Cameron Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the licensed staff maintained professional standards of quality in care and services according to accepted standards of clinical practice, when licensed staff did not follow through on known infections in the building by ensuring resident's with infections or those who were at risk for infections were identified, isolated appropriately and with proper posted signage outside the room. As well as ensuring that personal protective equipment was accessible and provided for staff to carry out care for the residents in the correct manor according to the infection. Additionally, this failure did not ensure ancillary staff or visitors who entered the resident's rooms were aware of the need for transmission based precautions. The facility additionally failed to offer and document yearly immunizations for four residents (Residents #9, #11, #41, #46). This had the potential to affect all residents in the building. The facility census was 67.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure the correct installation, use, and maintenance of bed rails included assessing residents for risk of entrapment from bed rails prior to installation, ensure the bed's dimensions were appropriate for the resident's size and weight, and follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. The facility also failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 17 residents sampled (Resident #2, #27, and #60). The facility census was 67. Facility did not provide a policy on bed rails or entrapment. 1. Review of Resident #2's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/24/25, showed: -Cognition intact; -He/She had clear speech, was able to make self-understood and clearly comprehend others; -He/She had no impairment to range 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 and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to four of seventeen sampled residents (Resident #27, #32, #37, and #69). The facility failed to prepare dietary menus according to their recipes by not using recipe ingredients resulting in bland and tasteless food and the facility failed to serve dessert at appropriate holding temperature. The facility census was 67. Review of facility policy, food temperatures, revised 1/1/25, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. -At starting of meal services Hot Foods should be above 135 degrees Fahrenheit (F) and cold foods should be served below 41 degrees F; -Acceptable serving temperatures: -Cereal, gravy 135 degrees; -Meat, entrees, greater than 135 degrees; -Pureed foods, greater than 135…

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 foods that were stored in resident personal refrigerators and freezers were monitored for safe and appropriate temperatures and discard potential spoiled contents to prevent the potential for food-borne illness. The facility census was 67. Facility did not provide a policy on food storage or resident room refrigerators. Review of facility policy, Food Brought in by Visitors, revised 2/2021, showed: -Food may be brought to a resident by the family members, the resident's responsible party, or friends if the food is compatible with the attending physician's diet order; -Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. Review of facility policy, food temperatures, revised 1/1/2025, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Cold foods should 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 2. Review of Resident #36's Quarterly MDS (Minimum Data Set) A federally mandated assessment, completed by facility staff, dated 1/9/25., showed: - Cognition severely impaired; - Diagnoses of: Wound Infection, yeast Infection, and stroke with right side paralysis; - Max assist of two for all activities of daily living (ADLS). Observation on 3/17/25 at 1:00P.M. showed the resident' was not on Enhanced Precautions for active infection and no PPE (personal protective equipment) available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty. Observation on 3/20/25 at 9:35 A.M., showed an isolation sign posted on the resident's door that read Enhanced Barrier Precautions. Review of the resident's care plan, dated 2/28/25., showed: - No care planning regarding wound…

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 obtain signed immunization refusals, or administer the influenza vaccine to four residents (Resident's #41, #46, #11 & #9). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain signed refusals, or administer the Covid vaccine to four residents (Resident's #9, #11, #41, and & #46). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure staff provided appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible when the facility staff failed to ensure proper catheter care of one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Catheter - Care of Policy, dated 06/22, showed: - A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. - Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. - Take care to ensure the collection bag does not touch the floor at any time. 1. Review of Resident #29's most current MDS dated [DATE] showed: - Cognition not intact - Resident has indwelling urinary catheter - Requires staff assistance of 1-2 for all ADLS (acitivites of daily living) - Diagnoses: Alzheimer's disease, diabetes…

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 recognize, evaluate, and address the hydration needs need of one and failed to offered sufficient fluid intake to maintain proper hydration and health for one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Nutrition/Hydration Management policy dated 06/20 showed: -The purpose is to ensure that each resident maintains acceptable parameters of nutritional/hydration status such as body weight and protein levels, unless the resident's clinical condition demonstrates this is not possible based on the resident's comprehensive assessment. - A comprehensive care plan is developed by the interdisciplinary care team that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need. 1. Review of Resident #29's most current (MDS) Minimum Data Set, a federally mandated assessment completed by facility staff, dated 01/10/25 showed: Resident has an activities of daily living (ADL) self-care performance…

