Current River Rehabilitation & Health Care Center

Based on interview and record review, the facility failed to ensure written transfer agreements with hospitals were in effect to assure residents of a timely hospital admission when medically appropriate and the necessary information would be exchanged between the providers. This failure had the potential to affect all residents. The facility census was 40. The facility did not provide a policy on transfer agreements. The facility did not provide transfer agreements with any hospitals. During an interview on 07/15/24 at 5:00 P.M., the Administrator and the Assistant Director of Nursing (ADON) said the corporate Quality Assurance Registered Nurse could not find transfer agreements for any hospitals. The Administrator said she had no knowledge of transfer agreements with any hospitals.

Based on interview and record review, the facility failed to provide written notice to the State agency responsible for licensing the facility when their Director of Nursing (DON) was no longer employed. This had the potential to affect all resident. The facility census was 40. Review of the Facility Assessment, dated 03/07/24, showed: - DON should work five days a week for eight hours; - Licensed Nurses should include a Registered Nurse (RN) eight hours per day when the Director of Nursing (DON) is not available and on weekends. Review of RN I's employee record showed: - RN I hired as the DON on 06/29/22, and a termination date of 05/18/23. Review of RN J's employee record showed: - RN J hired as the DON on 11/08/23, and a termination date of 12/11/23. Review of the last state agency Change of DON Form, dated 07/07/22, showed RN I started employment as the DON on 06/29/22. Review of the nursing schedules, dated 04/06/24 - 07/15/24, showed: - No documentation of a DON scheduled for 04/06/24 - 07/15/24; - No documentation a DON worked 04/06/24 - 07/15/24, with 107 out of 107 days…

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 a written copy of the notice of transfer or discharge to the resident and/or the the resident's responsible party and to the representative of the Office of Long-Term Care (LTC) Ombudsman for six residents (Resident #3, #8, #12, #23, #34 and #36) out of six sampled residents. The facility census was 40. The facility did not provide a transfer or discharge policy. 1. Review of Resident #3's medical record showed: - The resident transferred to the hospital on [DATE]; - No documentation of the written notification with the reason for the hospital transfer provided to the resident and/or the responsible party; - No documentation of the written transfer/discharge notification provided to the representative or the Office of the LTC Ombudsman. 2. Review of Resident #8's medical record showed: - The resident transferred to the hospital on [DATE]; - No documentation of the written notification with the reason for the hospital transfer provided to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to the resident and/or their representatives at the time of transfer for six residents (Resident #3, #8, #12, #23, #34 and #36) out of six sampled residents. The facility census was 40. The facility did not provide a bed hold policy. 1. Review of Resident 3's medical record showed: - The resident transferred to the hospital on [DATE]; - No documentation of the written notification for the bed-hold policy provided to the resident and/or the resident's responsible party for the transfer. 2. Review of Resident 8's medical record showed: - The resident transferred to the hospital on [DATE]; - No documentation of the written notification for the bed-hold policy provided to the resident and/or the resident's responsible party for the transfer. 3. Review of Resident 12's medical record showed: - The resident transferred to the hospital on [DATE]; - The resident transferred to the hospital on [DATE]; - 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.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three medication carts. This practice had the potential to affect all residents. The facility census was 40. Review of the facility's policy titled, Schedule II-V Medications, undated, showed: - All schedule II, III, IV, and V medications must be counted (comparing number of pills to disposition record) at every change of shift by two Certified Medication Technicians (CMT) or one CMT and one licensed nursing staff. Both personnel must sign verification of the correct count; - If at any time, the count is incorrect, the CMT must notify licensed nursing staff, who will call the Director of Nursing (DON) or designee for instructions. 1. Review of the 100/200 Hall Nurse Narcotic Count log for the controlled substances showed: - For 04/01/24 - 04/30/24, documentation of the narcotic reconciliation completed by staff with 50 out of 60 opportunities missed;…

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 The facility failed to provide appropriate documentation of tuberculosis (TB-an infectious bacterial disease that affects the lungs) testing for four residents (Resident #1, #24, #30 and #42) out of five sampled residents. The facility failed to perform hand hygiene and glove changes during wound care for one (Resident #34) out of two residents and incontinent care for one (Resident #245) out of four residents. The facility failed to develop and implement a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to provide an annually reviewed Infection Prevention and Control Program (IPCP - an antibiotic stewardship log that indicated the name of the infectious pathogen or copies of labs/radiology reports.) The facility's census was 40. Review of the facility's policy titled, Surveillance, undated, showed: - The primary purpose of infection control…

