Camdenton Windsor Estates

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for four residents (Resident #12, #18, #32, and #34) out of eleven sampled residents. Facility staff failed to protect residents' privacy when staff failed to provide privacy during perineal care for one resident (Resident #17) out of three sampled residents and during medication administration by feeding tube for one resident (Resident #202) out of one sampled resident. The facility's census was 46. 1. Review of the facility's policies showed staff did not provide a policy for privacy. Review of the facility's policy titled, Resident Rights, undated, showed each resident has the right to privacy and confidentiality. 2. Observation on 04/08/25 at 8:40 A.M., showed Certified Medication Technician (CMT) A left the computer screen open and unattended with Resident #32 medication information visible in the hallway. Observation showed residents and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to notify the Central Office Medical Review Unit (COMRU) or the state mental health authority of a change in condition Level I Preadmission Screening and Resident Review (PASRR) evaluation and determination after admission for one resident (Resident #18) of one sampled resident, when the resident was diagnosed with a new mental disorder and later experienced a significant change in his/her functional status. The facility's census was 46. 1. Review of the facility's policies showed it did not contain a policy to address the PASRR screening and referral process. 2. Review of Resident #18's electronic medical record (EMR) showed the resident admitted to the facility on [DATE] with diagnoses of Huntington's Disease and Depression (other than bipolar). He/She received a new diagnosis of schizoaffective disorder (a mental health condition with symptoms such as hallucinations and delusions, and mood disorder) on 06/10/24. Review of the resident's Significant…

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, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's Infection Prevention and Control Program. The facility's census was 46. 1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 08/2024, showed the IP is qualified to conduct IPC activities as a result of education, training and experience. He/she will complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module. 2. During an interview 04/09/25 at 1:53 P.M., the Director of Nursing (DON) said the facility does not currently have a qualified IP. He/She said a nurse was recently hired to be the facility's IP but the nurse is not certified, and he/she was not aware the IP needed to be certified. During an interview on 04/10/25 at 2:36 P.M., the administrator said he/she was not aware the IP needed to be certified. He/she said a nurse was recently hired to be the facility's IP but the nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to review and revise the comprehensive care plan for three residents (Resident #1, #2, and #3) out of three sampled residents care plans who sustained falls. The facility census was 49. 1. Review of the facility's Comprehensive Care Plan policy, undated, showed staff are directed as follows: -An individualized comprehensive care plan includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not required significant change assessment). 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), 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 staff failed to ensure services provided met professional standards of practice when staff did not complete and document neurological checks for two (Resident #1 and #2) of two sampled residents who had unwitnessed falls, as directed by the facility policy. The facility's census was 49. 1. Review of the facility's Neurological assessment form instructions, dated 01/01/25, showed staff are required to complete neurological checks for seventy-two hours post an unwitnessed fall or head injury. Staff are directed to perform neurological checks as follows: -First hour check every fifteen minutes; -Second hour check every thirty minutes; -Next two hours check every hour; -Next 72 hours check every shift. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 01/09/25, showed staff assessed the resident with severe cognitive impairment, one injury fall, and one non-injury…

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, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) out of one sampled residents to the Department of Health and Senior Services (DHSS) within the two hour required timeframe. The facility census was 50. 1. Review of the facility's Investigation policy, undated, showed all allegations of abuse will be reported no later than two hours to the State Survey Agency and if applicable, law enforcement, and there are instances where an alleged violation of abuse, neglect, misappropriation of resident property and exploitation would be considered to be a reasonable suspicion of a crime. In these cases, the facility is obligated to report to the Administrator, to the state survey agency, and to other officials in accordance with State Law. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/24/24, showed staff assessed the resident as admitted on [DATE] with 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 facility staff failed to ensure pureed food items were reheated to proper temperatures. Facility staff failed to follow puree recipes. Facility staff failed to ensure hot foods were held at 140 degrees Fahrenheit ºF or greater during meal service. Facility staff failed to ensure hot food on room trays for three residents (Residents #27, #25, and #105) of three sampled residents were maintained at 120 ºF at the time the food was delivered and to ensure employees who delivered food to the residents in the rooms knew what the appropriate temperature should be at the time of service. The facility census was 44. 1. Review of the facility's policy titled Food Temperatures, dated April 2011, showed staff shall ensure food is at least 120 ºF. A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form. 2. Review of Resident #27's Quarterly…

