Cedar Ridge Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of Post-Traumatic Stress Disorder(PTSD)/trauma for 3 of 4 sampled residents reviewed for PTSD. (#1, #5, #51) Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses to include PTSD. Review of Resident #1's clinical record on 1/28/25 revealed it lacked documented evidence that the current care plan had been developed and implemented in the area of PTSD to include goals, interventions and triggers. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses to include PTSD. Review of Resident #5's clinical record on 1/28/25 revealed it lacked documented evidence that the current care plan had been developed and implemented in the area of PTSD to include goals, interventions and triggers. 3. Resident #51 was admitted to the facility on [DATE]. Review of the residents medical record indicates he/she has a diagnosis of Post-Traumatic Stress Disorder (PTSD).…

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 maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 days of survey. (1/27/25, 1/28/25 and 1/29/25) Findings: 1. On 1/27/25 at 6:15 p.m. a surveyor observed on the Blue Spruce Unit a portable oxygen machine and nasal canula and tubing on the floor next to the exit door. On 1/27/25 at 6:15 p.m., in an interview, Licensed Practical Nurse (LPN #1) confirmed that the portable oxygen machine, the nasal canula and the tubing should not be on the floor and that it should be bagged and stored off the floor. On 1/27/25 at 6:30 p.m., in an interview, Registered Nurse (RN#1) confirmed that the portable oxygen machine, the nasal canula and the tubing was and should not have be on the floor and went on to say that no resident was using it at that point. 2. On 1/27/25 at 6:20 p.m., a surveyor observed oxygen tubing and a nasal canula hanging on the left…

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 sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 1/28/25 at 3:30 p.m., in an interview with a surveyor and review of weekend staffing for July 1, 2024, through September 30, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends. On 1/28/25 at 10:58 a.m., in an interview with a surveyor, Resident #327 stated on one day during the previous weekend, I had to pee myself, had to wait 30 minutes after using the call bell, due to lack of staff. When in bed Resident #327 stated compression devices are applied to both legs and he/she can't stand up without assistance due to dizziness. Resident #327 stated they need more…

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 interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 4 of 4 units reviewed (Hickory, Elm, Blue Spruce and Scotch Pine) and failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of a resident requiring intravenous antibiotics (Resident #329). Findings: A review of the facility's Controlled Medication Storage policy and procedure dated: 1/24, under #6 states: At each shift change or when keys are surrendered, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses or approved individuals…

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, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. Additionally, the facility failed to ensure foods were sealed, labeled, and dated in a dry storage room, a walk-in freezer and a walk-in refrigerator, as well as failed to ensure the emergency food supply was not stored with unsecured chemicals for 1 of 3 days of survey (1/27/25). Furthermore, the facility failed to ensure that the Dish Machine temperatures, Refrigerator temperatures, and Freezer temperatures were monitored for 3 of 3 months reviewed. Findings: Review of policy, Food Storage: Cold Foods, revised 4/2018, states, Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated . Review of policy, Food Storage: Dry Goods, revised 9/2017 states, Storage areas will be neat, arranged for easy identification, and date marked as appropriate .Toxic materials will not be stored with food . 1. On 1/27/25 between 6:10 p.m. and 6:40 p.m., a surveyor conducted a kitchen tour with Dietary Aide (DA) #1, during…

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 reviews, the facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to the residents or their representatives for 4 of 5 residents reviewed for Arbitration (Resident #35, #46, #57, #331). Findings: On 1/27/25 at 7:28 p.m., a surveyor conducted an entrance conference with the Administrator and the Director of Nursing and was told, when asked, that no residents in the facility had signed an arbitration agreement. 1. Review of Resident #35's medical record shows he/she was admitted to the facility on [DATE]. Further review of the resident medical record indicates he/she had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. On 1/30/25 at 3:50 p.m., a surveyor met with Resident #35 and asked if he/she signed an arbitration agreement with the facility during admission. He/she stated that he/she did not know what that was and stated that his/her child signed admission paperwork 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Residents #327 and #331) on 1 of 5 facility units. Findings: 1. On 1/28/25 at 10:40 a.m., in an observation on the Elm House unit, a surveyor briefly reviewed the electronic record for Resident #327 before entering the room. The record indicated Resident #327, admitted on [DATE], required Enhanced Barrier Precautions for CRE (Carbapenemase-producing carbapenem-resistant Enterobacteriaceae), a drug-resistant organism. The surveyor could find no signage at the entrance of the room, or within the resident's room indicating precautions were necessary. The surveyor asked the Registered Nurse on duty if Resident #327 required special precautions. The RN at first stated the resident did not require precautions, then remembered…

