Baisch Nursing Center

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility's census was 48. Review of the facility's Infection Control Policy, dated 04/10/19, showed: - Policies and procedures will be utilized as the standards of the IPCP; - The IPCP will be driven by coordination, oversight, surveillance, data analysis, outbreak management, prevention of infection, immunization, and monitoring; - The IPCP will be coordinated and overseen by the Director of Nursing (DON); - The IPCP committee will review surveillance data, and reporting data to determine potential issues or trends; - The outbreak management process will consist of determining the presence of an outbreak, managing the affected resident, preventing the spread to others, documenting information about the outbreak, reporting the information to appropriate public health, education, monitoring for reoccurrence, review after…

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

Based on interview and record review, the facility failed to ensure the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) was complete and reviewed annually. The facility census was 56. Review of the Facility Assessment policy, dated 04/01/19, showed: - A facility assessment will be conducted annually to determine and update our capacity to competently care for and meet the needs of our residents during day-to-day operations including during an emergency; - Once a year and as needed, a designated team will conduct a facility wide assessment to ensure that the resources are available to meet the specific needs of the residents; - The team responsible for conducting, reviewing, and updating the facility assessment includes the following: the Administrator; a representative of the governing body; the medical director; the director of nursing; and the directors of maintenance services, dietary, social services, activities, and rehabilitation; - The facility assessment will…

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

Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's QAPI Principles and Plan, undated, showed: - QAPI will be incorporated into the culture of the facility. We will use data gathered to make decisions and to drive improvement in all areas of our business. The underlying message to everyone working or living in our facility will be that we will take steps to identify, implement, and sustain continuous improvements in all departments. The method for approaching decision-making and problem solving will involve all members of our facility; - Our owners, board of directors, and all levels of management are engaged in and supportive of the performance improvement work being done in our organization and will be kept informed of the work that is being done and any changes which…

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 maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's census was 56. Review of the facility's policy, Quality Assurance and Improvement Program (QAPI), dated 04/10/19, showed: - The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; - The QAPI Committee will include at minimum: the Administrator; Director of Nursing; Medical Director; Activities Director; Social Service Director; Dietary Manager; Housekeeping and Laundry Supervisor; Maintenance Director; Additional Facility Staff; and contracted staff including but not limited to Pharmacy Consultant, Dietician, and Rehab Director; - The Committee will meet monthly at an appointed time. Review of the facility's QAPI sign in sheets showed: - A QAPI meeting held on 01/05/23 with the Administrator, Certified Occupational Therapy Assistant, Director of Nursing, a 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.

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's Antibiotic Stewardship policy, dated 03/26/20, showed: - The purpose is to reduce the use of antibiotics to make sure residents aren't receiving antibiotics unnecessarily; to educate resident, family, and staff on the use of receiving antibiotics unnecessarily; and to track antibiotic use and to make sure that the correct antibiotic is being prescribed; - The nurse will complete the criteria form specific to each individual's clinical symptoms and notify the doctor if it meets those specific criteria for an antibiotic order. The Director of Nursing will put this information of the Infection Control Log; - Specific cultured organisms (when required) will be logged on the Monthly Quality Assurance Infection Control log. This information will be taken to the monthly QA…

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 designate a qualified individual as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 56. The facility did not provide a policy regarding required primary professional training for the Infection Preventionist. During an interview on 01/25/24 at 2:49 P.M., the Director of Nurses (DON) said she is the IP. She has taken the classes, but hasn't taken the certification test. The facility doesn't have a certified IP. During an interview on 01/26/24 at 6:45 P.M., the Administrator said she would expect the facility to have a certified IP. During an interview on 01/30/24 at 3:45 P.M., the Administrator said the DON has been in the IP role for about two years.

