Pillars Of North County Health & Rehab Center, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure a comprehensive Care Plan was developed for two of 25 sampled residents (Resident (R) 111 and R27) to address R111's pain and R27's dependence on staff for activities of daily living (ADLs). These failures had the potential to contribute to inadequate or inappropriate pain intervention for R111 and lack of provision of ADL care for R27. Findings include: Review of the facility policy titled, Resident Assessment Instrument, dated November 2017, revealed, Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning .Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. 1. Review of R111's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted to the facility on [DATE] with diagnoses including arthritis, pain in the left…

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 observations and interviews, the facility failed to ensure nail care was provided for one of 22 sample residents (Resident (R) 34) reviewed for activities of daily living (ADL). This failure had the potential to cause R34 to have unmet care needs. Findings include: Review of R34's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed R34 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, and epilepsy. Review of R34's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/25 and located under the RAI (Resident Assessment Instrument) tab, reveal R34 has a Brief Interview for Mental Status (BIMS) of 12 out of 15 which indicated R34 was moderately cognitively impaired. Review of R34's Care Plan located in the EMR under the Care Plan tab and last revised 02/27/25,…

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 observations, interviews, and record review, the facility failed to ensure one of 22 sample residents (Resident (R) 55) reviewed for appointments had scheduled physician's appointments. The failure increased R55's risk of delayed medical care. Findings include: Review of R55's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including, quadriplegia, C5-C7 incomplete, depression, and hypertension. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/24, located under the MDS 3.0 Resident Assessments tab of the EMR, revealed a Brief Interview for Mental Status (BIMS)' score of 14 out of 15 which indicated he was cognitively intact. During an observation and interview on 03/20/25 at 4:00 PM, R55 stated he had an appointment that he was unaware he had and at the last minute he was notified so needed to get ready. R55 pointed to white board on wall that had his appointments written on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure one of three residents (Resident (R) 32) reviewed for dialysis received as-needed medication as ordered and her physician was notified when a dialysis appointment was missed of 22 sample residents. These failures had the potential to cause significant risks, including increased mortality, hospitalization, and cardiovascular complications, due to the buildup of toxins and fluids in the body. Findings include: Review of the facility policy titled, Care of a Resident with End-Stage Renal Disease, dated November 2017, revealed Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. The policy did not address procedures for missed dialysis appointments. Review of R32's Face Sheet located under the Face…

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, record review, and policy review, the facility failed to ensure one of one resident (Resident (R) 14) reviewed for dental was provided with a visit to the dentist as ordered by the physician to address a mouth infection of 22 sample residents. This failure had the potential to lead to spread of infection, increased pain, and difficulty eating for R14. Findings include: Review of the facility's policy titled, Dental Examination/Assessment, dated July 2014, revealed 1. Prior to, or within ninety (90) days after admission, the resident shall undergo a dental examination. 2. Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist. 3. Records of dental care provided shall be made a part of the resident's medical record. 4. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of R14's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR)…

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, record review, and policy review, the facility failed to ensure three of 22 sample residents (Resident (R) 2, R32, and R7) had accurate physician's orders. These failures had the potential to affect provision of hospice services for R2, provision of dialysis and communication with the dialysis center for R32, and provision of restorative services for R7. Findings include: Review of the facility's policy titled, Obtaining and Following Physician Orders, dated July 2014, revealed Physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified. Procedure: 1. Physician orders may be obtained by: a. The physician visiting and writing the order. b. The physician visiting 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 observations, interviews, record review, and policy review, the facility failed to ensure staff donned (put on) appropriate personal protective equipment (PPE) for three of five residents (Resident (R) 43, R61, and R262) reviewed for use of Enhanced Barrier Precautions of 22 sample residents. These failures had the potential to cause the spread of infection from staff to other residents. Findings include: Review of the facility's policy titled, Isolation Precautions/Enhanced Barrier Precaution (EBP), dated 04/01/24, revealed Enhanced Barrier Precautions is [sic] used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing .EBP will be used for any resident who meets the following criteria: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure two of five residents (Resident (R) 164 and R61) reviewed for vaccinations, who consented to receive vaccinations, were administered the vaccines of 22 sample residents. These failures had the potential to cause avoidable spread of pneumonia or influenza. Findings include: Review of the facility's policy titled, Infection Control, dated July 2017, revealed Residents and employees are offered the influenza vaccine annually between October and March. The pneumococcal vaccine is offered to all residents at the time of admission and throughout their stay as per current standards of practice. 1. Review of R164's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed she admitted to the facility on [DATE] with diagnoses including dementia and right lower leg fracture. Review of R164's Pneumococcal Vaccine Consent and Release, dated 02/03/25 and provided by the facility, revealed she consented 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 interview and record review, the facility failed to monitor a full code resident who was diagnosed with COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), in accordance with their policy (Resident #1). The facility did not document assessments of symptoms, vital signs, oxygen saturation levels and respiratory symptoms. The sample was four. The census was 57. Review of the facility's Change in Condition Policy, dated February 2012, showed the following: -Policy: It is the policy of the facility that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner; -Definition: -Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects less than two areas of activities of daily living; -Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects two or more areas of activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See Event ID 8DC412. Based on observation, interview and record review, facility staff failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were within reach for four sampled residents (Residents #204, #18, 406 and #405) with mobility limitations, and by failing to ensure a call light was installed at the bedside for one resident (Resident #407). The census was 58. Review of the facility's Answering the Call Light policy, revised July 2014, showed: -Policy: The purpose of this procedure is to respond to the resident's requests and needs; -General guidelines, included: --Be sure that the call light is plugged in at all times; --When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. Review of Resident #204's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/9/23, showed: -Moderate cognitive impairment; -Upper and lower extremity…

