Little Falls Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 3 of 3 residents (R24, R34, and R46), reviewed and observed for self-administration of medications. Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], identified R24 was cognitively intact, and required assistance/supervision with activities of daily living (ADL's). During observation and interview on 4/15/24 at 6:12 p.m., a nebulizer machine was sitting on R24's nightstand and had an unknown solution sitting in nebulizer cup. R24 stated she self-administers nebulizer after staff sets it up for her and there are times when she forgets to do nebulizer treatment. R24 stated the solution in nebulizer cup was from this morning as she forgot to do nebulizer treatment. During record review on 4/16/24, the medication self-administration assessment, that was completed on 3/22/24, indicated R24 could not correctly administer…

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 document review, the facility failed to ensure resident's family and/or representative were updated timely for a change in condition related to resident death for 2 of 2 residents (R203 and R205) reviewed for notification of change. Findings include: Review of R203 electronic health record (EHR) identified a progress note dated [DATE], indicated at 9:45 p.m. R203 was found unresponsive with no vital signs, call was placed to hospice agency at 9:51 p.m. However, R203's EHR failed to indicate family/resident representative was updated regarding R203 passing away. When interviewed on [DATE] at 1:28 p.m., family member (FM)-B stated the facility did not contact the family when he was declining the day he died, family was informed two hours after he had passed away. FM-B stated family was told someone had sat with R203 while he was declining but there was no phone call made. When interviewed on [DATE], at 2:46 p.m. assistant director of nursing (ADON) stated typically hospice would update 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 document review, the facility failed to provide the resident or their representative a written bed hold policy at the time of hospital transfer for 1 of 6 residents (R24) who was reviewed for hospitalization. Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], identified R24 was cognitively intact, and required assistance/supervision with activities of daily living (ADL's). R24's progress notes indicated R24 was hospitalized on [DATE] and returned to the facility on 2/15/24. R24's medical record lacked evidence of a bed hold was provided at the time of transfer for hospitalization. During an interview on 4/18/24 at 3:07 p.m., assistant director of nursing (DON) expected when a resident was transferred out of the facility a bed hold was initiated by the cart nurse. DON stated she expected the case manager to follow up to determine if the resident wanted to continue holding the bed. DON confirmed that she could not find communication with the resident in regard to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, facility failed to ensure provider orders were followed to monitor vital signs for 1 of 1 residents (R51) reviewed for following physician's orders. In addition, the facility failed to obtain a provider order for a lap positioning belt for 1 of 1 resident (R29) reviewed for use of a positioning belt. Findings include: R51's Resident Face Sheet printed 4/18/24, indicated R51 had several diagnoses which included arteriosclerotic heart disease (narrowing of arteries), hypertension, congestive heart disease, nontraumatic subarachnoid hemorrhage (brain bleed). Review of R51's electronic health record (EHR) identified R51 was seen by nurse practioner (NP) on 2/2/24, NP ordered vital signs three times daily for increased risk of brain bleed. R51's EHR failed to reveal vital signs completed three times daily for 3 days. A review of residents closed hard chart failed to reveal vital signs were completed per order. During interview on 4/17/24, at 11:10 a.m. nurse consultant 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 observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R24) residents reviewed who's diagnoses included post-traumatic stress disorder (PTSD). Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], identified R24 was cognitively intact, and required assistance/supervision with activities of daily living (ADL's). R24's diagnoses included PTSD, anxiety disorder, and depression. R24's care plan dated 2/21/24 lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization related to PTSD. R24's electronic health record (EHR) consisted of a trauma assessment that was completed on 2/9/24, which indicated R24 had trauma in her past that affected her daily. Medications and talking to others helped her cope with her trauma. During interview on 4/17/24 at 11:43 a.m., nurse…

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 document review, the facility failed to ensure consulting pharmacist identified irregularities in the monthly drug regimen reviews for 3 of 5 residents (R11, R21 and R34) reviewed for unnecessary medications. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 as medically complex with intact cognition and diagnoses of hypertension, schizotypal disorder, pain in right leg, polymyalgia rheumatica, localized edema, morbid obesity due to excess calories, insomnia due to other mental disorder, depression, and urinary tract infection (last 30 days). R11's provider order dated 8/30/23- included monthly orthostatic blood pressure (BP) monitoring while on trazodone to be obtained on the 14th of every month. R11's order dated 11/27/23- included trazodone HCL 100mg tablet. One tablet by mouth every day at 7pm-10pm. R11's vital sign documentation listed one orthostatic BP obtained 2/14/24. No additional readings were recorded from the 8/30/23 to 4/18/24.…

