Villa At Blue Ridge, The

Based on interviews and record reviews, facility staff failed to initiate and complete a thorough investigation of alleged misappropriation of one resident (Resident #1) narcotic medication. The facility census was 90.1. Review of the facility's, Abuse Prohibition Protocol Manual, undated, showed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident' medical symptoms. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to thoroughly investigate the alleged violations and take appropriate corrective action, as a result of investigation findings. The facility must have evident (documentation forms) of a thorough investigation including resident statements, witness statement, staff statements, environmental review, resident physical assessment, etc., including a timeline of events.Review of the facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to notify three resident's (Resident #1, #3 and #4) out of five sampled resident's representative and/or physician after a change in condition. The facility census was 80. 1. Review showed the facility did not provide a policy for notifying family or physician after a change in condition. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/17/25, showed staff assessed the resident as severely cognitively impaired and did not assess the resident with a fall since admission. Review of the facility's event report, dated 05/04/25 at 2:32 A.M., showed staff documented the resident fell. The report did not contain documentation staff notified the physician or the family related to the fall. The report contained documentation, dated 05/04/25 at 2:57 P.M., the resident's family member reported staff did not contact him/her of the fall or that he/she was sent to the hospital. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to review and update the plan of care with changes in the residents' care needs for four residents (Residents #1, #2, and #3) out of five sampled residents, and failed to update the plan of care on a quarterly basis for two resident (Resident #2 and #3) out of five sampled residents. The facility census was 80. 1. Review of the Facility's Care Plan Comprehensive policy, undated, showed staff are directed as follows: -The purpose of an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set); -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for…

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 the facility did not employ or engage one of four sampled employees prior to employment who had a class A Felony First Degree Assault - Serious Physical Injury or Special Victim which is a disqualifying factor for employment in a long term care facility. The facility census was 84. 1. Review of the facility's Abuse Prohibition Protocol Policy , dated 2017, showed the facility cannot employ individuals who have been found guilty of abuse or have an abuse violation against their professional license. Abuse is defined as willful infliction of injury with resulting harm, pain or mental anguish. Review of facility's Hiring Process Policy, undated, directs staff to conduct an Employee Disqualification List (EDL) and a Family Safe Care Registry check (FSCR) on any potential newly hired staff. 2. Review of CNA A's personnel file showed a hire date of 06/20/2023. Review of the CNA's CBC, dated 04/22/25, showed a Class A Felony in the First Degree Assault - Serious Physical Injury or Special Victim. During an interview 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, facility staff failed to provide written notification to the resident and/or the resident's representative of the facility bed hold policy at the time of transfer to the hospital for three residents (Resident #2, #3, and #4) out of four sampled residents. The facility's census was 88. 1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/20/25, showed staff assessed the resident as cognitively intact. Review of resident's medical record showed staff documented the resident: -discharged from the facility on 04/11/25 and readmitted to the facility on [DATE]; -discharged from the facility 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 facility staff failed to ensure one resident (Resident #1) received his/her pain medications as ordered when staff failed to obtain a physician's order to resume medications that were on hold for surgery after notification of surgery cancellation, and failed to administer his/her pain medication as ordered when staff documented the medication as not available. Facility staff failed to complete smoking risk assessments to re-assess smoking privileges for two residents (Resident #2 and #4), of two sampled residents who smoke. The facility census was 84. 1. Review of the Medication Administration policy, revised 02/07/2013, showed medications are given to benefit the resident's health as ordered by the physician. The policy did not address medication holds or unavailable medications. Review of Medication, Holding policy, dated March 2012, showed staff are directed as follows: -The resident's medical record must indicate that medications are being held and the entry must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, facility staff failed to ensure residents' environment remained free of accident hazards, when staff failed to ensure residents did not retain smoking materials while in the facility for two residents (Resident #2 and #4) of two sampled residents. The facility's census was 88. 1. Review of the facility's admission Packet, Resident Rules and Regulations, showed residents may not retain matches or lighters. Review of the facility's Smoking-Residents policy, undated, showed staff are directed as follows: -The facility shall establish and maintain safe resident smoking practices; -Any smoking related privileges, restrictions, and concerns (example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; -Smoking shall not be permitted in living/sleeping area; -This facility may check periodically to determine if residents have smoking articles in violation of our smoking policies. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for 19 residents (Resident #6, #9, #12, #20, #26, #28, #29, #31, #32, #33, #41, #44, #46, #51, #57, #63, #69, #70, and #71) out of 20 sampled. The facility census was 83. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA 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. The Assessment Reference Date (ARD) must be not more…

