date it was last changed. Americost Oxygen Operating Instructions instructs staff to change the nasal canula and tubing every 2 weeks. On 6/28/22 at 11:35 a.m., during an interview with a surveyor, Registered Nurse (RN) #3 stated that the oxygen tubing is changed on the night shift and should be listed on Resident #25's Treatment Administration Record (TAR). RN #3 reviewed Resident #25's TAR and was unable to find the treatment for this and confirm when the oxygen tubing was last changed. RN #3 stated she would add the treatment to Resident #25's orders. On 6/28/22 at 1:45 p.m., during an…

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 ensure that a resident's medical care was supervised by a physician when the facility did not follow a diet order and did not notify a physician that a resident was refusing a pureed diet. (#30). Findings: Review of facility policy Diets Available on Menu dated 2013 states, Individuals on restrictive diets often find the food unpalatable, which can result in reducing the pleasure of eating, decreasing food intake, unintended weight loss and undernutrition- the problems practitioners are trying to prevent. In an effort to provide individualized (and liberalized) diets, the following procedure will help to assure that the most appropriate diet is provided. Diets will be offered as ordered by the physician. If the RD [Registered Dietitian] or designee finds through nutritional assessment that the diet order is not appropriate for the individual, she/he will notify the physician with a recommendation for a more appropriate diet. Resident #30 was admitted…

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.