Harbor Post Acute Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained according to professional standards of practice for 4 residents (Resident #26, Resident #27, Resident #43 and Resident #48) out of 4 residents reviewed for respiratory care. Findings: Resident #26 (R26) Review of an admission Record Reflected R26 admitted to the facility with diagnoses that included chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen. During an observation on 10/06/24 at 11:28 AM, nebulizer equipment in R26's room was uncovered, assembled, resting on R26's bedside table without a barrier in place and appeared to have been used as evidenced by droplets in the equipment. During an observation and interview on 10/08/24 at 10:19 AM, R26's nebulizer equipment was assembled and in an undated clear plastic bag. R26 reported that staff sometimes clean her nebulizer equipment. Resident #27 (R27) Review of 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.

Based on observation, interview, and record review, the facility failed to ensure licensed personnel followed medication administration policy and procedures when a nurse pre-poured medications for eight residents (R9, R27, R30, R31, R35, R39, R50) and documented the administration of medications that had not been given to residents. Findings: During an observation on 10/7/24 at 7:33 AM, Licensed Practical Nurse (LPN) Q was asked to complete a medication pass. LPN Q was asked to open the top drawer of the medication cart for inspection, and it was discovered medications had been preset for 8 residents on the unit (R9, R27, R30, R31, R35, R39, R50). Pills, tablets and capsules were noted in plastic medication cups, a smaller paper medication cup was placed over the medications in each plastic cup with a number written on each paper cup. LPN Q said the numbers were rooms on the unit. LPN Q reported there were no controlled substances in any of the preset medication cups. A narcotic count was conducted to verify that no controlled substances had been preset that morning. 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 observation, interview, and record review, the facility failed to ensure two Residents (R20 and R26) of five residents reviewed for medication were properly assessed and monitored for self-administration of medication and failed to securely store and document medication self-administration after use. Findings: R20 R20 admitted to the facility [DATE] with pertinent diagnoses that included asthma and respiratory failure. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 13 which indicted R20 is cognitively intact. On [DATE] at 11:40 AM an observation and interview were conducted in the room of R20. An albuterol 90 micrograms (mcg) multi-dose inhaler in an aero chamber and a bottle of Flonase were observed on the over-the-bed table of R20. R20 reported she has had immediate access to both medications since admission. The policy provided by the facility titled Self-Administration of Medications, last revised [DATE] was reviewed. The Policy…

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, interview, and record review, the facility failed to assess, monitor and notify the physician of clinical changes in condition for 1 resident (Resident #48) out of 13 residents reviewed for quality care from a total sample of 13 residents. Findings: Resident #48 (R48) Review of an admission Record reflected R48 originally admitted to the facility on [DATE] with diagnosis that included end stage renal disease, dependence on renal dialysis, and Congestive Heart Failure (CHF). Review of a Minimum Data Set (MDS) admission assessment dated [DATE] reflected R48 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15/15. Review of a Care Plan initiated on 9/16/24 indicated R48 has altered cardiovascular status r/t (related to) hypertension, hypotension, pacemaker, HLD (hyperlipidemia), CAD (coronary artery disease). The goal of the care plan was that R48 would be free from signs and symptoms of complications of cardiac problems. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure antipsychotic medications were prescribed to treat a condition as diagnosed and documented with rationale in the clinical record for 1 resident (Resident #24) out of 5 residents reviewed for unnecessary medications. Findings: Review of an admission Record reflected R24 admitted to the facility on [DATE] with diagnoses that included Covid-19, acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R24 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8/15. Review of a Preadmission Screening(PAS)/Annual Resident Review(ARR) Level I Screening dated 9/5/2024 reflected R24 did not have a mental illness or dementia and was prescribed oral trazadone (an antidepressant) for delirium in the hospital. No chronic behavioral health diagnoses. Review of a hospital 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 observation, interview, and record review, the failed to ensure proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions for 1 resident (Resident #37) of 13 residents reviewed for infection control. Findings include: Review of an admission Record revealed Resident #37 (R37) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and peripheral vascular disease. Review of a Minimum Data Set (MDS) assessment for R37, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R37 was cognitively intact. Further review of same MDS assessment revealed R37 required assistance with toileting, transferring, and repositioning. Review of a current impairment to skin integrity Care Plan intervention for R37, initiated 8/13/2024, directed staff to maintain enhanced barrier precautions (gown and glove use) during high contact…

