Fulton Manor Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide staff in accordance with their Facility Assessment to meet the needs of the residents. Staff failed to provide care to meet basic hygiene needs for four residents (Resident #24, #32, #35, and #48) out of six sampled residents. The facility census was 43. 1. Review of the Facility Assessment, dated 01/07/25, showed direct care staff required to care for their facility census: -Days- Five nurse aides with census above 43 or three-four nurse aides with census lower than 40; -Evenings- Four nurse aides with census above 43 or two-three nurse aides with census below 40; -Nights- Two nurse aides; -Staffing plan is to ensure that facility has sufficient staff to meet the needs of the residents at any given time. Review of the employee schedule, dated August 2024, with average census of 42, showed: -Thursday 08/01/24: one nurse aide on day shift; -Friday 08/02/24: one nurse aide on night shift; -Saturday 08/03/24: two nurse aides on day…

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

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 43. 1. Review of the facility's policy titled, Nursing Services-Registered Nurse (RN), dated 01/01/24, showed the facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. 2. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Monday, 07/01/24; -Tuesday, 07/02/24; -Wednesday, 07/03/24; -Thursday, 07/04/24; -Monday, 07/08/24; -Tuesday, 07/09/24; -Wednesday, 07/10/24; -Thursday, 07/11/24; -Friday, 07/12/24; -Saturday, 07/13/24; -Sunday, 07/14/24; -Monday, 07/15/24; -Tuesday, 07/16/24; -Wednesday, 07/17/24; -Thursday, 07/18/24; -Monday, 07/22/24; -Wednesday, 07/24/24; -Thursday, 07/25/24; -Monday, 07/29/24; -Tuesday, 07/30/24; -Wednesday, 07/31/24. 3. Review of the facility's RN staff schedule, dated August…

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 complete the required nurse staffing information, which included the facility census, the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis in an area readily accessible to residents and visitors. The facility census was 43. 1.Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated 07/2016, showed: -Within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) in a clear and readable format; -Shift staffing information shall be recorded on the Daily Staffing form for each shift, the information recorded on the form shall include: -The name of the facility; -The date for which the information is posted; -The resident census at the beginning of the shift for which the information is posted; -Twenty-four hour shift…

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

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (5%). Out of 32 opportunities observed, nine errors occurred, resulting in a 28.13% error rate, which affected one resident (Resident #20) out of four sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, Medication Errors, dated 01/01/24, showed the facility must ensure that it is free of medication error rates of 5% or greater. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of the facility's Medication Pass times, provided by…

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 the dish washing machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. Facility staff failed to properly sanitize soiled kitchen wares to prevent cross-contamination. Facility staff failed to maintain an ice machine drain air gap. The facility census was 43. 1. Review of the facility's Dishwashing: Machine Operation policy, dated 2020, showed staff were instructed to: -Operate dishwashing machines according to manufacturer recommendations; -Record log documents twice daily for either final rinse temperature (high temperature machine) or sanitizer concentration (low temperature machine with chemical sanitizer); -If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes; -After troubleshooting, if the dish washing machine is not functioning, the employee should contact the Dining Services Manager or maintenance or outside…

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 staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program which included documentation and implementation of on-going systemic issues with resolution. The facility census was 43. 1. Review of the facility's policies showed the facility did not provide a policy for QA/QAPI program. During an interview on 01/30/25 at 10:23 A.M., the administrator said the department heads come together quarterly and discuss different items within the facility, however there is no documentation to provide about these meetings or issues and resolutions. The administrator said she was not aware the information needed to be documented and maintained.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to ensure the two-step purified protein derivative ((PPD) skin test for Tuberculosis (TB)) were completed in accordance with their policy for six employees (Licensed Practical Nurse (LPN) A, Nurse Aide (NA) B, NA C, NA D, Certified Nurse Aide (CNA) E, and Dietary aide F) out of ten employee files reviewed. Facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for three residents (Resident #20, #45, and #48) of three sampled residents. The facility's cenus was 43. 1. Review of the Facility's Employee Screening for TB, revised August 2019, showed: -All employees are screened for latent tuberculosis (LTBI) and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each…

