Marymount Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their written policy permitting residents to return to the facility after they have been hospitalized , for one of 9 sampled residents (Resident #1). The census was 80. Review of the facility's Discharge Procedures policy, undated, showed: -Discharge Procedures - The facility shall permit each resident to remain in the facility unless: -The transfer or discharge is appropriate because the resident's welfare and the resident's needs cannot be met by the facility; -The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; -The safety of individuals in the facility is endangered; -The health of individuals in the facility would otherwise be endangered; -The resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility; -Definitions: -Transfer: Moving a resident from…

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 allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This failure has the potential to affect all residents. The facility census was 74. 1. Review of the facility's Warewashing and Storage policy dated January 2019, showed the policy directed staff to allow all washed and sanitized dinnerware, utensils, preparation and service supplies to air dry prior to storage. Observation on 03/27/24 at 9:18 A.M., showed Dietary Aide (DA) V pulled a rack of sanitized plastic cups from the mechanical dishwasher, stacked the cups together while wet and then placed the cups on a service tray on a utility cart. Observation on 03/27/24 from 9:23 A.M. to 9:32 A.M., showed DA W removed two racks of sanitized insulated plate covers from the mechanical dishwasher, stacked the covers together while wet and then placed the covers on the service. Observation showed the DA then removed a rack of sanitized glasses from the dishwasher, stacked the glasses together…

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 perform appropriate hand hygiene, and glove changes during incontinence care for three (Resident #48, #65, and #37) out of three sampled residents. Facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two residents (Resident #67 and #30) out of three sampled residents to prevent the spread of infection causing contaminants. The facility census was 74. 1. Review of the facility's policy titled, Hand Washing/Use of Gloves Policy and Procedure, undated, showed the purpose of this procedure is to provide guideline to employees for proper and appropriate hand washing techniques that will aid in the prevention of transmission of infections.To prevent the spread of infectious disease, when to wash/sanitize hands: -After handling used dressings, specimen containers, contaminated tissues, linen, etc.; -After contact with blood, body fluids, secretions, mucous membranes, 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 implement an Antibiotic Stewardship Program with 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 74. 1. Review of the facility's policy titled, Antibiotic Stewardship, undated,showed as a facility, the facility will do the following to improve antibiotic use: -Review and monitor for trending during weekly risk meeting; -Commit resources for monitoring antibiotic use and providing feedback to staff; -Develop facility-specific standards for empiric antibiotic use, based on data from the facility; -Review antibiotic appropriateness and resistance patterns on a regular basis. Review of the facility's antibiotic stewardship program showed facility staff did not track antibiotic trends. During an interview on 03/28/24 at 10:45 A.M., the Assistant Director of Nursing (ADON) said they track antibiotics through a report generated by their electronic medical record (EMR). He/She said he/she looks at 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, interviews, and record reviews, facility staff failed to provide reasonable accommodation of needs for one resident (Resident #53) to ensure the water cup was obtainable and in reach, so the resident could drink independently and failed to ensure acceptable table heights to encourage meal independence for two residents (Resident #68 and #37) out of 18 sampled residents. The facility census was 74. 1. Review of the facility's policies showed staff did not provide a policy for accommodation of needs. 2. Review of Resident #53's quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with only set up help needed for meals; -Residents ability to stand or walk, not attempted due to medical condition or safety concern; -No impairment to upper extremity. Review of the residents care plan, last reviewed and updated 02/19/24, directed staff as follows: -Monitor oral intake of food and fluid; -Provide necessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms and the memory care unit common areas. Facility census was 74. 1. Review of the facility's policy titled, Maintenance Service, dated 12/19, showed staff were directed to do the following: -Maintenance services shall be provided to all areas of the building, grounds, and equipment; -Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards; -Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #38, #44, #63 and #78) out of 24 sampled residents. The facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for comprehensive care plans. 2. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/17/24, showed staff assessed the resident as: -Cognitively intact; -Somewhat important to have books, newspapers and magazines to read, to do things with groups of people, and do favorite activities; -Very important to listen to music he/she likes, to be around animals such as pets and get outside to get fresh air when the weather is good; -Not very important to keep up with the news or particpate in religious services or practices. Review of the resident's care plan, dated 01/23/24, showed the resident will take part in preferred activities pursuits through…

