Life Care Center Of Bridgeton

Based on observation, interview and record review, the facility failed to ensure one resident's physician (Resident #26) was notified after the resident developed an elevated temperature on the evening shift of 2/24/25. The resident was sent to the hospital the next morning on 2/25/25, and admitted with a diagnosis of sepsis (a serious condition in which the body responds to infection) pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.). The sample size was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/18, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law; -Federal Regulations: A facility must immediately inform the resident, consult 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.

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for Resident #29. The facility failed to ensure Resident #29's hair was clean, facial hair was shaved, body was clean and free from odors, and failed to provide foot care. The sample was 18. The census was 86. Review of the facility's ADL care policy, revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of the facility's foot care policy, dated 8/28/18, showed: -Policy: This facility will ensure that foot care provided is consistent with professional standards of practice and that foot care includes treatment to prevent complications from conditions such as diabetes, peripheral vascular disease (circulatory condition), or immobility. This facility will ensure that foot care also includes assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation…

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 obtain labs as ordered for one resident (Resident #14), and to document a thorough, ongoing assessment following the resident's change in condition, and to appropriately communicate the resident's change in condition to the next shift. In addition, the facility failed to ensure staff provided feeding assistance in accordance with physician orders for one resident identified as dependent on assistance for eating (Resident #9). The sample was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/28, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. -Procedure: The facility will utilize the Lippincott procedure - Change in status, identifying and communicating, long-term care. Review of the facility's Change in Status, Identifying 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 observation, interview and record review, the facility failed ensure staff obtained a treatment order, and provided daily monitoring for one resident (Resident #26) with a history of dermatitis (skin inflammation, typically characterized by itchiness, redness and rash) on his/her coccyx (tailbone)/sacrum (area located above the coccyx) that was observed to have an open area on the morning of 2/24/25. It was not identified by staff and the physician was not notified until the morning of 2/25/25. In addition, the facility failed to ensure licensed nurses who signed bath sheets showing an open area and/or a circle around the coccyx/sacrum of an anatomical figure on the bath sheet documented an assessment of the findings on the bath sheets. The sample size was 18. The census was 86. Review of the facility's Skin Integrity & Pressure Ulcer (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction)/Injury Prevention and Management policy, revised on 8/25/21, showed: -Policy: Provide associates and licensed nurses with…

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 necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by addressing the residents' behaviors related to his/her anxiety for one resident (Resident #68). The sample was 18. The census was 86. Review of the facility's Behavioral Health Services Policy, reviewed 9/6/24, showed: -Policy: The facility will provide behavior heal care and services that create an environment that promotes emotional and psychosocial will-being, meets each resident's needs, and includes individualized approaches to care; -Procedure: Complete the nursing assessment and social services assessment upon admission/readmission. Quarterly, and as needed with change in condition; -Through this assessment the facility should identify residents who: -Develop decreased social interaction and/or increase withdrawn, angry or depressive behaviors, and may have verbalizations indicating…

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, facility staff failed to discard expired medications from the medication carts, failed to ensure all medication bottles had a date of expiration, failed to ensure eye drops/ointments were dated when opened, and failed to ensure insulin pens were stored in the refrigerator and not in the medication cart. The facility identified four medication carts, two were sampled, and problems were identified in both. The census was 86. Review of the facility Medication Storage and Administration Quick Reference Guide, dated 8/2022, showed: -Insulin Vials and Pens: Store unopened insulin in the refrigerator; -Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow the manufacturer instructions, or facility policy. 1. Observation of the South 2 medication cart on 2/24/25 at 4:38 P.M., showed: -South 1 medication cart: -One opened stock bottle (used for multiple residents) of Rena Vite tablets (multivitamin) expired on 12/23/24. Licensed Practical Nurse…