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 document review, the facility failed to ensure monitoring for potential cardiovascular and neurological adverse effects with use of psychotropic medications for 3 of 5 residents (R11, R21 and R34) reviewed for unnecessary medications. Findings include:. R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 as medically complex with intact cognition and diagnoses of hypertension, schizotypal disorder, pain in right leg, polymyalgia rheumatica, localized edema, morbid obesity due to excess calories, insomnia due to other mental disorder, depression, and urinary tract infection (last 30 days). R11's signed provider order dated 8/30/23- included monthly orthostatic blood pressure (BP) monitoring while on trazodone to be obtained on the 14th of every month. R11's order dated 11/27/23- trazodone HCL 100mg tablet. One tablet by mouth every day at 7pm-10pm. R11's vital sign documentation listed one orthostatic BP obtained 2/14/24. No additional readings were recorded from…

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 document review, the facility failed to ensure 3 of 5 residents (R15, R24 and R34) reviewed for immunizations were offered and/or provided the Influenza vaccine and/or the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R15's face sheet, dated 4/18/24, indicated he was [AGE] years old. The immunization record, dated 4/16/24,…

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 call lights were answered in a timely manner that promoted dignity for 2 of 3 residents (R8, R9) reviewed for call lights. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE] identified moderately impaired cognition and no behaviors noted. R8 required substantial to maximal assistance with toileting hygiene, partial to moderate assistance with personal hygiene, and supervision or touch with all transfers. R8 used a manual wheelchair for transportation. R8 was always continent of bowel and bladder. R8's diagnoses included non-traumatic dysfunction, Alzheimer's, dementia, and anxiety. R8 was high risk for pressure ulcers. Nursing assistant (NA) care sheet dated 3/4/24, identified R8 was toileted at 12:00 p.m. and 4:00 p.m. R8's transfers were to be completed with a non-mechanical lift with assistance of one staff. R8's toileting plan required staff to toilet R8 upon rising in the a.m., every three to four hours, 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 observations, interview, and record review, the facility failed to respond to call lights timely for 2 of 3 residents (R8, R9) reviewed for call light responses and accommodation of needs Findings include: R8's admission Minimum Data Set (MDS) dated [DATE] identified moderately impaired cognition and no behaviors noted. R8 required substantial to maximal assistance with toileting hygiene, partial to moderate assistance with personal hygiene, and supervision or touch with all transfers. R8 used a manual wheelchair for transportation. R8 was always continent of bowel and bladder. R8's diagnoses included non-traumatic dysfunction, Alzheimer's, dementia, and anxiety. R8 was high risk for pressure ulcers. Nursing assistant (NA) care sheet dated 3/4/24, identified R8 was toileted at 12:00 p.m. and 4:00 p.m. R8's transfers were to be completed with a non-mechanical lift with assistance of one staff. R8's toileting plan required staff to toilet R8 upon rising in the a.m., every three to four hours, at bedtime…

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 document review, the facility failed to provide timely incontinence care for 1 of 3 residents (R3) who was dependent on staff to provide assistance with a check and change program for incontinence. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, disorganized thinking, and no behaviors. R3 was independent with activities of daily living (ADLs), ambulation with a walker, and all transfers. R3 was continent of bowel and bladder. R3's care area assessment (CAA) dated 3/5/24, identified R3 had a recent left hip fracture resulted from a fall. R3 diagnoses included dementia, muscle weakness, abnormalities of gait and mobility, bilateral hearing loss, benign prostatic hyperplasia (BPH) (enlarged prostate causes blockage of urine, frequent urination, and/or incontinence) with lower urinary tract systems and urinary urgency. Since R3 fractured hip he has required assistance with dressing, toileting, hygiene, and bed…