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 regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #3, #15, #20, and #46) out of four sampled residents. The facility census was 43. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's policy titled, Proper Use of Side Rails, undated, showed the facility will assure the correct installation and maintenance of bed rails prior to use ensuring that the beds dimensions are appropriate for the resident by: -Confirming the bed rails are appropriate for the size and weight of the resident using the bed; -Inspecting and regularly checking the mattress and bed rails for ares of possible entrapment; -Ensuring the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to ensure residents' personal information and privacy was protected when staff left the computer screen open in public hallways for two residents (Resident #9 and #13) of 16 sampled residents, and failed to close the privacy curtain and window blinds/curtain during incontinence care for one resident (Resident #48) out of two sampled residents observed during care. The facility's census was 43. 1. Review of the facility's policy titled, Quality of Life-Dignity, dated 01/01/24, showed: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem; -Staff protect confidential clinical information; -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. Observation on 01/28/25 at 8:18 A.M., showed the medication cart across from the nurses' station on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required time frame for three residents (Residents #20, #24 and #48) of six sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed staff are directed: -The Assessment Coordinator or designee is responsible for ensuring the resident assessments are submitted to Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system in accordance with the current federal and state guidelines; -Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; -Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for three residents (Resident #1, #15, and #16) out of 16 sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 01/01/24, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment; -Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. 2. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 who had a history of physical aggression grabbed Resident #1's arm. The facility census was 39. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 1/31/24, showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and certain resident to resident altercations. Review showed physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 9/08/24, showed staff assessed the resident with cognitive impairment. Review of the resident's plan of care, updated 12/12/24, showed staff were directed to notify the provider if the resident poses a threat 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, record review, and interview, facility staff failed to prevent the misappropriation of money from one resident's (Resident #1's) checking account when Certified Nurse Assistant (CNA) I cashed a check from the resident for his/her personal use. The facility census was 43. The administrator was notified on 8/12/24 of past Non-Compliance which occurred on 6/22/24. On 7/27/24, facility staff reported CNA I received, accepted, and cashed a check in the amount of $400.00 from a resident on 6/22/24. Upon discovery 7/27/24, facility staff began an investigation. Facility staff notified the Department of Health and Senior Services (DHSS), local police department, and the residents physician. Facility staff completed an investgation and all staff inserviced on abuse, neglect, and misappropriation by 7/30/24. CNA I terminated on 7/27/24 for misappropriation of resident money. Staff corrected the deficient practice on 7/30/24. 1. Review of the facility's policy titled Abuse, Neglect, and Exploitation dated 01/31/24 showed: -The facility will provide protection for the…

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

Based on interview and record review, staff failed to implement the facility's abuse policy to ensure resident safety when facility staff allowed Physical Therapy Assistant (PTA) A who was accused of abuse of one resident (Resident #1) out of three sampled residents to continue to have contact with residents. The facility census was 36. 1. Review of the facility's Abuse Prevention Policy, dated November, 2017, showed each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident who reside in our facilities will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Any alleged perpetrator of abuse, neglect, or misappropriation of resident funds, will be immediately suspended from employment and will leave the employment property and not return to the property and not return to the property until the investigation by the facility and/or law enforcement is…

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

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 37. 1. Review of facility provided policies showed they did not contain a policy related to the qualifications of kitchen staff. Review of facility provided e-mails showed the consultant dietician requested the current Dietary Supervisor's enrollment in the on-line Certified Dietary Manager's (CDM) course on 08/29/23. Review showed the consultant dietician provided the administrator with the Dietary Supervisor's login information for the on-line CDM course on 08/31/23. During an interview on 02/06/24 at 9:55 A.M., the Dietary Supervisor (DS) said he/she was not a CDM. The DS said he/she was hired as a cook and moved to the DS position a few months ago. The DS said he/she does not have any current food safety training but he/she had 13 or 14 years of nursing home kitchen…