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 This citation pertains to M100142556, M100143537, and M100143672. Based on interview and record review, the facility failed to provide residents a list of pertinent contact information to the State Agencies (SA), advocacy groups and the like, a description of the requirements and procedures for establishing eligibility for Medicaid, and Medicare/Medicaid coverage, and how to file a complaint with the SA, how to file a grievance, and resources for information regarding returning to the community for 4 (Resident #1, Resident #5, Resident #11, Resident #12) of 4 residents reviewed. This deficient practice affects all 54 residents who reside at the facility. Resident #1 (R1) Review of a Face Sheet revealed R1 admitted to the facility on [DATE]. In an interview on 5/14/24 at 10:28 AM, the Power of Attorney (POA) O for R1 reported the facility was to assist them in finding long-term care placement and was in the process of getting Medicaid which they were approved for. R1 had an acute condition and had to go 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes M100143672 AND M100142556. Based on interview and record review, the facility failed to have an admission policy and procedure and provide admission packets for 3 (Resident #5, Resident #11, Resident #12) of 3 residents reviewed, resulting in residents being uninformed of their rights and resources, and the absence of written information available to the resident/responsible party regarding costs, policies, procedures, and services. This deficient practice affects all residents admitted to the facility. Findings include: In an interview on 5/15/24 at 9:28 AM, Designated Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources, costs/ fees, or bed hold policies. This lack of information caused her to not have the resources to apply for Medicaid timely, be informed about bed hold policies in advance of a transfer to the hospital, or…

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 This citation pertains to intakes M100142556, 143537, and 143672. Based on interview and record review, the facility failed to prepare for discharges, provide a safe home discharge, and allow a readmission post hospitalization for 2 (Resident #4 and Resident #5) of 3 residents reviewed for discharges, resulting in both residents needing to find placement at another long-term care facility. Findings include: Resident #4 (R4) Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of acute kidney failure, muscle weakness and cognitive communication deficit. Review of the Minimum Data Set (MDS) dated [DATE] for R4 revealed he was moderately cognitively impaired and required partial to moderate assistance with mobility. Review of the discharge MDS dated [DATE] revealed R4 required supervision or touching assistance with some mobility. He was dependent for bathing, ambulation greater than 150 feet or walking 10 feet on uneven surfaces and picking up objects. He had a manual…

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.

This citation pertains to intakes M100142556, M100143537, and M100143672 Based on interview and record review, the facility failed to operationalize policies and procedures and notify the Office of the State Long-Term Care Ombudsman of monthly discharges that includes the reason for transfer or discharge, date and the receiving entity. This deficient practice affects all residents discharged from the facility since July 2023. Findings include: Review of a policy titled discharge: Notice of Intent Transfer or Discharge dated 1/1/23 revealed: It is the policy of this center that residents and/or responsible parties will be notified prior to transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Office of the State Long-Term Care Ombudsman will be notified via written communication of discharge or transfer. discharged residents will have documentation related to discharge or transfer in clinical record. 5. The facility will send a monthly listing, may be written or electronic notification, of residents discharged to the Office 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.