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, record review, and interviews, the facility failed to provide care to residents in a manner that maintains each resident's dignity by failing to serve all residents seated at the same table at the same time for 1 of 2 dining observations on 1 of 1 days of survey. Finding: Review of the facility's Resident Council Meeting Minutes, dated 12/31/24, revealed resident concerns that residents are concerned that trays are being served in rooms on units before the dining room service . Resident Council Meeting Minutes , dated 11/27/24 states, Dining Services .Trays in order of room on carts .Nursing: Tray served in dinning [dining] room first by table before room trays . Resident Council Meeting Minutes, dated 10/30/24 states, CNA's [Certified Nursing Assistants] are not serving residents at the table in the dining room first . On 1/28/25 between 12:23 p.m. and 12:40 p.m., during a dining observation on the Hickory Unit, a surveyor observed a table seating 3 residents. At 12:29 p.m., Resident #60 received his/her meal. Staff then proceeded to deliver meals to other…

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 appropriately notify a resident and or resident representative in a timely manor, prior to changing a residents room, for 1 of 1 residents reviewed for room change. On 1/21/25 the Division of Licensing and Certification received a complaint in regards to a resident's room being changed without proper notification. On 1/27/25 at 8:00 p.m., during an interview Resident #57 and his/her family member both stated that they had not received any notification of a room change prior to it occurring. Review of Resident #57's clinical record indicates that the resident was moved from Elm Unit to Hickory Unit on 1/15/25. Further review of the clinical record lacked evidence that any notification of the room change occurred. On 1/30/25 at 2:31 p.m., during an interview with the Market Clinical Advisor the above information was confirmed.

Based on interview and record review, the facility failed to review, revise and update a care plan in the area of Post-Traumatic Stress Disorder (PTSD) for 1 of 4 residents whose care plans were reviewed for PTSD. (#18) Finding: Resident #18 was admitted the facility on 12/23/21. On 4/14/23, the resident was identified/diagnosed with Post-Traumatic Stress Disorder (PTSD). Review of Resident #18's clinical record revealed the current care plan was not reviewed, revised and updated to include goals, interventions or triggers for PTSD. On 1/30/25 at 12:47 p.m. in an interview, the Market Clinical Advisor confirmed that the Resident 18's care plan was not reviewed, revised and updated to include goals, interventions or triggers for PTSD.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy, the facility failed to demonstrate evidence of behavior monitoring and monitoring for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#26). Finding: Facility policy, Medication Management, dated 1/2024, states, Policy . Evaluation of a resident's physical, behavioral, mental, psychosocial signs and symptoms .including adverse consequences of medications . The need for and response to therapy are monitored and documented in the resident's medical record .Guidelines for Psychotropic Medication Monitoring .Potential Adverse Consequences: The facility assures residents are being adequately monitored for adverse consequences . Resident #36 was admitted on [DATE] with diagnoses to include anxiety and depression. Resident #36's care plan, initiated 12/17/24, states, .at risk for complications related to the use of psychotropic drugs . complete behavior monitoring flow sheet .monitor for side effects . Review 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 observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 4 units observed for medication storage. (Scotch Pine House) Findings: 1. On [DATE] at 9:51 a.m., observation of Scotch Pine House treatment cart with the Registered Nurse (RN) the following was observed; one opened Aspart Insulin Flex Pen dated 12/22 and one opened and undated Insulin Glargine-yfgn Solution Pen with both with the manufacture's instructions of, after first use .discard after 28 days. At this time, the RN removed both of the insulin pens and confirmed they were either expired or undated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Finding: Review of policy, OPS416 Person-Centered Care Plan, dated 10/24/22, states .The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care .1. A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; PASRR recommendation, if applicable . Review 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 ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for wounds (Resident #1). Finding: Review of facility policy, Skin Integrity and Wound Management, dated 10/15/24, states, Practice Standards .6. The licensed nurse will .6.2 Document any newly identified skin/wound impairments .6.7 Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments .9. Notify physician/APP to obtain orders . Resident #1 was admitted on [DATE] with diagnoses to include Deep Tissue Injury on coccyx. Review of Resident #1's Wound Evaluation, dated 12/11/24, revealed Resident #1 had a Deep Tissue Injury located on his/her coccyx that was present on admission. Further review of the Wound Evaluation revealed, Treatment .Cleansing solution: soap & water .Primary dressing: no dressing applied . Review of Resident #1's Wound Evaluation, dated 12/18/24, revealed the coccyx…

