Meyer Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs were not bland; and failed to ensure that hot foods on room trays were at or close to 120 ºF (degrees Fahrenheit) at the time of delivery. This practice potentially affected one resident with a pureed diet and three residents who received room trays. The facility census was 53 residents. 1. Review of the recipe for five serving of pureed eggs, copyrighted 2024, showed: -Five boiled eggs and ¼ cup of warm milk. -Directions included: Place prepared eggs and milk in a washed and sanitized food processor, blend until smooth. Reheat to 165 ºF for at least 15 seconds and maintain at 135 ºF. Observation on 7/17/24 from 7:01 A.M. through 7:04 A.M. showed the Dietary [NAME] (DC) A made the pureed eggs, by adding 2 boiled eggs and a small portion of cold milk to the food processor. During an interview on 7/17/24 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.

Based on interview and record review, the facility failed to invite one sampled resident (Resident #22) to his/her quarterly care plan meeting out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Comprehensive Care Plans showed: -The comprehensive care plan would be prepared by an interdisciplinary that included the resident and the resident's representative, to the extent possible. -No policy related to the actual invitation to care plan meetings. 1. Review of Resident #22's face sheet showed he/she admitted to the facility with the following diagnoses: -Generalized Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Congestive Heart Failure (CHF- a weakness of the heart that leads to the build-up of fluid in the lungs and surrounding tissues). -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas 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, the facility failed to ensure the baseline care plan showed the primary health conditions and interventions implemented for two sampled residents with significant health conditions (Resident #154 and #155) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Baseline Care Plan dated 2023 showed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet the professional standards of quality of care. The baseline care plan will: -Be developed within 48 hours of the resident's admission. -Include the minimum healthcare information necessary to properly care for the resident, including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services. -The admitting nurse or supervising nurse on duty shall gather information from 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, the facility failed to ensure the low air loss mattress (LAL - an air mattress covered with tiny holes that are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) settings were set by weight according to physician orders for one sampled resident (Resident #20), who had pressure ulcers (pressure injuries - damage to an area of the skin caused by constant pressure on the area) out of 15 sampled residents. The facility census was 53 residents. Review of the facility policy for Use of Support Surfaces copyright 2023 showed: -Support surfaces will be used in accordance with evidence-based practices for resident with or at risk for pressure injuries. -For powered devises, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and inflation. -Support surfaces will be utilized accordance with manufacturer recommendations. 1. Review of the Resident #20's Physician Order Sheet…

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 failed to ensure respiratory nasal cannulas (a device used to deliver supplemental oxygen through a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), face masks and tubing was kept in a way to prevent cross contamination and failed to ensure that his/her care plan reflected that he/she used respiratory equipment and that there were interventions related to oxygen use for one sampled resident (Resident #36) out of 15 sampled residents. The facility census was 53 residents. 1. Review of Resident #36's Face Sheet showed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), and heart failure. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess resident pain risk and failed to ensure the resident's Baseline Care Plan included minimum healthcare information regarding the specific care need of the resident to include pain for one sampled resident (Resident #155) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Pain policy and procedure dated 2023, showed: -The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of the resident's pain. -Based on professional standards of practice, an assessment of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information as applicable to the resident: -History of pain and its treatment including pharmacological and non-pharmacological and alternative medicine and whether or not this treatment has been effective, history of addiction, past and…

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

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #22) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) received trauma based interventions or develop a care plan that showed interventions for the staff to provide to protect the resident and prevent trauma from recurring out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Comprehensive Care Plans showed: -Trauma-informed care was an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of traumas. -A trauma-informed approach to care delivery recognized the widespread impact, and signs and symptoms of trauma in residents, and incorporated knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. -The care planning process would include an assessment of the resident's strength and needs. -Services provided…

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

Based on observation, interview and record review, the facility failed to ensure nursing staff had the proper skills and competencies to promote resident safety when a Certified Medication Technician (CMT) who was not certified to administer insulin (a drug used to manage blood sugar levels) injections administered insulin to two residents (Resident #156 and Resident #157) sampled for insulin administration. The facility census was 53 residents. Review of an undated facility policy titled Medication Administration showed medications were to be administered by staff who were legally authorized to administer those medications and in accordance with professional standards of practice. Review of an undated facility policy titled Insulin Pen showed staff were to: -Perform hand hygiene prior to the insulin administration. -Prime the insulin needle by dialing the pen to two units of insulin and pushing the plunger until at least one drop of insulin appears on the tip of the needle. -Administer the insulin. -Perform hand hygiene after the administration. Review of the Certified Medicine…