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 services provided met professional standards of practice by not following the physician orders to hold one resident's (Resident #400) Eliquis (a blood thinner) three days prior to his/her surgical procedure. This resulted in the resident's urological procedure being canceled and rescheduled for two weeks later. The facility also failed to ensure a specialist's recommendation for nothing by mouth (NPO) was communicated to the physician and followed for one resident with a swallowing disorder (Resident #204). The sample was 11. The census was 58. Review of the facility's Obtaining and Following Physician Orders policy, revised 2014, showed: Policy: It is the policy that physician orders will be obtained by licensed personnel and followed. If the licensed professional does in his/her best judgment think that to the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling…

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 general accounting principles were followed for an accurate accounting of all monies, by failing to research outstanding checks and failing to reconcile the resident petty cash. The facility also failed to obtain documentation one resident or his/her responsible party were notified before using his/her funds to purchase personal items for the resident (Resident #4). In addition, the facility also failed to ensure the resident personal resident trust fund (RTF) account was not overdrawn (Resident #25). This affected residents whose funds were managed by the facility. The census was 55. Review of the facility's Resident Rights packet, undated, showed: -The resident has the right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds; -If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as fiduciary of the resident's funds and…

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

Based on interview and record review, the facility imposed a charge for a service for which payment was made under Medicaid for two residents (Resident #36 and #4) out of a sample of 3. The facility census was 55. Record review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed the following: -13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following: -(K) All routine care items, including disposables and including, but not limited to, those items specified in Appendix A to this rule; -Record review of Appendix A showed the following items covered under the per…

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 newly hired employees were screened to determine the presence of a federal indicator with the Nurse Aide Registry (NA) check for three of 10 sampled employees hired since the last survey. The facility hired at least 290 new employees since the last survey. The census was 55. Review of the facility's Abuse Prevention Program policy, revised 9/29/22, showed: -Procedures for Prevention; -Pre-employment Screening of Potential Employees; -The facility will not knowingly employ any individual convicted of resident abuse, neglect or misappropriation of property. The facility will not knowingly employ any direct care staff with findings of abuse listed on the Health Care Worker Registry. Prior to a new employee starting a working schedule, the facility will: -Obtain a copy of the state license of any individual being hired for a position requiring a professional license; -Check the Health Care Worker Registry on any individual hired prior to reports of abuse, previous fingerprint check results, and the sex offender website…

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 side rails were accurately assessed as a necessary device prior to installation and use. The facility also failed to obtain physician's orders for the use of side rails and failed to document usage in the resident's care plan for four (Residents #10, #47, #41 and #17) of 14 sampled residents. The census was 55. Review of the facility's Bed Rail Maintenance and Installation and Entrapment Prevention policy, revised December 2016, showed: -Purpose: To diminish the potential for and severity of adverse events related to bed rail usage and compatibility of bed rails, mattresses and bed frames; -Procedure; -Center will follow manufacturer's recommendations and specifications for installing and maintaining bed rails; -The maintenance department will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment; -Inspections will occur at least semi-annually and results will be documented…

