Country View Nursing

Based on observation, interview and record review, the facility failed to ensure residents received sufficient nourishing bedtime snacks. The facility census was 40. Upon request, the facility did not provide a policy for bedtime snacks. 1. Review of the facility provided, mealtime service schedule, showed the following:-Supper to be served at 5:30 P.M.;-Breakfast to be served at 7:45 A.M.;(14.25 hours between meals). 2. During the group interview on 01/07/26 at 2:42 P.M., residents said the following:-Resident #17 said staff used to pass snacks every night, but now the residents must ask for snacks; snacks most generally are cookies and snack cakes, sometimes graham crackers; there are not enough snacks available for everyone in the building to have one if they want it;-Resident #25 said snacks used to be put on a cart at the nursing station, but one resident would go up and take multiple snacks, so now they are not available for residents to go up and get one; he/she asks for snacks in the evening, and they frequently run out of snacks, so he/she does not get one;-Resident #20…

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 documentation to show the staff notified the resident's physician and the resident's representative following a significant weight loss and falls for one resident (Resident #5), in a sample of 17 residents. The facility census was 40. Review of the facility's policy Change in a Resident's Condition or status, revised December 2016, showed the following:-Our facility shall promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status;-The nurse will notify the resident's attending physician or physician on-call when there has been an accident or incident involving the resident, significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly;-Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident…

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 complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #6 and #2), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 40.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting;-Impacts more than one area of the resident's…

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

Based on interview and record review, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition of a resident who has mental illness for one resident (Resident #4) in a review of 17 sampled residents. The facility census was 40. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-Guidelines for Determining When a Significant Change Should Result in Referral for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation:-If a Significant Change in Status Assessment (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5;-Referral should be made as soon as the criteria indicating such are evident. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one resident's (Resident #2) of 17 sampled resident's, comprehensive care plan included direction to the staff for the resident with a diagnosis of Post Traumatic Stress Disorder (PTSD, (a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, accidents, or disasters.) to ensure trauma-informed care was provided. The facility did not communicate triggers or interventions to eliminate or mitigate the resident's triggers that may cause re-traumatization. The facility census was 40. Review of the facility's policy Comprehensive Assessment and the Care Delivery Process, revised December 2016, showed the following:-Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions;-Complete the Minimum Data Set (MDS) within 14…

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 one resident (Resident #29), received the prescribed insulin dosage when staff failed to prime the insulin pen prior to administration per the manufacturer's guidelines, in a review of 17 sampled residents. The facility census was 40. Review of the facility's policy, Specific Medication Administration Procedures, dated June 1, 2018, showed the following:-Purpose: To ensure safe, accurate, and consistent administration of insulin using insulin pens or syringes;-Policy statement: All licensed nursing staff must follow proper priming and administration procedures when giving insulin to prevent dosing errors and ensure resident safety;- Priming the Insulin Pen: -Dial two units (or per manufacturer instructions); -Hold pen upright with needle pointing up; -Tap gently to move air bubbles to the top; -Press injection button until a drop of insulin appears at the needle tip; -If no drop appears, repeat priming once. If still unsuccessful,…

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 a comfortable and homelike environment by not maintaining the indoor air temperatures in resident use areas including the end of the 300 hall resident hallway, dining room and nurses' station between 71.0 F. (degrees Fahrenheit) and 81.0 F. The facility census was 39. Review of email communication dated 07/28/25 AT 4:18 p.m., showed the administrator said the facility did not have a policy related to heating and cooling or an emergency heating and cooling policy.1. Observation on 07/20/25 at 1:10 P.M. showed the following:-The nurses station thermostat read 78 degrees F;-The area felt warm if moving or doing any tasks; the air temperature with a thermometer was 84 degrees Fahrenheit;-Staff carried portable battery operated fans. 2. Observation of the dining room on 07/20/25 at 2:08 P.M. and 2:13 P.M. showed the following:-The middle air conditioning unit on the far side of the room was unplugged;-The temperature in the dining room,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to comply with state laws and designate a person as an administrator who was employed in the facility and served in that capacity on a full-time basis. This had the potential to affect all facility residents. The facility census was 42. The facility did not have a policy regarding the administrator or their duties. 1. During an interview on [DATE] at 8:30 A.M. and 11:00 A.M., Administrator L said the following: -She introduced herself as the facility administrator; -She started as the administrator on [DATE] and fulfilled the duties as acting administrator for the facility; -She had not applied for a temporary emergency license; -Administrator K had her license hanging in the facility. During an interview on [DATE] at 12:00 P.M., Licensed Practical Nurse (LPN) H said the following: -He/She did not remember the last time Administrator K was physically in the building; -Around the first of May the facility was without an administrator for at least one week.…

