Aspire Senior Living Roaring River

Based on interview and record review, the facility failed to ensure all resident representatives were notified of regarding changes in condition in a timely manner when staff failed to inform one resident's (Resident #1) representative of a decline in his/her wound until two days after the decline was documented. The facility census was 64. Review of the facility policy entitled Notification of Changes, dated 10/01/25, showed the following:-This policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification;-The facility must inform the resident, consult the resident's physician, and notify, consistent with his/her authority, the resident's representative when there is a change requiring notification;-Circumstances that require notification include accidents, significant changes in resident's physical, mental, or psychosocial condition, circumstances that require a need to alter treatment such as a new treatment 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.

Based on record review and interviews, the facility failed to ensure staff provided care per standards of practice when staff failed to follow physician orders regarding elevated blood glucose levels and failed to document insulin administration amounts due to elevated blood glucose levels for one resident (Resident #1) of four residents sampled. The facility census was 61. Review of the facility policy entitled Blood Glucose Monitoring, revised 01/13/23, showed the following: -Purpose of the policy was to ensure the effective and accurate monitoring of blood glucose levels for individuals with diabetes or at risk for blood glucose abnormalities; to prevent low or high blood sugar; to guide healthcare professionals, caregivers, and patients in proper blood glucose monitoring practices to ensure safe and effective management of diabetes; -Doctors and nurses are responsible for ordering and interpreting blood glucose tests, providing guidance on target glucose levels, and adjusting medications accordingly; -Caregivers are responsible for regularly checking blood glucose, following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to store cleaning supplies in a separate area from food; failed to date stored food in refrigerator; failed to keep non-food contact surfaces clean and free of debris; failed to dispose of expired food items; failed to rinse dishes prior to placing them into the sanitizer in the three vat sink and sanitize at the minimum manufacturer's requirements; and failed to control flies in the kitchen. The facility's census was 59. 1. Review of the facility's policy titled, Non-Food Storage, undated, showed chemical and toxic products must be stored in a separate closet, closed cabinet, or outside of the kitchen area. Observation on 02/26/24, at 9:54 A.M., on 02/27/24, at 9:00 A.M., and on 02/28/24, at 8:02 A.M., of the dry food storage area showed cleaning supplies sitting on milk crates with the next table containing fresh bananas and a gold wire rack in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 59. Review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated [DATE], showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those…

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 implement an antibiotic stewardship program when staff failed to adequately track eight residents currently on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections, this failure could potentially place all residents at risk of infection. The facility census was 59. Review of the facility policy titled, Infection Control, General, revised on 02/18/24, showed: -It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulation, and national guidelines; -The facility will establish and maintain an infection prevention…

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 an effective pest control program to control the fly population when multiple flies were present in and around eight residents (Residents #54, #52, #41, #35, #2, #6, #46 and #57) and in resident common areas. The facility census was 59. Review showed the facility did not provide a pest control policy. 1 Review of Resident #54's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly minimum data sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 01/05/24, showed the following: -Moderately impaired cognitive ability; -Required supervision of staff while eating; -Dependent on staff for toileting hygiene and showers; -Substantial/maximum assistance of staff with personal hygiene and dressing. Observation and and interview on 02/26/24, at 11:15 A.M., showed the following: -Resident flat on his/her back in bed in his/her room located on…

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

Based on interview and record review, the facility failed to implement policies to prevent possible abuse, neglect, or misappropriation of residents when the facility failed to complete a Family Care Safety Registry (FSCR - a state registry that provides multiple checks on staff including a Criminal Background Check) or a Criminal Background Check (CBC) prior to hire to ensure two staff (Certified Nursing Assistant (CNA) J and Certified Medication Technician (CMT) K), did not have a disqualifying criminal background that would prevent the staff member from working in a certified long-term care facility; failed to perform an Employee Disqualification List (EDL) check on three staff (CNA J, CNA M, and CMT K); and failed to perform a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility)) check on two staff (CNA J and Licensed Practical Nurse (LPN) L) out of a sample…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed implement a comprehensive person-centered care for each resident when staff failed to complete a comprehensive and individualized care plan, including interventions, to address the specific needs of four residents (Resident #24, #30, #31, and #38) out of a sample of 22 residents. The facility had a census of 59. Review of the facility's policy, titled Care Plans, dated 01/01/24, showed the following: -It is the policy of the facility to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs; -This facility will help develop and implement a comprehensive person-centered care plan for each resident that includes: measurable objectives…