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 (LD- 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. The facility census was 84. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or…

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

Based on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for employee prior to hire to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) for five employees (Dietary Aide D, Nurse Aide E, Housekeeping F, Dietary [NAME] G, and Registered Nurse H) out of a sample of ten employees. Facility staff failed to complete a thorough investigate of an injury of unknown origin for one resident (Resident #61) out of one sampled resident. The facility census was 83. 1. Review of the Facility's Screening Abuse and Neglect Manual, undated, showed: -The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; or who has a finding in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has had a disciplinary action in effect taken against his/her…

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 meet professional standards of care one resident (Resident #31) , when staff failed to provided the resident's treatment as ordered and facility staff failed to provide consistent documentation in regard to choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) for two resident's (#3 and #30) out of three sampled resident. The facility census was 83. 1. Review of the facility's Physician Orders Policy, undated, showed a current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors. 2. Review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Lower extremity impairment on one side; -Dependent on staff for lower body dressing; -Diagnosis of Parkinson's and Diabetes. Review of the resident's Physician…

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 the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 83. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building for the dates of: -Thursday 07/04/24; -Friday 07/05/24; -Sunday 07/07/24; -Saturday 07/13/24; -Sunday 07/14/24; -Saturday 07/20/24; -Sunday 07/21/24; -Friday 07/26/24; -Saturday 07/27/24; -Sunday 07/28/24; -Monday 07/29/24; -Tuesday 07/30/24. 3. Review of the facility's RN staff schedule, dated August 2024, showed the facility did not have an RN in the building for the dates of 08/03/24 through 08/31/24. 4. Review of the facility's RN staff schedule, dated September 2024, showed the facility did not have an RN in the building for eight consecutive hours per day for the month of September. 5.Review of the facility's RN staff schedule, dated October 2024, 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 interview and record review, facility staff failed to follow policies and procedures for immunization of residents against Pneumococcal disease in accordance with national standards of practice and/or failed to assess and vaccinate two residents (Resident's #73 and # 92) of five sampled residents (over [AGE] years old) with doses of the Pneumococcal and/or influenza vaccine, as recommended by the Center for Disease control and prevention. Facility census was 83. 1. Review of the facility policy, Immunizations, undated, shows the following: -The resident's physician will be consulted and determine the level of risk and need for the vaccinations. A physician order is required to administer any medication/vaccination; -Pneumococcal vacinations in Persons aged 65 and older years, unless contraindicated, will be asministered according to the following guidelines when determining vaccination status: -Adults 65 years or older who have not received any pneumococcal vaccination should receive Pneumococcal…

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 complete a comprehensive discharge summary or post discharge plan of care form for one resident (Resident #77) of two discharged residents. The facility census was 83. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed to provide a safe departure from the facility and to provide sufficient information for aftercare of the resident staff will complete a discharge summary and post discharge plan of care form. 2. Review of Resident #77s medical record, showed the resident discharged on 07/09/24. The record did not contain a comprehensive discharge summary or post discharge plan of care of the resident's stay in the facility. During an interview on 10/10/24 at 10:00 A.M., the Social Services Director (SSD) said he/she is responsible for resident discharges. The SSD said he/she should have put a discharge summary and other discharge information in the resident's medical record, but just didn't do it. During an interview on 10/10/24 at 4:37 P.M., the Assistant Director of Nursing (ADON) said…