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 revise the plan of care with changes in the resident's care needs for four residents (Residents #47, #56, #78, and #79) of 18 sampled residents. The facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for comprehensive care plans. 2. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/17/24, showed staff assessed the resident as: -Severe cognitive impairment; -Did not contain documentation of bed rail use; -Required supervison or touching assistance from staff with rolling left to right; -Required partial to moderate assistance from staff with moving from sitting on side of the bed to lying flat on the bed; move from a lying on the back to sitting on the side of the bed with feet flat on the floor and with no back support; and to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Review 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 observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends and staff failed to provide an ongoing program of activities designed to meet the residents' interests for residents who reside on the memory care unit. This had the potential to affect all residents. The facility census was 74. 1. Review of the facility's policy titled, Activity Department, dated 08/17/21, showed staff were directed to do the following: -The facility takes a holistic approach to the care of all its residents. In order to have this approach, the facility maintains an Activity Department for it's residents. The facility provides, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the resident environment remained as free of accident hazards four resident's (#37, #47, #54 and #66) out of eleven sampled resident's when staff failed to apply the residents foot pedals to prevent accidents and propelled the residents in his/her wheelchair. The facility census was 74. 1. Review of the facility's policy titled, Wheelchair Safety, undated, showed staff were directed as follows: -It is often the responsibility of the facility staff to assist a resident from point A to point B via wheelchair/[NAME]-walker/pedal broda throughout the facility. It is utmost importance that facility staff assist with propelling the resident in the safest manner possible; -At no time should a resident be propelled by anyone while their feet are dragging on the floor. Foot pedals should be added to the resident's wheelchair to allow their feet to be elevated during transport; -In the event a resident is fatigued or for any reason unable…

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 complete entrapment assessments, review risk and benefits, side rail assessment and/or obtain consent for the use of bed rails for four (Resident #37 #47, #56, and #79) out of four sampled residents. The facility census was 74. 1. Review of the facility's Bed Safety and Bed Rails policy, dated June 2018, showed: -Assess the residents for risk of entrapment from bed rails prior to installation; -Review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation; -Ensure that the beds dimensions are appropriate for the resident's size and weight; -Following the manufacturers recommendations and specifications for installing and maintaining bed rails; -With installation, confirm bed rails are appropriate for the size and weight of resident, regularly check for areas of possible entrapment, and check beds regularly to make sure they are installed correctly as rails may…

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

Based on interview and record review, facility staff failed to ensure three Nurse Aide's ((NA) NA A, NA B and NA C) completed the nurse aide training program within four months of his/her employment in the facility. The census was 74. 1. Review of the facility's Nursing Assistant Facility Requirements policy, undated, showed individuals must successfully complete a nursing assistant training program approved by the department or shall enroll in and begin the first available approved training program which is scheduled to commence within (90) days of the date of the CNAs employment and which shall be completed within four (4) months of employment. 2. Review of NA A's Certified Nurse Aide (CNA) training report, showed a hire date of 09/06/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 3/28/24 at 1:37 P.M., the Director of nursing (DON) said he/she was told the NA had not started the program yet due to a conflict with his/her school schedule. During an interview on 3/28/24 at 3:10 P.M., the Corporate…

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 store and label medications in a safe an effective manner when staff did not date the opened medication in the medication cart and staff placed nonmedication in medication strorage room refrigerator. This had the potential to affect all residents. The facility census was 74. 1. Review of the facility's policy titled, Storage of Medication, dated 2022, showed staff were directed to do the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location; -Medications must be stored separately from food and must be labeled accordingly;…