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 notify the physician of a change in condition for one resident (Resident #30) when the resident complained to a nurse of pain, and stinging and burning in his/her legs, and expressed concerns about the possibility of urinary sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs). A sample of 22 residents were reviewed in a facility with a census of 59. Review of the facility policy titled, Resident Change in Condition, dated 01/01/24, showed the following: -The facility will keep the physician, who is in charge of the resident's medical care, informed of the resident's medical condition so they may direct the plan of care as needed; -Notification of the physician should occur promptly when there is a change in the resident's condition; -Examples of change in condition may include new pain; -Staff should document the symptoms and the observations associated with the change in condition and the date and time of contact…

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 bed-hold policy to one resident (Residents #39), out of a sample of four residents, who transferred to the hospital. The facility census was 59. Review of the facility's policy titled Bed Hold Policy, undated, showed before and at the time the facility transfers a resident for hospitalization or therapeutic leave, the facility will provide resident or resident's representative with written notice explaining the duration of the bed-hold policy. 1. Review of Resident #39's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 01/28/21; -The resident was his/her own responsible party; -Diagnoses included diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels), reduced mobility, and fracture of right lower leg. Review of the resident's nurse's progress note dated 01/11/24, at 4:39 P.M., showed the following: -Certified nursing assistant (CNA) called him/her to the resident's room to look at the resident's foot. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated assessment instrument completed by facility staff) were accurate for all residents when staff failed address one resident's (Resident #55) anti-anxiety medication on the resident's MDS. The facility census was 59. Review of the facility's policy titled Resident Assessment Instrument, dated 01/01/24, showed the following: -It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's MDS to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for 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, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to two dependent residents (Resident #55 and Resident #31) and failed to provide assistance with shaving to one resident (Resident #55) in out of a sample of two residents. The facility's census was 59. Review of the facility's policy titled Know Your Rights, undated, showed the following: -Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many states also include residents' rights in state law or regulation; -Right to self-determination: choice of activities, schedules, health care, and providers, including attending physician; reasonable accommodation of needs and preferences; participate in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician signed the Outside the Hospital Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) order for two residents (Resident #35 and Resident #57) out of a sample of four residents. The facility census was 59. Review of the facility's policy titled Code Status, (the level of medical interventions a resident wishes to have if their heart or breathing stops), dated [DATE], showed the following: -It is the policy of the facility to honor code status of the resident in accordance to State and Federal Regulations; -During the admission process the Social Services Designee (SSD) or charge nurse will discuss with each resident and/or the person accompanying the resident the following: -Whether they have a preference regarding code status in the event the resident is found without a pulse or respirations; -All DNR…

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, interview, and record review, the facility failed to consistently track and monitor the dry, scaly skin with multiple nodules to bilateral lower extremities skin condition for one resident (Resident #24) and failed to follow, physician ordered blood pressure parameters for determining administration of an antihypertensives (blood pressure) medication for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of facility policy titled Skin Assessments, dated 01/01/24, showed the following: -Facility should accurately record any chronic or acute abnormalities of resident's skin; -Skin assessment should be performed and documented weekly; -Nursing assessment should include lesions, redness or rash, edema (swelling), skin tears, abrasions, bruises, pressure injuries, cyanosis (blue color), and surgical wounds. Review of Resident #24's face sheet (a general information sheet) showed the following: -admission date of 05/11/23; -Diagnoses included…