Based on interview and record review, the facility failed to maintain a surety bond (a purchased bond for security of resident's personal funds) sufficient to ensure the protection of resident funds. The facility census was 56. Review of the residents' personal funds account for the period January 2023 through December 2023 showed an average monthly balance of $84,050.48. An average monthly balance of $84,050.48 rounded to the nearest thousand equaled $84,000.00, at one and one half times will equal the required bond amount of at least $126,000.00. Review of the facility's current surety bond, effective 05/08/23, showed the facility held a bond in the amount of $87,000.00, which was insufficient by $39,000.00. During an interview on 01/26/24 at 5:28 P.M., the Business Office Manager (BOM) said the surety bond should be one and one half times the average ledger balance. During an interview on 01/26/24 at 6:45 PM., the Administrator said the surety bond amount should be one and one half times the amount of the resident trust balance to meet the regulatory requirement. The facility 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.

Based on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) prior to hire for five out of ten sampled new staff. This deficient practice had the potential to affect all residents, staff and visitors. The facility census was 56. Review of the facility's policy, Abuse and Neglect Reporting Policy, undated, showed: - The purpose is to ensure the safety and comfort of all the residents residing within this facility and to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion, and misappropriation of property for all residents; - The facility will screen potential employees for a history of abuse, neglect, or mistreatment of residents, including checking with the appropriate licensing boards and registries, such as pre-employment criminal background check, employee disqualification list (EDL), nursing licensure check, childcare and elder care registry, and other checks as required by law; - The facility will not employ individuals who have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and document an advance directive (a written legal statement of a person's wishes in regards to medical treatment) or code status (the type of treatment a person would or would not receive if their heart or breathing were to stop) for two residents (Resident #114 and #115) out of 14 sampled residents. The facility census was 56. Review of the facility's policy, Advance Directive, revised [DATE], showed: - Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; - Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives; - 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 observation, interview and record review, the facility failed to conduct an assessment for the use of a shoulder strap (straps over both shoulders that buckle in the center of chest while in a wheelchair) as a restraint for one resident (Resident #5) out of one sampled resident with a restraint, who was unable to easily and intentionally remove the strap. The facility failed to identify a medical symptom that supported the use of the shoulder strap and failed to develop a care plan that included documentation of the medical symptom being treated, attempted alternatives or interventions nor was there any documentation of ongoing monitoring or re-evaluation of the device. The facility census was 56. Review of the facility's policy, Acknowledgement Facility Restraint Philosophy and Policy, not dated, showed the following: -Restraint use will only be considered in order to treat medical symptom(s)/condition(s) that endangers the physical safety of the resident or other residents and under the following conditions: 1) As a last resort measure after a trial period of least…

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 notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Resident #15 and #34) out of 14 sampled residents transferred to the hospital. The facility's census was 56. Review of the facility's Admission, Transfer & Discharge Rights policy, undated, showed: - The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Before a resident is transferred, the facility will notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and shall include the reason for transfer; - In the situation of immediate transfer or discharge required by the resident's urgent…

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 provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #15 and #34) out of 14 sampled residents. The facility census was 56. Review of the facility's Admission, Transfer & Discharge Rights policy, undated, showed: - The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Before a resident is transferred to a hospital, the facility will provide written information to the resident and a family member or legal representative specifying the duration of the bed hold policy during which the resident is permitted to return and resume residence in the facility. Review of the facility's Bed Hold Policy Notice, undated, showed: - If the resident or representative wants to hold the bed, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit two annual Minimum Data Sets (MDS, a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for two residents (Resident #1 and #5) out of 14 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual showed the ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment. Review of the facility's policy, MDS Resident Assessment, dated 02/20/20, showed assessments will be completed per RAI guidelines. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - A comprehensive annual MDS assessment with an ARD of 03/11/22 and a completion date of 03/16/22; - A comprehensive annual MDS assessment with an ARD of 06/14/23 and a completion date of 06/28/23. -No…

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 electronically transmit a discharge or death in facility Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for five residents (Resident #2, #24, #32, #44, and #46) outside of the 14 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual showed: - Discharge assessment to be completed no later than 14 days after the discharge date (Z0500B + 14 days) and transmitted no later than the MDS completion date + 14 calendar days; - Death in Facility tracking record to be completed no later than seven calendar days after the discharge (death) date (Z0500B + seven days) and transmitted no later than discharge (death) date + 14 calendar days. Review of the facility's policy, MDS Resident Assessment, dated [DATE], showed assessments will be completed per RAI guidelines. 1. Review of Resident #2's medical record showed: -…