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 facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of outbreak of Legionnaire's Disease (a serious type of lung disease caused by Legionella bacteria) (LD). Facility staff failed to perform proper hand hygiene for two (Resident #14, and #25) of two sampled residents. The facility census was 44. 1. 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 bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or…

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, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms and common areas. The facility census was 44 out of a capacity of 82 residents. 1. Review of the facility's policy titled, Housekeeping Department, Seven Step Cleaning Procedure undated, showed staff were directed to do the following: -Dust mop, keeping dust mop on floor; use pan and broom to pick up debris; -Sanitize Floor, do not over wet the floor; use scraper to remove items stuck to floor, and change mop water every three rooms (or when visually soiled). Review of the facility's policy titled, Deep Cleaning a Resident Room, undated, showed: -Deep cleaning is the segment of housekeeping that ensure total cleanliness of the resident room; -Floors: clean all corners, edges and baseboards; be sure to remove any buildup around closets, behind bed, furniture, and door jams; dust mop and wet mop entire room. 2. Observation on 03/17/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not accurately code for three residents (Residents #8, #25 and #38) who use a Bi-level Positive Airway Pressure ((BiPAP) a non-invasive ventilation machine capable of generating air pressure to ensure airways remain open) or Continuous Positive Airway Pressure ((CPAP), a non-invasive ventilation machine that uses mild air pressure to ensure airways remain open during sleep), for one resident (Resident #25) who rejected care and for anticoagulant (a medication used to inhibit coagulation of the blood) use for two residents (Residents #14 and #47) out of 14 sampled residents. The facility census was 44. 1. During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said the facility does not have a Policy for MDS. The facility uses the Resident Assessment Instrument (RAI) manual as guidance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #6, #14, #21, #25, #33) out of 14 sampled residents. The facility census was 44. 1. Review of the facility's policy titled Care Plan Comprehensive, dated March 2012, showed: -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well-developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels or…

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, facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and assist resident with facial hair for four residents (Residents #14, #24, #33, and #50) out of fourteen sampled residents. The facility census was 44. 1. Review of the facility's policy titled Activities of Daily Living (ADL), dated March 2012, the purpose is to assist resident in achieving maximum function. Review showed: -Directed staff on how to dress residents in appropriate clothing, footwear and assistive devices; -Did not address hair care, facial hair care, and nail care. Review of the facility's policy titled Shampoo (Resident in Bed), undated, showed staff were directed to: -Shampoos are usually given with the scheduled shower or tub bath; -Directed staff on how to appropriately shampoo a resident that is bedfast. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to lock the medication and treatment carts, failed to store medications and chemicals in a safe manner. The facility census was 44 out of a capacity of 82 residents. 1. Review of the facility's policy titled Storage of Medication, dated March 2012, showed staff were directed: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or locked in a medication cart; -All medication carts must be under visual control of the staff at all times when not stored safely and securely; -The key to the medicine cabinet, medicine room, or medication cart is the responsibility of the person authorized to handle and administer medications; -An unattended medication cart must be locked at all times; -All poisonous substances and other hazardous compounds must be kept in a locked container away from medications and may not be accessible to the residents. Review of policies provided by 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, facility staff failed to store oxygen/nebulizer masks and tubing in a manner to prevent infection-causing contaminants for six (Resident #8, #33, #38, #6, #25, and #105) out of 14 sampled residents. Staff failed to ensure two resident (Residents #25 and #105) out of a sampled residents had orders for oxygen therapy. The facility census was 44. 1. Review of the facility's policy titled Oxygen Administration, dated March 2012, showed staff were directed to check and clean oxygen equipment, masks, tubing and cannulas at regular intervals. Place oxygen tubing in plastic bag attached to concentrator when tubing is not in use. Review of the facility's policy titled Bi-level Positive Airway Pressure (BiPAP), a non-invasive ventilation device used to keep airways open during sleep, Administration, dated March 2012, showed staff were directed to use tap water, distilled water is optional for humidifier. Refer to Continuous Positive Airway Pressure (CPAP), a non-invasive…