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 review, interview and record review the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering excessive doses of Ativan in less than 7 hours and failed to monitor of psychotropic medication side effects for 1 of 9 sampled residents (#7). Findings: The facility's policy, Behaviors: Management of Symptoms, revised on 7/1/24 states, Staff will use non-pharmacological interventions as the first line of approach to managing challenging behaviors. The facility's policy, Medication Monitoring dated 1/24 under Guidelines For Psychotropic Medication Monitoring states, When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences and under section Chemical Restraints states, When any medication restricts the resident's movement or cognition, or sedates or subdues the resident, and is not an accepted standard of practices for 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 the facility's Falls Management policy, interviews and record review the facility failed to ensure that a resident's physician and/or representative were notified immediately of an unwitnessed fall and failed to follow its own policy and procedure for unwitnessed falls for 1 of 9 residents reviewed for falls. (#1) Findings: Cedar Ridge's Falls Management Policy and Procedure, revised 3/15/24 states under, 5. Post-Fall Management: 5.1 Evaluate the patient for injury. 5.1.1 First aid will be provided for minor cuts and abrasions. 5.2 Notify the physician / advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated. 5.2.1 If the injury is of an emergent nature, the patient will be transported to the hospital. 5.2.2 If the extent of injuries cannot be determined, the nurse will notify emergency medical services (EMS) for evaluation and transport to the hospital. 5.4 The patients representative will be notified of the fall and any follow up treatment needed. On 9/3/24 at 3:35 p.m., in an interview, Resident #1's…

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

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 9 residents reviewed. (#7) Finding: 1. Resident #7 was admitted to the facility 8/5/24 with diagnosis of cardiovascular accident with left side hemiparesis requiring anticoagulant treatment, dysarthria with modified diet texture, thrombocytopenia, depression, anxiety with ordered antianxiety medications and neurogenic bladder with indwelling supra-pubic catheter. On 9/3/24 resident #7's clinical record was reviewed and revealed that it lacked evidence of a base line care plan that included the instructions necessary to properly care for Resident #7's immediate health and safety needs for the use of an anticoagulant and antianxiety. In addition, a care plan for Activities of Daily Living, impaired swallowing, cognitive loss, chronic pain, indwelling supra- pubic catheter and risk of falls were not initiated until 8/13/24, eight days…

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 care plan was followed for a 2 assist transfer for 1 of 4 sampled residents requiring a mechanical device use for a transfer and failed to ensure the care plan was accurate to reflect the residents advanced directive code status. (Resident #7) Findings: 1. On 8/30/24 at 9:24 a.m. during an interview with Resident #7's representative, [he/she] stated Resident #7 fell on 8/7/24 due to only one staff assisting (him/her) during a transfer when there should have been 2 staff. Review of Resident #7's medical record contained an e-Interact note dated 8/7/24 stating, The resident in [room] had a fall today. The CNA (Certified Nurses Aide) was helping the resident to transfer to the commode. While standing pivoting to the commode, (he/she) lost (his/her) balance. And The CNA tried to catch the resident but the resident was moving too fast and ended up on the floor. The Nurse went to [room] and saw the resident was on the floor and the CNA tried…