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 consistently document a code status for one resident (Resident #12) out of 12 sampled residents. The facility census was 40. The facility did not provide a policy regarding a resident's code status. 1. Review of Resident #12's medical record showed: - An admission date of [DATE]; - The revised care plan, dated [DATE], showed a Do Not Resuscitate (A DNR instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating). - The face sheet, undated, showed a DNR status; - The Physician's Order Sheet (POS), dated [DATE], showed a full code (if a person's heart stopped beating and/or they stopped breathing, CPR procedures would be provided) status; - A DNR form signed by the resident on [DATE], and signed by the physician on [DATE]; - The resident's Medication Administration Record (MAR) showed a red DNR code sheet. During an interview on [DATE] at 9:34 A.M., Resident #12 said he/she had…

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 safe, clean, comfortable, homelike environment, and failed to clean and/or repair/replace wheelchairs for one sampled resident (Resident #22) and three residents (Resident #6, #9, and #20) outside the sample. The facility's census was 40. Review of the facility's policy titled, Orientation Manual Guidelines, dated May 2006, showed the maintenance manager responsibilities will be: - Supervise the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the environmental manager or the Administrator; - Assure the facility will be maintained in a safe and comfortable manner; - To repair and install drywall including mudding, taping and sanding; - Paint walls; - Assist in setting maintenance standards as well as establishing a preventative maintenance program; - Perform general rough and finish carpentry as well as rough and finish concrete work; - Sweep, mop, and buff…

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 assess the use of a bed and chair alarm (devices that contain sensors that trigger an alarm when they detect a change in pressure) to determine if utilized as restraints and to complete on-going evaluations for the continued need for one resident (Residents #24) out of three sampled residents. The facility census was 40. Review of the facility's policy titled, Nursing Guidelines Manual, undated, showed bed and chair alarm documentation should include: Date and time bed and chair alarm ordered and name and title of person ordering the restraint; Type of restraint; Reason or reasons for the use of the bed and chair alarm and the resident's response; All pertinent observations; Signature and title of person recording the data. 1. Review of Resident #24's medical record showed: - Diagnoses of Alzheimer's Disease (progressive mental deterioration), altered mental status, and osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures); - Required assistance of one staff for toileting; -…

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 update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #22) out of 12 sampled residents. The facility census was 40. Review of the facility's policy titled, Care Plan, Comprehensive, undated, showed: - Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; - A well developed care plan will be oriented to managing risk factors to the extent possible or indicating the limits of such interventions; - Addressing ways to try and preserve and build upon resident strengths; - Evaluating treatment of measurable goals, timetables and outcomes of care; - Use appropriate interdisciplinary approach to care plan development to improve the residents functional abilities; Involve direct care staff with the care planning process relating to the resident's expected outcomes; - The interdisciplinary care plan team is responsible for periodic review and updating of care plans; - When 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, the facility failed to obtain timely urine specimens when a resident had symptoms of a urinary tract infection and failed to notify the physician the urine specimen was not collected, which resulted in an emergency room visit for one resident (Resident #22) out of 12 sampled residents. The facility census was 40. Review of the facility's policy titled, Lab Reporting Guidelines, undated, showed it did not address what to do when lab orders were not completed. 1. Review of Resident #22's medical record showed: - An admission date of 10/16/23; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), dysuria (discomfort when urinating), muscle weakness, repeated falls, and urinary tract infection (UTI); - Nurses notes showed new orders for a urine analysis (UA - a test to check urine for infection) with culture and sensitivity (C&S - a test to find the the germs that cause an infection and find the type of medicine that will treat the infection), dated 03/19/24,…

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

Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was followed for three residents (Resident #6, #36, and #245) and failed to ensure oxygen tubing was dated when changed for two residents (Resident #195, and #245) out of five sampled residents. The facility census was 40. Review of the facility's policy titled, Oxygen Administration, undated showed: - The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; - Prefilled disposable humidifiers may be changed when empty; - Set the flow meter to the rate ordered by the physician; - Label humidifier with date and time opened; - Change humidifier and tubing per cleaning guidelines; - At regular intervals, check and clean the oxygen equipment, masks, tubing and cannulas; - At regular intervals, check the liter flow contents of the oxygen cylinder, fluid level in the humidifier and assess the resident's respiration. 1. Review of Resident #6's medical record showed diagnosis of chronic obstructive pulmonary disease…

