Crestview Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development and/or deterioration of pressure ulcers (PU) for four of 12 sampled residents (Resident #28, #92, #11, and #15). Facility staff failed to ensure the physician was notified of the PU and treatment obtained timely for one resident (Resident #92). The facility failed to ensure PU precautions were adhered to for one resident, resulting in the resident developing a PU (Resident #15), and failed to thoroughly assess and document assessments and measurements, and update the physician to obtain treatment orders for a new pressure ulcer for (Resident #92) and when a PU deteriorated for (Resident #11). Furthermore, the facility failed to follow their protocol assessment and documentation of skin issues when nurses did not consistently document and/or sign shower sheets at the time of a shower for two residents (Resident #28 and #92). The facility census 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 observation, interview and record review, the facility failed to provide adequate staffing to reposition and provide incontinence care for three residents who were at risk for pressure ulcers (Residents #28, #92, and #15), failed to answer the call light in a timely manner resulting in incontinence for one resident (Resident #92), and failed to provide two showers per week to one resident (Resident #28) as a standard of care. Additionally, the facility failed to ensure enough staff were in the dining room to assist residents who required assistance during meals, resulting in one staff member going between two tables to assist eight residents who needed nutritional assistance. The facility census was 40. The facility did not supply a policy on staffing. Review of staff schedules showed: -January 14th: day shift staff included 1 Licensed Practical Nurse (LPN), 1 Certified Medication Technician (CMT), and 4 Certified Nurse Aides (CNA); Night shift included: 1 Registered Nurse (RN), 2 CNAs and 1 Nurse Aide…

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 provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The census was 70. The facility did not provide a policy on staffing. Observation and interview on 02/23/25 at 9:44 A.M., showed: -Licensed Practical Nurse (LPN) B was the Charge Nurse; -He/She was the only nurse at the facility; -He/She was the only nurse the previous day; -There was no RN in the facility. Review of the daily staffing sheets showed no RN on: July 2024: 6th, 7th, 20th, and 21st; August 2024: 3rd, 4th, 17th, and 18th; September 2024: 1st, 14th, 15th, and 24th; No staffing sheets provided for October; November 2024: 16th, 17th, 23rd, 28th, 29th, and 30th; December 2024: 1st, 6th, 7th, 8th, 14th, 15th, 21st, 22nd, 24th, 26th, 27th, 28th, 29th, 30th, and 31st; January 2025: 4th, 5th, 11th, 12th, 15th, 18th, 19th, 25th, and 26th; February 2025: 1st, 2nd, 22nd, 23rd, and 26th. Observation of on-line staffing services showed an advertisement for a full time RN. During an interview on 02/27/25 at 12:28 P.M., the Quality…

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 nurse aides had a yearly performance review, with resulting individually based education plans, for three nurse aides employed longer than 12 months. The facility census was 40. The facility did not provide a policy for education, and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide (CNA) D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No competency assessment and training plan. -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. -CNA F, Date of Hire DOH 9/17/01, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. During an interview on 02/27/25 at 12:28 PM, the Quality Assurance Registered Nurse said trainings and tracking were completed by nurse leadership. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -The previous Director of Nursing (DON) completed the last competency. -He/She did not know the date of the last competency. -He/She expects 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, record review, and interview, the facility failed to ensure staff prepared foods in a way to meet the needs of individual residents, when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency and failed to ensure the mechanical soft diet contained meat that was ground and easy to chew. This affected two residents who had orders for a pureed diet (Residents #6, and #15) and one resident (Resident #3) who had an order for a mechanical soft diet. The facility census was 40. Review of the facility's policy titled, Types of Diets, dated, May 2015, showed: -Mechanical soft diet is a regular diet modified using chopped or ground meat; -Puree diet foods are blended to mashed potato consistency or altered to meet the needs of the residents. 1. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/08/25, showed:…

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 one of 12 sampled residents (Resident #15) received necessary assistance with activities of daily living (ADL). Resident #15 was dependent on a mechanical lift and two staff for transfers and required assistance with all his/her ADL's. Facility staff failed to reposition the resident every two hours and to provide timely perineal care. The facility census was 40. The facility did not provide a policy for timing and repositioning and perineal care for a resident's. 1. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, toileting needs, and get to dressed; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following…