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 resident's personal privacy was protected, when they left the Medication Administration Records (MAR) open and unattended in a public hallway. Facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for privacy during medication pass. 2. Observation on 03/25/2024 at 11:40 A.M., showed Licensed Practical Nurse (LPN) M left the MAR open and unattended with resident information exposed. Observation showed staff and residents walked past the cart. 3. Observation on 03/27/24 at 11:07 A.M., showed Registered Nurse (RN) E left the MAR open and unattended with resident information exposed. Observation showed staff and residents walked past the cart. During an interview on 03/27/24 at 12:03 P.M., RN E said that the computer screen should be shut off when walking away from the cart and not exposing resident information. 4. Observation on 03/27/24 at 11:33 A.M., showed Certified Medication Tech (CMT) D left the MAR open and unattended with resident information exposed.…

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 notice to residents or the resident's representatives regarding resident transfers to the hospital for three (Resident #15, #54 and #73) out of three sampled residents. The facility census was 74. 1. Review of the facility's Discharge/Transfer Policy, undated, showed the written notice should include: -The reason for the transfer or discharge; -The effective date of transfer or discharge; -The resident's right to appeal the transfer or discharge to the director of the Department of Health and Senior Services hearing official withing thirty days of receipt of the notice; -The address to which the request for a hearing should be sent to Administrative Hearings Unit; -That filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; -The location to which the resident is being transferred or discharged ; -The name, address, and telephone number of the designated…

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, record review and interview, facility staff failed to ensure staff provided three dependent residents (Resident #44, #63 and #78) out of 24 sampled, that were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain adequate grooming. The facility census was 74. 1. Review of the facility's policy titled, Activity of Daily Living (ADL), dated 08/17/17, showed it is the standard of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the upmost independence. In order to adhere to this standard, it is the policy that any resident that is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review showed: -Assistance with ADLs cannot be performed independently by the resident. The level of assistance with ADLs provided by staff are based on the resident's ability to maintain highest…

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

Based on observation, interview, and record review, the facility failed to ensure the alarm on the fire egress doors on the memory care unit were monitored while inoperable. One resident was observed to attempt to exit out the egress door (Resident #7) and one additional resident was identified as risk for elopement (Resident #6). The facility did not have designated staff monitoring the egress doors. The memory unit census was 24. 1. Review of the facility's Resident Services Policy (RSP) policy, provided as the staffing policy, dated 3/27/17, showed: -Resident Services: The facility will provide services by sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans; -Staffing levels in each department may vary depending on the census and individual resident needs. During an interview on 12/14/23 at 3:09 P.M., the Maintenance supervisor said he noticed on 12/13/23 at approximately 4:00 P.M., the wall scones on the memory care unit were not working…

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 appropriate staffing to meet the needs of the residents, when residents scheduled to receive showers on the memory unit and the 200 hallways did not receive the scheduled showers. The sample was 7. The census was 85. Review of the facility's Resident Services Policy (RSP) policy, provided as the staffing policy, dated 3/27/17, showed: -Resident Services: The facility will provide services by sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans; -Employment, advertising and incentives: the facility will advertise employment needs in various social media and new outlets. A staffing committee reviews staffing needs on a weekly basis and updates advertisements as needed; -The facility provides sufficient licensed nursing and ancillary services 24 hours a day, including a registered nurse for at least 8 consecutive hours a day; -Staffing levels in each department may vary depending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL, bathing dressing, toileting) received the necessary services to maintain adequate personal hygiene by not providing showers for six residents (Resident #6, #2, #4, #3, #5 and #1). The sample was eight. The census was 81. Review of the facility's ADL policy, dated 8/17/17, showed: -It is the standard, of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the upmost independence. In order to adhere to this standard, it is the policy that any resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; -Assistance with ADLs will be performed if the ADLs cannot be performed independently by the resident. The level of assistance with ADLs provided by staff are based on the resident's ability to maintain highest…

