Westchester House, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 33 opportunities, for errors, four errors occurred, resulting in a 12.12% medication error rate (Residents #242, #30, #23 and #29). The census was 78. Review of the facility's Administration of Medication Policy, dated 8/24/23, showed: -Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: -Right Drug: every drug administered must have an order from the provider. Compare the order with the Medication Administration Record (MAR) for accuracy. Compare the label on the drug…

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 infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, medical device care or use, and wound care) with residents on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (an umbrella term for bacteria and other microorganisms that are resistant to antibiotics and other drugs designed to kill them) that employs targeted gown and glove use during high contact resident care activities) for five residents (Residents #79, #74, #19, #242 and #36). Furthermore, the facility failed to follow their incontinent care policy when staff provided perineal area care (cleansing between the legs and buttocks…

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 a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge, for two of three residents investigated for discharge (Residents #54 and #89). The census was 78. 1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/24 showed; -Cognitively intact; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. Review of the resident's progress notes, showed; -On 3/17/2024 at 9:29 A.M., Note Text: Resident requested that Social Services send referral for possible transfer, will follow up on referral; -On 3/29/2024 at 4:16 P.M., Note Text: Resident does not want to transfer to another facility anymore. Attempted to contact resident's family regarding Medicaid benefits. No answer, left a voicemail; waiting on a call back; -On 4/12/2024 at 5:21 P.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 ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the wound treatment order, resulting in an untreated non-pressure wound, for one sampled resident (Resident #292). The sample was 18. The census was 78. Review of the facility's Wound Care Policy, revised on 7/12/24, showed: -Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the residents' choices; -The skin care program developed by the facility is interdisciplinary and implemented using a team approach; -The skin care program's interdisciplinary team functions as an action team; -Each discipline has a vital role in wound care. All disciplines focus on assessment, planning. implementing, and documenting care;…

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

Based on observation, interview and record review, the facility failed to ensure one resident with wounds received necessary treatments. and services to promote healing (Resident #31). The sample size was 18. The census was 78. Review of the facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management Policy, dated revised: 7/9/2024, showed: -Skin observations also occur throughout points of care provided by Certified Nurse Aide's (CNA) during Activities of Daily Living (ADL) care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/11/24, showed: -Cognitively intact; -Diagnoses…

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 residents were free from significant medication errors when the facility failed to administer medications as ordered for two of six sampled residents (Resident #1 and Resident #3). The census was 83. The administrator was notified on [DATE] of the past non-compliance. The facility had already began an investigation, counted the medication carts, added a corrected count to all controlled substance logs, interviewed staff and residents, notified the police, the resident's physician and family, in-serviced staff on abuse and misappropriation of resident property (including drug diversion) and terminated Licensed Practical Nurse (LPN) A. The deficiency was corrected on [DATE]. Review of the facility's Administration of Medications policy, reviewed [DATE], included: -Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication…

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 residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when a staff member misappropriated $13,300 of resident's money from their personal account, without the resident's consent. This affected one of eight sampled residents (Resident #8). The census was 75. Review of the facility's Abuse, Neglect and Exploitation policy dated 7/18/23, showed the following: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart; -Exploitation, is defined as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion; -Misappropriation of resident property, is defined as the deliberate misplacement, exploitation, or wrongful,…

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 who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs by not providing baths/showers for three residents (Residents #1, #2 and #3). The sample size was four. The census was 75. Review of the facility's Activities of Daily Living (ADLs) policy, revised on 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse; -A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/23, showed: -Rarely/never understood by others; -Rarely/never understood others; -Short and long term memory problems; -Severely impaired…

