Grand Avenue Rest Home

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 18 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 1/1/24 to 3/31/24 revealed there was no RN scheduled for 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/16/24, 2/17/24, 2/18/24, 2/24/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/30/24, and 3/31/24. During interview on 8/26/24 at 9:17 a.m., the interim director on nursing (DON) confirmed the dates identified that there was no RN coverage. During a follow up interview on 8/28/24 at 9:39 a.m., the interim DON stated they were to have an RN in the building at least 8 hours a day. Requested a policy regarding staffing, none provided.

Based on observation, interview and record review, the facility failed to identify quality deficiencies and to develop and implement appropriate actions to correct these deficiencies. Furthermore, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 18 residents. Findings include: A review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report (a quality measure report for nursing facilities) last updated 8/18/24, indicated the facility had the following deficiencies with a survey exit date of 9/01/23: - F727 RN Coverage for 8 hours per day for 7 days per week. - F758 Free from Unnecessary psychotropic medications. - F880 Infection prevention and control. - F881 Antibiotic Stewardship program - Emergency Preparedness (EP)0009 Local, State, Tribal Collaboration Process - EP0029…

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 off interview, observation, and document review the facility failed to utilize proper handling of linen to prevent contamination, failed to have a functioning infection surveillance program, and failed to have a functioning water management program. This had the potential to affect all residents who resided in the facility. Linen During an observation on 8/26/24 at 2:53 p.m., nursing assistance (NA)-A walked through the kitchen carrying a mesh-designed hamper and within it, dirty resident clothing. During an interview on 8/26/24 at 2:55 p.m., cook aide (CA)-B stated other staff will walk through the kitchen with laundry or go out and around the back. During an observation and interview on 8/27/24 at 2:04 p.m., NA-A carried an uncovered basket of clean linen through the kitchen. NA-[NAME] stated this was their process to bring clothing through the kitchen, clean and dirty. During an interview on 8/28/24 at 9:33 a.m., the interim director of nursing (DON) stated staff should be using the back door to the…

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

Based on interview and document review, the facility failed to have a functioning antibiotic stewardship program. This had the potential to affect any resident who had infections requiring antibiotic use. Findings include: During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning antibiotic stewardship program in place. IP stated it was their intention to rebuild the program. The one-page Grand Avenue Rest Home Antibiotic Stewardship Program policy undated, indicated the IP will track and assess all antibiotic use to review patterns of use and assure appropriate antibiotic use . The IP will review any antibiotic order and reassess the ongoing need for and choice of an antibiotic as more information becomes available. The policy lacked protocols and criteria for determining what was appropriate use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure orthostatic blood pressure monitoring was in place for 4 of 5 residents (R1, R8, R5, R13) reviewed for psychotropic medications. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R1's Care Area Assessment (CAA) for psychotropic drug use dated 2/28/24, indicated she mental illnesses and was being treated long-term with psychotropic medications for her personal best in mental health stability. The CAA indicated all disciplines…

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 notify and consult with the resident's physician after a resident (R1) was tested for Coronavirus disease 2019 (COVID-19). Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated 2/28/24, identified she had a respiratory disease that could affect her appetite or nutritional status. An initial nursing assessment, careplan, and progress notes document dated 2/21/24, indicated R1's lung sounds were clear with no labored breathing noted. The assessment further indicated R1 did not have…

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 personal privacy could be maintained in resident room for 1 of 3 residents (R8) reviewed for privacy. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and was independent with her activities of daily living (ADLs). R8's MDS also indicated she had diagnoses of anxiety, bipolar disorder, and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). Furthermore, the MDS indicated R8 experienced hallucinations and delusions and exhibited verbal and other behavioral symptoms for 1-3 days during the lookback period. R8's annual MDS dated [DATE], indicated she felt it was very important to take care of her personal belongings and things. A progress note dated 3/25/24 indicated staff knocked on R8's door and when they did not hear a response, opened the door, and…