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 resident's attending physicians documented their review of and response to irregularities identified by the facility's consulting pharmacist during monthly Medication Regimen Reviews (MRRs) for two residents (Resident #8 and Resident #32) of five residents reviewed for unnecessary medications. The facility census was 53. Review of an undated facility policy titled Psychotropic Medications showed effects of psychotropic medications on a resident's well-being would be monitored on an ongoing basis including during the pharmacist's monthly medication review but provided no other information on pharmacist medication reviews. A policy on pharmacist medication reviews was requested, but not provided prior to exit. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS-a federally mandated comprehensive assessment), dated 4/15/24, showed the resident had: -Diagnoses including dementia with behavioral disturbance, bipolar disorder (a mental disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #6 and #1) received routine dental services (an annual inspection of the oral cavity for any signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic (a specialized branch of dentistry dedicated to making artificial teeth) care and procedures) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Dental Services showed: -It was the policy of the facility to assist residents in obtaining routine and emergency dental care. -The dental needs of each resident were identified through physical assessment and the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) assessment processes and were addressed in each resident's plan of care. -For…

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

Based on observation, interview and record review, the facility failed to ensure to have monitoring and required documentation of Hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visits and failed to obtain pertinent documentation of the the delivery of Hospice care services for one sampled resident (for one sampled resident (Resident #35) out 15 sampled residents. The facility resident census of 53 residents. Review of the facility's Hospice Agreement dated and signed on 8/2/18 showed: -Hospice and the facility shall each establish and maintain it's own clinical record for each resident in Hospice program. -All services performed directly by the Hospice or under arrangement by the facility shall be promptly entered into respective clinic record. -The Hospice nurse will complete a system assessment of each resident enrolled in the program, make recommendation interventions for resident and reviewed with the facility. 1. Review of Resident #35's admission Record showed the resident was admitted to Hospice services. Review of the…

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

Based on observation and interview, the facility failed place a screen over the louvered vent in the basement boiler room to keep pests out of the boiler room area. This practice affected the boiler room area. The facility census was 53 residents. 1. Observation with the Maintenance Director on 7/16/24 at 9:45 A.M. showed the absence of a screen from the louvered vent in basement boiler room and the presence of dead insects, bird droppings and dried vegetation in the boiler room area. During an interview on 7/16/24 at 9:47 A.M., the Maintenance Director said birds have been in the boiler room in the past and he/she noticed there was no screen over the louvered vent.

Based on observation, interview, and record review, the facility failed to maintain the dishwasher spray wand nozzles free from debris inside the nozzles; to maintain the ceiling vents over the entrance to the kitchen free from a buildup of dust; to have a trash container available for Dietary [NAME] (DC) to use without having to touch the lid, which contributed to the DC not washing his/her hands after touching the trash container lid on multiple occasions; to ensure the shelf in the reach-in refrigerator labeled Pass Through, did not have visible rust on the shelf; and to ensure there was not a seven inch (in.) crack on the shelf of the food delivery cart. This practice potentially affected all residents who ate food from the kitchen. The facility census was 50 residents. 1. Observations on 9/26/22, showed: -At 11:55 A.M., debris was present in the nozzles of the spray wand of the dishwasher. -At 12:02 P.M., a buildup of dust was present on and in the ceiling vents close to entrance. -At 1:54 P.M., DC A touched trash container to discard a piece of trash and did not change 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a clean mattress for one sampled resident (Resident #32); to maintain the fans in the beauty shop free of a heavy dust buildup; to maintain a fan in resident room [ROOM NUMBER] free of a dust buildup; to maintain the floors in resident rooms 301, 306, 308, 310, 312, 317, 316 and 321, free from debris buildup and dust; to maintain the commode seat in resident room [ROOM NUMBER] in an easily cleanable condition; to maintain commode risers (an extender to an existing toilet, under or over the lid, that lifts the seat height to a more comfortable level for residents who may be disabled) in resident rooms [ROOM NUMBERS]; to maintain a stand-up lift free from a crack in the base of that lift, and to clean debris from that lift. This practice potentially affected at least 20 residents. The facility census was 50 residents. 1. Record review of Resident #32's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool…