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 accurately count controlled medications for two residents (Residents #13 and #16). Facility staff failed to remove and destroy expired medications and medical supplies. The facility census was 44. 1. Review of the facility's policy titled Medications, Scheduled II-V, dated March 2012, showed staff shall have disposition records for controlled medications. All scheduled medications must be counted, comparing number of pills to disposition record at every change of shift by two Certified Medication Technicians (CMT), or one CMT and one licensed nursing staff. Both personnel must sign verification of correct count. Any time the count is incorrect, licensed nursing staff will call the Director of Nursing (DON). Review of the facility's policy titled Narcotic Count, dated March 2012, showed staff shall reconcile by physical count the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. After the supply is counted, the nurse records the date and his/her signature, verifying…

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, facility staff failed to provide an appropriate 30 day discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the resident was ready for discharge from the hospital. The facility census was 49. 1. Review of the facility's Discharge/Transfer of Resident policy, undated, showed for the transfer of a resident staff are to explain the transfer and reason to the resident and/or representative and give copy of transfer or discharge notice to the resident and/or representative or person responsible for care. Review showed if it is an emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible. 2. Review of Resident #1's Entry and Discharge Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/17/24, showed the resident was admitted and discharged on 1/17/24. Review of the resident's progress notes, dated 1/17/24, showed the resident admitted to the facility and received an intravenous (IV) antibiotic medication. Review showed staff…

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

Based on observations and interviews the facility failed to offer internet, to the extent available to the facility, to all residents. The facility census was 49. 1. Review of the facility's policies showed the facility did not have a policy in regards to resident Internet usage. 2. Observation and Interview on 11/1/23 at 2:15 P.M., showed Nurse Assistant (NA) A using Matrix Care Software (an Internet based computer software used to maintain medical records) to document in resident medical records. NA A said the residents don't get access to internet and there is no computer set up for them to use. He/She said sometimes the staff feel bad for them and will allow them to use their hotspots to talk to their friends and family. During an interview on 11/1/23 at 11:50 A.M., Resident #1 said he/she wanted to remain at the facility because he/she had made a lot of friends there but they do not offer internet to the residents. Resident #1 said there were a lot of younger residents in the facility like himself/herself that would benefit from internet availability. For example, he/she would…

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 properly store open food to prevent contamination and outdated use, to maintain kitchen equipment in a clean and sanitary manner, and to perform hand hygiene as often as necessary to prevent cross-contamination. The facility staff also failed to ensure the ice machine drained through an air gap and to maintain the tools necessary to properly test the dishwashing machine sanitizing solution. This had the potential to affect all residents. The census was 43. 1. Review of the facility's Safe Food Handling policy, dated 4/2011, showed all food, including bulk items, should be tightly sealed with an identifying label and date. Observation on 11/28/22 at 9:51 A.M., showed: - Five pound can of spinach dented; - Five pound can of diced peaches dented; - Open bag of bread crumbs not labeled and undated; - Open bag of brown sugar not labeled and undated; - Bulk container of cereal flakes sat on the bottom shelf of the service counter with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, facility staff failed to accurately identify care areas for five residents (Residents #17, #25, #33, and #36) in the resident's comprehensive care plans (CP). Additionally, facility staff failed to include the resident's and/or resident's representative in the development of the comprehensive care plan for three resident's (Resident #7, #28, and #295). The facility census was 43. Review of the facility's Daily Care Needs Policy, undated, showed resident care plans are individualized and give specific instructions on care. Review of the facility's Care Plan Comprehensive Policy, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan…