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 laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they failed to perform quality control checks of the blood glucose (sugar) test machines to ensure accurate results. The census was 55. Review of the Evencare G3 Blood Glucose Monitoring System User's Guide, Copyright 2016, showed the purpose of the control solution testing is to validate that the EVENCARE G3 Meter is working properly with the test strips. Control solutions are not included in the kit; -You should perform a control solution test when: -Using the meter for the first time; -Using a new package of EVENCARE G3 Blood Glucose Test Strips; -At least once per week to verify that the meter and test strips are working properly together; -For vial strips, if the test strip bottle is left open; -The meter is dropped; -You suspect the meter and test strips are not working properly together; -A patient's test results do not agree with how they feel; -A patient's readings appear to 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, interview and record review, the facility failed to follow recipes to ensure adequate nutritive value, taste and texture for pureed foods (a very smooth blended food like applesauce or mashed potatoes) for three out of four observations. This deficient practice affected the four residents who ate pureed meals at the facility. The census was 55. Review of the facility's breakfast menu, dated 10/27/23, showed breakfast consisted of choice of cereal, eggs and sausage strata, wheat toast, margarine, juice, milk, coffee or tea. Observation on 10/27/23 at 7:33 A.M., showed [NAME] I prepared puree sausage for three residents. He/She added 6 sausage patties to the blender and one and one half cups of tap water to the blender and blended the mixture for approximately one minute and a half. He/She poured the mixture into a pan for serving. The sausage was runny, watery and choppy. Review of the facility's recipe for 25 servings of pureed sausage, showed: -25 sausage patties; -One and one fourth cups of water; -One and one fourth teaspoons of ham base concentrate; -Three…

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 and interview, the facility failed to label, date and properly store opened food items and failed to maintain cleanliness in the freezer and refrigerator for four of five days of observations. In addition, the facility failed to discard expired food items and properly store dry foods. This deficient practice had the potential to affect all residents who ate at the facility. The census was 55. 1. Observations of the walk-in freezer on 10/25/23 at 9:38 A.M., 10/26/23 at 10:13 A.M., 10/27/23 at 6:25 A.M. and 10/30/23 at 7:19 A.M., showed: -An opened bag of frozen hamburger patties in a box. The box was opened and the bag was also opened, with the meat patties exposed; -Three unidentified brown patties in a bag, not labeled or dated; -A bag of what appeared to be carrots, not labeled or dated. The bag was opened and the contents were exposed; -White specs all throughout the freezer floor; -A cup of ice cream on the floor, under a shelf in the freezer; -A dirty paper towel or napkin on the floor, under the shelf in the corner of the freezer. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to four out of five residents sampled for immunizations review (Residents #41, #23, #10 and #47). The census was 55. Review of the facility's Infection Prevention and Control Program Policies and Procedures, revision October 10, 2023, showed: -Immunization and vaccination, general statement: The organization receives one time consent from residents/patients for vaccines, as recommended by Center for Disease Control (CDC) and Prevention guidelines: pneumococcal; -These are standing orders for pneumococcal for all residents/patients; -Pneumococcal vaccination are offered to all residents/patients per CDC guideline and applicable regulation. 1. Review of Resident #41's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/25/23, showed: -admitted : 7/28/22; -Is the pneumococcal vaccine up to date? Yes. Review of the resident's electronic medical…

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 staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment, for four of 14 sampled residents (Residents #10, #47, #41 and #17). The census was 55. Review of the facility's Bed Rail Maintenance and Installation and Entrapment Prevention policy, revised December 2016, showed: -Purpose: To diminish the potential for and severity of adverse events related to bed rail usage and compatibility of bed rails, mattresses and bed frames; -Procedure; -Center will follow manufacturer's recommendations and specifications for installing and maintaining bed rails; -The maintenance department will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment; -Inspections will occur at least semi-annually and results will be documented on the Equipment and Device Safety Log. 1. Review of Resident…