This citation pertains to intakes M100142556 and M100143672. Based on interview and record review, the facility failed to provide Bed Hold policies to residents upon admission and transfers to acute care or therapeutic leave for 12 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12). This deficient practice affects all residents admitted to the facility and residents who get sent out for acute care or therapeutic leave. Findings Include: Review of a Notice of Bed Hold Policy revealed *This document must be signed by the patient upon discharge to the hospital or therapeutic leave* If unable to sign, notification from the patient and/or family/DPOA (Designated Power of Attorney) must be documented. Complete top section upon admission with resident or responsible party. Complete top section upon admission with resident or responsible party. This NOTICE OF BEDHOLD POLICY is provided to _______ on the effective date of admissions as well as upon any subsequent transfer to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100143672. Based on observation, interview and record review, the facility failed to have an effective telephone communication system to the facility for 1 (Resident #5) of 3 residents reviewed for communication from outside the facility. This deficient practice has the potential to affect all residents who reside at the facility. Findings include: Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, congestive heart failure, and cognitive communication deficit. Review of the MDS dated [DATE] revealed R5 was moderately cognitively impaired. In an interview on 5/15/24 at 9:28 AM, Designated Power of Attorney (DPOA) J for R5 reported she tried to call R5 in his room when he resided at the facility and his phone did not receive incoming calls. The DPOA J reported she would then call the front desk and the phone would ring for a while and then would get an automated message that did not give the option…

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 This citation pertains to intake M100143672. Based on interview and record review, the facility failed to assist and provide written information on how to apply for and use Medicare and Medicaid benefits for 1 (Resident #5) of 1 resident reviewed, resulting in the resident/representative not having Medicaid coverage in a timely manner and had an out-of-pocket expense. Findings include: Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, congestive heart failure, and cognitive communication deficit. In an interview on [DATE] at 9:28 AM, Designated Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources. DPOA J reported the process of R5's financial journey has been stressful. His Medicare insurance ended in January, and the facility tried to discharge him home. She told the facility there was no…

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 This citation pertains to intakes M100142672 AND M100142556. Based on interview and record review, the facility failed to readmit 1 (Resident #5) of 3 residents reviewed for readmissions after hospitalization, resulting in a resident who was pending Medicaid needing to find placement at another facility. Findings include: Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, congestive heart failure, and cognitive communication deficit. Review of the MDS dated [DATE] revealed R5 was moderately cognitively impaired and required substantial to maximum assistance for most Activities of Daily Living (ADLs) and dependent for toileting, bathing, and mobility. In an interview on [DATE] at 9:28 AM, Designated Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources, costs/ fees, or bed hold policies. This…

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 This citation pertains to intake M100144078. Based on observation, interview and record review, the facility failed to provide care and services for pressure ulcers for 2 (Resident #8 and Resident #6), that required repositioning, assessment and monitoring, daily dressing care and/or wound vac (vacuum) care (a treatment that uses a special dressing and a pump to apply suction to a wound and promote healing). Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 re-admitted to the facility on [DATE] with pertinent diagnoses of a sacral pressure ulcer, unspecified disruption of wound, and paraplegia. During several observations on 5/15/24, R8 was observed in his room in bed lying in the same position, flat on his back with his upper body and head dominantly towards the right corner side of his bed, middle torso toward the center of the bed, and the lower limbs towards the right lower side of the bed in a semi C position. The times were as followed; 8:37 AM, 10:45 AM, 11:00 AM, 2:15 PM, and 4:14 PM.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure respectful and dignified treatment of two facility residents (Resident #1 (R1) and R2) by a Certified Nurse Aide (CNA F) providing cares in an unprofessional manner. Findings: R1 was originally admitted to the facility 5/1/23 with diagnoses that included History of Stroke and Diabetes Mellitus. The Minimum Data Set (MDS) dated [DATE] reflected the Resident is cognitively intact. Section GG of this MDS reflected R1 requires substantial/maximal assistance with personal hygiene. The Facility Reported Incident (FRI) investigation dated 12/1/23 completed by the facility was reviewed. The Investigation reflected that at approximately 9:00 AM on 12/1/23, R1 refused to allow Certified Nurse Aide (CNA) F to provide personal care to her. The facility investigation reflected Licensed Practical Nurse (LPN) D was summoned and R1 reported to LPN D that CNA F had been rough with her. Additionally, R1 reported that CNA F had called her a baby. The facility…