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, resident and staff interview and record review, facility staff failed to meet professional standards when staff failed to document they followed physician orders for eleven residents (Resident #1, #5, #7, #9, #13, #20, #28, #33, #36, #37 and #295). Additionally, staff failed to administer gastrostomy (g-tube) (a tube inserted directly into the stomach to provide nutrition and medications) medications for one resident (Resident #7) per facility policy, failed to obtain an order for oxygen use, document daily weights and provide compression stockings as ordered for one resident (Resident #20), and failed to complete neurological checks for one resident (Resident #27) after a fall. The facility census was 43. Review of the facility's Medication Administration Guidelines Policy, undated, showed it is the purpose of this facility that resident's receive their medications on a timely basis and in accordance with established policies and the person administering the drugs must chart 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, facility staff failed ensure six dependent residents (Resident #1, #5, #16, #25, #33, and #34) received the necessary services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair, failed to ensure residents wore clean clothes, failed to provide timely incontinence care and failed to ensure residents were turned and repositioned. The facility census was 43. 1. Review of the facility's Positioning the Resident Policy, undated, showed it directs to reposition residents to relieve pressure, prevent skin breakdown and relieve pain. Review showed the policy did not contain guidance for staff in regard how often residents should be repositioned. Review of the facility's Shaving the Resident Policy, undated, showed it directs staff to remove resident's facial hair to improve the resident's appearance and morale. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by…

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, facility staff failed to provide activities to three dependent residents (Residents #5, #16 and #17). Additionally, staff failed to provide staff facilitated activities on the weekends. The facility census was 43. 1. Review of the facility's Activity Calendar, dated November 2022, showed staff offered the following activities: -Bingo on 11/28/22 at 2:00 P.M.; -Ball Toss on 11/29/22 at 10:00 A.M. and Crafts at 2:00 P.M.; -Fun and Fit on 11/30/22 at 10:00 A.M. and Birthday Party at 2:00 P.M. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/9/22, showed staff assessed the resident as: -Moderately Impaired Cognition; -Totally dependent on two staff members for transfers; -Impairment in Range of Motion (ROM) of all extremities; -Had no behaviors; -Locomotion on and off unit did not occur, during the seven day look back period (period of time used to complete assessment); -Diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to properly propel two resident's (Resident #12 and #29) in wheelchairs in a manner to prevent accidents. Additionally, staff failed to ensure razors/sharps and hazardous chemicals were stored in a safe manner, and failed to lock an unattended medication cart. The facility census was 43. Review of the facility's Wheelchair, Use of Policy, undated, showed: -The purpose is to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Lower footrests and place resident's feet on footrests if used. Position feet and legs in a good body alignment; -Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/15/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, facility staff failed to ensure licensed nursing staff had the required skills and competencies to meet the care needs for one resident (Resident #95) with a tracheostomy (an artificial opening into the trachea). Additionally, facility staff failed to ensure two Nurse Aide (NA)s completed the nurse aide training program within four months of his/her hire date. The facility census was 43. 1. Review of the facility's Tracheostomy Care policy, dated March 2012, showed an emergency tracheostomy tube and reinsertion supplies should be at the bedside and a resuscitation bag (ambu bag) should be available. Review of the facility's Facility Assessment, dated 12/21/21, showed: -Facility staff will assess the competency of staff as it relates to the residents' care needs and determine if any additional education should be provided, and who could provide it; -Facility staff could provide tracheostomy care; -Competencies to include tracheostomy care and suctioning;…