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

Based on interview and record review, the facility failed to ensure all employees were screened through the Nurse Aide Registry as part of the facility screening for Employee Disqualification and Criminal Background Check procedure upon hiring new employees for three of 10 sampled employee records. The facility census was 50 residents. Record review of the Facility's Abuse and Neglect policy and procedure dated May 2017, showed the facility would not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The community would not knowingly employ any direct care staff convicted of any of the crimes listed in the state criminal history of nurse aides or any other unlicensed employees or with a finding of abuse listed on the Nurse Aide Registry or criminal background check. 1. Record review of 10 sampled employee personnel files for the purpose of completing the criminal background check and employee disqualification listing portion of the survey process on 9/27/22, showed the following employee records did not include the Nurse Aide…

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 resident monthly pharmacy drug regimen review recommendations were reviewed and acted upon by the physician for three sampled residents (Resident #1, #5, and #15) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy Medication Regimen Reviews dated May 2019 showed: -The consulting pharmacist was to perform a Medication Regimen Review (MMR) for every resident in the facility receiving medication upon admission and at least monthly thereafter. -The pharmacist was to provide a written, signed, and dated copy of all medication regimen reports, including recommendations, to the Director of Nursing (DON) and Medical Director within 24 hours of the MMR. -The physician was required to document that the irregularity had been reviewed and what, if any, action was taken. -The facility was to maintain copies of the MMR reports, including the physician's response, as part of each resident's permanent…

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

Based on observation, interview, and record review, the facility failed to ensure that food items were labeled with a name and date when they were placed in to the resident food storage refrigerator, so the facility could follow the policy about discarding foods that needed to be discarded within 72 hours. This practice potentially affected two to three residents who had food items that were stored in that refrigerator. The facility census was 50 residents. Record review of the facility's policy entitled Foods brought by Family/Visitors revised 10/17, showed: -Food brought to the facility by visitors and family was permitted. Facility staff would strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Family members and visitors were requested to inform nursing staff of their desire to bring foods into the facility. -Food brought by family/visitors that was left with the resident to consume later would be labeled and stored in a manner that was clearly distinguishable from facility prepared food. -Foods that must be kept…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices during blood glucose monitoring, including handwashing and glove changing and glucometer sanitation for one sampled resident (Resident #41) and one supplemental resident (Resident #16); failed to perform handwashing and glove changing before and after assisting a resident with a transfer for one supplemental sampled resident (Resident #18); and failed to perform hand hygiene upon entering a resident's room to perform blood pressure monitoring and before exiting the resident's room for one sampled resident (Resident #146) out of 13 sampled residents and four supplemental residents. The facility census of 50 residents. Record review of facility Blood Glucose Monitoring Policy and Procedure, dated 06/28/2017, showed: -Routine Procedure for Performing Finger Stick Blood Glucose. -Collect items needed to perform procedure, including gloves, alcohol wipes, blood glucose meter, lancet, blood glucose meter…

