South Hampton Rehabilitation & Health Care Center

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain an air gap in two ice machine drains. These failures have the potential to affect all residents. The facility census was 57. 1. Review of the facility's Food Storage policy, undated showed: -All food items will be labeled and the label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date; -Wrap food properly. Never leave any food item uncovered and not labeled; -Set refrigerators to the proper temperature to ensure the internal temperature of the food is 41 degrees Fahrenheit (F) or lower. Place hanging thermometer in the warmest part of the refrigerator. Observation on 04/01/25 at 10:30 A.M., showed the kitchen contained a stand-up mixer which was uncovered and contained an accumulation of dried white material in the area above the blade connection. Observation showed a walk-in freezer contained…

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

Based on interview and record review, facility staff failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information to the Payroll-Based Journal (PBJ) from October 1, 2024, through December 31, 2024. The facility census was 57. 1. The facility did not provide a policy for Payroll-Based Journal submission. 2. Review of the CMS Electronic Staffing Data Submission PBJ Policy Manual for submission guidelines showed submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. Timeframes for each reporting period are as follows: Fiscal Quarter 1 - Date Range October 1-December 31 - submission deadline February 14; Fiscal Quarter 2 - Date Range January 1-March 31 - submission deadline May 15; Fiscal Quarter 3 - Date Range April 1-June 30 - submission deadline February 14; Fiscal Quarter 4 - Date Range July 1-September 30 - submission deadline November 14. 3. Review of the fiscal years CMS PBJ Staffing Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to follow infection control practices when staff did not disinfect the blood glucose monitor between uses for three residents (Resident #37, #33, and #48) out of four sampled residents. The facility failed to provide current infection prevention policies that were updated and reviewed annually. The facility census was 57. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a…

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

Based on interview and record review, facility staff failed to prevent the commingling of 17 resident's (Resident #13, #19, #21, #46, #63, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #77) personal funds with the facility operating funds out of 55 sampled residents. The facility census was 55. 1. Review of the facility's policy titled Facility Resident Trust Fund Policy, revised 05/12, showed the facility will maintain a full and complete separate accounting ledger for each resident. The facility will maintain current written individual ledgers of all financial transactions. If a check is received for the resident's Accounts Receivable balance along with money for their resident trust account, the entire check should be deposited to the resident trust fund. A check then must be written from the resident trust fund to the accounts receivable account for the portion relating to the resident's accounts receivable balance. The facility will refund the balance of the resident's personal funds when a resident is discharged . The amount will be refunded by the end 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, facility staff failed to obtain consent for the use of bed rails for five residents (Resident #3, #6, #7, #19 and #26) out of six sampled residents, failed to assess residents for the use of bed rails and perform an entrapment assessment for two residents (Resident #7 and #26) of six sampled residents. The facility census was 57. 1. Review of the facility's policy titled Bed Rails, dated December 2024, showed prior to the installation of bed rails, attempts to provide the resident with alternative measures to meet their need for positioning, mobility, or transfer ability while in bed will be made. When alternatives are deemed ineffective or not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, including the risk of entrapment, and informed consent is obtained from the resident or resident's representative. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated…

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

Based on interview and record review, facility staff failed to ensure three Nurse Aides (NA)s (NA B, NA C, and NA D) of five sampled NA's completed the required nurse aide training program within four months of employment in the facility. The facility census was 57. 1. Review of the policies provided by the facility did not contain a policy for NA qualifications. 2. Review of the Facility Assessment Tool, dated August 18, 2017, showed the Facility Assessment did not address Nurse Aide Qualifications and Training Requirements. 3. Review of NA B's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 4. Review of NA C's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 5. Review of NA D's personnel file showed a hire date of 07/06/24. The file did not contain documentation the NA completed the required nurse aide training program. During an interview on 04/03/25 at 11:30 A.M., NA D said he/she had not…

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

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 57. 1. Review of the facility's policy titled Antibiotic Stewardship & MDROs (Multiresistant Organisms), dated 2019, showed the Infection Preventionist (IP) will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON (Director of Nursing), Medical and Consultant Pharmacist and ongoing system review. Ongoing review and updates will be completed based on standards of practice, and collaboration with Medical Director and Pharmacy Consultant. Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse 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.

Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document neurological assessments for one resident (Resident #1) out of one sampled resident who had a fall with head injury. The facility census was 57. 1. Review of the facility's Fall Prevention policy, undated, showed it did not address a neurological post fall assessment for residents who incurred a head injury. Review of the facility's paper Neurological Evaluation flowsheet, revised November 2023, showed staff are directed to document neurological assessments for unwitnessed falls and head injuries every 15 minutes for one hour; every 30 minutes for two hours; every hour for four hours; and every shift for 72 hours. Review showed the neurological assessment should include: -Level of consciousness (Awake and Alert); -Orientation (Time/Place/Person); -Pupil reaction (pupils reaction to light); -Motor strength (extremity movement); -Sensation (numbness or tingling); -Gait and Balance (steps and pace); -Vital Signs (Blood pressure, pulse, respirations, and…

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

Based on interview and record review, facility staff failed to have a system in place to ensure Certified Nurse Aides (CNA)s received the required 12 hours in-service education based on performance reviews annually for three CNAs (CNA E, F, & G) out of three sampled CNAs. The facility census was 57. 1. Review of the policies provided by the facility did not show a policy for staff training, CNA training, or staff/CNA evaluations. Review of the Facility Assessment, dated August 18, 2017, showed the required in-services for nurse aides must: -Be sufficient to ensure the continuing competency of nurse aides (NA)s, but must be no less than 12 hours per year; -Address areas of weakness as determined in the NAs' performance training; -The Facility Assessment did not contain requirements of annual in-service education for nursing personnel by a registered nurse (RN) or qualified therapist to include turning and positioning for the bed-ridden resident, range of motion (ROM) exercises, ambulation assistance, transfer procedures, bowel and bladder retraining, or self-care activities of daily…

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

Based on interview and record review, facility staff failed to provide documentation for two residents (Resident #28 and #37) out of five sampled residents were provided education and offered the current COVID-19 immunization. The facility census was 57. 1. Review of the facility's policy titled Resident Immunizations and Vaccinations, dated 09/2/22, showed it did not address the vaccination policy for Coronavirus 2019 (COVID-19). 2. Review of the facility policy titled Severe acute respiratory syndrome coronavirus (SARS-CoV-2) Infection, dated 08/22/24, showed the community/facility should follow county, state and federal recommendations applicable for SARS-CoV-2 infection prevention and treatment. The community/facility and its employers are reminded that general population guidance is different from long term care/Senior Living guidance. The community/facility will follow long term care and guidance and county, state and federal recommendations consistent with SARS-CoV-2 policy. Healthcare professionals (HCP), residents and visitors should be offered resources and counseled about…