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

Based on observation, interviews and record review facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination and failed to store food in a manner to prevent cross-contamination, spoilage and out-dated use. Facility staff also failed to maintain the kitchen's physical environment and equipment in a sanitary condition. The facility census was 83. 1. Review of facility's undated policy on Food Service Handwashing showed hands will be washed before serving food, after collecting soiled dishes/food waste, prior to handling food trays, and any time hands become visibly soiled. Observation on 9/27/22 at 10:10 A.M., showed Dietary Aide (DA) Y placed soiled dishes on the dirty side of the mechanical dishwasher, removed clean dishes from a dishwasher rack and placed dishes on a cart. Observation showed the DA did not perform hand hygiene after he/she touched the soiled dishes or before he/she touched the clean dishes. Observation on 9/27/22 at 10:24 A.M., showed DA AA washed his/her hands and dried them with a paper towel. He/She then used the same…

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 resident and staff interview and record review, facility staff failed to notify seven sampled residents (Resident #3, #19, #27, #28, #39, #45 and #76) in a timely manner about the spend down plan for balances in excess of the Medicaid threshold. The facility census was 83. 1. Review of the facility's Policy and Procedure for Residents Funds Letter, revised 7/1/22 showed the facility bookkeeper will send out a letter to the resident or resident representative anytime a resident's trust fund balance is over five-thousand dollars. Review also showed, phone calls can be used as a supplement but not a substitute for the letter. 2. Review of facility Trust Fund Balance reports from January 2022 through September 2022 showed the following residents with balances that remained above $5,101.85 which is within $200 of the Medicaid eligibility absolute limit of $5,301.85: -Resident #3's trust fund balance remained above the eligibility limit in all months since January 2022; -Resident #19's trust fund balance remained above the eligibility limit in all months since January 2022;…

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 staff interview and record review, facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check prior to start date for four out of 8 sampled employees. The facility census was 83. 1. Review of the facility's Abuse, neglect, exploitation or mistreatment policy, undated, showed: -This facility will not knowingly employ an individual convicted of resident abuse or misappropriation of resident property; -The facility will not knowingly employ any direct care staff convicted of any of the crimes listed in the healthcare worker background check act, or with findings of abuse, neglect or exploitation listed on the nurse aide registry; -Prior to a new employee starting a work schedule, this facility will check the nurse aid registry on any individual hired. 2. Review of Certified Nurse Aide's (CNA) personnel record showed: -Hire date of 6/28/22; -The file did not contain documentation staff completed the NA Registry…

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 person-centered, measurable time frames to meet the residents' individual needs and goals identified in the comprehensive care plans for ten (Resident #26, #47, #50, #53,#55, #65,#73, #78, #336, and #337) out of 18 sampled residents. The facility census was 83. 1. The facility did not provide a care plan policy. 2. Review of Resident #26's comprehensive care plan, dated 8/21/22, showed the record did not contain measurable time frames to address the residents' individual care area problems, goals and/or how staff are to assist the resident to meet the goals. 3. Review of Resident #47's comprehensive care plan, dated 7/27/22, showed the record did not contain measurable time frames to address the resident's care area problems. 4. Review of Resident #50's comprehensive care plan, last reviewed 9/27/22, showed the record did not contain measurable time frames to address the resident's care area problems. 5. Review of Resident #53's comprehensive care plan, dated 7/25/22, showed the record did not contain measurable…

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, resident and staff interview, and record review, facility staff failed to provide appropriate personal hygiene care for five residents (Resident #25, #51, #56, and #58) out of 18 sampled residents. The facility census was 83. 1. Review of the facility's bathing policy, undated, showed shower staff are directed as follows: -Residents will remain clean, dry, and free of odors; -A shower/bathing schedule will be maintained at each nursing station to reflect day/shift for each shower assigned; -Accommodations will be made for requested days/time; -Certified nurse assistants will complete a visual assessment of a resident a report any abnormal findings; -A charge nurse will do a skin assessment and report of abnormal findings; -Shower schedules will be reviewed by clinical mangers to ensure necessary steps have been taken. 2. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/9/22, showed staff assessed the resident as: -Required extensive,…