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 maintain authorization forms for three sampled residents (Residents #1, #9 and #27), whose funds were managed by facility personnel, and to place the resident funds for two sampled residents (Residents #1 and #9) in an interest bearing account, since the total of their accounts exceeded $50.00. This practice affected all three residents whose resident funds were managed by facility personnel. The facility census was 50 residents. 1. Record review of Resident #1's guardianship paperwork, showed he/she was originally appointed a guardian on 10/22/08 and then appointed a successor guardian on 12/31/20, and the absence of an authorization form signed by the public administrator. 2. Record review of Resident #9's guardianship paperwork, showed the resident was originally appointed a guardian on 5/31/11 and appointed a successor guardian on 12/31/20, and the absence of an authorization form signed by the public administrator. 3. Record 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 interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted timely for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy titled Resident Assessments dated November 2019 showed comprehensive MDS assessment was to be conducted no less than once every 12 months. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: -A Comprehensive Significant Change MDS assessment with an Assessment Reference Date (ARD) of 4/30/21. -A Quarterly MDS assessment with an ARD of 7/6/21. -A Quarterly MDS assessment with an ARD of 10/5/21. -A Quarterly MDS assessment with an ARD of 1/27/22. -A Quarterly MDS assessment with an ARD 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, the facility failed to ensure the residents' Minimum Data Sets (MDS-a federally mandated assessment instrument completed by facility staff for care planning) were submitted quarterly (at least every 92 days) for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy titled Resident Assessments dated November 2019 showed: -A Quarterly MDS assessment was to be conducted no less than once every 3 months. -NOTE: The facility's policy did not address the time frame for submission. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: -A Quarterly MDS assessment with an ARD of 7/6/21 with a completion date (section Z0500b) of 8/16/21, 41 days after the ARD date. -A Quarterly MDS assessment with an ARD of 10/5/21 with a completion date (section…

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 transmit required Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) assessments within the regulatory time frame for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17 showed all MDS assessments must be submitted within 14 days of the Assessment Reference Date (ARD). 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid Services (CMS) MDS database submissions showed: -A Quarterly MDS assessment with an ARD of 7/6/21 was submitted 8/16/21, 41 days after the ARD date. -A Quarterly MDS assessment with an ARD of 10/5/21 was submitted 10/26/21, 21 days after the ARD date. -A Quarterly MDS assessment with an ARD of 4/29/22 was submitted 6/16/22, 48 days after…

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

Based on interview and record review, the facility failed to create a comprehensive care plan for a Continuous Positive Airway Pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) for one sampled resident (Resident #42) out 13 sampled residents. The facility census was 50 residents. Record review of the facility policy and procedure Care Plans-Service Plans dated 8/5/15 showed: -A preliminary Care Plan/Service Plan shall be developed upon the resident's admission to the community to meet his/her immediate care needs based on the initial nursing admission assessment. The preliminary Care Plan/Service Plan shall be used only until the comprehensive Care Plan/Service Plan has been developed. -The comprehensive Care Plan/Service Plan is developed within 14 days of the resident's admission unless state regulations state differently. -In coordination with resident's legal representative, the interdisciplinary team develops and maintains the Care Plan/Service Plan. A group conference shall be scheduled at least on a quarterly basis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician's order included the type of catheters (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine) the resident used to self-catheterize, how the facility would monitor urine output from the resident's self-catheterization and check for signs and symptoms of infection; to adequately assess the resident's knowledge of the process for self-catheterization and hand hygiene through demonstration; to monitor and document urine output for one sampled resident (Resident #146); to ensure infection control practices in prevention of cross contamination during care by performing hand hygiene (is a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) before and after assisting a resident with a personal and catheter care; and to monitor placement of a catheter drainage bag during cares for one supplemental resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician's orders for oxygen were obtained and documented on the Physician's Order Sheet (POS) timely and upon admission for one sampled resident (Resident #146); and to ensure a nasal cannula and Bilevel Positive Airway Pressure machine (Bipap a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) cannula and tubing were stored in a way to prevent cross contamination for one sampled resident (Resident #146) and one supplemental resident (Resident #145) out of 13 sampled residents and 5 supplemental residents. The facility census was 50 residents. Record review of the facility's Oxygen policy and procedure dated 3/2008, showed there was no procedure showing how oxygen equipment (nasal cannulas, face masks tubing) was to be stored when not in use. There was no documentation showing the physician's orders needed to be obtained prior to or upon administering any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 29 observed medication opportunities, two errors occurred during insulin (Insulin is a hormone that lowers the level of glucose (a type of sugar) in the blood) administration resulting in an error rate of 6.9% for two sampled residents (Resident # 16 and Resident #41). The facility census was 50 residents. Record review of the facility's Insulin Injection Policy dated 6/2017 showed no mention of proper procedure for using insulin pens. 1. Record review of Resident #16's face sheet showed he/she admitted to the facility on [DATE] with the following diagnosis of Type II Diabetes Mellitus (DMII-a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's Physician Order Sheet (POS) dated September 2022 showed Novolin…