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 staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. The facility staff failed to maintain freezer temperatures in a manner to prevent possible food spoilage. The facility staff failed to maintain the kitchen ceiling in good repair to prevent the growth and harborage of bacteria. The facility census was 58. 1. Review of the facility's Basics for Handling Food Safely policy, undated, showed the policy did not contain guidance for labeling and dating food or drinks. Review of the Registered Dietician kitchen inspection, dated 1/22/24, showed all food was not properly covered, labeled and dated. Observation on 02/20/24 from 10:20 A.M. through 11:30 A.M., showed an opened and undated bottle of ketchup set on the fire extinguisher cabinet in resident dining room. Observation showed the reach in refrigerator contained: -An opened and undated ten pound container of boiled, peeled eggs;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls and floors in good repair, and to maintain resident bed linens. The facility census was 58. 1. Review of the facility's policies showed the facility did not provide a policy for homelike environmental conditions. 2. Observation on 02/23/24 at 10:31 A.M., showed resident occupied room [ROOM NUMBER] bathroom with black residue on the toilet caulk, stained and chipped areas on the floor, and towel rack bolts exposed on the wall without a towel rack. 3. Observation on 02/20/24 at 10:35 A.M. and 02/21/24 at 08:56 A.M., showed Resident #51 in his/her bed. Observation showed the bed sheets and pillowcase with brown stains. During an interview on 02/21/24 at 8:56 A.M., the resident said he/she scratches sometimes and gets stuff on the bed. He/She said staff change the linens once a week. During an interview on 02/23/24 at 10:57 A.M., Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #1, #11, #27,#36, #41, and #51). The facility census was 58. 1. Review of the facility's policies showed staff did not provide a policy for care plans or care planning. 2. Review of Resident #1's Annual Minimum Data Set, (MDS), a federally mandated assessment tool, dated 01/04/24, showed staff assessed the resident as: -Cognitively impaired; -Received an anticoagulant (a blood thinner); -Diagnoses of a stroke, hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and aphasia (the loss of ability to understand or express speech). Review of the resident's Physician Order Sheet (POS), showed an order on 01/25/23 for Eliquis (a blood thinner that may cause easy bruising, or minor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to keep treatment carts locked when left unsupervised, failed to ensure one resident (Resident #11) did not have a lighter near oxygen while in use and failed to document a smoking assessment was completed. Staff failed to document an unwitnessed fall, notifiy of the family, and notify the physician of the fall for one resident (Resident #39). The facility census was 58. 1. Review of the facility's Medication, Storage of policy undated showed: -All medications for residents must be stored at or near the nurse station in a locked mobile medication cart; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile; -An unattended medication cart must remain locked at all times. In the event a nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving…

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

Based on interview and record review, facility staff failed to have a system in place to ensure a Certified Nursing Assistant (CNA) received the required 12 hours in-service education based on performance reviews annually for six CNA (CNA C, D, E, F, G, and H) out of six sampled CNAs. The facility census was 58 residents. 1. Review of the facility's policies showed facility staff did not provide a policy for staff training, CNA training, or staff/CNA evaluations. Review of the Facility Assessment, reviewed December 2023, showed the required in-service for nurse aides must: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Address areas of weakness as determined in nurse aides' performance training; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired; -Include dementia management training. Review of the monthly in-service training report showed: -January, April, June and December 2023 did not contain documentation an in-service was conducted;…

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

Based on interview and record review, facility staff failed to follow physician's orders in a timely manner for rehabilitation services for one resident (Resident #50) of eight sampled residents. The facility census was 58. 1. Review of the facility's policies showed staff did not provide a policy for therapy provision. Review of Resident #50's Significant Change Assessment Minimum Data Sets (MDS), a ferdally mandated assessment, dated 11/20/23, showed staff assessed the resident as: -Upper body dressing declined from required supervision to requiring partial/moderate assistance; -Lower body dressing declined from required supervision to requiring partial/moderate assistance; -Toilet transfers declined from required supervision to requiring partial/moderate assistance; -Wheeling a wheelchair 50 feet with two turns declined from required supervision to requiring substantial/maximal assistance; -The resident was assessed as dependent for walking. Review of the resident's care plan, reviewed and revised on 02/11/24, showed: -A problem start on 11/10/23: The resident was not able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to maintain proper infection control practices for two residents (Resident #17 and #57) during perineal care and during ostomy catheter care for one resident (Resident #210). The facility census was 58. 1. Review of the facility's Gloves policy, undated, showed staff are instructed to the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with the mucous membranes, non-intact skin, any moist body substances (blood, urine, feces wound drainage, oral secretions, sputum, vomitus or items/surfaces soiled with these substances) and/or persons with a rash; -Gloves must be changed between residents and between contact with different body sites of the same resident; -Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff made inappropriate comments to residents during care, failed to knock when they entered resident's room, provide privacy during care, and maintain a dignified dining room experience and protect their medical information for ten (Resident #7, #21, #22, #27, #38, #46, # 48, #49, #58, #322) residents. The facility had a census of 64. 1. Review of the facility policies showed staff did not provide a policy for dignity. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/17/22, showed staff assessed the resident as follows: -Required extensive assistance of one staff member for bed mobility; -Required total assistance of one staff member for toileting, and bathing; -Required total assistance of two staff members for transfers; -Always incontinent of bowel and bladder. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for four residents (Resident #24, #38, #47, and #61). The facility census was 64. 1. Review of the facility's Advance Directive Policy, undated, showed staff are directed to obtain information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 2. Review of Resident #24's Face Sheet in their Electronic Medical Record (EMR) showed staff documented the resident as DNR status. Review of the resident's paper chart showed it contained a Physician's Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], documented as a DNR status. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed an active order of Full Code status. Review of the resident's medical record showed the record did…