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, interview, and record review, the facility failed to secure 1 of 3 medication carts (100 Hall Medication Cart) and properly label a medication in 1 of 3 medication carts (100 Hall Medication Cart), resulting in the potential for misappropriation of medications and the potential for complications from administration of expired or contaminated medications. Findings include: During an observation on [DATE] at 02:10 PM, the 100 Hall Medication Cart was left unlocked at the nurse's station. The nurse was not within sight of the medication cart (she was in the lobby off of the unit). In addition, residents and visitors were walking up and down the hallway and using the elevator (the nurse's station was across the hall from the elevator). During an inspection of the 100 Hall Medication Cart on [DATE] at 02:20 PM with Registered Nurse (RN) D, three loose Thera-M tablets (multi-vitamins) were observed in a medication cup labeled Thera-M (being stored in an unauthorized container without proper…

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: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure proper concentration of quaternary ammonium sanitizer; and 3. Properly store chemicals to minimize the risk of contamination. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 55 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, at 9:15 AM on 10/3/23, it was observed that an accumulation of debris was found on the underside corners of the juice machine in the kitchen. When asked how often this piece of equipment gets cleaned, Kitchen Supervisor (KS) N stated every Friday. During the initial tour of the kitchen, at 9:42 AM on 10/3/23, observation of the clean utensil drawers found two mechanical scoops with stuck on food debris. Both scoops were taken to the dish machine to get cleaned. During a tour of the kitchen, at 9:48 AM on 10/3/23, it was observed that the top of the dish machine was found with 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.

Based on interview and record review, the facility failed to timely submit Payroll-Based Journal (PBJ) information for the Fiscal Year Quarter 3, 2023 (April 1 - June 30) resulting in no staffing data that is auditable or verifiable and the potential for inaccurate staffing information to be known to the state and federal entities. Findings: Review of the PBJ Staffing Data Report, Certification and Survey Provider Enhanced Report (CASPER) dated 9/27/23 reflected the facility failed to submit the required PBJ data for the above Fiscal Year Quarter. On 10/4/23 at 1:02 PM an interview was conducted with the Nursing Home Administrator (NHA) in his office. The NHA indicated that the deadline for the PBJ data was during a transition period within the facility organization. The NHA acknowledged the PBJ data was not submitted and reported that late submissions are not accepted.

This citation has 2 parts. Part A Based on observation, interview, and record review, the facility failed to protect clean and sanitary items from contamination and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in contamination of clean and sanitary supplies and an increased risk of water borne pathogens to exist and spread in the facility's plumbing system possibly affecting any or all of the 55 residents in the facility. During a walkthrough of the facility, with Maintenance Director (MD) O, at 2:45 PM on 10/3/23, observation of the laundry room found an accumulation of trash and debris underneath the false bottom of the laundry bin. Further observation found a spray bottle containing a blue solution that was not labeled with a common name. When asked to show how laundry flows through the laundry room, Laundry Aide C stated that she brings the soiled personal linen through the laundry door (Clean side), past clean linen, the folding…