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 store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents when medications were left at bedside for one resident (Resident #48) and when the medication cart was left unlocked and unattended. The facility census was 67. Review of facility policy, revised 8/2020, showed: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. 1. Observation on 3/17/25 at 9:26 A.M.…

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 prepare food in a form designed to meet individual needs when one resident was served food not consistent with their dietary orders (Resident #37). This affected one of seventeen sampled residents. The facility census was 67. Review of facility policy, Nutrition/Hydration Management, revised 6/2020, showed: -To ensure each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrations that this is not possible based on the residents comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem; -Diet orders including texture and consistency specifics. Review of facility policy, therapeutic diets, revised 1/1/25, showed: -Therapeutic diets are diets that deviate from regular diet and require a physician's order. Per the physician's order, therapeutic diets are planned, prepared, and served in consultation with the registered Dietician. The attending physician may…

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

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 64. Review of the facility's policy Cleaning of the Kitchen revised, December 2020, showed: The dietary staff will maintain a sanitary environment in the nutrition services department. The facility did not provide the requested policies for maintence and repair of the dining room and kitchen, cleaning of vents in the kitchen and dining room and dating and storage of food and storing dishes in the kitchen. 1. Observation of the kitchen on 02/27/24, at 10:02 A.M., showed: -Two vents covered with dirt and debris; -The wall by the electrical box with missing paint; -20 plates and 10 cups stored face up on the top shelf storage; -The top of the toaster covered in food debris; -Metal containers of utensils setting under the prep table with no lids with debris in the bottom of the containers. 2. Observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview , the facility failed to maintain a clean, safe, homelike enviornment when they failed to keep the floors, doors and handrails clean and in good repair. The facility census was 64. The facility did not provide a policy on cleaning and/or general maintanence. Observations on 2/29/24 begining at 12:05 P.M. showed: -The 100 hall had : -loose hand rails by room [ROOM NUMBER] and room [ROOM NUMBER] ; -baseboards had dark crusty debris at floor edges; -white, crusty salt like stains under the registers at the dining room entrance; -dust, crumbs and debris at the corners behind the fire doors; - cracked and dented green floor tile at dining room entrance; -a piece of missing baseboard at the dining room entrance; -heat registers in hallway had broken vents, peeling paint, and chipped and peeling caulk; -hallway walls have scrapes, gouges and nail holes throughout. -baseball sized hole in bathroom door of room [ROOM NUMBER]. - The 200 hall had: -loose hand rail by room [ROOM NUMBER]…

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 and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, unwitting and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic) and telephone number of the Office of the State Long-Term Care Ombudsman; and for resident's with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy 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, interviews and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services/cares to maintain good personal hygiene for four residents (Resident #14, #42, #13 and #54 ) out of 16 sampled residents. Residents dependent upon staff for assistance, did not receive repositioning, timely incontinent care or showers. The facility census was 64. The facility did not provide an Activities of Daily Living policy. Review of the facility provided Resident Rights Policy dated 8/2020 showed in part: -The resident has the right to a dignified existence. -The facility must care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life. 1. Review of Resident #14's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facilty staff) dated 11/27/23 showed: - A Brief Interview of Mental Status (BIMS) of 9, indicated severe cognitive defecits.…