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 serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff failed to inform residents what meals were being served and when changes were made to the menus. The census was 37. 1. Review of the facility's Pureed Diet policy, dated 2022, showed staff were directed to weigh or measure the number of drained portions required for the standardized recipe. Review showed the policy directed staff to serve with appropriate scoop number or divide equally to provide number of portions. Review of the facility's Mechanical Soft Diet policy, dated 2022, showed the policy did not contain direction related to portion sizes. Review of the standardized recipe for ground ham steak with gravy showed staff are instructed to place prepared ham in a washed and sanitized food processor; grind to the texture of fine hamburger. Final internal cooking temperature of 165 degrees Fahrenheit (F). Place in steam table pans with enough prepared low sodium (salt) broth to keep moist.…

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 maintain kitchen cleanliness in a manner to prevent potential food contamination. Facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dish wares in a manner to prevent cross-contamination when staff stacked dish wares together wet. The facility census was 37. 1. Review of the policies provided by the facility showed the policies did not contain guidance related to kitchen cleaning. Review of the facility's Ice Machines and Portable Ice Carts policy, dated 2024, showed: -Ice machines will be cleaned at a frequency specified by the manufacturer or, if the manufacturer specifications are absent, at a frequency necessary to preclude accumulation of soil or mold; -The ice machine or carts will be cleaned at any time contamination may have occurred or when…

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 appropriately perform hand hygiene during wound care, perineal care and catheter care for one resident (Resident #30), failed to perform hand hygiene during perineal care for one resident (Resident #16), failed to perform hand hygiene between residents during medication administration, and failed to change and store oxygen tubing in a manner to decrease the risk of the spread of infection for four residents (Resident #3, #11, #23, and #142). The facility census was 37. 1. Review of the facility's Hand Hygiene policy, reviewed January 2024,showed: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene is indicated and will be performed when hands are visibly dirty, between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves,…

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 refunds of personal funds to residents from the facility operating account in a timely manner for nine residents (Resident #1, #5, #7, #8, #10, #12, #14, #15, and #17) discharged from the facility. The facility census was 37. 1. Review of the Facility's Resident Personal Fund policy, dated January 2024, showed: -The facility will establish and maintain a system that assures a full and complete and separate accounting of each resident's personal funds entrusted to the facility on the resident's behalf. The system will preclude any comingling of resident funds with facility funds; -Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds with a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with state law. 2. Review of the facility's maintained Accounts Receivable Report, from 01/01/23 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 record review, observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when failed to repair a door covering, stored a bed side commode lid on the floor next to the sink and stored a wash basin on the floor in the bathroom by the toilet in room [ROOM NUMBER]. Staff failed to maintain and clean the portable ice chest and failed to maintain the front entranceway free of cigarette butts. The facility census was 37. 1. Review of the facility's Safe and Homelike policy, reviewed January 2024, showed: -The facility will create and maintain, to the extent possible, a homelike environment that deemphasized the institutional character of the setting; -Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment; -Report any unresolved environmental concerns to the Administrator. Review of the facility's Quality of Life - Homelike Environment policy, reviewed January 24, showed the facility…

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 follow physician orders for one resident's (Resident #25) indwelling urinary catheter (tube inserted into the bladder to drain urine) care and failed to obtain a physician's order for an indwelling urinary catheter which included an indication for the use, catheter care, and catheter/balloon size for one resident (Resident #30). The facility census was 37. 1. Review of the facility's Appropriate Use of Indwelling Catheters policy, reviewed January 2024 showed the following: -An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary; -Residents admitted with an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the clinical condition demonstrates that catheterization is necessary; -Use of an indwelling urinary catheter will be in accordance with the physician orders, which will include the diagnosis or clinical condition…