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 valid Advance Directive was in place for one Resident (R192), resulting in the Durable Power of Attorney (DPOA), that had not been activated, signing paperwork without the authority to do so and the potential for the Advance Directives to not reflect the medical wishes of all facility residents. Findings: Review of the Electronic Medical Record (EMR) reflected R192 originally admitted to the facility 7/24/23 with pertinent diagnoses that included Urinary Tract Infection and Unspecified Dementia. Review of the Face Sheet for R192 reflected the Resident was her own person, that a DPOA was in place but was not activated. Review of the EMR did not reveal documentation that R192 had been deemed incompetent or unable to make medical decisions. Review of the EMR Advance Directive revealed R192 was given the code status of Do Not Resuscitate but the form was signed by someone other than the Resident. During an interview conducted 10/5/23 at 10:16 AM, the Nursing Home Administration (NHA) acknowledged that R192 had 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 interview and record review, the facility failed to follow facility policy on the prevention of abuse resulting in an allegation of abuse to be not reported and investigated and the potential for allegations of abuse to not be identified for all facility residents. Findings: Review of the Electronic Medical Record (EMR) reflected R192 originally admitted to the facility 7/24/23 with pertinent diagnoses that included Urinary Tract Infection and Unspecified Dementia. The EMR Progress Note entry for 9/2/23 at 2:18 PM was reviewed. The entry reflected, Daughter (name of daughter) stopped at the nurse's station and voiced concern that her mother reported that staff has been rough with her during cares. CNA (Certified Nurse Aide) stated patient was tearful with her morning cares after being incontinent and had her brief changed. Review of the policy provided by the facility reflected Procedure, 4. d. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .immediately to their supervisor or Senior Staff Member. And e. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline and comprehensive care plan for one post-surgical resident (R32) at risk for falls, resulting in a Resident with a history of falls with injury to remain at unmitigated risk for falls. Findings: Review of the Electronic Medical Record (EMR) revealed R32 admitted to the facility on [DATE] for rehabilitation following a fall with fracture at home then hospitalized for spinal surgery. The hospital document titled After Visit Summary reflected R32 is at risk for Falls, must wear a neck brace at all times and a clamshell brace (a large brace covering the upper torso) when out of bed and ambulating. Review of the care plan for R32 revealed a care plan focus of I am at an increased risk for falls (related to) . (no further documentation on the focus) Date initiated 9/16/23. The care plan area for Intervention/Tasks (the space provided for actual measures to protect this resident and prevent falls) is blank. This indicates that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the At risk Comprehensive Care Plan for changing skin integrity for one Resident (R28), resulting in no care plan for actual wounds under treatment and the potential for all facility residents to not have their plan of care reflect their current physical or mental status. Findings: Review of the Electronic Medical Record (EMR) reflected R28 admitted to the facility 5/1/23 with pertinent diagnoses that included: History of Stroke and Hemiplegia (weakness to one side of the body). Review of the Minimum Data Set (MDS) dated [DATE] reflected R28 was at risk for pressure sores but did not have any wounds at that time. Review of the EMR Skin assessment dated [DATE] revealed an open area was identified, and measurements of the open area were recorded. Review of the EMR Skin assessment dated [DATE] revealed a new open area was identified with measurements recorded in the EMR. Review of the Doctor's Orders revealed that orders for wound dressing changes…

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, interview and record review, the facility failed to implement care planned interventions, evaluate and analyze hazards and risks after falls and implement effective interventions to mitigate accident hazards and prevent falls for one resident (Resident #3) out of 2 residents reviewed for falls, resulting in injury from repeated falls. Findings: Resident #3 (R3) Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included acute posthemorrhagic anemia, acute kidney disease, gastrointestinal hemorrhage, parkinsonism, major depressive disorder, congestive heart failure, insomnia, anxiety, atrial fibrillation, difficulty walking and a history of strokes and transient ischemic attacks (TIA, also known as mini-strokes). R3 was diagnosed with acute osteomyelitis of the left foot and ankle (bone infection) after admission. Review of an admission Minimum Data Set assessment dated [DATE] reflected R3 was able to make himself understood and could understand…

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, interview, and record review, the facility failed to provide necessary respiratory care and services for 1 resident (R97) utilizing a CPAP (continuous positive airway pressure) machine, resulting in R97's CPAP equipment not being cleaned per facility policy and the potential for the spread of illness and disease. Findings include: A review of R97's admission Record, dated 10/6/23, revealed R97 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 97's admission Record revealed multiple diagnoses that included Alzheimer's Disease, immunodeficiency, chronic obstructive pulmonary disease (COPD- a lung disease), and insomnia. A review of R97's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/18/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R97 was severely cognitively impaired. During an interview on 10/03/23 at 10:15 AM, R97 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and/or timely implement a pharmacy recommendation for 1 of 5 residents (R8), resulting in R8 not receiving a medication as per pharmacy recommendations and physician approval and a delay in implementing a pharmacy recommendation. Findings include: A review of R8's admission Record, dated 10/6/23, revealed R8 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included iron deficiency anemia, bilateral (both sides) hip osteoarthritis, bilateral knee osteoarthritis, low back pain, and moderate protein-calorie malnutrition. A review of R8's electronic medical record, dated 10/13/22 to 10/6/23, revealed the following pharmacy recommendations: - 6/29/23= To help avoid a potential drug-drug (drug to drug) interaction, please separate administration of Ferrous sulfate (iron) and Calcium tablets by 2-4 hours. - 7/31/23= To help avoid a potential drug-drug (drug to drug) interaction, please separate…