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

Based on observation, interview and record review, the facility failed to ensure staff performed appropriate hand hygiene during meal service and failed to serve food in accordance with professional food safety standards, which affected three residents (Resident #22, #24, and #27). The sample was 18. The Census was 86. Review of the facility's hand hygiene policy, dated 6/13/23, showed: -Policy: The facility has adopted the Centers for Disease Control and Prevention (CDC) core infection prevention and control practices for safe healthcare delivery in all settings for indications for hand hygiene; -Procedure: Hand hygiene should be performed before and after contact with resident, after contact with objects or surfaces in the resident's environment. 1. Review of Resident #22's medical record showed: -Diagnoses included dementia, diabetes, and Parkinson's disease (brain disorder causing unintended or uncontrolled movements); -Severe cognitive impairment. 2. Review of Resident #24's medical record showed: -Diagnoses included muscle weakness and dementia; -Severe 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for three residents (Residents #26, #29 and #45) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), or tracheostomies (a surgically inserted tube inserted into the windpipe to assist with breathing). The sample was 16. The census was 86. Review of the facility's EBP policy, revised 3/21/24, showed: -Policy: The facility should use EBP as an additional MDRO mitigation strategy for residents that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a kitchen exit door was locked and armed after one resident (Resident #1) eloped from the facility through the kitchen door during the early morning hours, and was out of the facility for approximately 30 minutes. The resident was found on the facility's premises, approximately 30 feet from the exit door. The facility census was 74. The facility was notified of past non-compliance on 12/31/24. Facility staff immediately searched for the resident, reported the incident, and began their investigation. The investigation consisted of written statements and interviews. The investigation showed the kitchen door was not locked and armed. Staff were in-serviced on elopement policy, and abuse and neglect. A second alarm was added to the kitchen door. The deficiency was corrected on 12/27/24. Review of the facility's Elopement policy, revised 11/19/24, showed: -Elopement occurs when a resident leaves the premises or a safe area without…

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 the rights of one resident of four sampled residents, for unrestricted visitation, when the facility prevented the resident's relative from visiting the resident due to an allegation of the relative being unruly and having erratic behavior. The facility also failed to provide alternate methods of visits via a private setting, room, or by video teleconferencing platform (Resident #1). The census was 77. Review of the facility's policy Locking Entrance and Perimeter Doors: After-Hours visitors policy, revised 07/21/23, showed: -The resident has a right to receive visitors of his or her choosing at the time of his or her choosing; -The facility must provide immediate access to a resident by immediate family and other relatives of the resident; -The facility must provide immediate access to a resident by others who are visiting with the consent of the resident. Review of the facility's policy titled, Area of Focus: Resident Rights, effective 11/27/2023, showed federal and state laws guaranteed certain basic rights while…

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 and implement policy and procedures to prevent abuse and neglect neglect of residents and prevent misappropriation of resident property when the facility continued to employ staff member, Certified Nurse Aide (CNA) A who was listed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified home) indicating he/she was ineligible to work in a certified long-term care facility. CNA A was hired on 12/17/14, put on the EDL list on 8/13/20 with a disqualification length of six years, and terminated from the facility on 1/12/24. The census was 74. The administrator was notified on 2/20/24, of the past non-compliance. Upon discovering CNA A was on the EDL on 1/12/24, the facility took him/her off the schedule. An audit of all current employees' background checks was completed on 1/12/24. The facility also requested their pre-hire criminal background check vendor to complete quarterly background checks on all active employees. The deficiency was corrected on 1/12/24. Review…

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 ensure the scales were in proper working condition for two of two scales in the facility. Findings include: Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE]. Review of R20's Weights located in the EMR under the Weights and Vitals tab revealed resident's weight on 10/25/23 was 387.8 pounds and on 12/06/23 was 288.6 pounds. During an interview on 01/03/23 at 2:44 PM, the Executive Director (ED) revealed that it was noticed in October 2023 that the scales needed to be calibrated. During an interview on 01/04/24 at 10:06 AM, the Registered Dietician stated the scales were not calibrated which caused the resident's weights to be documented incorrectly. During an interview on 01/06/24 at 9:26 AM, the Director of Nursing (DON) revealed the facility had been without scales to weigh residents since October 2023.