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 services provided met professional standards of practice by not following the physician orders to hold one resident's (Resident #400) Eliquis (a blood thinner) three days prior to his/her surgical procedure. This resulted in the resident's urological procedure being canceled and rescheduled for two weeks later. The facility also failed to ensure a specialist's recommendation for nothing by mouth (NPO) was communicated to the physician and followed for one resident with a swallowing disorder (Resident #204). The sample was 11. The census was 58. Review of the facility's Obtaining and Following Physician Orders policy, revised 2014, showed: Policy: It is the policy that physician orders will be obtained by licensed personnel and followed. If the licensed professional does in his/her best judgment think that to the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who discharged to the community had a recapitulation of stay, final summary of status, reconciliation of all pre and post discharge medications and a post discharge plan of care for one of three residents selected for a closed record review (Resident #53). The census was 55. Review of Resident #53's medical record, showed the resident admitted to the facility on [DATE] and discharged on 8/6/23. Review of the resident's progress notes, showed: -On 8/4/23 at 8:31 A.M., the Director of Social Services (DSS) spoke with the resident's family member to follow up on discharge planning. The family member is still planning on taking the resident home upon discharge. DSS and the family member discussed arranging a home health aide to help the family upon the resident's return to home; -On 8/6/23 at 9:26 A.M., discharged home with family. Alert to person, place and time with no signs of pain. Took face sheet and medication list, medications and…

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

Based on observation, interview and record review, the facility failed to transcribed one resident's treatment order onto the Medication Administration Record (MAR), which resulted in the treatment not being provided for three days (Resident #204). The sample was 14. The census was 55. Review of the facility's Wound Care Program, dated revision July 2014, showed: - In developing a comprehensive treatment plan for wounds, the clinician should assess not just the wound, but the whole person. The factors affecting the ability of the wound to close and ultimately heal need to be included in the overall treatment plan; -Provide for heel pressure relief by placing a pillow under the calves to completely off weight heels. -Suspected Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect…

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 smoking assessments were completed in a timely manner for two of 24 sampled residents (Residents #10 and #40). The census was 55. Review of the facility's Smoking Policy and Procedure, dated 10/21/22, showed: -Purpose: To assure that all residents are safe while smoking; -Procedure; -Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision that will be needed to ensure the resident's safety. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/23, showed: -Cognitively intact; -Current tobacco use: was blank; -Diagnoses included high blood pressure, end stage renal disease (ESRD, chronic irreversible kidney failure) and diabetes. Review of the care plan, in use at the time of survey, showed: -Problem:…

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 one resident (Resident #41) who received tube feeding (supplies liquid nutrition) through a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received the appropriate treatment and services when staff provided care with the resident laying flat while tube feeding formula infused and when staff failed to know how to operate or trouble shoot the tube feeding pump. The sample size was 14. The census was 55. Review of the monitoring Enteral Feeding-Tube policy, revised July 2014, showed: -Policy; -It is the policy of the facility that Enteral Feeding-Tubes will be monitored to ensure that feedings are delivered per physician's orders; -Procedure; -Maintain the head of the resident's bed at a minimum of 30 degrees elevation; -Enteral Feeding-Tubes are to be checked at the start of each shift to ensure that the flow rate is correct; -Enteral Feeding-Tubes are also to be checked periodically 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 32 opportunities observed, two errors occurred resulting in a 6.25% error rate (Residents #25 and #39). The census was 55. Review of the facility's Administration Medication policy, dated June 2020, included: -Policy: To administer all medications safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms, and help in diagnosis; -Procedure: -Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the medication; -Review the resident's Medication Administration Record (MAR). Read each order entirely; -If there is any discrepancy between the MAR and the label, check physician orders before administering medication; 1. Review of Resident #25's physician order sheets (POS), dated 10/1/23 through 10/31/23, showed: -An order, dated 4/15/22, for acetaminophen (medication used to treat elevated temperature/pain) 325 milligrams (mg), give two tabs by mouth, three times a day; -An order, dated…

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

Based on observation, interview and record review, the facility failed to store drugs and biologicals in accordance with State and Federal laws, when controlled medications were not stored in double locked compartments in the medication room refrigerator. In addition, the refrigerator had an undated vial of influenza vaccine that was half empty and a container of applesauce in the refrigerator. The facility did not complete refrigerator temperature checks per facility policy. These deficient practices affected one out of one medications rooms reviewed. The census was 55. Review of the medication storage in the facility policy, dated June 2020, included: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Procedure: -All drugs classified as Schedule II of the Controlled Substance Act will be stored under double locks. Schedule III-V medications…

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 admission policy did not require residents to waive potential facility liability for losses of personal property. This had the potential to affect all residents admitted to the facility. The census was 55. Review of the facility's undated admission agreement contract, showed the following: -The resident acknowledges receipt of the written items identified in the Supplement A: Required Consents and Notifications Index; -All items identified and checked in Supplement A: Required Consents and Notification are incorporated into this contract. The resident will abide by all rules and regulations of the facility and will cooperate in the carrying out of the resident's Plan of Care; -The facility is not responsible for money, valuables, or personal effects of the resident unless delivered to the Administrator for safekeeping. During an interview on 10/6/20 at 12:00 P.M., the administrator said she was not aware the facility's admission policy required residents to waive facility liability for loss of personal affects.