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 meaningful activities to meet the needs for two of 16 sampled residents (Resident #14, and #42). The facility census was 64 Review of the facility provided policy, Activities Program, dated 2/2020 showed in part: -Encourage residents tto participate in activities to make life more meangful, to stimulate and support physical and mental capabilities to the fullest extent and to enable to resident to maintain the hightest attainable social, physical and emotional functioning. -The facility provides an activity program designed to meet the needs, interests and preferences of residents. -A variety of activities should be offered -Activities are developed for individual, small group and large group participation. 1. Review of Resident #14's Activity assessment dated [DATE]., showed -The resident enjoyed television, bingo and word search games. -He/she also enjoyed exercise and sports, cultural events and news and food activities. 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 observation, interview and record review, the facility failed to ensure staff maintained proper positioning of the tubing and reservoir bag, for one resident (Resident #22) with an indwelling urinary catheter (a tube placed into the bladder to drain urine by gravity) and recent history of a urinary tract infection; and additionally failed to follow infection control practices when providing care of the catheter for two residents (Resident #22 and Resident #4) of the 16 sampled residents. The facility census was 64. Review of the facility provided policy Catheter- Care of, dated 6/2020 showed in part: -Purpose: to prevent catheter associated urinary tract infections. -Cleanse the skin folds, wiping front to back and cleanse the outside of the catheter wiping away from the opening of the body. -Position the catheter, drainage system and bag utilizing gravity to facilitate drainage. -Collection bags should always be kept below the level of the bladder, including during transport. 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 observation, interview and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made five errors out of 25 opportunities for error, which resulted in an error rate of 20%. This affected four of 16 sampled residents, (Resident #28, #34, #62, and #116). The facility census was 64. Review of the facility's undated policy for medication administration, showed, in part: - The purpose is to provide practice standards for safe administration of medications for residents in the facility; - The licensed nurse must know the following information about any medication they are administering: the drug's name (generic and trade); the drug's route of administration; the drug's action; the drug's indication for use and desired outcome; The drug's usual dosage; the drug's side effects and adverse effects; and any precautions and special considerations. Review of the facility's policy for blood glucose monitoring, revised 6/20, showed, in part: - The purpose is to monitor blood glucose concentrations as ordered…

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's licensed staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to remove and properly discard discontinued medication from two of two sampled medication rooms. The facility census was 64. Review of the facility provided policy Medication Destruction for non-controlled Medications dated 9/2018 showed in part: -Discontinued medications and medications left in the facility after a resident's discharge that do not qualify for return to the pharmacy for credit are destroyed. -Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. 1. Observation and interview on 3/01/24 at 10:37 A.M. of the north medication storage room showed: - 3 grey wash basins, each approximately 13 inches (in.) by 10 in. x 4 in. full of 79 total bubble packaged (a package consisting of a clear plastic overlay affixed to a cardboard backing for protecting and displaying a product) medications, 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to assure that staff served food to the residents that was palatable, attractive, and served at a safe and acceptable temperature. This affected four sampled residents (Resident #18, #30, #50, and #57). The facility census was 64. Review of the facility's Food Temperatures policy, revised, December 2020, showed: -Foods prepared and served at the facility will be served at the proper temperatures to ensure food safety; -Acceptable serving temperatures: o Casseroles - greater than 135 degrees Fahrenheit; o Meat - greater than 135 degrees Fahrenheit; o Potatoes - greater than 135 degrees Fahrenheit; o Pureed foods - greater than 135 degrees Fahrenheit; o Milk - less than 41 degrees Fahrenheit; -Heat plates that hot foods will be served on to maintain temperature. Review of resident council minutes showed: -10/6/23 resident complaint of no biscuits and gravy for breakfast; -11/2/23 resident complaints of cold food; -11/2/23 resident complaint…

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 are allowed to make meal choices when facility staff failed to provide three sampled residents (Residents #18, #30, and #53) with alternate food choices or allow choices of menu items. Facility census was 64. The facility did not provide the requested policy on resident choices. Review of the facility provided Resident Rights Policy dated 8/2020 showed in part: -The resident has the right to a dignified existence. -The facility must care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life. 1. Review of Resident #18's care plan dated 8/1/23, showed: -Limited physical mobility due to weakness in bilateral ankles; -Independent with eating; -The resident has a potential nutritional problem; -The resident will be served diet as ordered. Review of the resident's quarterly Minimum Data Set (MDS, A federally mandated assessment completed by the facility staff.), dated 2/15/24, 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 and interview the facility staff failed to maintain an effective infection control program when dietary staff did not wash their hands before applying clean gloves while preparing food in the kitchen and when staff failed to wash hands before applying clean gloves while preparing resident drinks in the dining room. Also, facility failed to annually review and implement a water management procedure to reduce the risk of bacterial growth and reduce the spread of Legionella (a bacteria that causes Legionnaires' disease, a serious type of pneumonia). This had the potential to affect all the resident in the building. Lastly, the facility failed to ensure that newly hired employees in the last year received a two-step Tuberculin Skin Test (TB), this affected five of the six sampled employees. The facility census was 64. Review of the facility's hand hygiene policy revised, June 2020, showed: -Staff will wash hands with soap and water before and after food preparation; -Staff will change gloves between tasks. The facility did not provide the requested policy regarding…