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, interview, and record review, facility staff failed to assist five residents (Resident #3, #11. #18, #38, and #142) out of 12 sampled dependent residents with grooming and bathing. The facility census was 37. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS); -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 2. 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, facility staff failed to propel four residents (Resident #11, #13, #18 and #43) in wheelchairs with foot pedals, failed to provide a safe mechanical lift transfers for two residents (Residents #16 and #22), and failed to secure chemicals and disposable razors in a manner to prevent accidents. The facility census was 37. 1. Review of the facility's No Pedals, No Push policy, dated June 2013, showed: -Staff will be aware to place foot pedals on wheelchairs if staff is going to push a resident to prevent a resident from having to hold up his/her own legs potentially causing a resident to drop their legs and throwing them out of the wheelchair; -If a resident requires the assistance of staff to push a wheelchair, the staff must place foot pedals on the wheelchair and position the resident's feet on the footrests prior to assisting the resident. 2. Observation on 02/07/24 at 7:59 A.M., showed Certified Nurse Aid (CNA) E propelled Resident #11 from the dining room to…

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

Based on observation, interview, and record review, facility staff failed to obtain a physician's order for an indwelling urinary catheter (tube inserted into the bladder to drain urine) which included an indication for the use, catheter care, and catheter/balloon size for one resident (Resident #30), failed to obtain an updated physician order and administer catheter care for one resident (Resident #25).The facility census was 37. 1. Review of the facility's Appropriate Use of Indwelling Catheters policy, reviewed January 2024, showed an indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. Review showed: -Residents admitted with an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the clinical condition demonstrates that catheterization is necessary; -Use of an indwelling urinary catheter will be in accordance with the physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, 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 accurately complete entrapment assessments, bedrail assessments, and obtain consents for the use of bed rails for four residents (Resident #6, #16, #32, and #142). The facility census was 37. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed: -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Bed dimensions are appropriate for the resident's size; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave not gap wide enough to entrap a resident's head or body. Any gaps in bed system are within the safety dimensions established by Food and Drug Administration (FDA); -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; -Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are in a variety of types,…

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 nursing staff had the appropriate skills and competencies to meet the care needs for the residents by not providing in-services or reevaluating and documenting skills and competencies on a regular basis for each employee. The facility census was 37 residents. 1. Review of the facility's Competency Evaluation policy, updated [DATE] showed it is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Review showed: -The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process; -Evaluating competency of staff is accomplished through the facility's training program; -Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified; -Subsequent and/or annual competency is evaluated at a frequency…

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 a system to monitor antibiotic use. The facility census was 37. 1. Review of the facility's Antibiotic Stewardship policy, reviewed January 2024, showed the purpose of the Antibiotic Stewardship program is to monitor the use of antibiotics in our residents. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: -Drug name; -Dose; -Frequency of administration; -Duration of treatment (start and stop date) or (number of days of therapy); -Route of administration; -Indication of use. Review of the facility's Infection Prevention and Control policy, reviewed May 2023, showed: -An antibiotic stewardship program will be implemented part of the overall infection prevention and control program; -Antibiotic use and protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program; -The infection preventionist, with oversight from the Director of Nursing (DON) serves as the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #6, and #29). The facility census was 37. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, reviewed January 2024 showed: -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan will include measurable objectives and timeframes; incorporate identified problem areas; incorporate risk factors associated with identified problems; -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change; -The IDT must review and update the care plan when…

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 update care plans with intervention for pressure ulcers, and complete weekly skin assessments after development of pressure ulcer for two residents (Resident #29 and #30). Facility staff failed to notify one resident (Resident #29) physician and family of new pressure ulcers and failed to recieve an treatment order and an order for wound care consult. Facility staff failed to initiate a wound care consult and did not document they provided physician order treatments for one resident (Resident #30). The facility census was 37. 1. Review of the facility's Prevention of Pressure Injuries policy, dated April 2020, showed staff are directed to: -Assess the resident on admission for existing pressure injury risk factors. Repeat weekly and upon any changes in condition. -Use a standardized pressure injury screening tool to determine and document risk factors; -Supplement the use of a risk assessment tool with assessment of additional risk…

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 as needed psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #25). The facility census was 37. 1. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy, reviewed 01/01/24, showed residents who use psychotropic drugs receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. The policy did not give direction for responses to GDR recommendations from the pharmacist or physician or for 14-day as needed psychotropic medications. Review of the facility's Medication Administration policy, reviewed 01/01/24, showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -If a resident uses as needed medications frequently, the attending physician and Interdisciplinary Care Team, with support of the Consultant Pharmacist as needed, shall reevaluate the situation, examine…