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 a resident who admitted to the facility on [DATE], received ordered medication timely (Resident #1). The facility did not administer medications until 24 hours after admission, when the pharmacy delivered the medication. Staff did not access the emergency kit. The sample was 3. The census was 60. The administrator was notified on 8/3/23, of the past non-compliance. The facility has changed their process on how medications are ordered and delivered from pharmacy providers. The deficiency was corrected on 7/15/23. Review of the Pharmacy Services Delivery and Receipt of Routine Delivery policy, revised 1/1/22, showed: -Procedure: Pharmacy and the facility should coordinate to determine delivery day(s) and times(s); -Receipt of pharmacy deliveries: -If any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy communication slip indicating back ordered medications, medications too soon for refill,…

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 interviews, record review, and facility policy review, the facility failed to allow resident access to personal funds on an ongoing basis. This practice affected 39 residents with personal funds accounts out of a census of 58 residents. Finding included: Review of the facility policy, titled, Resident Trust Policies, dated 06/15/2022, indicated, Each skilled nursing facility ('SNF' or 'facility') that is owned and/or managed by [Corporate Name] SHALL [emphasis not added]: 4. Provide residents with access to his or her funds within a reasonable amount of time. a. Requests for $50.00 or less ($100.00 or less for Medicare residents) should be honored within the same day). 1. Observation on 06/06/2023 at 10:02 AM, showed a green sign was observed hanging on a bulletin board outside the business office. The green sign indicated the facility banking hours were Monday through Friday from 9:00 AM until 3:00 PM. There was also a list of six holidays in 2023 when the bank would not be open. 2. Review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 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.

Based on observations, interviews, facility policy, and document review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the kitchen which had the potential to affect 56 of 58 residents who received food from the kitchen. Specifically, the facility failed to ensure food in the dry storage area was sealed and dated when opened; ensure temperature logs on the refrigerators and freezers were complete; ensure meal temperature logs were completed and logged before each meal; and monitor and clean the nourishment room refrigerator. Findings included: 1. The facility's policy, titled, Food Safety, revised on 04/26/2023, indicated, Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. The policy also indicated, Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable. During initial kitchen observations on 06/05/2023 at 10:05 AM, a 10-pound…

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 newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for nine of 23 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 63. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, revised on 8/10/21, showed the following: -Introduction: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse; -Policy: It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility has procedures in place to provide protection from the health, welfare and rights of each resident residing in the facility. In order to provide these protections, the facility has implemented procedures 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 observation, interview, and record review, the facility failed to ensure the practice of self-administration of medication was clinically appropriate for 1 (Resident #166) of 1 resident reviewed for self-administration of medication. The census was 58. Findings included: A review of Resident #166's admission Record revealed the facility admitted the resident on 05/27/2023 with diagnoses that included type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar), malnutrition, osteomyelitis (inflammation or swelling that occurs in the bone), end stage renal disease (advanced loss of kidney function), peripheral vascular disease (a blood circulation disorder), and muscle weakness. A review of the five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #166 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS revealed the resident was totally dependent on one-person physical assistance with bathing and incontinence care, 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.

Based on interviews, record review, facility document review, and a review of the facility's policy, the facility failed to protect a resident (Resident #1) from physical abuse by another resident (Resident #13). This affected 1 (Resident #1) of 3 residents reviewed for abuse. The facility census was 58. Findings included: Review of a facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, with a revision date of 08/10/2021, revealed, Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, and any other individuals. The policy indicated, It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. This facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. In order to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to address the presence and care of a port-a-cath (an implanted device that allows easy access to a patient's veins) and the use of intravenous antibiotics on the baseline care plan for 1 (Resident #216) of 3 residents reviewed for intravenous access. The facility census was 58. Findings included: A review of Resident #216's admission Record revealed the facility admitted the resident on 04/25/2023 with a diagnosis that included bacteremia (the presence of bacteria in the bloodstream). The admission record indicated the resident was discharged to the hospital on [DATE]. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2023, revealed the resident's cognitive status was not assessed as the Brief Interview for Mental Status (BIMS) and Staff Assessment for Mental Status assessments were not completed. The MDS indicated the resident required extensive assistance from staff with their…