Based on observations, interviews, and review of facility policy, the facility failed to maintain a clean and home-like environment for residents in the facility's common areas and in resident rooms. Specifically, six of six residents (R)8, R25, R29, R46, R59, and R68) that receive enteral feeding had residue buildup on the feeding pump and feeding tube pole; debris under R1's bed; R1, R10 and R49's over bed tables had peeling veneer around the edges; R4 and R12's footboard on their beds were loose; R8's specialty mattress had yellow and brown stains and torn covering; R12's drawer in the resident's nightstand was off the track; R59's room had dried beige residue on the floor next to the resident's tube feeding pole and six residents (R8, R25, R29, R46, R59, and R68) receiving enteral feeding had dried beige; brown splatter on the feeding pump and intravenous (IV) poles and, the upholstered chairs and a couch in the lobby area were stained and in need of cleaning. Findings include: Review of facility policy titled, Daily Room Cleaning with a revision date 07/19/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to serve food that was palatable. This failure affected five residents (R20, R42, R54, R48 and R39) who consume the fish from the kitchen. Findings include: Review of the undated facility policy titled Food and Nutrition Services, revealed, The facility provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. During initial screening on 01/02/24 at 10:54 AM, R20 complained the food was hard to eat and cold. Review of R20's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE]. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/06/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. During initial screening on 01/02/24 at 12:43 PM, R24…

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 policy review, the facility failed to ensure staff were wearing hair restraints in accordance with facility policy while serving food to the residents during one of four meal observations. Findings include: Review of the facility policy titled, Sanitation and Maintenance, revised on 04/06/23, revealed, The Director of Food and Nutrition Service is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with the federal .requirements. During an observation on 01/02/24 at 12:35 PM, the Food Service Director (FSD) and Infection Preventionist (IP) were observed in the kitchen with a bouffant cap on the top of their head with their hair exposed from under the cap, while serving food and condiments to the residents during meal tray line service. Interview on 01/02/24 at 12:35 PM with IP confirmed her hair was not covered completely while assisting with meal service. Interview on 01/02/24 at 7:22 PM, the FSD revealed, It is important to have all of your hair covered not just the top, none…

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, manufacturer's guidelines review and policy review, the facility failed to disinfect the glucometer between residents' uses as directed by the glucometer's manufacturer's instructions and facility policy for two residents (Resident (R) 44 and R52) of eight residents who received blood glucose monitoring. The facility's practice of inadequate cleaning of the glucometer between residents use places residents with blood glucose monitoring at risk for blood borne illnesses. Additionally, the facility staff failed to don a face mask or goggles when entering a COVID positive resident's (R130) room; failed to perform hand hygiene when passing trays between 11 resident rooms; failed to maintain a clean environment for one of one laundry room; four of four pill crushers were soiled with residue buildup; lift chairs on two of two units had dirt on the metal base of the chairs; bladder scan machine had dust and dirt on the screen and machine. Findings include: 1. Review of 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 record review and interview, the facility failed to ensure that residents' transfer and discharge information was communicated to the Regional State Ombudsman for one resident (R)129 of five residents sampled for hospitalization. Findings include: Interview on 01/03/24 at 1:36 PM, the Regional Ombudsman revealed that she had not received transfer/discharge notices from the facility for several months. Review of R129's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was discharged from the facility on 08/29/23. Additional review of the resident's EMR failed to reveal any documentation of discharge information being sent to the Ombudsman. Interview on 01/04/24 at 9:30 AM with Registered Nurse (RN) 1 revealed that she completes a transfer/discharge record and gives a copy of the record to the Social Services Director (SSD) who sends that information to the Ombudsman. Interview on 01/04/24 at 10:00 AM, the SSD stated he did not know it was his responsibility to send transfer and discharge notifications to…

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

Based on record review, interview, and facility policy review, the facility failed to ensure two (Residents (R) 18 and R29) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR) (an assessment performed to determine underlying mental health issues) had a Level I PASARR completed as required to determine if the residents require additional assessment and PASARR level II completion Findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review revised on 09/25/23 revealed, The facility will ensure that potential admissions are be (sic) screening for possible serious mental disorders . The policy further indicated, Procedure 1. Ensure Level I PASARR has been completed on potential admissions prior to admission. Further review of the policy revealed, A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to a nursing facility. Review of R18's Facesheet located in the electronic medical record (EMR), under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and document review, the facility failed to provide Activities of Daily Living (ADLs) to residents unable to carry out the necessary service for two (Resident (R) 20 and R24) of two residents reviewed for personal hygiene. Specifically, the facility staff failed to provide showers and/or bed baths to R20 and R24 twice per week. Findings include: Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with a diagnosis of chronic respiratory failure. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 11/06/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. Further review of this MDS revealed R20 was totally dependent upon staff for assistance with bathing. During an interview on 01/02/24 at 10:54 AM, R20 stated he was supposed to get bed baths two times…