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 one (Resident #55) of one sampled residents received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to provide orders, ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 83. 1. Review of the Facility's Care of a Resident Receiving Dialysis policy, undated, showed staff are directed to: -Feel for thrill (vibration that is felt on the skin overlying an dialysis shunt (connection from a hemodialysis access point to a major artery)) sensation daily; -Inspect access site for redness, swelling, or warmth; -Watch for bleeding after dialysis; -Monitor for signs of infection; -Nurse will maintain dressing to access site at all times. Site to be checked every shift and dressing reapplied or reinforced as needed; -Nurses will check the thrill daily and document 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 observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5% out of 31 opportunities observed. Two errors occurred, resulting in a 6.45% error rate, which affected one resident (Residents #60) of 6 sampled residents. The facility census was 83. 1. Review of the facility's policy Medication Administration, revised 2/17/13, showed: -The complete act of administration entails removing an individual dose from a previously dispensed, properly labelled container, verifying it with the physician's orders, giving the individual dose to the priper resident, and promptly recording the information; -If there is doubt concerning the administration, the physician's order must be verified before the medication is adminstered; -Certain medications should never be crushed. Refer to pharmacy manual if you are unsure a medication can be crushed. Review of the website dailymed.nlm.nih.gov, updated 04/18/23, showed Metoprolol succinate extended-release (ER)(used to lower blood pressure), tablets are scored and can be divided; however, do…

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 document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and local hospice provider for two (Resident #49 and #82) out of three sampled residents who received hospice services. The facility census was 83. 1. Review of the facility's Nursing Facility Services Agreement, dated October 15, 2009, showed, Coordination of Care: -General. Hospice and facility shall communicate with one another regularly and as needed for each particular hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day. -Design of plan of care. In accordance with applicable federal and state laws and regulations, Facility staff shall coordinate with hospice in developing a plan of care for each hospice patient. Hospice retains primary responsibility 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, interview, and record review, facility staff failed to maintain professional standards of practice when staff did not document they provided one resident (Resident #1) out of three sampled residents wound treatment has orders by the physician . The facility census was 80. 1. Review of the facility's policy titled, Physician Orders, undated, showed staff were directed to review and renew physician orders. The policy did not provide direction for staff in regard to ensuring accuracy when transcribing physician orders in the resident's medical records. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/25/24, showed staff assessed the resident as cognitively intact. Review of the resident's physician order, dated 07/17/24, showed a physician order to remove the old bandage, cleanse the wound, gently remove any dried blood from the wound with a wet Q-Tip, gently dry the wound, apply petroleum jelly ointment with a Q-Tip cut a nonstick pad to fit the wound and a small area around the wound. If the wound is…

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 revise the care plan after a fall for three resident's (Resident #1, #2, #3) out of three resident's. The facility census was 76. 1. Review of the facility's policy titled, RAI Guidelines, undated, showed staff were directed to do the following: -The Minimum Data Set (MDS) Coordinator is responsible to review all Care Area Assessment (CAA) documentation, consult with other Interdisciplinary Team (IDT) members, and make recommendations for further assessment and follow up as appropriate; -The resident plan of care is considered a dynamic interdisciplinary document and is to be used as a communication tool for all staff providing care; -Information relevant to the resident's plan of care should be communicated to the charge nurse and MDS Coordinator. Written communication is maintained on care plans and updated as appropriate by the MDS Coordinator or by members of the interdisciplinary team as assigned by the Registered Nurse (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to complete a baseline care plan for five residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). The facility census was 70. 1. Review of the facility's Care Plan, Temporary policy, dated March 2015, showed staff are to assure the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within 24 hours of admission. Review showed the interdisciplinary care plan team and/or admitting nurse will review the physician's orders and implement a nursing care plan to meet the immediate care needs of the resident. The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) process. 2. Review of Resident #1's entry Minimum Data Set (MDS), a federally mandated assessment, dated 9/25/23, showed the resident as admitted to the facility 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 record review and interview, facility staff failed to develop and implement a comprehensive person centered care plan which addressed the resident's medical, physical, and psychosocial needs for two residents ( Resident #7, and Resident #12). The facility census was 70. 1. Review of the Resident Assessment Instrument Manual (RAI), dated 10/1/17, showed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment. The comprehensive care plan is an interdisciplinary communication tool. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to resident's exercise of rights including the right to refuse treatment. The Care Area Assessment (CAA'S) provide a link between…

