Fulton Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to document the required fall documentation and neurological assessments (an assessment completed to determine if the nervous system is impaired) for five residents (Resident #11, #35, #53, #58, and #71) out of 25 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Resident Condition Change, undated, showed: -The purpose is to observe, record, and report any condition change to the physician so that proper treatment can be implemented;-After all resident falls, injuries, or changes in physical or mental function, monitor the following: observe for lacerations, swelling, discoloration, convulsions, pain, personality changes, alterations in consciousness, incontinence, sensory disorder, weakness, speech disorder, balance, reflexes, bleeding, unequal pupils, dyspnea, flushing or cyanosis, abduction/adduction/shortening of extremities;-Obtain vital signs;-Have someone stay with the resident while the nurse…

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 educate and provide influenza immunizations for two residents (Resident #42 and #50) and pneumococcal immunizations for three residents (Resident #42, #50 and #56) of five sampled residents. The facility census was 62.1. Review of the facility policy titled Immunization Recommendations for Long Term Care Facilities, undated, showed the resident's physician will be consulted and determine the level of risk and need for the vaccinations. Influenza vaccination is recommended annually for all residents. Pneumococcal vaccination will be administered according to state guidelines when determining vaccination status. Requirements for administering vaccinations include a physician order, consent and an information sheet with general information, risks and side effects.Review of the Centers for Disease Control (CDC), Adult Immunization Schedule by Age | Vaccines & Immunizations | CDC, dated 05/29/25, showed vaccines are recommended for those age [AGE] years…

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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated resident assessment tool, for two residents (Resident #41 and #35) out of 25 sampled residents who were admitted to hospice services. The facility census was 62.1. Review of the policies provided by the facility did not show a policy for completion of a SCSA.Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconciliation Act (OBRA), required Assessment Summary showed assessment time frames as follows:-A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice…

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 check and date oxygen tubing for one resident (Resident #18) and failed to provide orders for one resident (Resident #42), who received continuous positive airway pressure, (CPAP- a treatment that keeps the airway open during sleep). The facility census was 62.1. Review of the facility's policy titled Oxygen Administration, undated, showed at regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; and place cannula tubing in a plastic bag attached to the concentrator when not in use. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/25, showed staff assessed the resident as: -Moderate cognitive impairment; -Received oxygen; -Diagnoses of sleep apnea (disorder characterized by interruptions in breathing during sleep), asthma, and respiratory failure (occurs when the lungs can't adequately oxygenate). Review of the resident's care plan, revised…

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 maintain ongoing communication with the dialysis facility (a healthcare facility that provides dialysis treatment to individuals with kidney failure) and failed to document completion of dialysis care for one resident (Resident #18) of one sampled who received dialysis services. The census was 62. 1. Review of the facility's policy titled Dialysis, Care of a Resident Receiving, undated, showed staff were directed to: -Care for the Artery Vein shunt/fistula/graft (a surgical connection between the artery and vein): -Keep the area clean and dry; -Feel for the thrill (a vibration that can be felt when you place your fingers over the fistula site) sensation daily and document in the resident record, if no thrill, notify the physician; -Inspect access for redness, swelling, or warmth; -Avoid excessive pressure on the puncture site after dialysis; -Watch for bleeding after dialysis and monitor for signs of infection;-Communication between the facility and dialysis unit: -The dialysis communication record will 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 interview and record review, facility staff failed to contact one resident's (Resident #3's) responsible party after the resident had a change in condition. The facility census 61. 1. Review of the facility's Notification of Physician policy, undated, showed staff are directed to immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is a significant change in resident's physical, mental, or psychosocial status or a decision to transfer or discharge the resident form the facility. 2. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/22/25, showed staff assessed the resident as follows: -Severe cognitive Impairment; -Diagnoses of dementia with agitation, Senile degeneration of brain, Schizoaffective disorder bipolar type, Vascular dementia with anxiety, and personal history of traumatic brain injury. Review of the resident's care plan, dated 2/3/25, showed staff assessed the resident exhibits significant behaviors…