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

Based on observation, interview and record review, the facility failed to obtain a physician's order for oxygen use and orders for oxygen tubing (a small, flexible tube that contains two open prongs that sit in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for two residents (Resident #34 and #114) out of two sampled residents with oxygen. The facility census was 56. Review of the facility's policy, Physician Medication Orders, revised April 2010, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses; - Orders for medications must include name and strength of drug, quantity or specific duration of therapy, dosage and frequency of administration, route of administration if other than oral, and reason or problem for which given; - Drug and biological orders must be recorded on the…

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

Based on interview and record review, the facility failed to obtain a physician's order for dialysis (a process for removing waste and excess water from the blood) treatments for one resident (Resident #15) out of one sampled resident receiving dialysis. The facility census was 56. The facility did not provide a policy. Review of Resident #15's medical record showed: - admission date 06/12/23; - Diagnoses including type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), chronic kidney disease, and dependence on renal dialysis. Review of the resident's care plan, last revised 11/04/23, showed: - Resident will receive hemodialysis related to diagnosis of chronic kidney disease on Monday, Wednesday and Friday. Nursing sends communication forms with resident to dialysis and dialysis center faxes copy back to facility; - Monitor/record weight prior to dialysis and after dialysis; - Monitor/document/report any signs or symptoms of infection to access site: redness, swelling, warmth or drainage; - Monitor/document/report for signs or symptoms 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 interview and record review, the facility failed to ensure that a as needed (PRN) psychotropic medication's (a medication that changes brain function and changes perception, mood, consciousness, or behavior) order was limited to 14 days for one resident (Resident #1) out of 14 residents sampled. The facility census was 56. Review of the facility's policy, Psychotropic Drug Use, dated 02/20/20, showed any PRN antipsychotic shall be ordered for 14 days or less. The effectiveness and need for the PRN antipsychotic will then be reevaluated by the nurse and physician. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool), dated 12/15/23, showed: - No cognitive impairment; - Use of antidepressants and antipsychotics seven of seven days in the look back period (seven day period before the assessment is completed to capture the status of a resident); - Behavior symptoms not exhibited. Review of the resident's care plan, last reviewed 06/06/22, showed: - Monitor/document side effects and effectiveness; - Abnormal Involuntary Movement Scale…

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 maintain a medication error rate of five percent (%) or less. There were two errors out of 31 opportunities for errors, resulting in an error rate of 6.45%. Out of the six residents observed, this affected two residents (Resident #12 and #14), outside of the 14 sampled residents. The facility census was 56. Review of NovoLog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised February 2015, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing; - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button and make sure drop of insulin appears; - Select dose; - Give injection. Review of the facility's policy titled, Insulin Pen Injection Administration, revised 07/27/21, showed staff were directed to do the following: - Remove cap and wipe rubber stopper…

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 utilize proper technique during incontinent care for one resident (Resident #16) out of 14 sampled residents and one resident (Resident #27) outside the sample, when staff removed multiple clean disposable wipes from the package with soiled gloves and did not perform appropriate hand hygiene or glove changes. The facility failed to use proper hygienic practices in the dining room for two residents (Resident #5 and #33) out of the 14 sampled residents, when staff touched the resident's food with bare hands, and touched a resident's hair, clothing, and wheelchair with bare hands and assisted the resident to eat. The facility failed to develop and implement a water management program to prevent Legionella infection. The facility's census was 56. 1. Review of the facility's policy titled, Glove Use, dated 0 6/25/20, showed: - Purpose: To prevent the spread of infection; - Procedure: Wash hands before putting on gloves. Wash hands after removing gloves (NOTE: Gloves do not replace handwashing); - When to use…