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 provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of three sampled residents (Resident #7) when staff failed to obtain a physician ordered blood transfusion in January 2025 for an anemic resident in a timely manner. The blood transfusion was not carried out until fourteen days after it was ordered. The facility census was 43. Review of facility policy titled Physician Orders, undated, showed physician's orders must be signed by the physician and dated when such order was signed. Review of facility policy titled Lab Reporting Guidelines, undated, showed: -Guidelines will be followed to ensure that lab recommendations are completed timely; -Nurse will received the lab for a lab draw; write a telephone order and document the order on the physician order sheet (POS) or note the order on the POS when written by the physician. -The nurse will document on the lab report that the physician had been notified to include how they were notified,…

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 staff failed to ensure a resident (Resident #15) with limited range of motion (ROM) to his/her left hand received treatment to prevent further ROM loss. The facility census was 40. Review of the facility's undated policy titled, Range of Motion, showed: - ROM was suppose to be provided to prevent contractures from becoming worse; To maintain normal ROM; - The facility staff can provide passive range of motion (PROM) for residents that cannot complete it themselves; To simulate circulation. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, with toileting needs, and to dress; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed 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 observation, interview, and record review, the facility failed to prevent a significant weight loss for one of 12 sampled resident's (Resident #15), when the facility did not provide the resident with his/her physician ordered Magic Cup (a nutritional supplement that contains additional calories and protein for persons experiencing involuntary weight loss) daily at lunch. The facility census was 40. The facility did not provide a significant weight loss policy. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture) and dysphagia (difficulty swallowing); - He/She required assistance from staff to transfer, with toileting needs and to dress; - He/She received a therapeutic diet and a mechanically altered diet; - He/She had weight loss. Review of the resident's face sheet showed 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 record review, the facility staff failed to store nebulizer machine masks in a bag when not in use for two residents (Resident # 15 and #38) of 12 sampled residents. The facility census was 40. The facility did not provide a policy for nebulizer masks. 1. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), bronchitis, and weakness. Review of the residents Physicians Order Sheet (POS), dated February 2025, showed an order dated 9/16/24 for Ipratropium-Albuterol (a liquid medication inhaled to treat breathing problems) 0.5 milligram (MG)- 3 MG per 3 milliliter (ML)…

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 document identification and use of possible alternatives prior to use of Halo side rails (a circular bed rail used for repositioning and bed mobility); failed to document assessing risk versus benefits of Halo side rail use; failed to obtain informed consent for the use of Halo side rails prior to installation; and failed to complete ongoing assessments to ensure the side rails were appropriate for use for one resident, and do not pose an entrapment risk (Resident #6), in a sample of 12 residents. The facility census was 40. Review of the facility provided, undated, Bed Rails policy showed: -Once a bed rail observation is completed the facility will review the associated risks and benefits with the resident and/or resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well. -Educate the resident/legal representative on the benefits and risks of bed rails; -Develop a care plan that outlines the medical factors…

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, interviews and record review the facility failed to prevent compromised skin integrity for two of 4 sampled residents, (Resident #1 and Resident #2) when the staff did not alert the charge nurse when Resident #1 had open areas to the back of his/her upper right thigh and did not ensure the resident was turned to his/her side after cares. The staff did not ensure Resident #2 was turned to his/her side when the resident was found to have dark red buttocks after cares were provided. The facility census was 39. Review of the undated pressure ulcer care and prevention policy showed: - The purpose of the policy was to prevent and treat further breakdown of pressure ulcers; - Observe the resident's skin. Areas that remain reddened after pressure has been relieved is at risk for developing into a pressure ulcer; - Use pressure relieving devices; - Reposition resident's every two hours. 1. Review of Resident #1's annual Minimum Data Set, (a federally mandated assessment completed by 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.