Based on observation, interview and record review, the facility failed to ensure adequate staffing to provide consistent resident care for activities of daily living and restorative therapy. The census was 55. During an interview on 9/29/20 at 10:37 A.M., the administrator said the facility utilized agency staff due to a lack of facility staff. The facility has raised their starting salaries to the highest in the area and are hopeful they will be able to hire enough staff where they will no longer need agency staff. During the survey process, the survey team identified problems with residents receiving their showers and restorative therapy services as scheduled due to staffing shortages. During an interview on 10/5/20 at 10:06 A.M., Certified Nursing Assistant (CNA) I said it is not uncommon for there to be too many residents, 12 to 14, for one CNA to care for on day shift, and it happens frequently. CNAs are expected to give the showers, keep residents clean, dry and turned and repositioned, clean resident rooms, and feed the residents. When they have 12 to 14 residents, something…

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 the monthly pharmacist recommendations were being forwarded to physicians for their review and response. Of the 14 sampled residents, eight had pharmacy recommendations that were not forwarded to physicians for review (Residents #37, #44, #52, #57, #15, #32, #50 and #18). In addition, the facility failed to forward any of the pharmacist recommendations for physician review since April 2020. The census was 55. Review of the facility Drug Regimen Review policy, revised on 10/2017, showed: Purpose: -The intent of this requirement is that the facility maintains the resident's highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing a licensed pharmacist's review of each resident's regimen of medications at least monthly; Procedure: -The Consultant Pharmacist shall review the resident's drug regimen and make appropriate recommendations to…

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

Based on observation, interview and record review, the facility failed follow proper sanitation practices in order to prevent cross contamination by not ensuring the dishwashing machine sanitized dishware correctly. This deficient practice had the potential to affect all residents who ate at the facility. The census was 55. Review of the facility's Proper Dishwashing policy, revised January 2012, showed: -Proper dishwashing is an important part of a good sanitation program; -Operating instructions, including the correct water pressure (20 pounds per square inch (PSI)), should be posted. If the water pressure is too high or low, the sanitizer will not be effective in sanitizing dishware; -Temperature gauges should be checked before each use. The correct temperature of each cycle should be maintained according to manufacturer specifications; -When hot water is used to sanitize, the water should reach 180 degrees Fahrenheit (F). Temperature sensitive test strips need to be available to periodically check the appropriate water temperature is reached for hot water sanitizing. Observation…

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

Based on interview and record review, the facility failed to follow their Quality Assessment and Assurance (QAA) policy and procedures by not holding monthly QAA meetings, and failed to follow federal and state regulations by not holding QAA meetings at least quarterly for the past 12 months. In addition, the facility failed to ensure all required attendees attended their QAA meetings and failed to develop and implement corrective actions for systemic problems within the facility. The lack of consistent and complete QAA meetings and the failure to identify and implement corrective actions had the potential to effect all residents The census was 55. Review of the facility Quality Assurance and Performance Improvement Procedure, revised on 11/2017, showed: -The facility Quality Assessment and Assurance (QAA)/Quality Assurance and Improvement Procedure (QAPI) committee will meet monthly and document meetings on the QAPI minutes form; -Attendees sign page one of the minutes to indicate their attendance. Attendance includes at a minimum the Medical Director, Administrator, Director of…