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

Based on record review and interview the facility failed to ensure a potential incident of neglect was recognized and reported to the State Agency (SA) after the administration had knowledge of the incident. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During interview on 8/27/24 at 11:17 a.m. interim Director of Nursing (DON) stated she was aware of a fire that had taken place a few weeks before she started working at the facility. DON stated she did not see any investigation report regarding the fire. DON stated she did not know if the fire had been reported to the SA. During interview on 08/27/24 at 11:28 a.m. Administrator acknowledged there had been a fire in the smoking room on the second floor of the facility sometime in May 2024 and the incident should have been investigated by the social worker (SW). Administrator went on to say she expected staff to file an incident report, update the management staff and complete all appropriate reporting to SA. Administrator stated the SW was enroute to the facility 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 observation, interview, and document review, the facility failed to have a process in place to ensure resident medications were re-ordered in a timely manner for 1 of 1 residents (R1). Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated [DATE], identified she had a respiratory disease that could affect her appetite or nutritional status. R1's Care Area Assessment (CAA) for psychotropic drug use dated [DATE], indicated she mental illnesses and was being treated long-term with psychotropic medications for her personal best in mental health…

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 recognize a change in respiratory status for 1 of 1 residents (R1) reviewed for change of condition. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated 2/28/24, identified she had a respiratory disease that could affect her appetite or nutritional status. An initial nursing assessment, careplan, and progress notes document dated 2/21/24, indicated R1's lung sounds were clear with no labored breathing noted. The assessment further indicated R1 did not have a cough. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure smoking interventions were implemented to reduce the risk for avoidable injuries for 1 of 1 (R7) reviewed for smoking. Findings include: R7's annual Minimum Data Set (MDS) dated [DATE] indicated R7 had diagnoses to include depression, schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), and asthma. R7's smoking assessments dated 9/27/22, 12/27/22, 6/23/23, and 8/14/24 indicated R7 had a history of injuries secondary to smoking, and staff should store all smoking supplies in the nursing office. R7's care plan with an initiated date of 10/13/22 and revision date of 8/14/24, indicated R7 was on a smoking plan, could receive 10 cigarettes per day, and facility staff was to store her smoking supplies. The care plan also indicated R7 would be assessed for safe smoking practices at time of admission, significant change, and annually for determination of ability to smoke safely. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities for errors involving 1 of 5 residents (R1) who were observed during the medication pass. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and independent with most activities of daily living. The MDS indicated R1 had anxiety disorder, depression, and shortness of breath with exertion (activity). R1's annual MDS dated [DATE], identified R1 had chronic obstructive pulmonary disease (lung disease that limits airflow which may cause breathing problems). R1's care plan focus initiated on [DATE], indicated Resident uses Anti-Depressant (Zoloft) related to Diagnosis of Major Depressive Disorder: Resident displays: Depression, Feeling depressed, bad about self, sleep problems. Staff were tasked with providing medications per…

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 a once monthly injection was administered per physician orders, resulting in the monthly injection being administered twice over two days for 1 of 4 residents (R1) reviewed for medication errors. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact and independent with activities of daily living. R1's Face Sheet dated 7/18/24 indicated R1 had diagnoses of schizoaffective disorder, bipolar disorder,and extrapyramidal movement disorder (brain abnormalities that can lead to motor deficits). R1's Physician Order started 7/4/24 directed Invega Sustenna (Antipsychotic) Intramuscular Suspension Prefilled Syringe 234 milligrams/1.5 milliliters (Paliperidone Palmitate). Inject 1 dose intramuscularly one time a day every 28 days related to schizoaffective disorder. R1's care plan dated 7/10/24 indicated on 7/3/24, due to increased behaviors, nursing reviewed medication records and discovered that Invega…

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 maintain a system that assured full and complete accounting of resident personal funds entrusted to the facility which had the potential to affect 14 of 14 residents who had trust fund accounts. In addition, the facility failed to provide quarterly statements for individual resident trust fund accounts for 5 of 14 residents (R6, R9, R1, R10, R14) reviewed who had resident trust accounts accounts. Findings include: On 4/11/24 at 10:09 a.m., the director of nursing (DON) stated the facility kept petty cash withdrawn from the resident trust funds in two locations, a cash box for use during business hours and a cash box in the nursing cart for use after hours. The DON counted the cash in the business hours box which totaled $293.59 and the cash in the after hours box which totaled $99.05. The DON confirmed the combined total cash was $392.64. The business hours box also contained receipts for two resident withdrawals from 4/10/24 totaling…