Based on observation, interview, and facility policy review, the facility failed to ensure staff stored food for residents in a sanitary manner. Specifically, the facility failed to label, date, and discard left over food. This had the potential to affect 43 of 43 residents who received nourishment from the facility kitchen. Findings included: A facility policy titled, Food Safey Requirements, undated, indicated, Proper Labeling and Dating of all foods. All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after the third (3rd) storage day. An observation of the kitchen was conducted on 05/20/2024 at 9:37 AM with the Dietary Supervisor (DS). More than 50 heavily frosted freezer storage bags that contained left over food items were observed in the facility's deep freezer. Forty-two of the freezer storage bags were dated ranging from 03/17/2024 to 04/14/2024 with no description of the contents. Ten of the freezer storage bags did not contain a proper date or description of the contents. 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.

Based on interview and facility document review, the facility failed to maintain a water management program to minimize the risk of Legionella in the facility's water supply. This had the potential to affect all 43 residents who resided in the facility. Findings included: During an interview on 05/22/2024 at 11:15 AM, the Administrator stated the facility did not have a policy for general maintenance. The facility's Monthly Water Management Checklist, dated 05/06/2024, revealed, the date of the last annual cleaning and control measure checks were on 05/06/2024 and included the following systems and fixtures: showerheads/hoses, water heaters, hot tubs/saunas, pipes, valves, and fittings, ice machines, eye wash stations, aerators, and heating and air conditioning units. The checklist revealed a visual inspection of the areas showed no signs of biofilm or sediment. The checklist revealed no documented evidence the electric and manual faucets, hot and cold-water storage tanks, or the water on closed wings/halls had an annual cleaning or monthly control measure checks. In addition, 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 observation and interview, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition. The deficiency affected 2 of 3 ovens, 1 of 2 freezers, and 1 of 1 food steamers in the kitchen. Findings included: The Administrator was interviewed on 05/22/2024 at 12:43 PM. The Administrator stated that the facility had no general maintenance policy. 1. An observation of the kitchen was conducted on 05/20/2024 at 9:48 AM with the Dietary Supervisor (DS). During this observation, a drip pan was observed inside of the walk-in freezer, positioned under the motor fan, and filled with ice. The pipes attached to the freezer's motor fan were covered with ice. During an interview at the time of the observation, the DS stated that staff had to throw away the drip pan about every day and replace it with a new one to catch the dripping water. An observation of the walk-in freezer was conducted with the Maintenance Supervisor (MS) on 05/21/2024 at 4:55 PM. The observation revealed ice build-up around the top of the door, across the ceiling, and on 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, record review, and facility policy review, the facility failed to notify the physician when blood pressure medication was held for 1 (Resident #41) of sampled 3 residents reviewed for notification of change. Specifically, the facility held Resident #41's blood pressure medication on three occasions when the resident's blood pressure (BP) was outside the physician-ordered parameters, with no notification made to the physician. Findings included: An undated facility policy titled, Condition Change, Resident (Observing, Recording and Reporting) (Includes Fall or Injury) revealed 6. Notify physician of condition change, need for treatment orders and/or medication order changes. A Resident Face Sheet revealed the facility admitted Resident #41 on 02/06/2023. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of essential (primary) hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 2, which…

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 facility document review, the facility failed to ensure residents' rooms were maintained in a homelike manner for 2 (Resident #13 and Resident #17) of 43 total residents who resided in the facility at the time of survey. Specifically, Resident #13 and Resident #17's closet doors were missing. Findings included: On 05/22/2024 at 12:43 PM, the Administrator stated the facility did not have a general maintenance policy. An observation on 05/21/2024 at 3:53 PM revealed Resident #17's closet was missing a door on the right side. During concurrent interview and observations with the Maintenace Supervisor (MS) on 05/21/2024 beginning at 5:06 PM, the MS said that for any maintenance issues, staff should report the concern to the MS or Administrator, and the MS would generate a work order. While touring the facility with the MS, an observation was made of Resident #13's room on 05/21/2024 at 5:12 PM. Resident #13's closet was missing a door on the right side, and the resident's clothing was exposed. At the time of the observation, the MS denied knowledge…