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, observation and record review, the facility failed to revise the care plan to reflect a resident's current status for 1 of 2 residents reviewed for infection prevention and control (#1). Findings: On 9/3/24, review of Resident #1's electronic medical record, on the front page stated, Infection Prevention and Control Covid 19(Coronavirus) Onset Date 8/24/2024 Infection Status Confirmed (D) Isolation Precautions Airborne, Contact Isolation Start Date 8/24/2024 - Expected End Date 9/4/2024 PPE Requirements - Gloves, Gown, N95 Respirator, Eye Protection (Face Shield or Goggles) On 9/3/24 at 9:00 a.m., a surveyor observed signage on the Resident #1's room door which stated Airborne and contact precautions N95 mask, a gown, a face shield, and gloves. There was a wheeled cart outside the residence door with personal protective equipment in it. Review of Resident #1's current care plan lacked evidence of updating and revised to reflect the current status of the resident. On 9/3/24 at 10:20 a.m., in an interview, the Director of Nursing confirmed that Resident #1's…

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

Based on facility policy, observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer use for 2 of 2 residents reviewed for respiratory care. (Resident #4 and #6) Findings: The facilities procedure on Nebulizer: Small Volume last revised on 11/1/2023, section 21 states to rinse small volume nebulizer, mouthpiece, and T piece with sterile water and dry. In subsection 21.1 the procedure states to place in treatment bag labeled with patient name and date. Subsection 21.2 the procedure then states to replace and date the setup daily, if used. The facilities Oxygen Nasal Cannula procedure dated 8/7/23 instructs nursing to, replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. 1. On 9/4/2024 at 9:00 a.m., observation of Resident #4's unlabeled nebulizer tubing and mouthpiece stored on bedside table with other personal belongings. No treatment bag was observed in the resident's room. Review 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 record review and observation, the facility failed to ensure the Treatment Administration Record (TAR) was accurately documented for changing of oxygen tubing for 1 of 2 residents reviewed for oxygen use (#6). Finding: On 9/3/24 at 9:08 a.m., and at 11:06 a.m., a surveyor observed Resident #6 using Oxygen (O2), via nasal cannula with the tubing dated for Sunday 8/25/24 and the filter located on the back of the concentrator coated with a layer of dust. Review of the residents TAR, nursing documented the oxygen tubing was changed and the filter was cleaned on 9/1/24. On 9/3/24 at 12:07 p.m., both the surveyor and the registered Nurse (RN) #2 observed resident #6's O2 tubing dated 8/25/24 and the filter coated with dust. RN #2 stated the tubing should be changed on Sunday nights. On 9/3/24 at 12:12 p.m., during an interview, the above was discussed with the Director of Nursing

Based on record review, interviews and observations the facility failed maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 day of survey. Findings: On 9/3/24 at 9:00 a.m., two surveyors observed signage on Resident #1's bedroom door which stated, contact and airborne precautions. N95 mask, a gown, a face shield, and gloves needed when entering room. There was a wheeled cart outside the resident's door with personal protective equipment in it. On 9/3/24 at 9:10 a.m., in an interview, when asked by a surveyor what precautions were needed to enter Resident #1's room, the Registered Nurse (RN #1) stated that resident #1 is on contact and airborne precautions and a N95 mask, a gown, a face shield, and gloves were needed. On 9/3/24 at 9:13 a.m., two surveyors observed two Certified Nursing Assistants (CNA #2 and CNA #3) go in to Resident #1's room, without donning a N95 mask, a gown, a face shield and gloves. When…

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 a resident's bed was maintained in good repair and safe operating condition for 2 of 2 observations for 1 of 1 day of survey. (9/3/24) Findings: On 9/3/24 at 3:35 p.m., in an interview with Resident #1's representative [RR], [he/she] stated that the bed rail had been broken for a long time and it was stuck in the up position. Resident #1s representative demonstrated to the surveyor that the side rail would not function properly on the right side of the bed as you're looking at it from the foot of the bed. The surveyor observed [RR] trying to put the railing down and it would not go down as it was stuck in the up position. The [RR] then went around to the other side of the bed and easily put down the left side rail. [RR] stated [RR] had reported this to the nursing staff many times over the past few weeks and no one had done anything about it. On 9/3/24 at 4:20 p.m., in an interview, Certified Nursing Assistant/Medication Tech(CNA/M) told the surveyor that when the ambulance brought Resident #1 back to the…