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 follow professional standards of practice when physician orders for wound care for two residents (Resident #2 and Resident #9) in a review of 12 sampled residents, were not completed as ordered. The facility failed to follow all orders from the outside Wound Care Clinic or add orders to the resident physician order sheets (POS). Additionally, the facility failed to ensure Resident #9 had transportation to the Wound Care Clinic for scheduled appointments. The facility census was 42. Review of the facility policy, following physician's orders, undated, showed the following: -The facility was committed to ensuring physician orders were carried out properly; -Nursing staff will follow this policy and Nurse Practice Act in receiving, recording and following physician orders, as well as delegating, communicating and care planning orders; -Transcription of orders such as telephone or fax orders shall be transcribed as given by the physician; -When a physician…

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 follow physician orders for one resident (Resident #1), in a review of 14 sampled residents. Staff failed to remove a 100 microgram (mcg) fentanyl patch (topical narcotic pain patch) as ordered before applying another 100 mcg fentanyl patch. Staff who applied the patch failed to follow facility policy and did not label the new 100 mcg fentanyl patch with the date of application and staff initials. The facility census was 38. Review of the facility policy, Specific Medication Administration Procedures, dated June 1, 2018, showed the following: -Transdermal drug delivery system (patch) application; -To administer medication through the skin through proper placement of the patch and care of the applications site(s); -Procedure included to remove the old patch from body and to label the new patch with date and nurse's initials. Do not write on patch after application to resident's skin. Review of the MedlinePlus.gov website for fentanyl patches showed patches that have been worn for three days still contain enough…

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 serve food to one resident (Resident #4), in a review of 14 sampled residents, that accommodated the resident's preferences. The facility census was 38. 1. Review of the facility provided, resident diet type report, dated 02/27/25, showed the following: -Resident #4 was listed on the report; -He/She had allergies listed that included milk. 2. Review of Resident #4's Face Sheet showed the following: -His/Her allergies included milk; -He/She had diagnoses that included lactose intolerance (the inability to digest lactose, the sugar in milk; causes digestive symptoms such as diarrhea, gas and bloating after eating or drinking dairy products). Review of the resident's clinical allergies, listed in the resident's electronic medical record (EMR), showed the resident had milk listed as an allergy (noted 06/04/20). Review of the resident's Care Plan, dated 10/31/24, showed the following: -He/She had an intolerance to milk, but was able to have milk related products such as cheese, ice cream, yogurt and food items…

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 care in a dignified and respectful manner for two residents (Residents #3 and #4), in a review of eight sampled residents, when staff failed to answer call lights timely, resulting in incontinence and residents waiting in soiled briefs for staff to respond. The facility census was 41. Review of the facility's undated policy, Call Lights, showed the following: -All nursing personnel must be aware of call lights at all times; -Answer ALL call lights promptly whether you are assigned to the resident; -Answer all call lights in a prompt, calm, courteous manner, turn off the call light as soon as you enter the room; -Never make the resident feel you are too busy to give assistance, offer further assistance before you leave the room. 1. Review of Resident #3's Care Plan, updated 6/13/24, showed the following: -The staff checked the resident at least every two hours for incontinence, washed, rinsed, and dried soiled areas; -The resident…