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, interview, and review of facility policy, the facility failed to ensure that one resident (R)8 of two residents with an indwelling urinary catheter was secured to the resident's thigh to prevent trauma to the resident urethra and failed to position for the urinary drainage bag to allow for adequate drainage and prevent contamination. The failure has the potential to contribute to reoccurrence of urinary tract infections for this resident. Findings include: Review of the facility policy titled Indwelling Catheter (Foley) Management) revised 08/24/23 indicated Keep the catheter and collecting tube free from kinking. b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter; and securing the catheter to facilitate flow of urine, preventing kinking of the tubing . Observation 01/03/24 at 10:30 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure resident's medical record reflected the resident's accurate weight for one (Resident (R) 20) of five residents reviewed for nutrition. Findings include: Review of facility policy titled Weights and Heights revised August 2023, indicated All residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with a diagnosis of chronic respiratory failure. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) date of 11/06/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. Review of R20's Weights located in the EMR under the Weights and Vitals tab revealed resident's weight on 10/25/23 was 387.8 pounds and on 12/06/23 was 288.6…

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 residents have the right to make choices about aspects of their life in the facility that are significant to the resident. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to permit the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed at the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Resident #227 and #36). The facility failed to allow residents who voiced a desire to eat in the dining room the right to eat in the dining (Resident #10 and #13). In addition, the facility failed to allow residents who voiced the desire to go outside the right to go outside to an enclosed courtyard (Resident #38,…

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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of each resident. The facility failed to employ an activity director qualified for the position, failed to employ sufficient numbers of activity staff based on the facility assessment, failed to ensure scheduled activities occurred as scheduled, failed to provide outdoor activities per residents request, failed to provide activities per residents choice as identified in grievances and resident council, failed to ensure residents on quarantine were provided with in room activities and failed to ensure group activities occurred in sufficient numbers to ensure residents who wanted to attend were able to attend for nine of 12 residents investigated for activities (Resident #73, #227, #13, #38, #44, #52, #36, #22 and #523). These failures had the potential to affect all residents…

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 the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to activities provided. In addition, the facility failed to develop policies specific to the facility to address feedback, data collection systems and monitoring, including adverse event monitoring; to address how the facility will use a systematic approach to determine underlying causes of problems, how the facility will develop corrective actions, or how the facility will monitor the effectiveness of its performance improvement activities. This had the potential to affect all residents in the facility. The census was 82. Review of the facility's Quality Assurance and Performance Improvement Program Framework, dated 12/20/19, showed: -Purpose: To provide guidance in the development and implementation of an effective QAPI program that takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining 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 promptly, upon the grievances and recommendations of the resident council, demonstrate their response and rationale for such response concerning issues of quality of life. The resident council reported concerns with activities during the three most recent meetings and the facility failed to document a follow-up with the concerns, act upon the recommendations and/or document a rationale as to why the facility could not act upon the concerns. The census was 82. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; -The resident has a right to prompt efforts by the facility to resolve grievances, including those with respect to the behavior of other…