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 document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the total balance of the resident trust fund, which had the potential to affect 14 of 14 residents (R1 to R14) who had a personal trust account managed by the facility. Findings include: The transaction history for the facility's resident trust fund savings account from 4/1/24 to 4/11/24, identified the account balance on 4/11/24 was $21,783.88. The transaction history for the facility's resident trust fund checking account from 4/1/24 to 4/11/24, identified the account balance on 4/11/24 was $2,636. The combined total balance on 4/11/24 of the two resident trust fund accounts was $24,419.88. The facility's surety bond (legally binding contract protecting the resident trust funds) with effective date of 9/9/23, was for a sum of $20,000. The sum was inadequate to cover the balance of the resident trust fund on 4/11/24. During an interview on 4/15/24 at 10:36 a.m., the chief financial officer (CFO) stated the surety bond did not cover the balance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to update a care plan to include a resident history of leaving the facility against the leave of absence policy for 1 of 3 patients reviewed when R1, who was her own person, left the facility overnight and did not inform staff when she would return. R1 admitted to the facility on [DATE] at 10:10 a.m. from an outside facility. R1's diagnoses included paranoid schizophrenia, post-traumatic stress disorder, schizoaffective disorder, delusional disorders, and major depressive disorder. On 3/27/24, a progress note indicated R1 left the facility at approximately 10:30 a.m. On 3/28/24 at 8:52 a.m., a progress note indicated R1 had returned at an undetermined point and planned to leave the facility again on 3/28/24. On 3/29/24 at 6:26 a.m., a progress note indicated R1 did not return to the facility during the overnight shift. On 3/29/24 at 10:10 a.m., a progress note indicated R1 refuse to disclose her whereabout to the facility but would contact 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 interview and record review the facility failed to grant a resident request to access their personal funds within three business days for one of one resident (R1) reviewed for personal funds when the facility was notified on 1/8/24 the resident would like to access her money and the facility denied her access. Findings include: R1's admission Record printed on 2/16/24 indicated R1 was admitted to the facility on [DATE] with primary diagnoses of a traumatic brain injury and depression. R1's Trust Account Authorization dated 8/25/23, indicated R1 authorized the facility to handle any or all her personal funds and to assist her with business mail as needed. R1's care plan initiated 8/1/22 and revised 11/8/22 and 5/23/23 indicated R1 was her own person, and she managed her own finances responsibly. R1's care plan indicated R1 continued to manage her finances independently and staff would assist with money management if requested. R1's care plan indicated R1 brief interview for mental status (BIMS) score 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a resident with quarterly statements and upon request for two of two residents (R1, R2) reviewed for personal funds when R1 and R2 stated they have not received quarterly statements from the facility. Findings include: R1's admission Record printed on 2/16/24 indicated R1 was admitted to the facility on [DATE] with primary diagnoses of a traumatic brain injury and depression. R1's Resident Funds Policy dated 10/27/21 signed by R1 indicated each resident would have a financial record of beginning balances, deposits, and withdraws. R1's Trust Account Authorization dated 8/25/23 signed by R1 indicated quarterly statements would be issued to the resident or guardian at the end of each calendar quarter. The policy indicated review and/or additional statements would be available upon request during regular business hours. R2's admission Record printed on 2/21/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report staff to resident abuse timely for 1 of 1 resident (R1) who alleged verbal abuse by staff. Findings include: R1's quarterly Minimum data set (MDS) dated [DATE], identified intact cognition. During an interview on 10/25/23 at 3:30 p.m., licensed social worker (LSW) indicated on 10/22/23, she had gone into the facility electronic records from home to review progress notes and read a progress note the director of nursing (DON) had wrote on 10/20/23 at 12:31 p.m. regarding a staff to resident verbal altercation which should have been reported. LSW stated she spoke with the DON on 10/22/23, around 3:30 p.m. and informed her the incident should have been filed with the state and the immediately investigated. LSW stated she then notified the administrator (out on funeral leave) on 10/22/23. LSW verified they filed the complaint with state agency (SA) on 10/22/23, between 5:00 p.m. and 6:00 p.m. (more than 48 hours later). 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 interview and document review, the facility failed to prevent potential further abuse during an investigation and ensure allegations of potential abuse were thoroughly investigated for 1 of 1 resident (R1) who reported allegations of staff to resident abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). R1's medical diagnoses included: anxiety disorder, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). R1's progress noted on 10/20/23 at 12:39 p.m., director of nursing (DON) indicated R1 reported she had been yelled at by a staff in the morning, felt suicidal, and did not want to get out of bed. DON wrote R1 was out of bed and appeared anxious. DON spoke with R1 and she denied suicidal ideation's, endorsed being yelled at by staff, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to ensure medications were administered as prescribed by the physician for 1 of 3 residents (R1) who reported symptoms of constipation. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). R1's medical diagnoses included: anxiety disorder, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). R1 was independent with personal hygiene, toileting, and continent of bowel. R1's face sheet dated 10/26/23, identified diagnoses constipation and intestinal obstruction. R1's physician orders identified: - 4/20/22, Metamucil Fiber Packet (Psyllium) give 1 packet by mouth two times a day related to constipation. Take in 8 ounce (oz) liquid. -12/24/22, Bowel monitoring 1 unspecified miscellaneous…