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

Based on interview and record review, the facility failed to provide the resident's representative with a copy of the resident's medical records upon written request within 24 hours of the resident's representative request for one resident (Resident #8), in a review of 8 sampled residents. The facility census was 41. 1. Review of Resident #8's face sheet showed the following: -The resident was admitted to the facility from the hospital on 7/30/24; -He/She was discharged on 9/7/24. During an interview on 9/20/24 at 8:06 A.M., the resident's power of attorney (POA) said the following: -He/She asked Licensed Practical Nurse (LPN) A to view the resident's medical records. LPN A said he/she was unable because the records were on the computer; -LPN A provided the POA a copy of the resident's physician orders from the facility; -He/She emailed the Social Services Director on 9/8/24 requesting a copy of the resident's medical records; -The Social Services Director emailed the POA back stating the request was forwarded to medical records staff; -He/She did not receive a copy 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.

Based on interview and record review, the facility failed to follow facility policy to notify the resident's power of attorney for two residents (Residents #1 and #2), in a review of eight sampled residents, following a resident-to-resident altercation. The facility census was 41. Review of the facility's undated policy, Significant Condition Change and Notification, showed the following: -To ensure the resident's family and/or representative and medical practitioner are notified of resident changes; -A significant change in the resident's physical, mental, or psychosocial status, including resident-to-resident altercation, which require notification for both residents. 1. Review of Resident #1's undated face sheet, showed the following: -The resident had a power of attorney; -Diagnoses of dementia (a condition that causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life), disorientation (state of mental confusion), and anxiety disorder. Review of the resident's Care Plan, last updated 6/13/24, showed the resident had…

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

Based on interview and record review, the facility failed to follow hospital discharge orders for post operative appointments and administer anticoagulant medication (medicine that helps prevent blood clots) as ordered for one resident (Resident #8), in a review of eight sampled residents. The facility census was 41. Review of the facility's undated policy, Following Physician Orders, showed the following: -admission orders are received from the discharging physician and communicated to the primary care physician at the time of admission; -Medical records will conduct chart audits on a monthly basis to help monitor correct documentation. 1. Review of Resident #8's undated face sheet showed the resident's diagnoses included surgery on the digestive system, cholecystitis (condition that occurs when the gallbladder becomes inflamed, swollen, and red), and hemiplegia and hemiparesis (conditions that cause loss of strength or paralysis on one side of the body) following cerebral infarction (loss of blood flow to part of the brain) left non-dominant side. Review of the resident's undated…

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 three residents, (Resident #1, #2, and #5), in a sample of 14 residents, were treated with dignity and respect when Nursing Assistant (NA) H told Resident #1 don't cry, I didn't hurt you that much and when Certified Nurse Assistant (CNA) K turned off Resident #1's call light because he/she could not understand Resident #1. CNA I and CNA J made statements to Resident #2 about his/her smoking and medical diagnosis that upset and made Resident #2 mad. Additionally, Resident #5 said NA H was,very rude to him/her in the resident's room. The facility census was 42. Review of the facility's policy, Quality of Life -Dignity, dated 2/2020, showed the following: -Each resident shall be cared for in a manner the promotes and enhances each resident's sense of well-being, level of satisfaction with life, feeling of self-esteem and self-worth; -Residents are treated with dignity and respect at all times; -Staff speak respectfully to residents 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 interview and record review, the facility failed to provide/designate a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 44. Review of the facility's staffing policy, dated October 2017, showed the following: -Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; -The policy did not contain information regarding registered nurse coverage for at least eight hours daily. 1. Review of the daily staffing sheets, dated 11/12/23-11/18/23, showed no RN coverage on 11/16/23. Review of the daily staffing sheets, dated 11/19/23-11/25/23, showed no RN coverage on 11/25/23. Review of the daily staffing sheets, dated 11/26/23-12/2/23, showed no RN coverage on 11/26/23, 11/27/23, 11/29/23, 11/30/23, and 12/1/23. During an interview on 12/5/23 at 5:08 P.M., the Director of Nursing (DON) said the following: -The facility had issues with having an RN for eight hours every day; -The previous DON did not come to the facility some days he/she was scheduled to work, and did not tell…