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 two Certified Nurse Assistants (CNAs) (CNA G and CNA H) out of two sampled CNAs, received nurse aide performance reviews annually. The facility census was 40. The facility failed to provide a policy regarding annual training. Review of the facility assessment, dated 03/07/24, showed staff competencies and annual training requirements per regulatory authority and/or facility policy to include: Abuse, Neglect, Exploitation and Misappropriation, Care/ Management for persons with dementia, Infection Control, Culture change, Person centered care, Disaster planning, Communication, and Resident rights. 1. Review of CNA G's employee file from 11/08/22 to 11/08/23, showed: - A hire date of 11/08/22; - No documentation of annual performance review. 2. Review of CNA H's employee file from, 09/05/2022 to 09/05/23, showed: - A hire date of 09/05/19; - No documentation of annual performance review. During an interview on 07/15/24 at 5:00 P.M., the Administrator and Assistant Director of Nursing (ADON) said the CNA's should have…

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 limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for two residents (Resident #3 and #33) and the facility also failed to ensure an appropriate diagnosis for the use of a psychotropic medication and to attempt a gradual dose reduction (GDR) for three residents (Resident #5, #31 and #33) out of five sampled residents. The facility census was 40. The facility did not provide a policy on PRN, appropriate diagnoses, and GDR's of psychotropic medications. 1. Review of Resident #3's July 2024 Physicians Order Sheet (POS) showed: - Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hospice services (health care that focuses on the quality of life of a terminally ill person); - An order for lorazepam ( an antianxiety medication) 2 milligram per milliliter (mg/ml) administer 0.5 ml orally…

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 properly monitor the refrigerator temperatures for stored medications, including insulin (medication used to treat diabetes). This had the potential to affect all residents. The facility census was 40. Review of the facility's policy titled, Refrigerator Temperature, undated, showed: - All refrigerators being used for resident medication must be checked daily for temperature; - Task should be completed every night by night shift nurse; - Temperatures will be logged in the temperature log binder located at the nurses station; - This is mandatory and regulation; - Temperature should range between 36 - 42 degrees. If it is not correct, please adjust the temperature and recheck it within your shift. Review on 07/12/24 at 2:47 P.M., of the Refrigerator Temperature Logs for the Nurse Medication Room, the Medication Technician #1 room and the Medication Technician #2 room showed: - For 04/01/24 - 04/30/24, no documentation of the refrigerator temperatures for 04/01/24, 04/07/24, 04/13/24, 04/14/24 and 04/28/24, with five out 30…

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 a written agreement with hospice (health care that focuses on the quality of life of a terminally ill person) for two Residents (Resident #3 and #33) out of eight sampled residents. The facility census was 40. The facility did not provide a policy on hospice services. 1. Review of Resident #3's medical record showed the resident admitted to hospice services on 04/05/24. Review of the resident's hospice care plan, dated 04/05/24, showed the resident admitted to hospice services on 04/05/24. The facility did not provide a hospice agreement with the resident's hospice service provider. 2. Review of Resident #33's medical record showed the resident admitted to hospice services on 03/19/23. Review of the resident's hospice care plan, dated 03/19/23, showed the resident admitted to hospice services on 03/19/23. The facility did not provide a hospice agreement with the resident's hospice service provider. During an interview on 07/15/24 at 5:00 P.M., the Administrator said the facility did one time agreements with…

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 have a Quality Assurance and Performance Improvement (QAPI - a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility census was 40. The facility's policy titled, QAPI Plan, dated, September 2022 showed: - The purpose of our facility's QAPI plan is to take a proactive approach to promote excellence in quality of care, quality of life, resident directed care and resident choice incorporating staff, care partners, and family; - The QAPI program will be developed with governance and leadership; - The governing body ensures staff accountability; - Performance indicators for all QAPI-designated goals will be established; - At a minimum, the leadership will report annually on the status of the current QAPI plan as well as the proposed QAPI plan and goals 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, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a program to improve the processes for the delivery of health care and quality of life for the residents) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies using a Performance Improvement Project (PIP). This had the potential to affect all residents in the facility. The facility census was 40. Review of the facility's policy titled, QAPI Plan, dated September 2022, showed: -The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment; - The QAPI Steering Committee will implement any PIP topics indicated by data analysis; - Quality improvement activities are also developed in collaboration with the support of providers, residents, families, and staff; - PIPs are implemented in accordance with Centers for Medicare and Medicaid (CMS - a government agency) protocols…