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 conduct at least twelve hours of nurse aide in-service education per year. This affected three out of four sampled Certified Nurse Assistants (CNAs). The facility census was 56. Review of the facility's policy, In-Service Training Program, Nurse Aide, revised December 2011, showed: - All nurse aide personnel shall participate in regularly scheduled in-service training classes; - Annual in-services must be no less than 12 hours per employment year; - Enhance the skills of the nurse aides in providing care for residents with dementia and preventing resident abuse. 1. Review of the in-service record for CNA K showed: - A hire date of 02/23/21; - A total of seven hours of annual in-service training for February 2022 through February 2023; - Less than twelve hours of in-service education for February 2022 through February 2023; - No documented annual Abuse and Neglect training. 2. Review of the in-service record for CNA L showed: - A hire date of 03/15/11; - A total of seven and one half hours of annual in-service training for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 and a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for one resident (Resident #18) out of 13 sampled residents who remained in the facility when benefits were not exhausted. The facility census was 49. Record review of Resident #18's medical record showed the resident admitted to the facility on [DATE]. Medicare Part A services started on 05/05/22, ended on 06/05/22, and the resident remained in the facility. The facility did not issue a CMS SNFABN Form…

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 complete a Level I Preadmission Screening or Resident Review (PASARR-a federal requirement to help ensure individuals are not inappropriately placed in a nursing home for long term care) as required, for three residents (Resident #15, #25, and #30) out of 13 sampled residents with mental health diagnoses. The facility census was 49. 1. Record review of Resident #15's electronic health record (EHR) showed: - An admission date of 3/5/22; - Diagnoses included major depressive disorder (mood disorder) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows); - No documentation of a Level I PASARR. 2. Record review of Resident #25's EHR showed: - An admission date of 5/13/22; - Diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves) and major depressive disorder; - No documentation of a Level I PASARR. 3. Record review of Resident #30's EHR showed: - admission date 5/25/22; - Diagnoses included schizophrenia and…

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

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs for one resident (Resident #97) out of 13 sampled residents. The facility census was 49. Record review of the facility's Baseline Care Plan Policy, dated 2/20/20, showed: - Each resident will have a baseline care plan developed within 48 hours of admission; - The baseline care plan will include the minimum healthcare information necessary to properly care for the resident. 1. Record review of Resident #97's Physician Order Sheet (POS), dated 6/29/22, showed: - admission date of 6/29/22; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), major depressive disorder ((long-term loss of pleasure or interest in life), generalized anxiety disorder (persistent worry and fear about everyday situations), seizures (a burst of uncontrolled electrical activity…

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 develop an individualized comprehensive care plan which includes measurable goals to meet the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #97) out of 13 sampled residents. The facility's census was 49. 1. Record review of Resident #97's Physician's Order Sheet (POS), dated 6/29/22, showed: - admission date of 6/29/22; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), major depressive disorder ((long-term loss of pleasure or interest in life), generalized anxiety disorder (persistent worry and fear about everyday situations), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), hypertension (high blood pressure), cerebrovascular disease (stroke, damage to the brain from interrupted blood…

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

Based on record review and interview, the facility failed to ensure two certified medication technicians (CMT) and two certified nursing assistants (CNA) received the required annual twelve hours of nurse aide in-service education training. This deficient practice had the potential to affect all residents. The facility census was 49. 1. Record review of Certified Medication Technician (CMT) L showed: - Date of hire 11/14/2003; - No record of education. 2. Record review of CMT M showed: - Date of hire 10/21/2019; - An in-service on Abuse and Neglect for an unspecified amount of time on 4/06/2022; - An in-service on Emergency Preparedness for an unspecified amount of time on 5/20/2022. -No additional record of education. 3. Record review of Certified Nursing Assistant (CNA) N showed: - Date of hire 11/25/2020; - No record of education. 4. Record review of CNA O showed: - Date of hire 2/23/2021; - No record of education. During an interview on 8/05/2022 at 11:05 A.M., the Administrator said she would expect CNAs/CMTs to have the required 12 hours of training that includes abuse,…

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.