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 monitor the monthly Medication Regimen Review (MRR) reports for August and November of 2023, completed by the pharmacist, to ensure they reported irregularities to the attending physician, and failed to address these recommendations with the resident's physician until January of 2024. This affected one of 16 sampled residents, (Resident #24). The facility census was 64. The facility did not provide a policy for Medication Regimen Reviews. 1. Review of Resident #24's pharmacist's medication regimen review, dated August 2023, showed: - The resident received Omperazole 40 mg. twice daily since 5/23; - On 8/25/23 the physician noted and agreed to reduce the Omeprazole to every day. The order was not dated or noted by staff. Review of the pharmacist's medication regimen review, dated November 2023, showed: - On 11/14/23 the resident received Duloxetine 90 mg. since 5/23. The resident received Loxapine 10 mg. three times daily 5/23. The pharmacist recommended a gradual dose reduction; - On 1/29/24, the physician signed it and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) of seven sampled residents remained free of mental abuse when staff used racial stereotypes multiple times, taunting the resident. The facility census was 60. Review of the facility policy Abuse Prevention and Prohibition Program dated 8/2020 showed in part: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. -Staff must not allow anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment or misappropriation. -The facility is committed to protecting residents from abuse by anyone including staff. Review of the facility policy Resident Rights policy dated 8/2020 showed in part: -All residents have the right to a dignified existence. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his…

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, observation and record review, the facility failed to maintain resident dignity when the facility staff did not knock on resident doors prior to entry affecting one resident (Resident # 51), facility staff was rude to a resident affecting one resident (Resident # 38), and facility staff failed to keep one resident's body covered to maintain dignity (Resident #168) of 17 sampled resident's. The facility census was 67. Review of the resident dignity policy dated 12/1/21 showed: - All staff members are involved in providing care to residents and are to maintain resident dignity and respect resident rights. - Staff are to respond to requests in a timely manner. - Staff are to speak to resident's respectfully. - Staff are to respect the resident's living space and personal possessions. - Staff are to groom and dress resident's according to the resident's preference. Review of the undated resident rights policy showed: - The resident has the right to be treated with respect, dignity, and to live…

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 Resident #7 was able to safely self-administer medications when 4 pills were left in a medication cup on the resident's bedside table. The facility also failed to ensure Resident #13 was able to safely self-administer medications when 12 pills were left in a medication cup on the resident's bedside table, and Resident #36 was able to safely self-administer medications when 11 pills were left in a medication cup on the bedside table, all unattended by licensed staff. This affected three of 17 sampled residents. The facility census was 67. Review of the medication administration policy dated 12/1/21 showed: - Medications are to be administered by licensed staff as ordered by the physician. - Observe the resident consuming the medications. Review of the resident self-administration of medication policy dated 12/1/21 showed: - When determining if the resident is appropriate to self-administer medications, the interdisciplinary team…

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 notify the physician of changes in resident's condition when the facility failed to notify the physician of significant weight loss in Resident #5, Resident #53, Resident #61, and the facility failed to notify the physician when Resident #60 legs began to swell and the resident experienced difficulty breathing out of 17 sampled residents Resident #60 was hospitalized and found to have blood clots in his/her legs. The facility census was 67. Review of weight monitoring policy dated 12/1/21 shows: - Significant weight changes may indicate a nutritional problem. - A comprehensive nutritional assessment will be completed upon admission to identify residents at risk for unplanned weight fluctuations. - Weight monitoring will be performed upon admission and weekly for four weeks and residents that have weight loss are to be weighed weekly. - The physician is to be notified of a significant weight change. Review of the notification of changes…