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 meet professional standards when staff did not complete weekly skin assessments as ordered by the physician for five sampled residents (Resident #13, #14, #15, #16 and #17). The facility census was 70. 1. Review of the Facility's Wound Protocol Policy, undated, did not direct staff on the expected time frame to complete resident skin assessments. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/02/23, showed staff assessed the resident as: -Cognitively intact; -At risk for pressure ulcers; -Application of medication/ointment to area other than feet. Review of the resident's physicians order sheet (POS), dated 02/20/23, showed an order for weekly skin assessments to be completed every Monday. Review of the resident's weekly skin assessments form, dated 8/28/23 to 10/27/23, showed staff did not document they completed a weekly skin assessment for the weeks of 9/4/23, 9/11/23, 9/25/23, 10/09/23,…

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 observation, interview and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary to prevent cross-contamination. The facility census was 70. 1. Review of the facility's Glove Use policy, dated May 2015, showed the policy directed staff to remove their gloves and wash their hands when they change or walk away from a specific task. Review also showed the policy directed staff to wash their hands after they dispose of trash or food, after handling dirty dishes, after they pick up anything from the floor, when they change tasks, and any other time deemed necessary. Observation on 05/01/23 at 10:28 A.M., showed Dietary Aide (DA) D washed soiled dishes in the mechanical dishwashing station. Observation showed, without performing hand hygiene, the DA then put away sanitized dishes from the clean side of the station. Observation on 05/01/23 at 1:44 P.M. and 1:50 P.M., showed [NAME] B washed soiled dishes in the mechanical dishwashing station with gloved hands. Observation showed, without removing his/her gloves and performing hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to create a comprehensive person-centered care plan for one resident (Resident #11). Additionally, facility staff failed to revise care plans for five residents (Resident #10, #17, #18, #44, and #51). The facility census was 70. 1. Review of the facility's Care Plan Comprehensive policy, undated, showed: -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; -The interdisciplinary care team (IDT) is responsible for the periodic review and updating of care plans at least quarterly. 2. Review of Resident #11's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Totally dependent for assistance from two staff members for bed mobility, transfers, toilet use, personal hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to properly propel three residents (Residents #10, #42, and #46) in wheelchairs in a manner to prevent accidents. The facility census was 70. 1. Reviews of the facility's Use of Wheelchair Policy, dated March of 2015, shows it instructed staff to assist resident into wheelchair, lower the foot rests and place the resident's feet on the foot rests, and assist the resident to the area of facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 2. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/27/23, showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance from one staff member for transfers; -Independent with locomotion on and off the unit; -Used a wheelchair; -Range of Motion (ROM) impairment to both lower extremities. Review of the resident's Care Plan, revised 1/9/23, showed staff were directed 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, facility staff failed to maintain resident dignity by failing to properly cover a urinary catheter bag for one resident (Resident #46). The facility census was 70. 1. Review of the facility's Resident Rights Policy, undated, showed the residents shall be treated with consideration, respect and full recognition of their dignity and individuality, including privacy in treatment and in care of the resident's personal needs. Review of Resident #46's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/23, showed staff assessed the resident as: -Cognitively Impaired; -Required extensive assistance from one staff member for transfers; -Required total assistance from one staff for locomotion off the unit; -Used a wheelchair for locomotion; -Indwelling urinary catheter (tube inserted into the bladder to drain urine). Review of the resident's care plan, revised 2/28/23, showed staff documented the resident is to use a urinary drainage leg bag when out of bed. Observation on 5/01/23 at 11:55 A.M., 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.

Based on interview and record review, facility staff failed to prevent the misappropriation for one resident's (Resident #1) checking account when Certified Nurse Aide (CNA) Q used the resident's bank card numbers, without authorization of the resident, to make digital cash application transfers, totaling $107.00, from 4/24/23 to 5/03/23. The facility census was 70. 1. Review of the facility's New Abuse/Neglect Report Regulation, dated 11/28/16, showed misappropriation defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review showed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment of any type by anyone. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/12/23, showed staff assessed the resident as cognitively intact. Review of the facility's investigation, dated 5/10/23, showed on 5/10/23, the Social Service…

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.