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 ensure a medication error rate of less than 5%. Out of 25 opportunities observed, 5 errors occurred, resulting in a 20% error rate, which affected four residents (Resident's #4, #5, #13, and #37). The facility census was 43. 1. Review of the facility's Medication Administration Policy, undated, stated the purpose is to administer medications to benefit the resident's health, as ordered by the physician. Review of the facility's Medication Error Policy, undated, stated to report all medication errors immediately to the attending physician, Director of Nursing (DON), and the Administrator. Review of the facility's Medication Administration Guidelines Policy, undated, showed it is the purpose of this facility that resident's receive their medications on a timely basis and in accordance with established policies and the person administering the drugs must chart the medications immediately following the administration. 2. Review of Resident #4's Physician Order Sheet (POS), dated November 2022, 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.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when staff failed to use appropriate hand hygiene during the provision of care and failed to use appropriate infection control procedures during incontinence care for three residents (Resident's #16, #1 and #5). Additionally, staff failed to follow their facility policy to ensure six out of ten sampled employees, were screened upon hire for tuberculosis (TB), (disease caused by bacteria called Mycobacterium tuberculosis, that usually attacks the lungs). The facility census was 43. 1. Review of the facility's Perineal Care Policy, undated, showed the purpose is to prevent infection and odor. The policy did not contain direction for staff when disposable wipes are used for perineal care or when to change gloves and perform hand hygiene. Review of the facility's Handwashing policy, dated 3/2012, 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 observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over one resident (Resident #17) while assisting the resident to eat, and failed to serve one resident (Resident #16) their meal while staff fed another resident at the same table. Additionally, facility staff failed to provide one cognitive, totally dependent resident (Resident #5) with a call system he/she was able to use. The facility census was 43. 1. Review of the facility's Resident Rights Policy, undated, showed each resident shall be treated with consideration, respect and a full recognition of his/her dignity. Review of the facility's Feeding the Resident policy, undated, showed staff are directed to: -Give the resident your complete attention; -Sit so you are at the same level as the resident, when possible; -Converse with the resident in an appropriate manner. 2. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff,…

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 provide a comfortable and homelike environment, when staff failed to ensure resident common areas and rooms were clean, free of odors, and maintained. The facility census was 43. 1. Review of the facility's Daily Care Needs Policy, undated, showed it directed to ensure the resident's room is clean and neat with all equipment properly stored and furniture clean. Review of the facility's Cleaning Guideline- Bed Mattress Policy, undated, showed: -Purpose: To ensure mattresses are clean and free of odors; -Soiled mattresses will be cleaned on the residents' bath days by housekeeping and nursing staff; -Mattresses are to be cleaned when soiled, on bath days, or when the room is deep cleaned. 2. Observation on 11/28/22 at 9:45 A.M., showed the lobby and 100 hallway had a lingering urine odor. Observation on 11/28/22 at 9:50 A.M., showed the lobby and 100 hallway had a persistent foul odor. Observation on 11/30/22 at 4:06 A.M., showed a foul urine odor lingered in the lobby and down the 100 hallway. Observation 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, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) in accordance with their facility policy for nine out of ten sampled staff. Additionally, facility staff failed to check the Family Care Safety Registry (FCSR) or complete a Criminal Background Check (CBC) for one employee (NA C), and failed to check the Certified Nurse Aide (CNA) Registry for one employee (LPN D). The facility census was 43. 1. Review of the facility's Background Checks Policy, undated, showed: -The FCSR or the EDL and CBC must be checked before the applicant/employee has any contact with residents. The CNA Registry must also be checked for all persons that have been chosen for hire; -Always keep a hard copy of the EDL results for each employee. Also, always keep a hard copy of the CBC request and the results for each employee; -In addition to the pre-employment EDL checks, a quarterly EDL check update must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure two dependent residents (Residents #5 and #16) were offered sufficient fluid intake to maintain proper hydration and health. The facility census was 43. 1. Review of the facility's Hydration Policy, undated, showed staff are directed to offer fluids to residents as follows: -On arising, 120 (cc) of water; -Breakfast, 400 (cc) of fluid; -Mid-morning, 240 (cc) of fluid; -Lunch, 400 (cc) of fluid; -Mid-afternoon, 240 (cc) of fluid; -After nap, 240 (cc) of fluid; -Supper, 400 (cc) of fluid; -Bedtime, 240 (cc) of fluid; -At night offer 120 cc of fluid every two hours, if the resident is awake; -Fresh water will be distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be assisted by the staff. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/1/22, showed staff…

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.