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

Based on interview and record review, the facility failed to ensure they maintained an adequate bond in the amount of one and one-half times the average monthly balance for the past 12 months. The census was 55. Review of the resident trust account, showed: -From September 2019 to August 2020, the average monthly balance was $40,566.54. This would require a bond in the amount of $61,000; -Review of the Department of Health and Senior Services data base for approved bonds, showed the facility had a bond in the amount of $55,000; -Review of the resident current balance report for September 2020, showed an amount of $62,453.10 in the trust account. During interviews on 9/30/20 at 11:50 A.M. and 10/2/20 at 10:15 A.M., the business office manager was not sure who was responsible to ensure the bond amount was sufficient. She would have to check as the company has homes in different states. She provided a form on 10/2/20, showing an increase in the bond amount and was being mailed to corporate for review.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue written emergency transfer/discharge notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, and failed to send a copy of the notice to a representative of the State Long-Term Care Ombudsman, for six of six sampled residents (Residents #44, #50, #53, #9, #18 and #32). The sample was 18. The census was 55. Review of the facility's Notice of a Transfer and/or Discharge policy, revised October 2017, showed: -Procedure: -A resident and/or his or her representative will be given notice as soon as practicable before transfer or discharge when: -An immediate transfer or discharge is required by the resident's urgent medical needs; -The written notice to the resident and/or representative will include the following: -The reason for the transfer or discharge; -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue bed reserve notification notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, for six of six sampled residents (Residents #44, #50, #53, #9, #18, and #32). The sample was size was 14. The census was 55. Review of the facility bed reserve policy notification, undated, showed: The bed reserve policy will be given to the resident at the time of admission and a copy will be given to the resident each time you are transferred from the facility; -Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room; -Under certain conditions, we can reserve your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before; -Neither Medicare of Medicaid will pay to hold your same bed if you are hospitalized . If you are a private pay,…

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 received their showers as scheduled for 10 of 14 sampled residents, three expanded sample residents and one closed record. (Residents #53, #18, #9, #42, #3, #50, #30, #32, #36, #37, #14, #57, #29 and #17). The sample size was 14. The census was 55. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/20, showed: -admitted [DATE]; -Cognitively intact; -Always understood; -Rejection of care not exhibited; -Required extensive assistance for transfers, personal hygiene and bathing; -Diagnoses include heart failure, wound infection and diabetes. Review of the facility's shower schedule, showed the resident scheduled for showers during day shift on Mondays and Thursdays. Review of the resident's medical record, showed no documentation of showers offered or provided in August or September 2020. Observations of the resident on 9/29/20 at…

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 received Restorative Therapy (RT) as ordered. The facility identified 25 residents receiving RT services. Of those 25, seven were sampled and problems were identified with three. In addition, problems were identified with three of four expanded sample residents. (Residents #15, #42, #55, #3, #52 and #58). The census was 55. Review of the facility Rehabilitative (Restorative) Nursing Care policy, dated 2/2012, showed: Policy: -Rehabilitative nursing care is provided for each resident admitted ; Procedure: General rehabilitative nursing care is that which does not require the use of a Qualified Professional Therapies to render such care. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. The facility's rehabilitative nursing care program is designed to assist each resident to achieve…

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 provide a thorough, documented assessment after one resident (Resident #38) sustained an injury of unknown origin and another resident (Resident #36) sustained an injury from improper wheelchair positioning. Furthermore, the facility failed to prevent resident access to razors in two of three unlocked shower rooms. This had the potential to affect all residents who were able to move freely around the facility. The sample size was 14. The census was 55. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed the following: -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; -Diagnoses included heart failure, peripheral vascular disease (PVD-lack of blood circulation usually affecting the legs), diabetes, Parkinson's disease (a brain disorder that leads 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, the facility failed to obtain physician's orders for the use of side rails for three sampled residents (Residents #52, #42 and #32), and failed to properly assess residents for the use of side rails, to attempt alternative interventions prior to installing side rails, and to update resident care plans regarding the use of side rails for three sampled residents (Residents #44, #57 and #37). The facility identified 30 residents with side rails and six were sampled. The census was 55. Review of the facility's Restraint policy, revised April 2020, showed: -Policy: Restraint usage will always be an interdisciplinary decision, including the resident or responsible party and based on a comprehensive assessment. Residents with restraints will be assessed on admission and periodically (at least quarterly) by the interdisciplinary team (IDT) for application, reduction, or continuation of a restraint; -Procedure: -Determine the level of risk a resident exhibits concerning…