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, record review, and facility policy review, the facility failed to develop a care plan addressing the use of a psychotropic medication for 1 (Resident #34) of 6 sampled residents reviewed for unnecessary medications. Specifically, the facility failed to develop a care plan addressing Resident #34's use of antipsychotic, antidepressant, and antianxiety medications, including information regarding target behaviors and monitoring for potential side effects of the medications. Findings included: An undated facility policy titled, Drug Review indicated, 5. Medications should not show unnecessary or excessive use and should have a diagnosis to support them. The section of the policy addressing Reviewing Antipsychotic Drugs, specified, 1. Antipsychotic drugs should only be given when necessary to treat a specific condition. 2. Review all charts of residents receiving the following drugs. Check for one or more specific diagnoses or conditions for antipsychotic drugs including: a. Schizophrenia b. Schizo-affective disorder c. Delusional disorder d. Psychotic and mood…

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, record review, and facility document and policy review, the facility failed to provide showers as scheduled/preferred for 2 (Resident #34 and Resident #37) of 5 sampled residents reviewed for activities of daily living (ADL). Findings included: An undated facility policy titled, Daily Care Needs indicated, 2. Before beginning care, check the bathing schedule and resident's care plan. Make note of special problems or special care needed by each resident. Resident care plans are individualized and give specific instructions on care. 1. A Resident Face Sheet revealed the facility admitted Resident #37 on 03/08/2023. According to the Resident Face Sheet, the resident had a medical history that included unspecified dementia, generalized muscle weakness, myocardial infarction (heart attack), and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment.…

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, record review, review of an American Heart Association (AHA) blood pressure publication, and facility policy review, the facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for 1 (Resident #32) of 5 sampled residents whose medication regimen was reviewed. Specifically, on 04/06/2024 when Resident #32's blood pressure (BP) met the criteria for hypertensive crisis as defined by the AHA, nursing staff did not re-evaluate the resident or consult with the resident's physician. Findings included: An undated facility policy titled, Condition Change, Resident (Observing, Recording, and Reporting) (Includes Fall or Injury) indicated the purpose of the policy was To observe, record, and report and condition change to the attending physician so that proper treatment can be implemented. The policy revealed, 6. Notify physician of condition change, need for treatment orders and/or medication order changes. An AHA publication titled, Understanding Blood Pressure Readings, last reviewed 05/17/2024,…

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

Based on observation, record review, interview, and facility policy review, the facility failed to keep medication secure for 1 (Resident #30) of 1 sampled resident reviewed for accident hazards and failed to thoroughly investigate a fall and failed to implement fall interventions to prevent falls for 1 (Resident #28) of 1 sampled resident reviewed for falls. Findings included: 1. An undated facility policy titled, Medications, Self-Administration, Self Storage, Leave at Bedside, indicated, A physician's order will be obtained for each medication to be kept at the bedside. The policy also indicated, If the resident does not provide a locked box, the facility must provide a locked area for the medications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2024, revealed the facility admitted Resident #30 on 09/01/2020. The MDS revealed Resident #30 had active diagnoses that included hypertension, seizure disorder, anxiety, and depression. The MDS revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated 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 observation, interview, record review, and facility policy review, the facility failed to monitor and record fluid intake for 1 (Resident #28) of 3 sampled residents reviewed for nutrition, who had a physician's order for a fluid restriction. Findings included: A facility policy titled, Fluid Restriction, dated 05/2015, specified, 2. The DSM [Dietary Supervisor/Manager] or designee will consult with nursing staff to determine amounts of fluid to be given at meals, medication passes and at bedside. According to the policy, 6. Input/Output (I/O) records will be completed daily by the nursing department on all residents with fluid restriction prescriptions. A Resident Face Sheet revealed the facility admitted Resident #28 on 07/08/2019. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of end-stage renal disease and edema. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe…

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, record review, and facility policy review, the facility failed to communicate with a dialysis provider for 1 (Resident #28) of 1 sampled resident reviewed for dialysis services. Findings included: An undated facility policy titled, Dialysis, Care of A Resident Receiving, indicated, Communication between the Facility and Dialysis Unit included, The Dialysis Communication Record will be sent with the resident on each dialysis visit. All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person. The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physician orders. The lower portion will be signed by the dialysis nurse and returned to the facility. These records will be maintained in the medical record. A Resident Face Sheet revealed the facility admitted Resident #28 on 07/08/2019. According to the Resident Face Sheet, the resident had a medical history that included a 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.