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 document review, the facility failed to ensure the purchased surety bond (a contract or promise by a surety or guarantor to pay if a second party fails to meet the obligation) had sufficient coverage to protect the total account balance of the resident trust fund. This had the potential to affect 15 of 15 residents who had a trust account while residing at the facility. Findings include: A facility provided Trust Transaction History report dated 8/31/23, identified 15 current resident trust accounts were managed by the facility. The sum of all 15 resident trust accounts on 8/31/23 totaled $16,659.88. During an interview on 8/31/23 at 2:06 p.m., the medical records specialist (MRS)-A, who was responsible for the day-to-day accounting for resident trust accounts, indicated he was unaware of a surety bond. During interview on 9/1/23 at 8:02 a.m., the administrator stated he would have to request the surety bond as he did not have it on hand. A Nationwide Mutual Insurance Company Verification Certificate dated 2/1/23 and effective until 1/31/23 was provided 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.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 17 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 6/1/23 to 8/28/23 revealed there was no RN scheduled for 6/24/23, 7/8/23, 7/9/23, 7/31/23, 8/12/23, 8/26/23 and 8/27/23. During an interview on 8/30/23 at 8:46 a.m., the director of nursing (DON) stated the facility tried to keep an RN on staff 8 hours per day 7 days a week, but sometimes did not happen. The DON stated she was the RN coverage during the weekdays, but there were occasional RN call-ins that took place on the weekend that could only be replaced by licensed practical nurses (LPNs) from a staffing agency. During an interview on 8/31/23 at 10:31 a.m., the administrator reviewed staff schedules and staffing hours from 6/1/23 to 8/28/23. The administrator verified no RN was onsite 6/24/23, 7/8/23, 7/9/23. 7/31/23, 8/12/23, 8/26/23 or 8/27/23. The administrator stated 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 ensure cooking utensils were properly sanitized (i.e., high temperature) in 1 of 1 commercial dishwashers observed in the main production kitchen. This had potential to affect all 17 residents, visitors, and staff who consumed food from the kitchen. Finding include: During interview on 8/30/23 at 10:49 a.m., dietary manager (DM) stated she usually worked at another facility but was spending more time at this facility due to staffing shortages and was training a new full-time dietary supervisor (DS). DM identified the dishwasher was [NAME], used heat to sanitize, was installed in 1998, held one rack, and required a wash temperature of 150 degrees Fahrenheit (°F) and a rinse temperature of 180°F to ensure dishes were sanitized. Staff tracked temperatures at each meal on a form located on the counter. During observation and interview on 8/30/23 at 1:15 p.m., the dishwasher wash temperature was observes at 134°F, and the rinse temperature…

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 transport and store linens to prevent contamination, remove and replace soiled furniture to prevent the spread of bacteria, and failed to implement a surveillance plan, for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. This had the potential to affect all residents, visitors, and staff in the facility. Findings include: Furniture During interview on 8/28/23 at 7:17 p.m., anonymous resident (AR)-A stated staff said the facility would replace the communal living room leather furniture because it was all stained with urine. She stated the residents needed to sit on a towel or their clothes smelled like urine, and both the furniture and the room lighting were so dark it was hard to see what one could be sitting in. R10's quarterly Minimum Data Set, dated [DATE], indicated she was severely cognitively impaired, required extensive assistance of one staff 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.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, and trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: The Grand Avenue Residence Antibiotic Stewardship Monthly Log listed four occurrences where antibiotics were dispensed to residents from 1/1/23 through 8/31/23. The form included resident name, date, infection, antibiotic, completion date and outcome, but lacked evidence of review for appropriate antibiotic use and appropriate action taken. The 'Details Rxs and supplies categorized by therapeutic class and/or products' pharmacy report for the period 1/1/23 through 8/31/23, included 16 dispensed prescriptions for antibiotic/antibacterial medications. During interview on 9/1/23 at 9:33 a.m., director of nursing (DON) stated she was the infection preventionist for the building for the past year. She identified she did not have a report or log of all residents who had orders…