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 keep Resident #1 free from physical abuse when floor technician E aggresively pulled the residents wheelchair which resulted in the resident falling out of the wheelchair and on to the ground. The facility census was 58. The administrator was notified on 4/30/25 of past Non- Compliance, which occurred on 4/22/25, when staff reported the allegation. Staff immediately suspended floor technician E, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/30/25. 1. Review of the abuse, neglect, exploitation, and misappropriation of property fact sheet, dated 2017, showed abuse is the deliberate inflection of injury, unreasonable confinement, intimidation, or punishment, which results in physical harm, pain, or mental anguish. This includes verbal, sexual, physical, or mental abuse, as well as abuse enabled through the use of technology. Examples include scolding, ignoring, ridiculing, or cursing a resident and rough…

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 use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene during medication administration for two (Resident #4 and #21) of five sampled residents. The facility staff failed to ensure all employees were screened for Tuberculosis ((TB) a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and annual PPD tests completed and documented as per policy and state law for three employees ( Dietary Aide O, Certified Nurses Aide (CNA) E , and Certified Medication Technician (CMT) P) out of 10 sampled employees . The facility census was 44. 1. Review of the facility's Medication, Administration Guidelines, showed the guidelines did not address hand hygiene between administration of medication between one resident and another resident, pouring tablets or pills out from a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain bathroom doorframes, sink counters, and floors in good repair. The facility census was 44. 1. Review of the facility's policies showed staff did not provide a policy regarding environment. Review of the facility's housekeeper job description, dated May, 2006, showed housekeeping staff expectations include: - Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfection, etc; - Clean, wash, sanitize, and polish bathroom fixtures, ensure that water marks are removed from fixtures. Review of the facility's maintenance manager job description, dated May 2006, showed maintenance staff performs minor plumbing repairs, including unplugging, repairing, and replacing toilets, lavatories, and sinks and replacing faulty gate and ball valves. 2. Observation on 04/29/24 at 7:45 P.M., showed resident occupied room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide written information of the facility's bed hold policy at the time of transfer to the hospital to the resident and/or resident's representative for three residents (Residents #14, #24, and #45) out of three sampled residents who were discharged to the hospital. The facility census was 44. 1. Review of the facility's Bed Hold Guidelines, undated, showed the facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given at the time of transfer to the hospital. 2. Review of Resident #14's medical record showed: -Transferred to the hospital on [DATE] and returned on 03/28/24; -Did not contain documentation staff notified the resident or the resident's representative of the facility's bed hold policy at time of discharge. 3. Review of Resident #24's medical record showed: -Transferred to the hospital on [DATE] and returned on 04/09/24; -Did not contain documentation staff notified 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 perform a significant change in status Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for one (Resident #37) of one resident who elected hospice and one (Resident #14) of six sampled residents who had a decline in their ability to feed self with supervision, transfer with substantial/maximum assistance and perform toilet hygiene. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the RAI manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time…