Based on interview, record review, and facility policy review, the facility failed to ensure residents' medication regimen was free of unnecessary medications for 2 (Resident #34 and Resident #41) of 6 residents reviewed for unnecessary medications. Specifically, the facility failed to specify the target behaviors for which antipsychotic medications were prescribed, failed to monitor for potential adverse drug reactions, and failed to complete behavior tracking for Resident #34 and Resident #41 to ensure continued use of an antipsychotic was indicated. Findings included: An undated facility policy titled, Drug Review indicated, 5. Medications should not show unnecessary or excessive use and should have a diagnosis to support them. The section of the policy addressing Reviewing Antipsychotic Drugs, specified, 1. Antipsychotic drugs should only be given when necessary to treat a specific condition. 2. Review all charts of residents receiving the following drugs. Check for one or more specific diagnoses or conditions for antipsychotic drugs including: a. Schizophrenia b.…

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 provide pneumococcal vaccine to 1 (Residents #8) of 5 residents reviewed for vaccinations. Findings included: A Resident Face Sheet revealed the facility admitted Resident #8 on 08/01/2019 and readmitted the resident on 03/04/2022. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of acute upper respiratory infection. Resident #8's Pneumococcal Immunization Informed Consent revealed the resident's responsible party (RP) gave consent for the resident to receive a pneumococcal vaccine on 09/26/2022. The Pneumococcal Immunization Informed Consent was signed and dated by the resident's RP on 09/26/2022. Resident #8's Immunization: Consent or Refusal form revealed the resident's RP gave consent for the resident to receive a pneumococcal vaccine 09/18/2023. The Immunization: Consent or Refusal form was signed and dated by the resident's RP on 09/18/2023. Resident #8's Preventative Health Care vaccination record revealed no evidence the resident had received a pneumococcal…

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 maintain an ongoing an antibiotic stewardship program that promotes the appropriate use and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The facility census was 57. The facility did not provide a policy and procedure regarding an antibiotic stewardship program. During an observation and interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - She had completed the online training for an Infection Preventionist but was not able to locate it; - She had been in the DON position for about 6 months. - She did not know where the previous DON had placed the Antibiotic Stewardship book; - She looked through several different binders and finally found the Antibiotic Stewardship book but it did not have anything in it; - She said it should be updated and current. - Review of the Antibiotic Stewardship book showed it was empty.

Based on observation, interview and record review, the facility failed to maintain residents' dignity when they served the residents their meals on Styrofoam plates, bowls, cups and plastic silverware which affected all residents who participated in meal service. (Resident #17, #19, #45, #49) and all residents who ate in the facility and failed to ensure residents' personal information was kept confidential The facility census was 57. Review of the facility's policy for meal service sequencing, dated May 2015, showed, in part: - Meal service sequencing is used in a facility to assure that all residents at a table are served at the same time; - The policy did not specify what type of dinnerware should be used. 1. Observation on 8/2/22 at 12:00 P.M., showed: - The staff were passing out packages of plastic silverware with a napkin and a package of salt and pepper in it; - The residents were served on Styrofoam plates, bowls and cups; - Resident #17 said the staff use the plastic silverware and Styrofoam dishes because the dietary staff do not want to wash the dishes; - Staff passed…

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 provide residents receipts for each transaction from the Resident Trust Fund (RTF) and failed to maintain signed authorization from residents/representatives to manage resident funds. This affected three of 15 sampled residents (Residents #13, #38, and #40). The facility census was 57. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, revised 8/4/22, did not show information regarding providing a receipt to the resident for each transaction. 1. Review of Resident #38's ledger showed the following: - Withdrawal of $20 on 7/11/22; - There was an initial from the resident showing he/she received the funds but there was no copy that a receipt had been provided. 2. Review of Resident #40's RTF records included the following: - Withdrawal of $10.00 on 1/19/22; - There was an initial from the resident showing he/she received the funds but there was no copy that a receipt had been provided. 3. Review of Resident #13's RTF records included the following: - Agreement Concerning…