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 safeguard the confidentiality of medical records for one resident (R32), resulting in the potential for unauthorized access to the medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: During an interview on 10/04/23 at 08:55 AM, Licensed Practical Nurse (LPN) H stated she hides her computer screen whenever she walks away from the computer. She stated she does this so no one can read her computer screen while she's away from the medication cart. During an observation on 10/05/23 at 10:10 AM, the medication cart computer screen was open to R32's medication administration record (MAR), specifically the pain assessment screen. The unattended medication cart was located outside of R32's room in the hallway where anyone walking by could view and access it. After the surveyor walked by and wrote down the information that was on the computer screen LPN E pulled the medication cart into R32's room. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 14 sampled residents (R94) had a means to contact staff in the case of needing assistance, resulting in R94 having no way to contact staff for help when in distress and the potential for a serious negative outcome. Findings include: A review of R94's admission Record, dated 10/5/23, revealed R94 was an [AGE] year-old resident admitted to the facility on [DATE] with pneumonia, chronic obstructive pulmonary disease (COPD- a lung disease), atrial fibrillation, an ascending aortic aneurysm, congestive heart failure (CHF), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD), and a history of falling. A review of R94's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/5/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which indicated moderate cognitive impairment. During an observation on 10/03/23 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 interview and record review, the facility failed to address 2 Residents (R3 and R4) concerns in a timely manner resulting in R3 not receiving her medications as ordered and R4's concern of neglect and abuse not getting addressed. Findings included: Review of the facility Grievances Policy dated 1/1/2023 reveal, It is the policy of this center that staff will promptly attempt to resolve grievances the resident may have, including those, which involve the behavior of others. They will be able to voice grievances without fear of reprisal or discrimination. 2. The Grievance Official will be the Administrator/Social Worker who is responsible for overseeing the grievance process, receiving and tracking grievances through their conclusions; leading any necessary investigation by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident 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 interview and record review, the facility failed to conduct a complete and thorough investigation regarding incidents involving 3 Residents (Resident#2, Resident#4, Resident#7) resulting in mental anguish and discomfort for the residents with the potential for ongoing abuse and neglect for all residents living at the facility. Findings include: R2 Review of the MDS dated [DATE] revealed R2 was originally admitted to the facility 12/13/22 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Pneumonia due to Coronavirus, and Diastolic (Congestive) Heart Failure. The MDS reflected the Resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS reflected that R2 required extensive assistance by 2 people for most areas of care. During an interview on 9/20/23 at 10:39 AM NHA- stated they did not have any staff interviews regarding R2's allegation on 12/17/22 at 2:00 AM. R2 alleged being denied care and was told by a staff member…

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 provide 1 Resident (R3) medications as ordered, resulting in R3 not sleeping well. Findings included: Review of R3's face sheet dated 9/20/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple sclerosis, neuromuscular dysfunction of bladder, cramp and spas, anxiety disorder, muscle weakness and repeated falls. She was her own responsible party. Review of R3's physician order dated 1/19/23 at 5:00 PM revealed, Diazepam oral tablet 5 mg, give 1 tablet by mouth in the evening for anxiety. Review of R3's January 2023, Medication Administration Record (MAR) revealed R3 received 11 doses of Diazepam from 1/19/23 to 1/31/23 and R3 should have received 13 doses. For 1/23/23 and 1/24/23 the MAR was coded a 9 (see nursing notes). Diazepam was not given on 1/23/23 and 1/24/23. Review of R3's nursing progress note dated, 1/23/23 at 9:49 PM revealed, Diazepam Oral Tablet 5 mg, give 1 tablet by…

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.