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 ensure residents did not experience a reduction in range of motion unless unavoidable when staff failed to evaluate the need for restorative therapy for one resident (Resident #11) who expressed concerns with his/her decreased hand/finger range of motion (ROM) and expressed a desire for restorative therapy. A sample of 22 residents was reviewed in a facility with a census of 59. 1. Review of Resident #11's face sheet showed an admission date of 01/18/19 and readmission date of 01/07/24. Review of the resident's February 2024 physician orders showed: -Dependence on wheelchair, weakness, acquired absence of right and left legs below the knees, chronic pain, type 2 diabetes mellitus with diabetic neuropathy (nerve damage), end-stage kidney disease, and dependent on dialysis (a treatment for people whose kidneys are failing); -An order, dated 01/18/19, for activity as desired or as health permits; -An order, dated 01/28/19, may be seen and…

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

Based on observation, interview, and record review, the facility failed to ensure residents only had catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) when necessary when staff obtained an order for a catheter for one resident (Resident #24) without a documented clinical condition that demonstrated necessity. The facility census was 59. Review of the facility policy titled, Indwelling Urinary Catheters, dated 01/01/24, showed it was the policy of the facility that indwelling urinary catheters should be used only when a medical condition exists requiring the use of the catheter. 1. Review of Resident #24's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 05/11/23; -Diagnoses included diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and muscle weakness. 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.

Based on interview and record review, the facility failed to ensure all residents maintained acceptable parameters of nutrition, unless unavoidable, when staff failed complete physician ordered weekly weights and failed to care plan weekly weights and new interventions for weight loss for one resident (Resident #36) with weight loss out of two sampled residents. The facility's census was 59. Review of the facility's policy titled Resident Weights and Weight Management, dated 01/01/24, showed the following: -It is the policy of the facility to accurately measure and record residents' weights to provide a baseline and track weights as an indicator of nutritional status and medical condition of the resident. Residents should be weighed on admission and monthly, unless otherwise indicated; -The physician should be informed of a significant change in weight and may order nutritional interventions. Significant weight changes may be described as, but not limited to, greater than or equal to 5% loss in 30 days, greater than or equal to 10% loss in 180 days, gain of three pounds in one day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to administer oxygen as ordered for two residents (Residents #31 and #49). The facility census was 59. Review of facility policy titled Supplemental Oxygen, dated 01/01/24, showed the facility shall provide oxygen to any resident with a doctor's order for treatment of certain diseases or conditions. 1. Review of Resident #31's face sheet (a general information sheet) showed the following: -admission date of 04/11/23; -Diagnoses included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide in blood), congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and chronic kidney disease. Review of resident's Minimum Data Set (MDS - a federally mandated…

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

Based on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to have a contract with the dialysis provider, failed to document routine assessment and monitoring of the dialysis site, and failed to document ongoing communication with the dialysis center for one resident (Resident #31) who received dialysis. The facility census was 59. Review of the facility's policy Dialysis Service, dated 02/18/24, showed the following information: -The facility must ensure that residents that require dialysis service receive services consistent with the professional standards of practice, comprehensive person-centered care plan, and residents' goals and preferences; -Facility shall ensure transportation to and from dialysis 1. Review of Resident #31's face sheet (a general information sheet) showed the following: -admission date of 04/11/23; -Diagnoses included diabetes with diabetic neuropathy (nerve damage), congestive…

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 trauma-informed care in accordance with standards of practice when staff failed to identify, assess, care plan, and provide supportive interventions for one resident (Resident #41) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 59. Review showed the facility did not provide a policy related to Trauma Informed Care. 1. Review of Resident #41's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 09/12/23; -Diagnoses included PTSD, depression, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument…