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 employ sanitary practices in accordance with professional standards for food service regarding the storage, preparation, and serving of residents' food and beverages. Staff failed to employ proper equipment cleaning and maintenance, dish handling and storage, and handwashing and gloving techniques to prevent potential contamination to residents' food and beverages. Staff failed to ensure food items were labeled, dated, sealed, and stored appropriately, including in dent-free cans, not in single-use containers, and within the manufacturer's best by date. Staff failed to ensure the kitchen dishwashing machine utilized the appropriate water temperature and sanitizer chemical level to clean and sanitize dishes and that staff were knowledgeable of the machine's acceptable temperature and chemical parameters. Staff failed to maintain the kitchen ice machine water filtration system per the manufacturer's recommendations and failed to maintain a proper air gap at the drain of the ice machine to guard against back…

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 develop a policy to address Legionella Control that included specific control parameters based on Center of Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment to identify potential sources of Legionella growth (discussed but not started). The facility's water management team had not had a meeting and the facility's water flow map was not completed. The facility failed to store respiratory and oxygen equipment in a manner to protect it from contamination when not in use for four residents (Residents #6, #29, #32 and #43), in a review of 15 sampled residents. The facility census was 44. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in…

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 resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 11 residents (Resident #9, #12, #15, #26, #30, #502, #503, #504, #505, #506 and #507). The facility census was 44. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 12/06/23, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #9 $1,694.85 #12 $1,224.87 #15 $959.94 #26 $5,639.96 #30 $75.60 #502 $321.92 #503 $6,724.00 #504 $49.80 #505 $8,697.55 #506 $2,926.00 #507 $4,396.32 Total $32,710.81 During an interview on 12/07/23 at 9:53 A.M., the Business Office Manager (BOM) said residents had credits from resident liability and insurance payments that needed refunded. The BOM also said he/she has been working on cleaning up the operating account but the account still needed improvement.

Based on interview and record review, the facility failed to provide a written statement of the individual resident's trust fund balance and activity in the account (deposits and withdrawals) to the resident and/or his/her responsible party quarterly and upon request. The facility managed funds for 24 residents. The facility census was 44. Review of the facility policy, Deposit of Resident Funds, last revised April 2017, showed resident personal funds that are held and managed by the facility will be safeguarded. The resident is provided a confidential quarterly statement of funds on deposit with the facility, including activity since the previous statement. During the group interview on 12/4/23 at 2:22 P.M., the residents in attendance said the following: -Resident #14 said he/she had asked for a statement several times and never received one; -All nine residents said they had never received a quarterly or any type of statement. During an interview on 12/5/23 at 11:15 A.M., the Business Office Manager (BOM) said the following: -The facility held funds for 24 residents; -There were…

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 update interventions in the resident's care plan to reflect current care needs for four residents (Resident #18, #33, #41 and #200) in a sample of 15 residents. The facility census was 44. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised on October 2018, showed the following: -A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Assessments of residents are ongoing and care plans are revised as information about the residents and 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 staff provided four residents (Resident #3, #18, #36 and #41), who were unable to perform their own activities of daily living (ADLs), in a review of 15 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 44. Review of the facility's policy, Quality of Life - Dignity, revised August 2009, showed the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Review of the facility's policy, Mouth Care, revised February 2018, showed the purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. 1. Review of Resident #18's significant change Minimum Data Set (MDS), a federally mandated assessment instrument…

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 follow resident's care plan interventions to prevent the development of pressure ulcers for four residents (Residents #3, #18, #20, and #35), in a review of 15 sampled residents, who were dependent on staff and were at risk for developing pressure ulcers. The facility failed to float Resident #20's heel and apply a heel protector to the heel as directed in his/her plan of care, and failed to reposition Residents #3, #18, and #35 at least every two hours according to their plan of care. The census was 44. Review of the facility's policy for prevention of pressure ulcers/injuries, last revised October 2018, showed the following: -The purpose was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors; -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Reposition 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 provide food items at a safe and appetizing temperature and taste. The facility census was 44. Review of the facility policy, Food and Nutrition Services, revised October 2017, showed the following: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature; -Meals will be provided within 45 minutes of either resident request or scheduled meal time; -If a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. 1. Review of the Diet Orders, printed 12/04/23, showed the following: -Nine residents with a physician-ordered mechanical soft texture diet; -One resident with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop, implement, and provide a copy of a baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility, for two residents (Resident #41 and #200), in a review of 15 sampled residents. The facility census was 44. Review of the facility's policy, Care Plans - Baseline, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to: a. The initial goals of the resident; b. A summary of the resident's…