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 document review, the facility failed to follow physician orders and provide appropriate wound care to promote healing and prevent potential worsening of a moisture-associated skin damage (MASD) for 1 of 1 resident (R2) with current MASD. Findings include: R2's annual Minimum Data Set, dated [DATE], identified intact cognition with verbal behavioral symptoms such as screaming, threatening that significantly interfered with resident cares and disrupted care and living environment 1 to 3 times out of 7 days a week. R2 refused cares 1 to 3 days out of 7. R2 had impairment upper and lower body extremities on both sides and required substantial to maximal assistance with eating, toileting, upper and lower body dressing, roll right and left, chair/bed transfers, and does not walk. R2 was dependent on staff for oral hygiene, showers/bathes, personal hygiene, sit to lying, lying to sitting, sit to stand, and toilet transfers. R2 was frequently incontinent of bladder and always…

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 document review, the facility failed to implement recommended influenza A infection control procedures for the use of personal protective equipment (PPE), for masks, during direct cares with residents to prevent the spread of infection for 2 of 3 residents (R2, R7) observed. This deficient practice had the potential to affect all residents currently residing in the facility. Findings include: R2's influenza nasopharynx/nasal test results dated 3/1/24 at 5:54 p.m. revealed positive for influenza A. During an observation on 3/4/24 at 10:56 a.m., R2 laid in bed with curtain pulled to room. Sign posted before room entrance revealed STOP! Contact precautions, Gloves, Gown, Equipment, Transport (nothing on sign about a mask). Registered nurse (RN)-C entered R2's room with a mask, isolation gown, gloves on and pushed a vitals machine. At 11:00 a.m. RN-C exited R7's room, wiped off vitals machine and cuff, removed gloves, mask, isolation gown, and sanitized hands. R2 was heard coughing frequently, with his couch sound loose and wet. During an observation…

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 document review, the facility failed to ensure resident representative and physician were notified of falls with and without injuries for 1 of 3 residents (R1) reviewed for accidents. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia, anxiety disorder, and had severely impaired cognition. R1 was noted to have two or more falls with no injury and one fall with injury. Review of R1's Fall Investigations for falls on 8/8/23, 8/10/23, 8/14/23, 8/20/23, 8/24/23, 9/10/23, 9/23/23, 9/25/24 and 9/27/23 all lacked evidence of resident representative or physician being notified. R1's Progress Notes revealed: -On 9/19/23, R1 was found on the floor next to his bed. Multiple bruising noted from multiple falls in the past. Progress note lacked evidence of resident representative or physician being notified of fall. -On 9/28/23, R1 had unwitnessed fall no injuries noted however progress note lacked evidence 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 interview and document review, the facility failed to comprehensively assess and implement continuous monitoring for signs and symptoms of urinary tract infection (UTI) and notify physician timely with change in condition and/or worsening symptoms for 1 of 3 residents (R1), who were reviewed for change in condition. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia, anxiety disorder, and benign prostatic hyperplasia (BPH). R1 had severely impaired cognition and required intermittent catheterization and was noted to be occasionally incontinent of bladder and bowel. R1's care plan dated 1/23/24, identified R1 had bladder incontinent related to urinary retention and not being able to empty bladder requiring intermittent catheterization and occasional incontinence. R1's toileting schedule consisted of every 3-4 hours and as needed and directed staff to monitor urinary output and voiding pattern every shift, bladder scan if 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively re-assess and revise resident's care plan for 1 of 3 residents (R1) reviewed, who was cognitively impaired and had multiple falls resulting in minor injuries. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia, anxiety disorder, and had severely impaired cognition. R1 was noted to have two or more falls with no injuries and one fall with injury. R1's care plan dated 1/23/24, indicated R1 was identified to have periods of restlessness and would crawl out of bed onto fall mat due to delusions and staff were directed to distract resident and keep resident in the commons area when up in wheelchair. R1 was identified to have decreased ability to communicate and rarely or never understood others. Further, R1 was identified to be at risk for falls or injury due to cognitive deficits and directed staff to assist with proper footwear, encourage call light use 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 interview and document review, the facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for 3 of 3 residents (R1, R2, R3) reviewed who were prescribed schedule psychotropic medications. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of depression and did not exhibit any behaviors. R1's medication administration record (MAR) dated 10/1/23 through 10/31/23, revealed R1 had scheduled sertraline (Zoloft) 100 mg once daily with a start date of 8/7/23. R1's orders lacked evidence of behavior monitoring for any target behaviors. R1's Psychoactive Medication Informed Consent Form dated 8/7/23, identified R1 was prescribed Zoloft, an antidepressant, however document lacked evidence reason for use, target behaviors, and non-pharmacological interventions. R1's care plan lacked evidence of R1 requiring the use of an antidepressant, target behaviors staff would be expected…