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 store medication in a safe and effective manner. The facility census was 37. 1. Review of the facility's Storage of Medications policy, dated 01/01/24, showed facility staff were directed as follows: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing; -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. Observation on 02/08/24 at 01:25 P.M., showed the medication storage room contained: -Two bottles of drug buster ( a chemical used to destroy medications) stored on the same shelf as active residents medications, as well as above other residents medications; -Two 4.5 ounce (oz) bottles of enema lubricate laxative (to treat constipation) with an expiration date of January 2024; -One bottle of 400 milligram (mg) Magnesium Oxide…

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 maintain kitchen equipment in a clean and sanitary manner and to perform hand hygiene as often as necessary to prevent cross-contamination. This failure had the potential to affect all residents. The census was 32. 1. Review of the facility's Dietary Cleaning and Sanitation policy, undated, showed: - The floors shall be swept and mopped prior to the end of each shift; - The floors shall be swept and mopped if they become dirty; - Ovens need to be cleaned on a regular basis and whenever they are soiled; - Cabinets and drawers should be cleaned on a regular basis and whenever they are soiled. Review of the facility's Daily Checklist for cleaning, undated, showed: - The dietary aid to wipe down wall tiles of any visible splashes, wipe down trash cans, and sweep and mop the dishwashing area; - The day cook to wipe down trash can and sweep after every meal; - The evening cook to wipe down trash can, sweep after every meal, and mop at end of shift; - The checklists did not address the bulk bins. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents when staff failed to lock an unattended medication storage room and unlocked medication cart and failed to provide safe mechanical lift transfers for two residents (Residents #20 and #30) in a manner to prevent accidents. The facility census was 32. 1. Review of the facility's Safety and Supervision of Residents policy, dated July 2017 showed: -Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/22/22, showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Required…

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 develop a comprehensive care plan for two residents (Resident #6 and #15) of six sampled residents. The facility census was 32. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 showed the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. 2. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/16/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Moderate depression; -Physical behaviors directed toward others on 1-3 days; -Behaviors significantly interfere with the resident's care; -Total dependence for bed mobility, transfer, dressing, locomotion, eating, toilet use, and personal hygiene; -Diagnoses included urinary tract infection, atrial fibrillation (rapid heart beat of upper heart chambers), heart failure,…

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 obtain a physician order for the use of oxygen for one resident (Resident #27). The facility census was 32. 1. Review of the facility's Medication and Treatment Orders policy, revised July 2016, showed: -Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Review of policies provided by the facility showed they did not provide a policy specific to oxygen administration. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 11/17/22, showed facility staff assessed the resident as follows: -Diagnoses included asthma; -Did not receive oxygen while a resident or while not a resident. Review of the resident's Physician Order Sheet (POS) dated December 2022, showed the record did not contain an order for oxygen. Observation on 12/13/22 at 10:47 A.M., showed the…

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

Based on observation, interviews, and record reviews, facility staff failed to prepare pureed food according to recipes, to ensure residents with pureed diets received all items on the menu, and to serve pureed food at the appropriate consistency. This failure had the potential to affect two out of two residents (Resident #16 and #19) who received a pureed diet. The census was 32. 1. Review of the facility's Standardized Recipes policy, undated, showed standardized recipes will be used for all menu items, including pureed and therapeutic diets. Review of the diet spreadsheet for residents with pureed diets showed, staff directed to prepare pureed beef cube steak, pureed creamed corn, pureed stewed tomatoes, pureed buttered dinner roll, and pureed bread pudding for the resident's lunch meal. Review of the pureed bread pudding recipe showed, staff directed to: - Place two-and-a-half cups bread pudding into food processor; - Add three quarters cup milk gradually; - Blend until smooth; - Achieve a smooth, pudding or soft mashed potato consistency. Observation on 12/13/22 at 11:15 A.M.,…

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.