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 the monthly pharmacist recommendations, for gradual dose reductions for psychotropic medications, were being forwarded to physicians for their review for a possible gradual dose reduction. Of the 14 sampled residents, six had pharmacy recommendations for psychotropic medication gradual dose reductions and the facility failed to forward any of those six residents' pharmacy recommendations to their physicians for review for possible gradual dose reductions (Residents #37, #44, #52, #57, #32 and #18). In addition, the facility failed to forward any pharmacy recommendations for possible gradual dose reductions of psychotropic medications since April 2020. The census was 55. Review of the facility Drug Regimen Review policy, revised on 10/2017, showed: Purpose: -The intent of this requirement is that the facility maintains the resident's highest practicable level of functioning and prevents or minimizes adverse consequences related to…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 35 opportunities for error, 2 errors occurred resulting in a 5.71% medication error rate (Residents #16 and #15). The census was 55. Review of the facility's policy on Medication Administration, updated 5/1/10, showed: -Procedure: 4.1: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct rate, at the correct time, for the correct resident; -Confirm that the Medication Administration Record (MAR) reflects the most recent medication order; -Check the expiration date on the medication; -Check for allergies to the medication; -If necessary, obtain vital signs. 1. Review of Resident #16's physician's order sheet (POS), dated 10/1/20 through 10/31/20, showed: -Carvedilol (medication used to treat high blood pressure and heart failure) 25 milligram (mg) by mouth twice a day, contact the physician for blood pressure not within normal limitations for the medication; -No documentation of blood pressure…

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 and interview, the facility failed to ensure insulin (used to regulate blood sugar levels) vials and flex pens (pre-filled insulin pens) were labeled with the date opened on one of two nurse medication carts for nine of nine vials and flex-pens observed. In addition, the facility failed to write the resident name on multi-use medications and relied solely on bins with resident room numbers for two of two certified medication technician carts. The census was 55. Review of the undated facility policy regarding insulin, showed: -Opened/in use Humalog insulin is good for 28 days; -Opened/in use Novolog insulin is good for 28 days; -Opened/in use Lantus insulin is good for 28 days; -Levemir insulin not addressed; -No information in the policy regarding steps to follow when opening a new vial or flex-pen of insulin. 1. Observation on [DATE] at 8:15 A.M., of the 200/400 nurse medication cart, showed: -Two undated, opened and in-use Humalog (fast acting insulin) vials; -Two undated, opened and…

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

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. In addition, the facility failed to review their antibiotic utilization during the quarterly quality assessment and assurance meetings. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 55. Review of the facility antibiotic stewardship policy, dated 10/2017, showed: Policy statement: -Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship; Policy Interpretation and Implementation: 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection…

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

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two expanded sampled residents (Residents #39 and #47) who remained in the facility upon discharge from Medicare Part A services. The census was 55. 1. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered…

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 follow their policy and federal regulations by not reporting one resident's injury of unknown origin to the state licensing agency (Department of Health and Senior Services (DHSS)) within the required time frame. This failure affected one resident (Resident #38). The sample size was 14. The census was 55. Review of the facility's Abuse Prevention Program policy, last revised 12/16/16, showed the following: -External Reporting of Potential Abuse: -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation…

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 all physician orders were followed when staff failed to complete treatments for wound care and administer insulin as ordered for one sampled resident (Resident #53) and failed to notify the physician when one resident's blood sugar was outside parameters as ordered (Resident #60). The sample was 14 and the census was 55. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/1/20, showed: -admission date 8/26/20; -Cognitively intact; -Required extensive assistance with dressing, toileting and personal hygiene; -Diagnoses included heart failure, diabetes, end stage renal disease and wound infection; -Number of venous ulcer (A wound on the leg or ankle caused by abnormal or damaged veins) or arterial ulcer (caused by poor blood circulation to the lower extremities): 3; -Special treatments received as a resident: Dialysis (Process for removal of waste 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 interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for one sampled resident (Resident #53) and one resident (Resident #15) selected from an expanded sample. The facility identified five residents as receiving dialysis. The sample size was 14. The census was 55. 1. Review of the Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/1/20, showed the following: -admission date of 8/26/20; -Cognitively intact; -Required extensive assistance with transfers, dressing and personal hygiene; -Diagnoses included high blood pressure, diabetes and end stage renal (kidney) disease; -Special treatments received while a resident: Dialysis. Review of the resident's care plan, revised on 8/27/20 and in use during the survey, showed…

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

Based on observation, interview and record review, the facility failed to have adequate indications to support the use of a behavior altering medication for one resident (Resident #38) and failed to inform the resident's responsible party of the order for and use of the medication. The sample size was 14. The census was 55. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed: -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; -Behaviors not exhibited; -Diagnoses included heart failure, diabetes, Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination) and dementia. Review of the physician's order sheet (POS) showed: -Diagnoses included dementia without behavioral disturbance; -An order, dated 7/17/20, to administer Depakote (anti-seizure medication also used for episodes of mania (excessive enthusiasm and delusions)), 125…

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.