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

Based on interview and record review, the facility failed to ensure the physician responded timely to a pharmacist's request to discontinue a medication during the monthly drug regimen review for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #54's face sheet showed an admission date of 03/29/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 01/05/24, showed the following: -Moderate cognitive impairment; -No symptoms of depression and no problem behaviors; -Diagnoses of compression fracture of spine, coronary artery disease (CAD - caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension (high blood pressure), type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), and depression. Review of the pharmacist's recommendations to prescriber (ordering physician), dated 09/11/23, showed: -The pharmacist sent a medication discontinuation request 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, the facility failed to ensure one resident (Resident #30) did not receive unnecessary drugs when staff administered two different antibiotics simultaneously, despite physician directions to the contrary, out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #30's face sheet showed: -admission date of 09/26/22 and re-admitted on [DATE]; -Diagnoses of type 2 diabetes mellitus, hypertension (high blood pressure), dysuria (painful or uncomfortable urination), muscle weakness, history of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs), and history of urinary tract infections. Review of the resident's current physician orders showed: -An order, dated 10/18/23, for Hiprex (an antibiotic - used to prevent and control urinary tract infections) tablet 1 gram, give one tablet by mouth two times a day for urinary tract infection (UTI). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure a medication regimen was free from unnecessary psychotropic medications when the facility failed to document target behaviors for administration of antipsychotic medications and reevaluate a gradual dose reduction (GDR-a step wise tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose or medication can be discontinued) for one resident (Resident #16) and failed to document use of other non-pharmacological interventions, target behaviors, and adverse reactions for one resident (Resident #57) out of a sample of 22 residents. The facility's census was 59. Review of the facility's policy titled Behavioral Health Services, dated 01/01/24, showed the following: -The behavior management team will meet monthly (for each resident) to review those residents receiving antipsychotic medications; -The goals of the GDR are to achieve the lowest effective dose, to discontinue the medications…

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

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made two errors out of 25 opportunities resulting in an 8% error rate. Staff administered medication when the blood pressure was out of the parameter for medication to be given for one resident (Resident #31) and failed to assess resident's pulse rate prior to administration for one resident (Resident #46) during random medication pass observations. The facility had a census of 59. Review of the facility's Medication Administration Policy, dated 01/01/24, included the following information: -It is the policy of the facility to safely and accurately administer physician ordered medication to each resident. -Record vital signs as ordered before administering medications; -Follow physician orders regarding holding medications based on a vital sign parameter; -Record any vital sign included in the physician's order for the medication. 1. Review of the Resident #31's February 2024 Physician Order Sheet (POS) showed the following: -An order, dated 10/22/23,…

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

Based on record review and interview, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 61. Record review of a facility document entitled Director of Nursing (undated) , showed the following information: -Objective to maintain effective and efficient operations of the facility, to ensure resident provision of appropriate care, safety and optimal level of functioning; -Daily Tasks included be available at least, within the facility between the hours of 8:00 A.M. and 5:00 P.M., except for prearranged situations; on call for medical issues; review of physician orders against telephone and written orders; hall rounds to monitor resident care (at least twice daily); and monitoring of change of condition charting; -Weekly Tasks included weekly skin audit sheet completed and distributed to members by 3:00 P.M. on Wednesday; standard of care meeting facilitation and documentation; weekly lab tracking; Certified Nurse Aide (CNA) assignment sheets completed, copied and distributed for the next week;…

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

This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated . Based on observation, interview, and record review, the facility failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. Additionally, the facility failed to maintain an effective infection control program when staff failed to wear N95 masks appropriately. The facility census was 61. 1. Record review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water…

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

Based on observation and interview, the facility failed to ensure a clean homelike environment when staff failed to clean one cloth recliner and one cloth couch in the special care unit (SCU). The facility census was 61. 1. Observations of the SCU television room showed the following: -On 12/7/21, at 10:47 A.M., Resident #38 sat on a cloth recliner in the SCU television room. Several dried white spots, some crusted with white debris, stained the arms of the cloth recliner. -On 12/8/21, at 11:37 A.M., and 12/9/21, at 12:17 P.M., the cloth recliner had several dried white spots, some with crusty debris, on the arms and seat of the cloth recliner. The cloth couch had a dark liquid-type substance pooled on the seat of the couch that dripped down the front of the couch. Observation and interview on 12/9/21, at 3:40 P.M., showed the following the cloth recliner in the SCU television room, had several dried white spots, some with crusty debris, on the arms and seat of the recliner. The cloth couch in the SCU television room had a dark stain on the seat of the couch that extended down the…