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 residents were aware of available hours to receive their money during the week or to have money available to residents on the weekends. The census was 82. Review of the facility's Resident Trust Policy and Procedures, showed: -Cash on hand shall be held in a cash box clearly marked Personal Needs in a secure location; -Personal needs cash on hand is operations funds made available to advance cash to residents requesting withdrawals from their respective accounts; -The policy did not have times as to when residents' money was available. Review of the Authorization and Agreement to Handle Resident Funds form signed by the resident, did not show when their money was available to them or how to obtain funds on the weekends. Observations of the facility throughout the survey, showed no hours posted for when residents could have access to their money. During an interview on 6/10/21 at 11:00 A.M., Resident #35 said he/she can call ahead to get money during weekdays, but not on weekends. 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 perform a yearly review of code status for full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate (DNR), no life prolonging methods are performed) and obtain a signed code status form upon admission to the facility (Residents #13, #71, #61 and #227). In addition, the facility failed to ensure two witnesses signed a code status form for a resident who could not sign their name (Resident #324). The sample was 20. The census was 82. 1. Review of Resident #13's medical record, showed: -An admission face sheet, showed an admission date of 10/13/12; -A signed code status form, dated 9/22/17, for full code; -A physician's order sheet (POS), dated June 2021, showed an order dated 10/8/18, for full code status; -No updated code status form found since 9/22/17. Review of the resident's current signed code status form, provided by the facility on 6/14/21, showed signed code status form, dated 9/22/17, for full code. 2. Review of Resident #71's medical record,…

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 residents could retain personal property safely from loss or theft, when they failed to complete an inventory sheet for 6 of 20 sampled residents (Residents #426, #378, #376, #373, #425 and #276). The census was 82. Review of the facility's admission packet, provided on 6/7/21, showed: -Section 12 Resident Funds, Valuables and Possessions: -You or your representative agree to inform the facility of all valuable property upon admission, and at any time new items are added to your possession. Upon admission, a detailed inventory of your possessions will be done; -The facility will attempt to reasonably safeguard your non-monetary personal property and belongings left in the facility, to the extent required by law. The facility will dispose of any non-monetary personal property and belongings that remain unclaimed 14 days after your discharge from the facility. 1. Review of Resident #426's medical record, showed: -admitted : 11/13/20;…

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.

Based on interview and record review, the facility failed to disclose and provide to a resident or potential resident prior to time of admission, notice of service limitations of the facility. The facility is a smoking facility and the admission packet provided to residents identify the smoking area and smoking times. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to grandfather in the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed in the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Residents #227 and #36). The facility also failed to ensure residents who signed the admission agreement were cognitively intact enough to sign a contract (Resident #232). The sample was 20. The census was 82. Review of the resident's bill of rights, provided to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure notification to the resident and the resident's representative in writing of a discharge, including the reason for the discharge, the effective date of the discharge, the location to which the resident is discharged and a statement of the resident's appeal rights. The facility also failed to follow their transfer or discharge policy for 9 of 20 sampled residents (Residents #25, #57, #227, #223, #23, #61, #71, #276, and #67). The census was 82. Review of the facility's policy for Transfers and Discharges, dated 5/16/19, showed before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move, in writing. 1. Review of Resident #25's medical record, showed: -discharged to the hospital 3/16/21; -Returned to the facility from the hospital on 3/24/21; -No transfer notice provided for the hospitalization on 3/16/21 through 3/24/21.…

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 inform the resident and family or legal representative of the bed hold policy at the time of transfer to the hospital for various medical reasons for eight of 20 sampled residents (Residents #35, #23, #71, #57, #227, #67, #276 and #25) The census was 82. Review of the facility's Bed Hold/Reservation of Room Policy, dated 5/2/19, included the following: -The facility's bed hold policy will be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence; -The facility will provide written information to the resident or resident's representative the nursing facility policy on bed-hold periods and the resident's return to the facility to ensure that residents are made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility; -Procedure: 1. Bed hold…

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 obtain vitals and neurological checks for a resident who had fallen (Resident #425), ensure physician's orders were obtained/followed for tube feedings and oxygen, and ensure braces, splints, or palm guards were applied as ordered, for five of 20 sampled residents (Residents #67, #23, #54 and #22). The census was 80. 1. Review of the facility Fall Management Policy, dated 6/4/20, showed: -Purpose: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patient fall indicators; -Definition: Fall: refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to…

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

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The facility's activity director had worked at the facility for approximately four months and did not meet the requirements to be the activity director. The census was 82. Review of the activity director's resume and application for employment, showed: -Education: Bachelor of Science in Wellness with an emphasis in Kinesiology (body movement and positioning); -Work experience included experience as a Maître D (food service specialist) and home services provider (cleaning, cooking and shopping); -Volunteer experience in the Month of April, 2019 at a long term care facility in the activity program; -No documentation of certification in a state approved activity director training course; -No documentation of 2 years experience in a social/recreational program with one year full time in a therapeutic activity program. During an interview on 6/10/21 at 1:07 P.M., the activity…