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 update patient-centered care plans when one two resident's had a significant weight loss not updated on the care plan, (Resident #53 and Resident #61), two resident's do not have bed rails care planned, (Resident #36 and Resident #51), and one resident does not have dialysis care planned, (Resident #62). This affected six of the 17 sampled resident's. The facility census was 67. Review of the baseline care plan policy dated 12/1/21 shows: - Will be developed within 48 hours of a resident's admission. - Will include physician orders, dietary orders, therapy and social services. - The baseline care plan is to include special needs such as dialysis. - A written summary of the baseline care plan shall be provided to the resident and or the resident representative and written in a language that the resident and or representative can understand. The facility did not provide a care plan policy. Review of the weight monitoring policy dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility staff failed to provide services that meet professional standards when two residents, (Resident #61 and Resident # 168), had a physician's order for the placement of fall mats on the floor, and the facility staff failed to place the fall mats on the floor, and one resident, (Resident #46) had a physician's order to obtain a urine specimen to check for an infection on 1/7/22 and the facility staff did not obtain the urine specimen until 1/27/22, and one additional resident (Resident #10), that did not receive his/her levothyroxine medication as ordered out of 17 sampled residents. The facility census was 67. Review of the physician's orders policy dated 12/1/21 shows: - The nurse is to note the physicians order, and transcribe the order to the medication administration record or treatment administration record. Review of the medication administration policy, dated 12/1/21, showed: - Wash hands prior to administration of medications. - Remove 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 provide standard and specific care planned Activities of Daily Living (ADLs), including showers/bathing, nail care, hair care, turning/repositioning; including the standard of care to turn/reposition and provide incontinent care every 2 hours for residents who are incontinent of urine/bowel, for eight of 17 sampled residents (Resident #24, #26, #19, #23, #61, #36, #38, and #44), that were unable to perform their own activities of daily living. The facility census was 67. Review of the shower policy dated 11/30/21 shows: - Residents will be provided showers as often as the resident requests and per the facility schedule protocols. - Partial baths may be given between regular shower schedules. - The certified nurse assistant (CNA) will assess the skin during the shower and notify the nurse of any skin changes. Review of the resident dignity policy dated 12/1/21 shows: - Respond to requests for assistance in a timely manner. - Groom and dress…

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 of activities designed to meet the resident's interests for ten of 19 sampled residents (Resident #23, #24, #26, #5, #53, #169, #7, #13, #38 and #44) . The facility census was 67. 1. Review of Resident #23 Minimum Data Set (MDS: a federally mandated assessment completed by facility staff) dated 12/1/21 showed: -Brief Interview of Mental Status (BIMS) of 14. Indicates no cognitive impairment. -Activity preferences that are very important to him/her include: -listening to music -newspapers, books to read -to go outside and get fresh air -participate in favorite activities. -Activity preferences that are somewhat important to him/her include: -participating in activities with groups of people. -Diagnosis include: Transverse Myelitis (inflammation of the spinal cord that causes pain,, abnormal sensation and weakness), Morbid obesity, Reduced mobility, and Need for assistance with personal cares. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that three sampled residents (Resident #5, #53, and #61) maintained acceptable parameters of nutritional status and failed to implement interventions after the residents experienced a significant weight loss. The facility census was 67. Review of the facility's Weight Monitoring Policy, dated 12/1/2021, showed: -A weight monitoring schedule will be developed upon admission for all residents. -Newly admitted residents-monitor weight weekly for 4 weeks -Residents with weight loss-monitor weekly weight -Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: -5% change in weight in 1 month (30 days) -7.5% change in weight in 3 months (90 days) -10% change in weight in 6 months (120 days). -Interventions will be identified, implemented, monitored and modified, as appropriate, consistent with the resident's assessed needs, choices, preferences,…