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

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Residents #1), in a review of 15 sampled residents, and for one additional resident (Resident #200). The facility failed to administer and monitor Resident #1's oxygen therapy as ordered, failed to ensure Resident #1 had geri-sleeves (a sleeve of breathable material worn to protect against skin tears) in place on his/her bilateral upper extremities as directed in his/her care plan, and failed to administer Resident #198's medications at the prescribed time or within one hour of the prescribed time. The facility census was 44. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal…

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 two nurse aides completed a State-approved training and competency evaluation program within four months of their date of hire. The facility census was 44. Review of the facility's nurse aide qualifications and training requirements, dated October 2017, showed the following: -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: a. That individual is competent to provide designated nursing care and nursing related services; b. That individual has completed a training program and competency evaluation program, or a competency evaluation program provided by the state; c. That individual has been deemed competent as provided in 483.150(a) and (b) of the Requirements of Participation; -Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of 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 observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, three errors occurred, resulting in a 10% error rate which affected three additionally sampled residents (Resident #24, #42 and #200). The facility census was 44. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); -The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility provided, medication pass times, showed the following: -Administration one time a day - pass…

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 one additional sampled resident (Resident #24) and one closed record resident (Resident #500), in a sample of 15 residents, was free from a significant medication error. The facility census was 44. Review of the facility's policy, Medication Orders, effective January 2017, showed the purpose of his procedure is to establish uniform guidelines in the receiving and recording of medication orders. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders; -The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. Review of Resident #24's electronic health record 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 observation, interview, and record review, the facility failed to provide quarterly statements of the resident trust funds account to the resident or their representative for all residents who maintained a balance in the resident trust fund, including petty cash; failed to ensure residents did not carry a negative balance in the resident trust fund; and failed to establish and maintain an effective bookkeeping system and follow the facility's policy for ensuring the resident trust fund account was accurately monitored and reconciled. The facility managed funds for 31 residents. The facility census 32. Review of the facility's Resident Trust Policy, dated May 2012, showed the following: -Resident Trust Fund would be managed and accounted for in accordance with state and federal regulations; -A copy of the Resident Trust Statements would be available upon request to the resident and and/or his/her legal representative during normal administrative business hours to allow review of entries and support documentation; -Individual responsible for the day to day receipts,…

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 purchase a surety bond in an amount of at least one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. The facility census was 32. Review of the facility's Resident Trust Fund policy, dated May 2012, showed the following: -Resident trust account would be managed and accounted for in accordance to State and Federal regulations; -The facility must purchase and maintain a surety bond that would protect resident personal funds against loss, theft, and insolvency. The surety bond must be greater than all resident funds managed by the facility and adheres to State and Federal guidelines. 1. Review of the resident trust fund account for November 2020 through October 2021, showed an average monthly balance of $43,009.37, which required a surety bond of $64,500.00. The current ledger amount was $47,855.05. Review of the Department of Health and Senior Services approved bond list, showed the facility has an approved surety bond for $30,000.00. 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 record review the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. The facility census was 32. 1. During entrance conference on 11/15/21 at 10:30 A.M., the administrator said RN A was providing DON coverage. 2. Review of the October 2021 nursing schedule showed RN A worked as the day shift charge nurse from 7:00 A.M. to 7:00 P.M. on 10/16, 10/17, 10/18, 10/21, 10/22, 10/25, 10/26, 10/30 and 10/31. Review of the November 2021 nursing schedule showed RN A worked as the day shift charge nurse from 7:00 A.M. to 7:00 P.M. on 11/1, 11/2, 11/5, 11/8, 11/9, 11/12, 11/13, 11/14, 11/17 and 11/18. During interview on 11/18/21 at 5:00 P.M., RN A said the following: -She became a RN in May 2021; -She had not been functioning as the DON for the facility. She has been working full time as a charge nurse. During interview on 11/18/21 at 5:00 P.M., the Regional Nurse said the following: -The tasks for the DON have been divided between the assistant director of nursing (ADON) and Licensed Practical Nurse (LPN)…