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 appropriate side-effect monitoring (i.e. blood pressures [BP], involuntary movements) was completed for 3 of 5 residents (R1, R15, R17), failed to identify a duplicate as needed (PRN) psychotropic medication (drugs that affect a person's mental state) for 1 of 5 residents (R1), failed to ensure residents were reassessed for continued use of PRN antipsychotic medications (used for a variety of mental health disorders), beyond the 14 days for 3 of 5 residents (R1, R9, R15), failed to identify a possible drug allergy for 1 of 5 residents (R1), and failed to appropriately schedule administration of medication to treat orthostatic hypotension (a rapid drop in BP with change in position) for 1 of 5 residents (R15) reviewed for unnecessary medications. Findings include: R1 - Monitoring of Orthostatic BP and Side Effects, Duplicate Antipsychotic Order, 14-day PRN, Allergy R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure written notice was sent to the resident and/or the resident's representatives after emergent transfer from the facility to the hospital for two residents (R5, R8) who were reviewed for hospitalization. Further, the facility failed to send a copy to a representative of the Office of the State Long-Term Care Ombudsman. The failure to provide the required written notices containing all required information places the residents at risk of involuntary transfer and/or not being informed of their rights, including how to appeal their transfer. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact. R5's progress note dated 8/22/2023 at 11:44 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R5's medical record revealed no evidence a hospital transfer notice was provided to the resident. During interview on 8/28/23 at 6:44 p.m., R5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure each resident and/or responsible party was provided a written bed hold policy/notice at the time of each discharge for 2 of 2 resident (R5, R8) reviewed for hospitalization. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact. R5's progress note dated 8/22/2023 at 11:44 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R5's progress note dated 8/24/23 at 12:09 p.m. indicated medical record specialist (MR) sent a copy of the bed hold policy directly to the hospital, one for the hospital chart and one for R5. R5's medical record revealed no evidence a bed hold policy/notice was provided to the resident. During interview on 8/28/23 at 6:44 p.m., R5 stated she recently went to the hospital via ambulance and indicated she did not receive any paperwork including a bed hold notice. R8's quarterly MDS dated…

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 make a followup appointment for 1of 1 resident (R7) reviewed for vision received services to obtain assistive devices needed to maintain vision abilities. Findings include: R7's admission Record accessed 8/31/23 indicated R7 had a diagnosis of diabetes and bilateral myopia (difficulty seeing things at a distance). R7's Minimum Data Set (MDS) Annual assessment dated [DATE] indicated R7 was in need of corrective lenses. During an interview on 8/28/23 at 6:35 p.m., R7 stated they had been to an eye specialist several months ago and received a new lens prescription. R7 further stated they had been waiting to receive new glasses since at least May but had not received any new lenses or a notification from the facility about an appointment to pick up new glasses. A document in R7's medical record indicated R7 went to an optometrist on 4/17/23. During this visit, it was determined R7 needed a lens prescription change and received a recommendation for new…

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 2 of 5 residents (R6, R15) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Centers for Disease Control (CDC) recommendations. Findings include: R6's Medical Diagnosis list printed 8/31/23, indicated she was [AGE] years old and had diagnoses of Type 2 diabetes mellitus and nicotine dependence, and no allergies to vaccines or contraindications to the pneumococcal vaccine. R6's immunization documentation indicated she had one dose of PPSV 23 on 12/19/09, and another dose of PPSV 23 on 12/19/17. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 19-64 who have not received PCV15 or PCV20, with a risk factor of Type 2 diabetes mellitus and nicotine dependence and had a PPSV23, Give one dose of PCV15 or PCV 20 at least one year after their last dose of PPSV23. If PCV 20 is used their vaccinations are complete. R15's Medical Diagnosis list printed 8/31/23, indicated she was [AGE] years old and had a diagnosis…

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.