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

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to develop and/or implement a comprehensive resident-centered care plan for 2 (Resident #165 and Resident #13) of 38 sampled residents. Specifically, the facility failed to develop a care plan for the care and treatment of a peripherally inserted central catheter (PICC) line (a type of intravenous (IV) access) and the use of IV antibiotics for Resident #165. In addition, the facility failed to implement Resident #13's care plan intervention to supervise the resident to prevent physical aggression. The facility census was 58. Findings included: 1. Review of a facility policy titled, Comprehensive Care Plans and Revisions, dated 08/17/2022, indicated, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident…

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

Based on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised when the resident sustained a fall during the quarterly review period for 1 (Resident #61) of 3 residents reviewed for falls. The facility census was 58. Findings included: The facility's policy, titled, Comprehensive Care Plans and Revisions, with a revision date of 08/17/2022, indicated, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident representative, if applicable, is involved in developing the care plan and making decisions about care. A review of Resident #61's admission Record revealed the facility admitted the resident on 01/25/2023 and re-admitted the resident on 05/05/2023 with diagnoses that included cognitive communication deficit, respiratory failure, need for assistance with personal care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to collaborate with the hospice provider to coordinate a plan of care for 1 (Resident #365) of 1 resident reviewed who was receiving hospice care and failed to provide care in accordance with physician's orders/facility procedures for 1 (Resident #216) of 2 residents who had vascular access devices (a tube placed in a large vein to allow for repeated and long-term access to the bloodstream for medication administration). The facility census was 58. Findings included: 1. A review of the facility policy, titled, Hospice Coordination of Care, with a review date of 05/05/2020, indicated under Procedure, that 8. A communication process is established between the facility and hospice to ensure the needs of the resident are addressed and met 24 hours/day and that the communication is documented to reflect concerns and responses. Review of the Hospice Services Agreement for Individual/Limited Duration between the facility and the hospice…

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, record review, and facility policy review, the facility failed to ensure accident hazards were identified through investigation of falls for 1 (Resident #61) of 3 residents reviewed for falls. Resident #61 sustained a fall from their wheelchair on 04/28/2023 and the facility failed to conduct an investigation to determine the root cause of the fall and ensure accident hazards were identified for the resident. The facility census was 58. Findings included: The facility's policy titled, Fall Management, revised on 09/29/2022, indicated, The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. The policy also indicated, Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition, and with any fall, utilizing the Fall Risk Assessment. The policy also revealed, All patients have fall indicators. Fall indicators are patient specific information…

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, interviews, and facility policy review, the facility failed to have ongoing communication and collaboration with the dialysis center for 1 (Resident #56) of 2 residents reviewed for dialysis services. The facility census was 58. Findings included: A review of the facility policy, titled, Hemodialysis Offsite Policy, revised on 04/17/2023, indicated, The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with professional standards of practice. The policy indicated this included, 2. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The policy indicated that on the day of dialysis, staff were to observe vascular access site prior to dialysis and initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident. (Med Pass Form #LCCA-528). The policy indicated that post-dialysis, the facility was to follow routine dialysis instructions on dialysis transfer form, and 7. Maintain dialysis transfer form 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.

Based on observations, interviews, record review, and facility policy review, the facility failed to accurately assess residents for risk of entrapment from bed rails and attempt alternatives prior to use for 1 (Resident #40) of 1 resident reviewed for bed rails. The facility census was 58. Findings included: Review of a facility policy titled, Bed Rails - Safe and Effective Use of Bed Rails, revised on 12/30/2022, revealed, To prevent entrapment and other safety hazards associated with bed rail use. The policy indicated, Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for Use of Bed Rails Assessment (Admission/Readmission/Initial). If bedrails are determined to be appropriate for use with a resident, a reassessment of bed rail(s) use will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation for Use of Bed Rails Form (Quarterly). The policy further indicated, The facility will document alternatives to the use of bed rail(s) and how these alternatives did not meet the resident's…