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

Based on interview and record review, the facility failed to fully implement the facility's abuse prevention policies when staff did not check the Nurse Aide (NA) Registry prior to hiring four out of ten sampled staff (Registered Nurse (RN) N, [NAME] M, Business Office Manager (BOM) L, and Laundry Services O) to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 61. Record review of the facility's policy entitled Abuse Prevention, dated 2/18/2015, showed the following: -All applicable licenses or registries shall be called and verification of license obtained; -Written verification of the call shall be placed in the employee's permanent record; -In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), the Human Resources Department will conduct a background investigation that includes a criminal record check as well as personal reference checks on all employees making…

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 have a system in place to provide consistent showers for two residents (Residents #48, and #56) who resided on the special care unit and one resident (Resident #4) who resided in the main facility. The facility census was 61. Record review showed the facility did not provide a bathing/showering policy. 1. Record review of Resident #48's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE] and readmitted on [DATE]; -The resident had a responsible party; -Diagnoses included depression, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), and need for assistance with personal care. Record review of the resident's care plan, dated 8/4/21, showed the following: -The resident required…

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 routinely provide individualized and meaningful activities to the residents of the Special Care Unit (including Resident #38, Resident #45, Resident #48 and Resident #56) Fifteen residents resided on the SCU and the facility census was 61. Record review of the facility's undated policy titled Activities Meet Interest/Needs of Each Resident, undated, showed the following: -It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs; -The facility will provide, based on the comprehensive assessment and care plan and the preferences of each…

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 complete a a risk/benefit review and document alternatives attempted prior to bed rail use, failed to obtain informed consent for the use of bed rails, and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for three residents (Residents #4, #10, and #34). The facility failed to care plan the use of the bed rail for one resident (Resident #4). The facility census was 61. Record review of a facility document entitled Procedure: Bedrails, date blank, showed the following information: -The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being; -The facility will attempt to use appropriate alternatives prior to installing a side or bed rail; -If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails,…

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 all residents reasonable access to the use of a phone when the facility did not have a phone the one resident (Resident #56) could use to talk with family while on isolation precautions due to coronavirus disease 2019 (COVID-19- an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)). The facility census was 61. Record review showed the facility did not provide a policy related to providing forms of communication with privacy to every resident. 1. Record review of Resident #56's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 07/28/21; -Resident had a guardian; -No medical diagnoses listed. Record review of the resident's care plan, dated 9/15/21, showed the following: -Interventions related to cognitive function, dementia, or impaired thought process included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion; -No medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to a hospital, including the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification or monthly log showing transfers, for two residents (Residents #4 and #13). The facility census was 61. Record review showed the facility did not provide a policy regarding notifications upon transfer to a hospital. 1. Record review of the facility monthly Transfer/Discharge Log, dated March 2021, showed the following: -Resident #4 was transferred to the hospital on 3/12/2021 for an unplanned evaluation, admitted to the hospital, and returned to the facility on 4/1/2021; -The column marked Resident/Representative Notified in Writing was left blank. Record review of the resident's nurses' progress notes showed the following information: -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 observation, interview, and record review the facility failed to identify, document on, and treat new non pressure wounds on the feet of one resident (Resident #45) in a timely manner. The facility's census was 61. Record review of the facility's Wound Prevention Program policy, undated, showed the following: -The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds; -Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR); -Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse and the licensed nurse will proceed as mentioned in step 2 and complete a Wound Event; -The facility complies with State and Federal guidelines as it relates to wound prevention and definitions. Adherence to these program is under the direction of the Director 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, the facility failed to keep one resident (Resident #56) free from possible harm by not supervising the resident while smoking as care planned and by not providing a receptacle to put used cigarette butts. The facility also failed to keep residents who reside in the special care unit (SCU) free from possible harm by not securing hazardous chemicals, cigarettes, and a lighter in a small storage room in the dining room. Fifteen residents resided on the SCU and the facility census was 61. 1. Record review of the facility's undated policy titled Smoking Policy showed the following: -It is the policy of Roaring River Rehab and Health to allow residents to smoke in designated areas; -Smokers will dispose cigarette butts in the appropriate available receptacles; -Residents who choose to smoke will be assessed upon admission, and quarterly thereafter, to determine if they are able to manage their smoking program independently; -If it is determined by the Smoking…

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.