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 for each resident to meet the resident's medical and nursing needs for four (Resident #14, #20, #35, and #37) of six sampled residents. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise 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, staff interview and record review, facility staff failed to meet professional standards of care when nursing staff did not obtain orders for water for one (Resident #14) out of one resident who received all hydration via gastric tube, failed to complete resident weights for three (Resident #6, #29, and #35) out of twelve sampled residents, failed to obtain wound measurements with weekly skin assessments for one resident (Resident #35) of three sampled residents with wounds. The facility staff document falls and fall follow-up for one (Resident #2) of two sampled residents. The facility census was 44. 1. Review of the facility's Enteral Nutritional Therapy (tube feeding) policy, undated, showed to follow the feeding with the prescribed amount of water. 2. Review of Resident #14's Physician Order Sheet (POS), dated 05/01/24, showed: -On 03/28/24, Nothing by mouth; -On 03/29/24, Gastric feeding of Jevity 1.2 calories (a type of nutrition) 300 milliliters four times a day; -The POS did 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 observation, interview, and record review, facility staff failed to provide appropriate personal hygiene for three residents (Resident #28, #35, and #251) out of 12 sampled dependent residents, The facility census was 44. 1. Review of the facility's Daily Care Needs guidelines, undated, showed after meals staff are diected to wash hands and face of the residents and remove any food particles from resident clothing. 2. Review of Resident #28's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/09/24 showed staff assessed the resident as: -Moderately cognitively impaired; -Dependent on staff for toileting hygiene, showering/bathing, and personal hygiene; -Did not reject care; -Diagnosis of debility, heart disease, lung disease, and dementia. Review of the residents care plan, reviewed 11/27/23, showed staff assessed the resident required assistance for transfers, bathing dressing and grooming daily, may experience bladder incontinence related to muscle weakness 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 reviews, facility staff failed to ensure residents environment remained safe from hazards when staff failed to safely propel three (Resident #8, #22, and #34) out of 12 sampled residents while in wheelchairs. Facility staff failed to provide two (Resident #14 and #36) out of two sampled residents safe mechanical transfers, and facility staff failed to safely store medications in one residents room (Resident #13). The facility census was 44. 1. Review of the facility's Wheelchair, Use of policy, undated, showed staff were directed to lower footrests and place resident's feet on footrests if used and position feet and legs in good body alignment. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/30/24, showed staff assessed the resident as: -Cognitively impaired; -Required set-up assistance for wheelchair locomotion of 50 feet with 2 turns; -Independent wheeling 150 feet in wheelchair. Observation on 04/30/24 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 interview and record review, facility staff failed to ensure all resident's drug regimens were free from unnecessary drugs when staff failed to ensure gradual dose reductions (GDR) were attempted for psychotropic medications for four (Resident #3, #12, #28, and #36) out of six sampled residents. The facility census was 44. 1. Review of the facility's Drug Review guidelines, undated, showed staff are instructed as follows: -All medication given to each resident will be reviewed on a monthly basis in order to review drug interactions, ensure adherence to stop orders, ensure accuracy in administration, and evaluate medications appropriate to diagnosis. -Problems identified shall be addressed according to need in consultation with physician. -Follow up on problems needs either the Director of Nursing's (DON's) or pharmacist's signature to show that the problem has been addressed. -Develop an interdisciplinary care plan to evaluate behavior pattern in relationship to current medication. -Notify physician of…

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

Based on observation, interview, and record review, facility staff failed to monitor and store medication in a safe and effective manner when staff did not dispose of expired medications and left resident's medication on top of the cart. The facility census was 44. 1. Review of he facility's Storage of Medications policy, undated, showed facility staff were directed as follows: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medications carts; -No discontinued, out dated, or deteriorate drugs or biological may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. 2. Observation on 05/01/24 at 8:29 A.M., showed the facility medication room contained: -One bottle of extra strength Acetaminophen/diphenhydramine HCI with an expiration date of 08/23; -Two bottles of Therma-M with an expiration date of 03/24; -Five bottles of mucus relief with an expiration date of 04/23; -One bottle of Zinc with an expiration…

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 designate a person to serve as the Dietary Manager (DM) with the appropriate qualifications. The facility census was 44. 1. Review of facility policies showed staff did not provide a policy related to the qualifications of kitchen staff. 2. Review of the DM's personnel record showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview on 04/30/24 at 08:19 A.M., the DM said he/she was not certified yet, but was currently working on the certification and was about half way done. The Dietary Manager said he/she did not know all of the requirements. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said the Dietary Manager should be certified, and if new to the job at the facility they thought he/she should be certified within four to six months. If the Dietary Manager is not certified, they may not know the guidelines, and residents may…