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

Based on observations and interviews the facility failed to promote care for resident in a manner that maintains the resident's dignity by allowing an uncovered urine filled Foley catheter bag to be seen by passersby for 1 of 3 residents (Resident #9) observed for dignity related to urinary collection bags during 1 of 2 days of survey (5/7/24). Findings: On 5/7/24 at 9:20 a.m., a surveyor observed Resident #9's Foley catheter bag hanging on the side of the bed, containing yellow urine, visible from the hallway/dining room. At this time, Resident #9 indicated he/she would like to have it covered and would be embarrassed if people could see it from the hallway/dining area. On 5/7/24 at 9:30 a.m., in an interview, Registered Nurse (RN)3 confirmed that Resident #9's Foley catheter bag with urine was visible to passersby in the hallway/dining room. On 5/8/24 at 8:15 a.m., in an interview, the surveyor discussed the finding with the Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and facility policy the facility failed to complete a Self-Administration of Medication Assessment for 1 of 4 resident reviewed for medication administration. (Resident #1) Findings: Review of facility policy titled NSG309 Medications: Self Administration last reviewed 3/1/22 states Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self- administer: A physician/advanced practice provider (APP) order is required. Self-administration and medication self-storage must be care planned. Resident#1 was initially admitted [DATE] with diagnoses including hypertension, peripheral vascular disease, renal disease, and arthritis. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) of 11 of 15, indicating he/she has mild/moderately impaired cognition.…

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 update/implement goals and interventions for 3 of 9 care plans reviewed (Resident #1, #4 and #6). Findings: Review of facility policy Person-Centered Care Plan dated 10/24/22 states A comprehensive person-centered care plan must be developed for each patient .Included measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychosocial needs . 1. Review of Resident#1's active medication orders dated May 2024 revealed order with start date of 11/6/23 for Venlafaxine HCl ER Tablet Extended Release 24 Hour 75 MG Give 1 tablet by mouth one time a day for depression, Review of Resident#1's entire clinical record lacked evidence for monitoring side effects. Review of Resident#1's Care Plan dated 4/5/24 states [Resident #] is at risk for complications related to the use of psychotropic drugs for depression. [Resident #] will have the smallest most effective dose without side effects by next review . Monitor for side effects…

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 review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 2 sampled residents (Resident #6). Findings: Review of facility policy Person-Centered Care Plan dated 10/24/22 states . a comprehensive, individualized care plan will be developed after each assessment .and review and revise the care plan after each assessment. After each assessment means after each .Minimum Data Set (MDS). The care plan will be prepared by the interdisciplinary teams . In conjunction with the patient/and or patient representative During review of Resident 6's medical record, the surveyor noted quarterly Minimum Data Set (MDS) Assessments dated 1/23/24. The clinical record lacked evidence that a care plan meeting was held by the Interdisciplinary Team (IDT), resident and/or representative for this assessment. In addition, the last documented IDT meeting was held on 10/23/23. During an interview on 5/8/24 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.

Based on record review and interviews, the facility failed to monitor and document targeted behaviors to support the use of an antipsychotic and antianxiety medication for 1 of 2 residents reviewed for unnecessary medications (Resident #6). Findings: Review of facility policy Psychotropic Medication Use dated 10/24/22 states .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions . Review of Resident #6's care plan initiated 4/2/21 states [Resident #6] exhibits physical and verbal behaviors .Ineffective coping skills, i. e., poor anger management, Poor impulse control. removes [his/ her] colostomy appliance and throws it at times.will not harm others by next review (became agitated . and struck other resident…