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 document review, the facility failed to ensure an emergency room (ER) dental referral for follow-up dental services was acted upon and provided for 1 of 1 resident (R1) observed to have numerous missing and broken teeth with dental pain and reported difficulty chewing. Findings include: R1's face sheet indicated R1's primary payer source was Medicaid (government funded health insurance). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and independent with personal hygiene. R1's Admission/General Observation Assessment Results dated 6/26/23, identified an assessment section labeled Oral which indicated R1's mouth, gums, and teeth were free of problems. R1's ER visit progress note, dated 8/20/23, identified R1 complained of upper and lower plate dental pain for a three day duration in which he was assessed to have dental tenderness, gingival swelling, dental caries (tooth decay), dental abscesses (pockets of pus), and gum lesions (sores)…

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 document review the facility failed to ensure range of motion exercises were completed to prevent further contractures for 4 of 4 residents (R15, R29, R21 and R37) reviewed for range of motion (ROM). In addition, the facility failed to ensure an ordered hand splints was applied consistently to maintain range of motion for 1 of 1 resident (R21) reviewed for position and mobility. Findings include: R15's annual Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R15 was dependent on staff for all ADL's. R15's diagnoses included post-concussional syndrome (persistence of various symptoms such as headache, dizziness, problems with concentration and memory weeks after a mild head injury), dysphagia (difficulty swallowing) and contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of left wrist. R15's care plan dated 8/26/22, indicated R15 had a decline in ROM (range of motion)…

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 document review, the facility failed to ensure 4 of 5 residents (R28, R42,R5, R8) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Centers for Disease Control (CDC) recommendations. Findings include: The CDC's PneumoRecs VaxAdvisor identified: Based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose and patients age [AGE]-64 with the risk factor of diabetes mellitus are recommended to have one dose of PCV15 or PCV20 at least 1 year after their last dose of PPSV23. The CDC's Pneumococcal Vaccine Timing for Adults identified: Together with the patient, vaccine providers may choose to administer PCV20 to adults 65 years and older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. R28's facesheet dated 6/29/23, identified he was [AGE] years old, had a diagnosis of Type 2 diabetes mellitus and admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 2 of 2 residents (R22 and R37) reviewed who had a seatbelt in their wheelchairs and/or a device in the bed to prevent them from getting up. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required extensive assistance with activities of daily living (ADL's) and was diagnosed with Parkinson's disease. The MDS further identified physical restraints were not used. R22's care plan dated 12/13/22, indicated R22 was at risk for falls related to Parkinson's disease and had the following interventions in place: monitor for bleeding/bruising/cognitive changes with any fall or other injury, monitor pain after a fall, anti-tip backs located on chair, anti-tip backs on wheelchair so wheelchair did not tip backwards when resident was transferring. R22's care plan further indicated R22 would safely operate and maneuver a motorized wheelchair.…

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 R21's quarterly MDS dated [DATE], identified moderate cognitive impairment, was dependent on staff for most ADL's. Diagnoses included disease of spinal cord, and upper and lower extremity contractures. R21's care plan dated 12/29/22, indicated R21 was totally dependent on staff for grooming hygiene, dressing, and bathing. During observation and interview on 6/26/23 at 12:20 p.m., R21's face was unshaven, and fingernails were long. R21 stated he had not been shaved in a few days and did not remember the last time he received oral care. R21 stated he was supposed to receive assistance with oral care and shaving every day, but staff did not offer to help him. R21 stated his nails were longer than he preferred and would like them trimmed. During an observation on 6/28/23 at 7:40 a.m., nursing assistant (NA)-C and NA-F assisted R21 morning cares but did not offer to shave his face, or assistance with oral care. R37's quarterly MDS dated [DATE], identified moderate cognitive impairment, was dependent on staff for most…

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 document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R17) resident reviewed who had post-traumatic stress disorder (PTSD). Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, required supervision with most activities of daily living (ADLs). R17's diagnoses included PTSD, adjustment disorder, and depression. R17's care plan dated 12/28/22 lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization related to PTSD. During an interview on 6/26/23 at 12:43 p.m., R17 indicated he had a diagnosis of PTSD however did not like to discuss this with others as he was a private man. During an interview on 6/29/23 at 9:15 a.m., nursing assistant NA-B stated she was not aware of any current residents that had PTSD. During an interview on 6/29/23 at 10:02…