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 staff had an Out of Hospital Do Not Resuscitate form (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, (CPR), if the resident's breathing stopped or if the resident's heart stopped beating) for two of 15 sampled residents (Resident #49 and #42) and failed to ensure the code status matched the physician's order sheet (POS) and the resident's face sheet for two of 15 sampled residents, (Resident #43 and #21).The facility census was 57. Review of the facility's undated policy for advance directives, showed, in part: - The facility will respect advance directives in accordance with state law; - Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; - Upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for residents. The facility census was 57. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on [DATE] at 10:52 A.M. the resident said: - His/her floor was embarrassing. Staff do come in and mop it but it was beyond mopping. He/she had even been on his/her hands and knees trying to scrub it; - He/she did not walk around bare foot on his/her own floor because it was dirty. Observation of the resident's room showed: - 1 inch () by 4 inch hole in the wall behind the door; - Large brown discoloration on the floor under the resident's bed and around the toilet and brown around the base of the toilet. 2. Observation on [DATE] beginning at 10:00 A.M. showed the following: - room [ROOM NUMBER]- The floor was discolored black 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 observations, interviews and record review, the facility failed to develop and implement comprehensive person-centered care plans consistent with resident rights that include measurable objectives and timeframes to meet the resident's medical, nursing and psychosocial need for five of 15 sampled residents (Residents #37, #40, #20, #42, and #51). The facility census was 57. Review of the facility's undated Comprehensive Care Plan policy, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. - A well developed care plan will be oriented to: Preventing avoidable declines in functioning or functional levels. Managing risk factors to the extent possible or indicating the limits of such interventions. Evaluating treatment of measurable goals, timetables and outcomes. Assessing and planning for care to meet the resident's medical, nursing, mental 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 record review, the facility failed to provide the professional standards of following doctors orders regarding medications. This affected one of fifteen sampled residents (Resident #1). The facility also failed to ensure they followed their procedures for sending medications with one sampled resident (Resident #40) when he/she left the faciity on pass causing him/her to miss multiple doses of evening medications and failed to follow physicians' orders regarding monitoring and recording percentage of meals eaten which affected one sampled resident (Resident #4). Facility census was 57. Facility failed to provide a policy addressing following physicians' orders. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 00, indicating that 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 observation, interview and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for two of 15 sampled residents, Resident #13 and Resident #21. The facility census was 57. Review of the facility's undated policy for baths or showers showed included: - The purpose was to maintain skin integrity, comfort and cleanliness. 1. Review of Resident #13's care plan, revised 6/1/22 showed: - The resident required assistance with ADLs; - The resident needed assistance of one staff in the shower. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Required extensive assistance of one staff with dressing; - Did not address bathing; - Lower extremities impaired on both sides; - Had a colostomy (a surgical operation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff used proper transfer techniques to reduce the possibility of accidents or injuries when transferring one of fifteen sampled residents (Resident #46) when they failed to use the proper lift sling during a transfer with the mechanical lift and when staff failed to ensure the low air loss mattress was set on the correct setting for Resident #37. The facility census was 57. Review of the facility's policy for Hydraulic Lift (Hoyer Lift) undated, showed, in part: Guidelines 1. Open lift to widest point and set the brakes. 2. Roll resident on his/her side away from you. Avoid unnecessary exposure. 3. Place widest seat part under the residents' buttocks and thighs so that the lower edge of the seat is under knees. 4. Place narrow part of the seat just above the small of the residents back. 5. Roll resident toward you and position slings comfortably. 6. Position seat sling and elevate head of bed to facilitate hook up. 7. Move the…

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

Based on observations, interviews and record review, the facility failed to discard expired medications and biological's stored within the medication cart and medication rooms, failed to ensure staff did not place food in the medication refrigerator in the [NAME] medication room, failed to ensure staff dated opened medications and food containers and disposed of expired food, failed to record refrigerator temperatures in the [NAME] medication room, failed to ensure there were no loose pills in the medication cart. This affected three of 15 sampled residents (Resident #43, #45, #46) and had the potential to affect all residents within the facility. The facility census was 57. Review of the facility's undated policy for storage of medications, showed, in part: - All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile; - Drugs must be stored at appropriate temperature levels. Drugs required to be stored at room temperature must be stored between 59 and 86…

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

Based on interviews, observation and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 57. 1. Record review of the facility's dietary staffing scheduled showed the facility did not currently employ a qualified dietary manager. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -There is not currently a dietary manager. -He/she is doing their best to manage the kitchen and cook meals. -If he/she needs direction or has a question, he/she goes to the administrator. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -The facility does not currently have a dietary manager and has been without one for quite some time.