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

Based on observation, interview and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' Electronic Health Records (EHR) open and unattended in public hallways. The facility census was 44. 1. Review of the facility's Medication Administration Guidelines, undated, showed the record did not contain direction for protection of residents' privacy. 2. Observation on 04/30/24 at 8:49 A.M., showed Certified Medical Technician (CMT) A left the EHR screen with resident information on the screen unlocked in the hallway when he/she administered to a resident in their room. Observation on 04/30/24 at 8:51 A.M., showed CMT A left the EHR screen unlocked in the hallway with resident information on the screen when he/she adminsitered medication to a resident in their room. Observation on 04/30/24 at 9:05A.M., showed CMT A left the EHR screen unlocked in the hallway with resident information on the screen when he/she administered medication to a resident in their room. An unsecured box with drawers containing residents' 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, facility staff failed to complete the required Comprehensive Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two (Residents #1, and #3) out of two sampled residents The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion…

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 Quarterly Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of four (Resident #18 and #30) sampled residents. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the RAI manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than Assessment Reference Date (ARD) + 14 calendar days; -Quarterly assessment for a resident must 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to correctly assess one resident (Resident #2) who received an anticoagulant (a blood thinning medication used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation medication) and failed to assess one resident (Resident #12) for their preferences and oral/dental status. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary, Section N, showed instruction for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete neurological checks and fall follow up documentation for three (Resident #1, #2, & #3) of three residents who had a fall and failed to complete weekly skin assessments for two residents (Resident #4 and #5). The facility census was 41. 1. Review of the facility's Fall Champion Program, undated, showed the post fall follow up period is 72 hours which includes assessment and document of the resident's condition in healthcare tracking program Progress Notes and neurological checks. 2. Review of Resident # 1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/23/23, showed staff assessed the resident as: -Cognitively intact; -No falls since admission or prior assessment. Review of the resident's care plan, dated 11/27/23, showed staff assessed the resident at risk for falls due to history of falls. Staff are directed to provide proper, well-maintained footwear with nonskid soles, adjust bed to lowest level, 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 record review and interview, the facility failed to ensure they assessed residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every three months for seven residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). The facility census was 46. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type are as follows: -Assessment Completion refers to the date that all…

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 maintain a clean, comfortable and homelike environment. Facility staff failed to maintain resident restrooms free of floor discolorations, missing toilet bolt covers and caulk at the base of the toilet. In addition, bathroom cabinets had laminate peeled off and drawers missing. The facility staff also failed to maintain resident rooms free of discolored floor tiles. The facility census was 50. 1. Review of the facility's policies showed staff did not provide a Facility Maintenance Policy. Observation on 4/10/23 at 11:45 A.M., showed dark black/gray stains in and around the cracks in the bathroom tiles, rust colored discoloration around the toilet bowl, and missing caulk and bolts at the base of the toilet bowl in room [ROOM NUMBER]. Observation on 4/10/23 at 11:49 A.M., showed two black skid marks, approximately 3/8 of an inch wide and three feet long in the middle the floor in room [ROOM NUMBER]. Observation on 4/10/23 at 11:51 A.M., showed a drawer…

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 meet professional standards of care when they failed to weigh two residents (#4 and #41), check Depakote (to treat seizures, bipolar disorder or migraine headaches) levels for one resident (#11), and to take a blood pressure prior to administration of blood pressure medication for one resident (Resident #303) as ordered by the physician. Additionally, staff failed to failed to provide consistent documentation in regard to a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one resident (Resident #20), and failed to ensure physician medications orders were signed for two residents (#31 and#40). The facility census was 50. 1. Review of the facility's policies showed the staff did not provide a policy for following physicians orders or for medication or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide assistance with personal hygiene for four residents (Resident #1, #2, #11, and #17) dependent on staff for care. The facility census was 50. 1. Review of the facility's policies showed the staff did not provide a bath (shower) policy. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/23, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member for bathing, dressing, personal hygiene, and toileting; -Diagnoses of hemiplegia or hemiparesis; -Does not reject care; -No behaviors towards others; -Occasionally incontinent of urine and always incontinent of bowel. Review of the resident's care plan, dated March 2023 showed staff are directed to assist with showers at least two times per week, wash hair as needed (PRN), and provide nail care on bath days. Review of the resident's shower record, dated January 2023,…