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

Based on observations, record review, and interviews, it was determined that the facility failed to ensure there were no significant medication errors for 1 (Resident #56) of 7 residents reviewed for medication administration. Specifically, the facility failed to ensure Resident #56, a dialysis resident, received their medications with meals as ordered by the physician to lower their high phosphorus levels. The facility census was 58. Findings included: A review of the admission Record revealed the facility admitted Resident #56 on 03/20/2023 with diagnoses that included end stage renal disease (advanced loss of kidney function) with dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to- to remove waste and extra fluids in your blood). A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2023, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident was independent or required supervision with all…

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 and staff interviews, the facility failed to ensure privacy curtains provided full visual privacy for residents who resided in 3 (rooms [ROOM NUMBER]) of 22 rooms. Findings included: On 06/05/2023 between 1:25 PM and 1:38 PM, Resident rooms [ROOM NUMBER] were observed. All three rooms were semi-private rooms. room [ROOM NUMBER] had a privacy curtain that extended down the middle of the room between the beds that was approximately 30 inches too short resulting in the curtain not extending from wall to wall. This made it possible to look around the end of the curtain and see the resident in the bed next to the window. There was no curtain track in place enabling the curtain to be pulled around the foot of the bed for the bed near the window. There was a curtain track in place between the first bed and the door that curved around the foot of that bed and connected to a track that was in the center of the room. No privacy curtain was installed on that track. At the time of this observation,…

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 a functioning call light was provided for 1 (Resident #44) of 24 residents observed. The facility census was 58. Findings included: Review of Resident #44's admission Record indicated the facility admitted the resident on 11/17/2021 with diagnoses that included chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems) and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/25/2023, indicated Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #44's Care Pla revealed a concern, dated 10/15/2022, related to a history of cerebral vascular disease. An intervention directed staff to Encourage [the resident] to call for assistance if chest pain starts. The Care Plan also included a focus area, with a revision date of 11/18/2021,…

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 followed physician's orders expectations regarding elevated blood sugars. The facility identified 13 residents that received routine blood sugar checks (accu-checks). Of those 13, three had elevated blood sugars that exceeded the physician's parameters, and problems were found with all three. (Residents #4, #20 and #44). In addition, the facility failed to ensure physician approved pharmacist recommendations were added to a resident's orders, compression stockings were applied as ordered and proper hygiene and grooming was provided. (Residents #24, #6 and #15). The census was 92. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed: -Limited assistance of one person required for bed mobility; -Supervision of one person required for transfers and eating; -Diagnoses of diabetes, dementia and depression; -Received insulin six 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 properly assess residents for the use of bed/side rails, obtain physician's orders for the use of bed rails, attempt to use alternative measures prior to installing a bed/side rail and to update resident care plans regarding the use of bed/side rails for seven of 24 residents sampled. (Resident #83, #91, #54, #79, #32, #24 and #15). The census was 92. 1. Review of Resident #83's admission record, showed: -admitted on [DATE]; -Diagnoses included central cord syndrome of cervical spinal cord (the most common form of cervicl spinal cord injury, characterized by loss of motion and sensation in arms and hands), diabetes, muscle weakness, fractures and quadriplegia (paralysis that results in the total or partial loss of use of all four limbs). Review of the resident's Evaluation for Use of Bed Rails, dated 9/20/19, showed: -Appropriate alternatives for the use of bed rails was not checked; -The use of bed rails being considered was blank; -The…