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 adequately monitor and provide assistance to promote good nutrition and to maintain acceptable parameters of nutritional status. Staff failed to ensure a timely nutrition assessment by the Registered Dietician (RD), failed to ensure response to the RD recommendation regarding resident weight loss, failed to notify the physician of significant weight loss, failed to implement interventions regarding nutrition per the care plan (Residents #54, #227 and #235). Furthermore, staff failed to provide meal assistance as needed, ensure the resident was positioned at a 90 degree angle when eating, and provide health shakes as ordered (Resident #324). The sample was 20 and the census was 82. 1. Review of Resident #54's care plan, initiated on 5/6/21 and in use during the survey, showed: -Focus: At risk for weight fluctuation related to current health status; -Goal: Resident wishes to maintain current weight through next review; -Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the proper storage of medications in two of three medication carts observed. One medication cart contained an unidentified, pre-pulled pill in the top drawer and a tube of anti-fungal cream located inside of a box of lancets (small double-edged blades or needles used to make a puncture to obtain a blood specimen) in the bottom drawer. A second medication cart contained a box with various medications stored together, not labeled as stock or for a specific resident, a bottle of liquid Pro-source (a nutritional supplement) that lacked an opened-date, spilled over the side and into to the bottom of the medication cart and an unidentified pill on the bottom, right ledge of the cart. The facility had five medication carts. The census was 82. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised on [DATE], showed: -Policy governs procedures relating to the storage 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 observation, interview and record review, facility staff failed to maintain kitchen equipment, walls, ceiling tiles and floors in a clean and sanitary manner to prevent to the growth of bacteria and potential harborage of pests. Facility staff failed to ensure the meat slicer remained covered when not in use to prevent cross contamination and failed to ensure the inside perimeter of the mop bucket was clean. The census was 82. Observations on 6/7/21 at 8:28 A.M., 6/8/21 at 11:39 A.M., 6/9/21 at 8:05 A.M., 6/10/21 at 1:01 P.M., 6/11/21 at 10:16 A.M., 6/14/21 at 11:05 A.M., 6/15/21 at 1:57 P.M. and 6/16/21 at 7:03 A.M., showed the following: -The uncovered meat slicer positioned next to a food preparation sink; -The convection oven had a layer of grease and dust on top. The interior walls and the racks had a heavy carbon build up; -The vat walls of the deep fat fryer had caked on food particles extending 3 inches above the oil. Sediment floated on top of the oil. The oil was very dark in color and the bottom of the vat was not visible; -The metal cabinet housed underneath 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 conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility failed to address the activity services required by the resident population considering the need for quarantine, the activity director staff competencies and the physical plant considerations such as the family dining room and courtyard utilized for meals and activities. In addition, the facility assessment failed to identify the smoking resident population and/or the location of the resident smoking area in the court yard. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Resident #227 and #36). The census was 82. 1. Review of the facility assessment tool, dated 6/5/20, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent staff neglect from occurring when a staff member transferred one resident (Resident #10) using a sit to stand lift (mechanical lift) without assistance. The resident required a Hoyer lift (mechanical lift) with assistance of two staff members for all transfers. The resident fell and sustained a hematoma (a collection of blood outside of blood vessels) to the back of his/her head. The sample was 20. The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, dated Revised: 1/21/19; Reviewed 4/15/19, showed: - Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any…

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 report an alleged violation of abuse to the Department of Health and Senior Services (DHSS) promptly, no later than 2 hours after the allegation was brought to the facility's attention, for two of 20 sampled residents (Residents #10 and #44). The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, revised: 1/21/19 and reviewed 4/15/19, showed: -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals; -It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a preadmission screening for individuals with a mental disorder and individuals with intellectual disability by failing to ensure a resident had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screen is required) as required, for one of 20 sampled residents (Resident #67) The census was 82. Review of Resident #67's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/21, showed the following: -Date of admission on [DATE]; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; -Diagnoses included dementia, depression and schizophrenia (a mental condition that causes both psychosis (a loss of contact with reality) and mood problems). Review of the resident's medical record,…