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 staff failed to ensure the resident's environment remained free of accident hazards when facility staff failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents. In addition, facility staff failed to maintain the hot water temperature below 120 degrees Fahrenheit in the resident rooms. The facility census was 50. 1. Review of the facility policy and procedure manual showed they did not have a policy for hazardous chemical storage, sharps storage for razors or nail clippers. Observation on 4/11/23 at 10:29 A.M., showed the 300 hall shower room unlocked and unattended with the following: -Two sharps containers, with the tops open contained uncovered disposable razors; -A can of shaving cream; -A bottle of body wash; -A mop bucket filled with dirty water and a mop; -A can of Spray Deodorant labeled, Keep out of reach of children, if swallowed, get medical help or contact a Poison Control Center…

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 that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #2, and #34), and failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #5). The facility census was 50. 1. Review of the facility's Drug Review policy, undated, showed the following: All medication given to each resident will be reviewed on a monthly basis in order to: -Review drug interactions; -Evaluate medications appropriate to diagnosis; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -The policy did not given direction for Gradual Dose Reductions. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/6/23, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of Schizophrenia (a disorder that…

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 medications were stored in a safe and effective manner, additionally staff failed to ensure two medications carts were locked at all times. The facility census was 50. 1. Review of the facility's Medications, Storage of, from Nursing Guidelines Manual, undated, directed staff as follows: -Drugs must be stored in an orderly manner in cabinets, drawers, or carts; -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. 2. Observation on 4/12/23 at 11:00 A.M., showed the Certified Medication Technician (CMT)'s medication cart contained the following loose pills: -One small round yellow pill stamped with W40; -Half of a small oval white pill. During an interview on 4/12/23 at 11:04 A.M., CMT B said when they find loose pills in the medication carts they dispose of the pills into the locked trashcan on the side 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 use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per the facility policy for three residents (#1, #11, and #34). The facility census was 50. 1. Review of the facility provided Screening for Tuberculosis in Long Term Care Facilities guideline, undated, showed the guidance directs staff as follows: -All residents new to long-term care who do not have documentation of a previous skin test reaction >10mm or a history of adequate treatment of tuberculosis infection or disease, shall have the initial test of a Mantoux PPD two-step skin test to rule out tuberculosis within one month prior to or one week…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for two of two sampled residents (Resident # 20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Notice of Transfer or Discharge, if necessary -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Transferred to the hospital on 3/29/23; -Returned to the facility on 3/31/23; -Staff did not document they notified the resident and resident representative of the transfer. 3. Review of Resident #27'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 interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two sampled residents (Resident #20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Bed Hold Forms. -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. The Guidelines did not include mention of the Bed Hold Form. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on 3/29/23; -Resident returned to the facility on 3/31/23; -Transferred to the hospital on [DATE]; -Resident returned to the facility on [DATE]; -Staff did not document they notified the resident or…

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

Based on observation, interview and record review, facility staff failed to provide orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), and have ongoing communication with the dialysis clinic for one resident (Resident #24) who received dialysis. The facility census was 50. 1. Review of the facility's Dialysis Care of a resident receiving policy, undated, showed staff are directed as follows: Communication between the Facility and Dialysis Unit: -The Dialysis Communication Record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after, any dialysis, any labs completed, medication given, follow up information and any new physician orders; -The lower portion will be signed by the dialysis nurse and returned to the facility; -The records will be maintained in the medical record. 2. Review of Resident #24'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.