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 respiratory care, consistent with professional standards of practice for four of 17 residents (Resident #5, #38, #51, and #53) when staff did not date oxygen tubing, failed to cover the tubing when not in use and staff failed to cover nebulizer (a machine that delivers medication into the body by being inhaled as a vapor) tubing when not in use for two sampled residents (Residents #7 and #38). The facility census was 67. Review of the oxygen administration policy, dated 12/1/21, showed: - Change the oxygen tubing weekly and as needed if it becomes contaminated or soiled. - Change humidifier bottle and nebulizer tubing every 72 hours and as needed if they become contaminated. - Keep oxygen tubing and nebulizer tubing covered in a plastic bag when not in use. 1. Review of Resident #5's quarterly MDS, dated [DATE], showed: - Adequate hearing, vision, and speech; - Brief Interview of Mental Status (BIMS, a structured evaluation aimed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure the safety of resident's that use U-rails, (rails installed at the head of the bed on both side of the bed that is in the shape of an upside-down U) and halo rails, (rails that are installed at the head of the bed on both sides of the bed that are in a circular shape with a stem that extends to the bed frame), (Resident #36 and Resident #51), when the facility staff failed to do an entrapment assessment when the rails were initiated and periodically, failed to obtain informed consent from the resident and/or the responsible party before the installation of U-rails and halo rails, and failed to obtain a physician's order for the use of the rails. This affected two of 17 sampled residents. The facility census was 67. Review of the side rail policy dated 12/1/21 shows: - Side rail is defined as a rail that is installed on the side of the bed and may be also called a safety rail, grab bars, and assist bars. - The use of side rails will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff to provide showers, grooming, repositioning and to answer call lights in a timely manner for six of 17 sampled residents (Resident #19, #23, #24, #26, #38, #44). The facility census was 67. Review of the facility policy for Call Lights: Accessibility and Timely Response updated 12/1/21 showed in part: -All staff members who see or hear an activated call light are responsible for responding. -Process for responding: -If assistance is needed with a procedure,summon help by using the call light. Stay with the resident until help arrives. Review of the facility policy Turning and Repositioning date revised 12/1/21 showed in part: -All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated. -The frequency of turning and positioning will be documented in the resident's care plan. -Use the appropriate number of staff to perform the task safely. -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 provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 residents. The census was 67. Review of facility policy Nursing Services and Sufficient Staff, dated 12/1/21, showed in part: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnosis of the resident population will be considered on the facility assessment. -The facility will supply services by sufficient numbers on a 24 hour basis to provide nursing care for all residents in accordance with resident care plans. -Except when waived the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of facility staffing sheets for October, November and December 2021 and time punches for all RNs showed: -No RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dietary staff maintained clean and sanitary conditions when staff failed to store and dispose of food in a safe and sanitary manner and failed to maintain the scoops for ice machine in a sanitary manner. This had the potential to affect all residents of the facility. The facility census was 67. Review of the facility's Food Safety Requirements Policy, dated 12/1/21, showed: - Food will be stored, prepared and served in accordance with professional standards for food service safety. - Food safety practices shall be followed throughout the facility's entire food handling process. *Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms; *Preparation of food, including thawing, cooking, holding, and reheating; *Equipment used in the handling of food, including dishes, utensils, mixers, grinders and other equipment that comes in contact with food; - 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain proper infection control protocol when the facility staff failed to perform hand washing when providing resident care for one of 17 sampled resident's, (Resident #51), and one additional resident, (Resident #46); failed to provide perineal care using infection control standards for one resident (Resident #26) ; and failing to follow standards of practice during medication administration when a facility staff member touched a pill with an ungloved hand and placed the pill back in the multi-dose bottle, that affected one additional resident, (Resident #17). The facility census was 67. 1. Review of the facility's hand hygiene policy, dated 11/1/21, showed: - All staff will perform proper hand hygiene to prevent the spread of infection to other resident's. - Hand hygiene is defined as cleaning the hands with soap and water or the use of alcohol-based hand rub (ABHR). - Staff are to use soap and water when: Their hands are visibly…

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 safety of one of 17 sampled residents, (Resident #51), by ensuring the resident was free from falls and the facility staff did not do consistent neurological assessments. Facility staff also failed to transfer one additional resident, (Resident #46), in a safe manner. The facility census was 67. Review of the facility fall policy dated 1/20/22 showed: - When a resident falls, the facility will assess the resident. - Complete a post fall assessment and incident report. - Notify the physician and family of the fall. - Update the care plan. Review of the head injury policy dated 11/1/21 showed: - The assessment of the resident with a suspected head injury includes: vital signs, neurological assessment, assessment of the head, ears, eyes, and face, and pain. - Compete a neurological assessment as indicated. - Continue monitoring for 72 hours following the incident. Review of the gait belt policy dated 11/1/21 shows: - Employees…

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 fully develop and implement their staff vaccination policy for COVID-19 when the policy did not include specific additional measures unvaccinated staff would adhere to in order to mitigate the transmission and spread of COVID 19 and failed to implement a process for tracking and documenting the COVID-19 vaccination status for all staff. Facility census was 70. Review of facility policy; Employee COVID-19 Vaccinations, dated 3/14/22 showed in part: -The facility will ensure that all eligible employees are fully vaccinated against COVID 19 unless religious or medical exemptions are granted per Centers for Medicare and Medicaid Services (CMS) guided time frames. -Proof of vaccination status may include -CDC COVID-19 vaccination card (or legible photo of the card) -Documentation of vaccination from a healthcare provider or electronic health record or -State immunization information system record. -The facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all 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.