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 on 3 of 5 Units (Elm, Blue Spruce, and [NAME]) for 1 of 1 Environmental Tour. Findings: On 6/15/22 from 8:25 a.m. to 8:50 a.m., an Environmental Tour was conducted with the Administrator, the Center Nurse Executive, and the Maintenance Director in which the following findings were observed: Elm House - Resident room [ROOM NUMBER] - The wall was gouged and had chipped/missing paint behind Bed-A recliner. Both window screens on Bed-A side were broken and in disrepair. - Resident room [ROOM NUMBER] - The wall along the side of Bed-A was gouged and had chipped/missing paint. Bed-A bedrail had a broken tab on it and had chipped/missing paint. Blue Spruce House - Resident room [ROOM NUMBER] - The wall fan was dusty/dirty. The bureau had chipped/missing laminate on the entire front creating an uncleanable surface. - Resident…

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 a food mixer, a food slicer, ceiling vents, and ceiling tiles. Additionally, the facility also failed to date, label and/or seal foods in the dry storage area, the reach-in refrigerator, the walk-in refrigerator and the walk-in freezer. Findings: On 6/12/22 from 11:10 a.m. to 11:40 a.m., a kitchen tour was conducted in which the following findings were observed by the surveyor and discussed with the Head Cook. Kitchen - The food mixer had food particles on the mix arm and the base. - The food slicer had food particles on the blade and blade guard. - The 2 ceiling vents and the 2 ceiling tiles they were mounted in, above food preparations areas, were dusty/dirty. - The dry storage area had an opened bag of biscuit mix, an opened bag of cake mix, a large bowl of biscuits, and an opened bag of coconut that were not labeled and dated. - The reach-in refrigerator had a drink cup full of liquid that was not labeled and dated. - The walk-in refrigerator had 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 record reviews and interviews, the facility failed to develop a discharge plan that focused on resident discharge goals, preparation, and effective transition of care for 3 of 24 sampled residents (Resident #64, #71, and #375). Findings: 1. During review of Resident #64's medical record, the surveyor noted that the resident's current care plan, revised 2/24/22, had no discharge plan. On 6/15/22 at 9:00 a.m., during an interview with the Center Nurse Executive (CNE), a surveyor confirmed this finding. 2. During review of Resident #71's medical record, the surveyor noted that the resident's current care plan, created on 2/23/22; revised 4/5/22, had no discharge plan. On 6/15/22 at 9:32 a.m., during an interview with the Clinical Quality Specialist , a surveyor confirmed this finding. 3. During review of Resident #375's medical record, the surveyor noted that the resident's current care plan, revised 11/16/2021, had no discharge plan. On 6/15/22 at 9:04 a.m., during an interview with the Center Nurse Executive (CNE), a surveyor confirmed this finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure that Oxygen was administered according to physician's orders for 2 of 2 days (#20). Finding: During a medical record review, Resident #20 was admitted to the facility on [DATE]. A review of Resident #20 physician's orders dated 5/11/22 indicated Oxygen at 2 liters per minute (LPM) via Nasal Cannula continuously for Chronic Respiratory Failure. On 6/12/22 at 12:30 p.m., and on 6/13/22 at 9:40 a.m., it was observed that Resident #20's Flowmeter on the Oxygen Concentrator was set at 3.5 LPM delivering a continuous flow of oxygen at 3.5 LPM. At the time of observation on 6/13/22 at 9:40 a.m., Resident #20 stated he/she was to receive oxygen at 2 LPM. The surveyor discussed this finding in an interview on 6/13/22 at 10:09 a.m. with the Center Nurse Executive (CNE). At approximately 10:20 a.m. the Clinical Quality Specialist acknowledged the physician's order should have been changed to 3.5 LPM.

Based on observation and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 dumpsters for 1 of 4 days of survey. (6/12/22) Findings: On 6/12/22 at 11:10 a.m., 1 of 3 dumpsters by the kitchen was observed to have the left side door open exposing trash. Additionally, there were used face masks, paper products and trash debris on the ground around the dumpsters. On 6/12/22 at 11:40 a.m., in an interview, the findings were discussed with the Head Cook. On 6/12/22 at 1:00 p.m., in an interview, the findings were discussed with the Food Service Director.