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, staff failed to maintain professional standards of care when staff failed to follow physician's orders for two residents (Resident #48, and #63), and failed to ensure one resident (Resident #24) had a physician order for dialysis and and one resident (Resident #47) had an order for hospice in their medical record. The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for following physician orders. 2. Review of Resident #48's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/3/22, showed facility staff assessed the resident as follows: -Severely cognitively impaired; -Required extensive assistance from staff for dressing, personal hygiene and bathing; -Diagnosis of Anoxic brain damage (harm to the brain due to a lack of oxygen), Spastic hemiplegia (when the part of the brain that controls movement is damaged); -At risk for developing pressure ulcers. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to ensure safe propulsion for three residents (Resident #22, #46, and #51) in wheelchairs in a manner to prevent accidents, failed to position one resident in the wheelchair with the wheelchair brakes on (Resident #46), and failed to use the mechanical lift (an assistive device used to help transfer residents between a bed and chair) in a manner to prevent accidents for one resident (Resident #38). The facility census was 64. 1. Review of the facility's Wheelchair, Use of policy, undated, showed: Purpose: To provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living. Guidelines: -Apply brakes to lock wheels of the wheelchair; -Lower footrests and place resident's feet on footrests if used; -Position feet and legs in good body alignment;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Residents #64 and #318) and failed to obtain an appropriate diagnosis for the use of antipsychotic medications for two residents (Residents # 61 and #318). The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for PRN Psychotropic medications. 2. Review of Resident #64's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 01/31/23, showed staff assessed the resident as follows: -Received antianxiety medication and antidepressant 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); -Had diagnoses of anxiety and depression. Review of the resident's Physician Order Sheet (POS), dated February 2023 showed 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 staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene and glove changes during incontinent care for two (Resident #1 and #38) residents, failed to clean away from a urostomy catheter and perinal area for one resident (Resident #19), and staff wiped multiple times with the same area of the wipe for one resident (Resident #21) during perineal care. The facility census was 64. 1. Review of Centers for Disease Control and Prevention CDC Hand Hygiene in Healthcare Settings guidelines, last reviewed 1/10/20, showed the guidance directs healthcare personnel to follow the following recommendations: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient; -Before performing an aseptic task (e.g., placing an…

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 they assessed residents using the quarterly Minimum Date Sets (MDS), a federally mandated assessment completed by staff, no less frequently than once every three months, for three residents (Resident #46, #58, and #322). The facility census was 64. 1. Review of the facility provided policies, showed the facility did not provide a policy for MDS completion. Review of the October 2019 RAI Manual, page 2-33, showed: The Quarterly assessment is an non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. 2. Review of Resident #46's medical record showed an admission date of 6/15/22. Review of Resident #46's MDS, showed staff completed: -An admission MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #61 and #64). The facility census was 64. 1. Review of the facility's Comprehensive Care Plan Policy, undated showed: Purpose: An individualized care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment. -A well-developed care plan will be oriented to assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs. 2. Review of Resident #61's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 1/27/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive, one person…

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.