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 notify five residents (Residents #28, #15, #30, #12, and #23) or his/her legal representative, who received Medicaid benefits, when the resident's trust fund balance reached $200 less than the Supplemental Security Income (SSI; Federal income supplement program designed to help aged, blind, and disabled people who have little to no income) resource limit ($5,000). The facility census was 32. Review of the facility's Resident Trust Fund policy, dated May 2012, showed the following: -Resident trust fund would be managed and accounted for in accordance with State and Federal regulations; -Any individual resident trust account that was nearing the state specified maximum balance would require the following action: A) Notification to resident/responsible party as to balance. Discussion should include an inventory of resident's material needs and make a comfort item purchase. B) If a resident does not have a responsible party, the social service director shall be notified. An inventory of resident's belongings would proceed 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 interview and record review, the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 32. Record review of facility's admission Packet Policy - Resident's Rights State and Federal, dated 5/13/10, showed the resident has the right to send and promptly receive mail that is unopened, as well as have access to stationary, postage, and writing implements at the resident's own expense. During group interview on 11/16/21 at 9:30 A.M., Resident #12 said he/she gets a big pile of mail on Monday and doesn't get mail brought to him/her on Saturday. During an interview on 11/18/21 at 9:48 A.M., the activity director said he/she was responsible for obtaining mail from the post office and delivering it to the residents. He/She worked Monday through Friday and did not come to the facility on Saturdays to deliver mail. Residents did not receive their mail on Saturdays. During an interview on 11/18/21 at 5:35 P.M., the administrator said residents did not receive mail…

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 a comfortable and homelike environment free from the presence of urine odors by not ensuring one resident's (Resident #29's) wheelchair cushion was cleaned after an episode of urinary incontinence that left the cushion soiled. The facility also failed to ensure floors and walls were clean and in good repair, and failed to ensure ceiling vents were clean and free from a buildup of dust and debris. The facility census was 32. 1. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/12/21, showed he/she was always incontinent of bowel and bladder. Observation on 11/16/21 at 11:20 A.M. showed the following: -The resident sat in his/her wheelchair. He/She was incontinent and his/her pants were visibly soiled with urine; -Certified Nurse Assistant (CNA) L and CNA M transferred the resident from his/her wheelchair to the bed, provided incontinence care, put…

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 implement an ongoing activities program designed to meet individual interests for three residents (Residents #12, #22 and #29), in a review of 12 sampled residents. The facility also failed to provide activities on the weekends and after 2:00 P.M., conduct scheduled activities that were on the calendar, and assess activity preferences. The facility census was 32. 1. During an interview on 11/18/21 at 2:30 P.M., the regional director of operations said there were no facility policies related to activities. 2. Review of facility's activity calendar, dated 9/1/21 to 9/30/21, showed the following: -There were no scheduled activities after 2:00 P.M. Monday through Friday; -There were no scheduled activities on the weekends. Review of facility's activity calendar, dated 10/1/21 to 10/31/21, showed the following: -There were no activities scheduled after 2:00 P.M. Monday through Friday; -There were no activities scheduled on the weekends.…

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 the activity program was directed by a qualified professional. The facility census was 32. 1. Review of the activity director's employee file showed no documentation she was eligible for certification as a therapeutic recreation specialist, or as an activities professional by a recognized accrediting body on or after October 1, 1990, or had two years of experience in a social or recreational program with the last five years, one of which was full-time in a therapeutic activities program or was a qualified occupational therapist or occupational therapy assistant or had completed a training course approved by the state. During an interview on 11/16/21 at 8:10 A.M. the activity director said she assumed the role as activity director in the middle of September/first of October 2021. She had not received any training and was not aware of any classes he/she was required to take to become certified. There were no other activity staff to assist him/her that was certified. During an interview on 12/1/21 at 2:47 P.M. 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 drugs and biologicals were stored in accordance with currently accepted professional standards when facility staff failed to keep medications in a medication cart secured and locked. Staff left a medication cart unlocked and unattended in a hallway and in an open, unattended area that residents passed by. The medication cart was not locked or attended, and the cart was not behind a locked door. The facility census was 32. Review of the facility policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/2016, showed the following: -It is the policy of this facility to ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in…