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 document review, the facility failed to ensure supply and administration of ordered medication for 1 of 5 resident (R19) reviewed for pharmacy services. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required extensive assistance with most activities of daily living (ADLs). Diagnoses included epilepsy, heart failure, diabetes, and depression. R19's current physician orders indicated an order for Keppra 500 mg three times daily for diagnosis of epilepsy. During an interview on 6/26/23 at 12:54 p.m., R19 stated she had not received her Keppra for a few days and did not know why. During observation and interview on 6/27/23 at 8:44 a.m., trained medication aide (TMA)-A administered R19's morning medications which included Keppra 500 mg. R19 asked TMA-A why she had not received her Keppra over the weekend. TMA-A explained R19 had not received the noon dose of Keppra for a few days because it had not been delivered from 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 observation, interview and document review, the facility failed to provide occupational therapy as ordered for 1 of 2 residents (R15) reviewed for therapy services. Findings include: R15's annual Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R15 was dependent on staff for all ADL's. Diagnoses included post-concussional syndrome (persistence of various symptoms such as headache, dizziness, problems with concentration and memory weeks after a mild head injury), dysphagia (difficulty swallowing) and contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of left wrist. R15's care plan dated 8/26/22, indicated R15 had a decline in ROM (range of motion) related to Dementia and accident history as evidenced by non-ambulatory, decreased movement in all extremities. During observation on 6/27/23 at 11:44 a.m., R15 had a rolled washcloth that was placed in left hand, between his thumb and pointer finger…

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 document review, the facility failed to ensure dishes were properly sanitized when their hot water temperature dishwasher failed to reach proper temperature and utilized a sanitizer spray, but instead of air drying the dishes, used the unsanitary practice of drying them with a towel. This had to the potential to affect all 52 current residents who were served food on the dishes. Findings include: On 6/27/22, at 1:23 p.m. during an initial tour of the kitchen dietary aide (DA)-A was observed washing dishes using a CMA brand, high temperature dishwasher. The thermometer on the wash cycle was registered at 110 deg F (degrees Fahrenheit), and the rinse temperature was 130 deg F. DA-A stated any time the rinse was below 180 the dishes should have been sprayed with sanitizer. DA-A proceeded to spray 3 plates and 2 glasses with sanitizer spay and then towel dried the dishes. During an interview on 6/27/22, at 1:32 p.m Cook-A stated she was not sure how long the dishwasher had not been working properly, but they were to spray the dishes with sanitizer…

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 document review, the facility failed to ensure narcotic and controlled substance cabinet in the COVID area was properly secured to prevent medication diversion for 2 of 2 residents (R4 and R205) whose narcotic and/or controlled medications were stored in the cabinet. Findings include: On 6/29/22 at 1:45 a.m. When interviewed trained medication aid (TMA)- A stated narcotic and controlled medications were stored in the steel cabinet bolted to the wall in the clean room for residents residing in the COVID unit. A gray steel cabinet was observed secured to the wall, the cabinet had 2 doors which had separate locks and different keys to open each door. Cabinet was observed to have both doors open with the keys attached to a lanyard hanging in the lock of the second door. TMA was located in the room with the cabinet and was able to view the cabinet while in the room. On 6/30/22 at 10:47 a.m. the narcotic and controlled medication cabinet was observed in the COVID unit to have both doors open, with keys on lanyard hanging from second door lock, there was…

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

Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 3 of 3 residents (R5, R39, and R52) reviewed for food. Findings include: On 6/27/22, at 2:33 p.m. R5 stated the food was always served cold and tasted horrible. On 6/28/22, at 3:30 p.m. R39 stated, the food had been fairly hot until recently when there had been a few times the food was not always warm when it reached her room. On 6/29/22, at 7:33 a.m. food service for the breakfast meal began on the units. On 6/29/22, at 7:51 a.m. R5 stated his breakfast was cold this morning. R5 was sitting in a chair in his room with a plate of eggs, bacon, and toast sitting on a tray in from of him about 25 percent of the food was eaten. R5 stated it was unappetizing when served cold. On 6/29/22, at 7:55 a.m. R52 stated her food was not very warm. R52 was sitting in her room with eggs and hot cereal on a tray in front of her. Only a few bites of hot cereal were eaten, and stated it was due to the temperature. On 6/29/22, at 8:09 a.m. a tray was…

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