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 - a program to improve the processes for the delivery of health care and quality of life for the residents) committee meetings with the required members. The facility census was 40. Review of the facility's policy titled, Quality Assurance and Improvement Plan (QAPI Plan), dated September 2022,showed it did not address the specific members required for the QAPI committee. Review of the QAPI attendance sheets, dated 02/21/24, showed the Director of Nursing (DON) did not attend the QAPI meeting. During an interview on 07/12/24 at 12:55 P.M., the Administrator said the last QAPI meeting was on 02/21/24. The DON did not attend the QAPI meeting because the facility hasn't had a DON since November 2023. The QAPI committee did require the DON to be a required member.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year for two Certified Nurse Assistants (CNA) (CNA G and CNA H) out of two sampled CNAs. The facility's census was 40. The facility did not provide a policy regarding annual training. Review of the facility assessment, dated 03/07/24, showed staff competencies and annual training requirements per regulatory authority and/or facility policy to include: abuse, neglect, exploitation and misappropriation, care/ management for persons with dementia, infection control, culture change, person centered care, disaster planning, communication, and resident rights. 1. Review of CNA G's employee record, dated November 2022 through November 2023, showed: - Hire date of 11/08/22; - No documentation of any annual in-service trainings provided; - The facility failed to provide CNA G with at least twelve hours of in-service education for November 2022 through November 2023. 2. Review of CNA H's employee record, dated September 2022 through September 2023, showed: - Hire…

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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 43. Record review of the facility's Glove Use policy, dated May 2015, showed: - To ensure safe and proper food handling during food preparation and services; - The food code states that food items should not be handled with bare hands; - Hand washing per guidelines should occur between each task; - Gloves should be worn when handling food. Record Review of the facility's Nutrition and Dining Services Guideline Manual, dated April 2011, showed: - The responsibility of the Dining Services Manager will be to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; - Sweep and mop the floors; - Be sure to mop under and around equipment, along walls and in corners; - Dietary floors must be kept in good repair (cracked tiles should be repaired or replaced); - Areas behind and under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The facility's census was 43. Record review of the facility's Orientation Manual Guidelines policy, dated May 2006, showed the maintenance manager responsibilities will be: - Supervise the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the environmental manager or the Administrator; - Assure the facility will be maintained in a safe and comfortable manner; - To repair and install drywall including mudding, taping and sanding; - Paint walls; - Assist in setting maintenance standards as well as establishing a preventative maintenance program; - Perform general rough and finish carpentry as well as rough and finish concrete work; - Sweep, mop, and buff floors; - Clean, disinfect and sanitize bathrooms, kitchens and bedrooms; - 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 maintain quarterly quality assurance assessment (QAA) committee meetings with the required members. The facility's census was 43. Record review showed no documentation the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview on 2/9/23 at 12:33 P.M., the Administrator said she has daily quality assurance (QA) meetings with all of the department heads in the facility, but had not been holding quarterly meetings with the Medical Director (MD) because she cannot get the MD to come to the facility nor get him/her to attend a conference call. The facility did not have wifi capabilities yet, and the MD had told her that he/she refused to come to the facility until the wifi was set up. The corporate office had not provided the wifi service to the facility yet. The facility did not provide a policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program. The facility's census was 43. Record Review of the facility's Nutrition and Dining Services policy, dated April 2011, showed: - The dietary department must be free from vermin at all times; - Food must be properly covered and stored; - The dietary department must be kept free from soil and clutter; - Arrangements will be made by the Administrator for an effective pest control program to provide routine services. Observations of the kitchen on 2/6/23 at 10:23 A.M., showed: - Thirty gnats crawled on the inside shelves of the commercial double door reach-in refrigerator in the middle aisle; - The commercial double door reach-in refrigerator in the middle aisle with bug debris; - The commercial double door reach-in refrigerator near the coffee pot with bug debris inside. Observations of the dry food storage area on 2/6/23 at 10:50 A.M., showed: - Six gnats flew around and crawled on the food…

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 a copy of the notice for transfer or discharge to the resident and or the resident's representative for two residents (Resident #19 and #24) out of two sampled residents. The facility's census was 43. Record review of the facility's Post Discharge Plan of Care policy, dated April 2006, showed: - A post discharge plan of care to be completed prior to the time of the discharge, and to include the resident's needs and referrals, the responsible party's signature and date, and obtained at the time of the discharge; - The social worker maintains the primary responsibility of the discharge plan and coordinates the discharge process; - The charge nurse to complete the remaining sections of the Post-Discharge Plan of Care form and obtains the signature from the responsible party. 1. Record review of Resident #19's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE]; - No documentation of the notification…