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 practice acceptable infection control practices when nursing staff failed to record annual tuberculin skin test (TST) screenings for four sampled residents (Residents #4, #8, #30, and #33), in a review of 12 sampled residents. The facility census was 32. Review of the facility's Tuberculosis (TB) Control Plan, dated 2019, showed the following: -Residents in long-term care facilities have been identified as a high-risk group for re-activation of latent TB infection, acquisition of TB infection and potential spread of TB within the facility; -Some states may have different requirements for annual screening. Follow state and local guidelines. (The facility's policy did not direct staff to conduct an annual evaluation to rule out signs and symptoms of TB disease as directed in state regulation.) 1. Review of Resident #4's electronic medical record (EMR) showed the following: -Original admission date 10/20/20; -No documentation staff completed an annual screening for signs and symptoms of TB. 2. Review of Resident #8's EMR…

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 develop an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 32. Review of the facility's Antibiotic Stewardship Policy, dated 2019, showed the following: -It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy; -Antibiotic Stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate closing, route, and duration for antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed; -When a resident is suspected of having an infection, the nurse will…

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 follow policies and procedures for immunization of residents against pneumococcal disease (an infection caused by bacteria) as required for six residents (Resident #29, #4, #17, #21, #22, and #26) in a review of 12 sampled residents, six additional residents (Resident #505, #23, #1, #11, #16, and #20) and one closed record (Resident #36). The facility failed to document if residents received the pneumococcal vaccine or did not receive the vaccine due to medical contraindications, previous vaccination or refusal, and failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 32. Review of the facility policy Pneumococcal Vaccine Program dated 2019 showed the following: Policy: -It is the policy of this facility that residents will be offered immunization against pneumococcal disease. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one resident's (Resident #14) representative was notified when the resident had a change in condition in a review of 12 sampled residents. The facility census was 32. Review of the facility's policy, Significant Condition Change and Notification, not dated, showed the following: Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: - An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention; - A significant change in the resident's physical, mental or psychosocial status. (see below for examples); sudden onset of shortness of breath,symptoms of an infectious process, abnormal lab values, other abnormal assessment findings; - A need to significantly alter treatment; When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical…

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 check the Certified Nurse Assistant (CNA) Registry for any Federal Indicators of abuse, neglect, or misappropriation of property prior to hiring one employee, in a review of six employees hired since the previous annual survey. The facility census was 32. Review of the facility's Abuse, Prevention and Prohibition Policy, dated November 2018, showed the facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation. The facility will make reasonable efforts to uncover information about any past criminal prosecutions. The facility will prescreen potential residents for behaviors, needs and personal histories, which might lead to conflict, neglect, or abuse. 1. Record review of Laundry Aide's employee file showed the following: -Hire date 10/16/20; -Family…

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

Based on interview and record review, the facility failed to follow physician's orders for daily weights for one sampled resident (Resident #12), in a review of 12 sampled residents. The facility census was 32. 1. Record review of Resident #12's January 2021 physician's orders showed an order for weekly weights. Record review of the resident's progress notes showed a new physician's order was issued for daily weights on 1/18/21. Record review of the resident's January 2021 Treatment Administration Record (TAR) showed the following: -Daily weights (ordered 1/18/21); -No documentation staff obtained the resident's weight on 1/18/21 through 1/27/21; -Staff documented obtaining the resident's weight on 1/28/21. Staff did not document the resident's weight; -No documentation staff obtained the resident's weight from 1/29/21 through 1/31/21. Record review of the resident's electronic weight record for January 2021, showed no evidence staff obtained a daily weight for the resident on 1/18/21 through 1/31/21. Record review of the resident's February 2021 physician's orders showed an order…

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.