Based on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals in a timely manner and maintain the cleanliness of the kitchen. This has the potential to affect all residents of the facility. The facility census was 57. During the entrance interview on 8/02/22 at 9:42 AM, the administrator said: -Meal times are as follows: -Breakfast at 7:15 A.M. - Lunch at 12:00 P.M. - Dinner at 5:15 P.M Observation of the facility on 8/2/222 at 9:45 A.M., showed: -No meal times are posted in the facility. Observations of meal service in the facility showed: -8/2/22 The first resident was served lunch at 12:35 P.M. -8/3/22 The first resident was served breakfast at 7:28 A.M. -8/4/22 The first resident was served lunch at 12.41 P.M. During an interview on 8/2/22 at 11:23 A.M., Resident #25 said: -He/she never knows when meals are going to be served. -Meals are always late. During an interview on 8/2/22 at 2:26 P.M., Resident #2 said: -He/she has to wait a long time for food, meals are always late. -He/she will usually go to the dining room at…

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

Based on observation, record review and interviews, the facility failed to assure they prepared foods in the appropriate manner when staff did not follow a recipe for pureed foods and prepared pureed food more than 90 minutes before the scheduled meal services. The facility census was 57. The facility did not provide a policy regarding pureed foods. Observation of a pureed test tray on 8/3/2022 at 12:22 P.M. showed: -Pureed Chicken: 132.5 degrees Fahrenheit. The texture is smooth but has little flavor. -Potatoes: 143.4 degrees Fahrenheit. The consistency is very thick, a spoon stood up. They are very sticky in the mouth and difficult to swallow, with a bitter flavor. -Green Beans 114.2 degrees Fahrenheit. They are lukewarm with a thick gel-like texture, with little flavor. -Bread Stick: 97.7 degrees Fahrenheit. It felt cold in the mouth, with a very sticky consistency. Observation of the kitchen on 8/4/22 at 10:30 A.M, showed: -The pureed food was in metal containers in the steam warmer. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -He/she did not use a recipe…

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, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 57. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed: -The Dietary Department will store dry food and supplies according to facility guidelines and state regulations. -The storeroom must be neat and orderly. Shelving is kept clean and free of rust and chipped paint. -Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing open products. -Open boxes are to be effectively re-sealed. Bulk crackers, cereal, cookies, pasta, etc., are to be stored and properly labeled in sealed containers. Food-grade plastic bags are to be tightly closed after opened. -Date stock with date of delivery. -Food is to be stored a minimum of six inches above the floor and 18 inches from the ceiling and sprinkler heads. -Contents of open cases will be…

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

Based on record review and interview, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) plan and implement appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 57. 1. When the QAPI plan was requested, the Administrator provided a copy of a Template that had not been completed to be individualized to the facility. When the Administrator provided the plan she acknowledged it was a template. 2. Review of the facility's morning meeting notes dated 4/18/22 included the following: - The QAPI items included: o Meal intake not being done; o Meal intake sheets re-done for each side; o Certified Medication Technician (CMT) will record on paper log including room trays; o CMT/designee will chart. If designee, charge nurse to be notified. - A Performance Improvement Project for the deficient practice was not in the records. Record review did not show a pip and how the facility was monitoring correction of the deficiency.…