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 information to the resident and/or the resident's legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #19 and #24) out of two sampled residents. The facility's census was 43. 1. Record review of Resident #19's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE]; - No documentation with the notification for the bed hold policy provided to the resident and/or the resident's responsible party upon transfer to the hospital. 2. Record review of Resident #24's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], 12/9/22, 1/23/23, and 1/29/23; - No documentation with the notification for the bed hold policy provided to the resident and/or the resident's responsible party upon transfer to the hospital. During an interview on 2/8/23 at 2:12 P.M., the Administrator said she would expect a bed…

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 develop and implement a baseline care plan (plan for immediate needs) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of one resident (Resident #142) out of two sampled residents. The facility census was 43. Record review of the facility's Temporary Care Plan guidelines, dated March 2015, showed: - A temporary care plan will be implemented to meet the new resident's immediate needs; - To assure that the resident's immediate care needs will be met and maintained, a temporary care plan will be implemented for the resident within 24 hours of admission; - The interdisciplinary care plan team (professional staff involved in the resident's overall care) and/or admitting nurse will review the physician 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 completion of the comprehensive…

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 physician orders for one resident (Resident #142) out of 12 sampled residents. The facility census was 43. Record review of the facility's Physician Orders Guidelines, dated March 2015, showed: - Each resident must be under the care of a licensed physician authorized to practice medicine in this state; - Physician's orders must be dated and signed by the physician; - Orders must be written and maintained in chronological order; - Physician orders must be reviewed and renewed; - A Foley catheter (a flexible tube placed into the bladder to drain urine) order should specify the size and the frequency of the change; - Catheter care specifies what will be used according to the facility procedure. 1. Observations of Resident #142 showed: - On 2/6/23 at 11:38 A.M., the resident lay in bed with a Foley catheter collection bag attached to lower side of bedframe; - On 2/8/23 at 11:25 A.M., the resident sat in recliner in his/her room with a Foley catheter collection bag attached to the lower side of bedframe.…

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 closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #39) out of two sampled discharged residents. The facility census was 43. Record review of the facility's Post Discharge Plan of Care policy, dated April 2006, showed: - A post discharge plan of care to be completed prior to the time of the discharge, and to include the resident's needs and referrals, the responsible party's signature and date, and obtained at the time of the discharge; - The social worker maintains the primary responsibility of the discharge plan and coordinates the discharge process; - The charge nurse to complete the remaining sections of the Post-Discharge Plan of Care form and obtains the signature from the responsible party. 1.…

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 closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #39) out of two sampled discharged residents. The facility census was 43. Record review of the facility's Post Discharge Plan of Care policy, dated April 2006, showed: - A post discharge plan of care to be completed prior to the time of the discharge, and to include the resident's needs and referrals, the responsible party's signature and date, and obtained at the time of the discharge; - The social worker maintains the primary responsibility of the discharge plan and coordinates the discharge process; - The charge nurse to complete the remaining sections of the Post-Discharge Plan of Care form and obtains the signature from the responsible party. 1. Record review of Resident #39's closed medical record showed: - The resident discharged to another facility on 11/28/22; - No documentation of a comprehensive discharge summary. During an interview on 2/8/23 at 1:20 P.M., the social worker said the facility did not complete a discharge summary. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was transferred by staff with safe transfer techniques for one resident (Resident #9) out of two sampled residents. The facility census was 43. Record review of the facility's Gait Belt (a device used for assistance with transfers and walking) Transfers policy, undated, showed: - Assist resident to a sitting position; - Apply belt to the resident's waist and tighten to fit snugly with the buckle at the side; - Face the resident; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. Record review of Resident #9's medical record showed: - Resident admitted on [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with 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, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two out of two sampled Certified Nurse Assistants (CNA) (CNA D and E). The facility's census was 43. 1. Record review of CNA D's in-service record showed: - A hire date of 4/10/15; - A total of eight 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. 2. Record review of CNA E's in-service record showed: - A hire date of 12/3/21; - 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. During an interview on 2/8/23 at 4:50 P.M., the Administrator said she knew they provided more in-services to the staff than they could find sign-in sheets for, but the previous Director of Nursing walked out on them and took a lot of documents from her office when she left. She believes that included some 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.