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

Based on observation, interview and record review, the facility failed to ensure medication error rates of less than 5 %. Out of 26 opportunities observed, there were two errors resulting in a 7.69% medication error rate. (Residents #71 and #8). The census was 92. 1. Review of Resident #71's physician's order sheet (POS), dated 10/1/19 through 10/31/19, showed an order for gabapentin (medication used to treat seizures and pain) 300 milligram (mg) by mouth twice a day at 8:00 A.M. and 8:00 P.M. Observation on 10/7/19 at 9:45 A.M., showed Nurse E administered the resident's morning medication which included gabapentin 300 mg. During an interview on 10/7/19 at 10:30 A.M., Nurse E said he/she should have administered the medication as ordered. 2. Review of Resident #8's POS, dated 10/1/19 through 10/31/19, showed an order for carvedilol (medication used to treat high blood pressure and heart failure) 25 mg by mouth at 9:00 A.M. and 5:00 P.M. Observation on 10/07/19 at 3:47 P.M., showed Certified Medication Technician (CMT) J administered the resident's evening medication which 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.

Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor and appearance by failing to follow three out of three recipes for four residents on a pureed diet. The census was 92. 1. Review of the pureed food guidelines for one serving of sausage, showed: -Two sausage patties; -Broth; -Begin with 1/2 cup (c) liquid; puree, then continue to alternate adding liquid and pureeing until product is correct consistency; -Consistency of pureed food should not be thinner than pudding or thicker than mashed potatoes. Observation and interview on 10/9/19 at 6:45 A.M., showed [NAME] L had the pureed food guidelines above the food prep counter. He/she said he/she was making seven servings of pureed sausage. [NAME] L used tongs to place seven sausage patties into the blender. He/she added approximately one cup of hot water. He/she pureed the mixture for approximately 20 seconds, checked the mixture and pureed again for another 10 seconds. He/she used a spatula to scrape the sides of the blender and pureed the mixture 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.

Based on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety by exhibiting poor hand hygiene and using contaminated equipment during meal preparation, leaving trashcans uncovered while not in use and leaving scoops inside a dry bulk storage container. The census was 92. 1. Observation on 10/9/19 at 5:55 A.M., showed [NAME] L began breakfast meal preparation. He/she put on a pair of clean gloves and removed biscuits from the oven. A biscuit fell on the floor and [NAME] L picked it up with his/her right hand and threw it in the trashcan. He/she touched several pans when placing them in the warming server. With the same pair of gloves on, [NAME] L picked two dishwasher crates off the floor and moved them to a different area. He/she removed hanging pots and placed them on the gas range. He/she filled a measuring cup with hot water and poured it into the pot. He/she used a paper towel to wipe out the measuring cup and refill it with cream of wheat. With the same pair of gloves on, [NAME] L touched…

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 treatment, consistent with professional standards of practice, to pressure ulcers acquired by two residents. The facility identified two residents with pressure ulcers and problems were found with one (Resident #91), as well as another resident with a new pressure ulcer identified by hospice (Resident #32). The census was 92. 1. Review of the facility's Weekly Pressure Ulcer Tracking Report, dated 8/24/19, showed, for Resident #91: -A Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) to the coccyx (tailbone), measuring 2 centimeters (cm) in length, 1 cm in width and 0 cm in depth (2.0 x 1.0 x 0); -Description: Pink; -Drainage: Small bloody; -Pain: No; -Treatment: Allevyn (a brand of wound dressing pads that protect open cuts, lesions or burns) every three days; -A Stage II…

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 followed their policy for infection control during two of three observations of residents receiving incontinence care. (Residents #86 and #71). The census was 92. 1. Review of Resident #86's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/30/19, showed: -Understood/understands; -Short/long term memory problem; -Extensive assistance of two (+) persons required for bed mobility, transfers, dressing and toilet use; -Limited assistance of one person required for personal hygiene and bathing; -Diagnoses of heart failure, stroke and dementia. Observation on 10/9/19 at 7:12 A.M., showed the resident lay in bed. Certified Nurse Aides (CNAs) B and C donned gloves and prepared to clean and dress the resident. CNA B washed the resident's genitalia, then assisted the resident onto his/her side and cleaned the resident's buttocks. After cleaning the resident, the CNA failed…

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.