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 maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 57. The facility did not provide a policy regarding the QAA committee. 1. Review of the facility's QAA committee records showed the medical director had not attended a QAA committee meeting since January 2022. During an interview on 8/5/22 at 3:43 P.M. the Administrator said: - QAA meetings were held monthly and the Medical Director came quarterly except when he/she had COVID-19; - The Medical Director did not attend in April due to having COVID-19, he/she did not attend in May because it conflicted with his/her schedule and did not attend in June, he/she did not respond to a text. The facility did not have a meeting in July.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure staff followed their policy to provide a Two-Step Purified Protein Derivative (PPD) Tuberculosis (TB, a highly contagious lung disease) skin test for three sampled residents (Resident #13, #45, #49) and failed to follow their policy that all staff would receive a Two-Step PPD TB skin test upon hire. This effected 6 of 10 staff members sampled. Additionally, the facility failed to ensure staff did not handle medications with their bare hands, which affected Resident #20 and failed to follow proper infection control practices when staff did not wash hands during medication pass and blood glucose monitoring to prevent the spread of infection which affected four residents (Residents #38, #35, and #47). The facility's census was 57. 1. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain records and assist one of 15 sampled residents (Resident #40) with obtaining prescription eyeglasses. The facility census was 57. The facility did not provide a policy regarding vision/eye glasses. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/24/22, included the following: - Date admitted [DATE]; - Cognitively intact; - Indicated corrective lenses (contacts, glasses, or magnifying glass) for vision. Review of the resident's care plan dated 7/5/22 showed staff did not include any information regarding the resident's vision or need to wear corrective lenses. During an interview on 8/3/22 at 8:18 A.M. the resident said: - He/she went to get new glasses because he/she could to get a new pair every two years and it had been over four years. - His/her current glasses were not sufficient anymore. His/her vision has gotten worse and could not read with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure correct installation, use, and maintenance of bed rails, assess the residents for entrapment, review risks and benefits with the resident and/or resident representative and obtain informed consent prior to installation, and obtain physician orders for. This affected four of 15 sampled residents (Resident #1, #5, #15, and #46). The facility census was 57. Facility did not provide requested copies of policy regarding halo and half rail entrapment assessments, informed consents, and orders for side rails or halos. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 00, indicating that the resident has a severe cognitive deficit. - Diagnosis in part of bile duct cancer, digestive cancer,…

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

Based on observations, interviews, and record review, the facility failed to post accurate and current nurse staffing information, per shift, on a daily basis. The facility census was 57. The facility did not provide a policy for posting nurse staffing information. 1. Observation on 8/2/22 at 10:35 A.M., and at various times from 8/3/22 to 8/5/22, showed three different sheets with the nurse staffing posted on a clipboard on the wall across from the South Nurses' station, showed: - The first sheet was dated 12/2/22. Census was 64. Licensed staff: Registered Nurse (RN): days- one for eight hours; Licensed staff: Licensed Practical Nurse (LPN): 6:00 A.M. to 6:00 P.M.- two for 24 hours; 6:00 P.M. to 6:00 A.M. - two for 24 hours; Non licensed staff: Certified Medication Technician (CMTs), Certified Nurse Aides (CNAs) and nurse aides (NAs):days: 6:00 A.M. to 2:00 P.M.- three for 24 hours; 6:00 A.M. to 6:00 P.M.- six for 72 hours; evening shift: one for eight hours; nights- 6:00 P.M. to 6:00 A.M. - five for 60 hours; - The second sheet was dated 12/6/21. Census was 64. Licensed staff: RN:…

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

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 30 opportunities for error which resulted in a medication error rate of 16.66%, which affected four of 15 sampled residents, (Resident #19, #46 and #6). The facility census was 57. Review of the facility's undated medication administration guidelines, showed, in part: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - The person administering the drugs must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data; - If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered. 1. Review of Resident #19's physician order sheet (POS), dated August 2022, showed: - Start date: 8/2/22 -…

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

Based on observations, interviews and record review the facility failed to follow the physician's order for a renal diet when staff served the resident a regular diet which affected one of 15 sampled residents, (Resident #3). The facility census was 57. Review of the facility's policy for diet orders, dated May 2015, showed, in part: - Diet orders prescribed by the attending physician shall be reviewed monthly by Dietary Service Manager (DSM) to assure that the diet orders in the resident's chart and the dietary meal cards are accurate; - Nursing will be responsible for written notification to the dietary department of changes and additions in diets or eating habits. Review of the facility's policy for monthly diet audits, dated May 2015, showed, in part: - Monthly audits will be conducted by the DSM; - The diet summary report will be obtained from nursing when pharmacy monthly summary reports are received by the facility; - The diet cards will then be audited by comparison to the diet summary sheet, noting any discrepancies on the sheet; - After all discrepancies have been noted 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.