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 have a system in place to monitor residents on the memory care unit (MCU), with a history of wandering, from exiting the facility unnoticed. Staff removed the wander alert system (alarm used to notify staff if a resident tries to exit the facility) and unlocked an exit door residents had access to. Additionally, staff failed to ensure residents on the memory care unit remained free of accident hazards when they did not to remove a disposable razor from Resident #16's room. Further, facility staff failed to properly propel nine residents (Resident #333, #26, #47, #35, #37, #68, #21, #40 and #14) in their wheelchair, and provide care to one (Resident #9) in a manner to prevent accidents. The facility census was 83. 1. Review of the facility's Resident Elopement Prevention/Precautions and Missing Resident, revised 12/15/13, showed: -All resident with a history of wandering, based upon family or caregiver history and all resident with potential to elope, will have wrist or ankle signaling device implemented 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 staff interview and record review, facility staff failed to ensure the attending physician and the Family Nurse Practitioner (FNP) saw nine of eighteen sampled residents (Residents #26, #47, #50, #53, #55, #65, #73, #78, and #337) every thirty days for the first ninety days, then every sixty days after that. Facility staff also failed to ensure the physician documented his/her notes regarding their visit/examination of the residents. This could lead to residents not receiving timely assessments and the appropriate care by a qualified provider. The facility census was 83. 1. Review of the facility's Physician Services policy, revised 01/12/14, showed the following: - Upon admission, a history and physical examination shall be performed within seven days unless performed within thirty days prior to admission; - Residents requiring skilled level of care will be seen by the attending physician at least every thirty days; - The resident's total program of care (including medications and treatments) shall 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.

Based on observation, staff interview, and record review, facility staff failed to store and label medication in a safe and effective manor in one of two medication storage rooms and in one of two medication storage carts. The facility census was 83. 1. Review of the facility's Medication Storage and Labeling Policy, dated revised 2/22/22, showed staff were directed: -Expiration dates must be checked prior to administration; -Expired medications are removed from the area of care immediately, and disposed of according to facility medication disposal policy, per state and federal guidelines. 2. Observation on 9/29/22 at 10:56 A.M., showed the medication storage room on the 300 hall contained: -One 200 tablet bottle of women's multivitamin with and an expiration date of 6/22; -One 100 tablet bottle of oyster shell calcium 250 milligram (mg) with an expiration date of 1/22. Observation on 9/29/22 at 11:05 A.M., showed the medication cart on the 300 hall contained: -One loose clear capsule with florastar 250 mg printed on it; -One loose white tablet with 439 stamped into it; -One loose…

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

Based on observation, interviews, and record reviews facility staff failed to properly maintain the temperature of hot foods at or above 120 Degrees Fahrenheit (°F) and cold foods at or below 41° F for six residents (Resident #25, #51, #73, #67, #66, and #336) at the time of meal service. Facility staff failed to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents. Further, staff failed to prepare food in a palatable manner. The facility census was 83. 1. Review of the facility's policy Meal Service Temperatures, dated revised January, 2020, showed staff were directed as follows: - meals temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees; - temperatures shall be taken and may be recorded on the food temperature record; - food which does not meet the appropriate temperatures shall be removed and reheated or rechilled prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for three residents (Residents #3, #6, and #331). Additionally the facility failed to change, date and bag respiratory equipment for one resident (Resident #38). The facility census was 83. 1. Review of the facility's Hand Washing policy, revised 12/22/13, showed it directed staff to wash their hands whenever they are soiled with body substances, before performing invasive procedures, and when each resident's care is completed. Review of the Hand Washing Inservice and Competency handouts, held 7/22/22 through 8/10/22, showed the following: -Gloves do not take the place of hand washing; -Wash/sanitize hands after contact with blood, body fluids, secretions, mucous membranes, or broken skin; -Wash/sanitize hands after removing gloves; -Whenever in doubt, wash your hands. Review of the facility's Peri-Care policy, dated 1/25/17, directs staff 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.