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 appropriate discharge procedures and complete discharge and/or transfer documentation. This affected three of three reviewed closed records (Residents #276, #373 and #376). The census was 82. Review of the facility's Transfer and Discharge Policy, dated 5/6/19, showed: -Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations; -The facility will provide equal care regardless of diagnosis, severity of condition, or payment source. Transfer and discharge policies are the same for residents regardless of payer source; -Documentation: When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(l )(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to use a urinal and/or stand over a bedside commode or toilet (Resident #36). In addition, the facility failed to ensure residents were shaved and their fingernails were cleaned/trimmed as needed. (Residents #71, #54 and #73). The sample was 20. The census was 82. Review of the facility Activities of Daily Living (ADLs) policy, reviewed on 5/5/21, showed: -Purpose, to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's physical, mental and psychosocial needs; -A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living; -Hygiene, bathing, dressing, grooming and oral care; -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition,…

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 maintain proper placement of indwelling urinary catheters (a tube inserted into the bladder for purpose of continual urine drainage). The facility identified four residents as having indwelling urinary catheters. Of those four, one was chosen for the sample and issues were found (Resident #61). The sample size was 20. The census was 82. Review of the facility's Indwelling Urinary Catheter and Management Policy/Procedure, dated November 20, 2020, showed the following: -Critical Notes: Life Care Centers of America has approved the following information as an addendum to the Lippincott procedure: 1). Conduct a comprehensive, interdisciplinary review and assessment of the resident's continence status on admission, quarterly and with significant change of urinary function including factors that predispose the resident to the development of urinary incontinence and the use of an indwelling catheter; 2). Monitor the catheter daily and assess for complications resulting from the use of an indwelling catheter such as…

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, staff failed to execute appropriate technique while administering medications via gastrostomy (g-tube, a surgical opening into the stomach from the abdominal wall for the insertion of food and fluids) to one resident observed (Resident #23). Staff failed to follow standard, recommended practice when checking for g-tube placement and did not raise the head of bed (HOB) while administering medications to the resident via g-tube. The sample was 20. The census was 82. Review of the facility's Medication Administration through an Enteral Tube policy, effective date 4/4/19, showed: -Purpose is to set forth the procedures for medication administration through an enteral tube; -Check gastric residual volume (GRV, the amount of liquid drained from stomach following the administration of enteral feed) and observe the external length of the tubing for changes in size to verify g-tube patency prior to the administration of medications; -Adjust head of bed. Review of the facility's Enteral Nutrition Therapy policy, revised on 5/19/20, 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 a medication error rate of less than 5%. Out of 31 opportunities observed, 2 errors occurred, resulting in a 6.45% error rate (Resident #38). The sample was 20. The census was 82. Review of the facility's Administration of Medications policy, revised on 5/6/20, showed: -All medications to be administered as ordered; -A physician order includes dosage, route, frequency, duration, and other required considerations; -Federal regulation is to have less than 5% error rate. Review of the facility's Reordering, Changing, and Discontinuing Orders, policy revised on 10/31/16, showed: -Facilities are encouraged to reorder medications electronically. Review of Resident #38's Electronic Health Record (EHR), showed: -Diagnoses included multiple sclerosis (MS, a disease in which one's immune system attacks the protective barrier of nerves), atrial fibrillation (an irregular heart beat), depression, muscle weakness, cognitive communication deficit, convulsions, high cholesterol, obesity and bladder disorder; -A care…

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 to maintain medical records that are complete, accurately documented, readily accessible and systematically organized for four of 20 sampled residents (Residents #379, #56, #227 and #12). The census was 82. 1. Review of Resident #379's medical record, showed the following: -admission date [DATE], discharged to county medical examiner on [DATE]; -Diagnoses included Stage 4 Pressure Ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue separating from living tissue) or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling) located at the sacrum (triangle shaped bone located above the coccyx (tailbone), end stage kidney disease, elevated white blood count, metabolic encephalopathy (brain function is disturbed due to different diseases or toxins in the body) and dementia; -A progress note, dated [DATE] at 12:44 P.M., showed the resident had an elevated…

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.