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 observations, interviews, and record review the facility failed to assure that the nutritive value and safe consumption of food was not compromised by ensuring hot foods were prepared by reaching proper internal temperatures (poultry at 165 degrees Fahrenheit (F) and fish at 145 degrees F) and served at a safe and appetizing temperature (135 degrees F). This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations on 10/1/19 between 11:37 A.M. and 11:49 A.M. showed foods being taken out of the oven and placed on carts to be taken to the dining rooms for the lunch meal service. During an interview on 10/1/19 at 11:57 A.M. the Dietary Manager said that temperatures were not logged when hot food came out of the oven or off of the stove, just at the steam tables in the dining rooms before being served. 2. Observations in the Countryside Lane dining room on 10/1/19 between 12:03 P.M. and 12:27 P.M. showed the following: - Foods were taken off of a cart 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 observations, interview, and record review, the facility failed to keep the kitchen floors clean to avoid foodborne illness; failed to maintain sanitary food preparation and serving utensils; and failed to take measures to prevent non-food particles from getting into foods. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations during the kitchen inspection on 10/1/19 between 8:56 A.M. and 12:03 P.M. showed the following: - There were two butter pods, plastic and paper debris, and a coffee-colored stain approximately 2 feet by 3 feet under the racks in the walk-in refrigerator; - There was paper debris under the racks of the walk-in freezer; - Both walk-ins' doors each had a sign stating Floor Must Be Kept Dry and Clean At All Times; - Several herb and spice plastic containers were greasy to the touch; - Four plastic spatulas in a utensil drawer had varying degrees of chipped edges; - Two metal slotted spoons in a utensil…

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 interviews and record reviews, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 49 with a licensed capacity for 56 residents. Record review on 10/2/19 at 9:45 A.M. of the facility's Emegency Preparedness manual entitled [NAME] Care Center Disaster Manual, obtained from the [NAME] Meadows nurse's station, showed an absence of a waterborne pathogen prevention program that included the following: - A facility-specific risk assessment that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard; - A…

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

Based on interview and record review, the facility failed to check the State Certified Nurse Aide (CNA) Registry to determine if a newly hired individual had a Federal Indicator (shows abuse, neglect or misappropriation of property occurred while the individual was employed as a CNA in a Medicaid and/or Medicare federally certified facility, which prohibits the individual from working in a certified facility) prior to hiring, for seven out of seven sampled employees. The facility hired 72 employees since the last annual survey. The facility census was 49 residents. Record review of the facility's Background Check Procedure dated 6/10/19 showed: -Staff were to check the CNA Registry unit on Certified Nurses Assistants (CNAs) and Certified Medication Technicians (CMTs); and --The policy did not direct the staff to check the CNA Registry for all staff. 1. Record review of the facility's untitled, undated employee list showed the facility hired 72 new employees in the past year. Record review of Employee A's personnel file on 10/3/19 showed: -He/she was hired as a food services worker…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a safe and sanitary environment in two areas by allowing ceiling tiles to become dampened to the point of having visible mold growth on them. This deficient practice affected numerous residents, visitors, and staff who resided in, passed through, used, or worked in those two areas. The facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations during the facility room-by-room Life Safety Code inspections with the Maintenance Assistant on 10/2/19 between 12:07 P.M. and 12:45 P.M. showed the following: - There were eight 2 foot by 2 foot ceiling tiles in the northeast corner of the Countryside Lane dining room that had visible mold near the sections by the wall; and - In the hallway by room [ROOM NUMBER] there was a 2 foot by 4 foot ceiling tile with an approximately 9 inch diameter circular patch of mold. During interviews on 10/2/19 between 12:07 P.M. and 12:45 P.M. the Maintenance Assistant said the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff document a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) measurements and description weekly; and failed to ensure the resident's physician visited and visually assessed the resident every 30 days after admission to the facility for one sampled resident (Resident #23) out of 13 sampled residents. The facility census was 49 residents. Record review of the facility's undated Pressure Ulcer Prevention and Management policy showed: -The Interdisciplinary Team (IDT) Risk Team Representative reviews all new pressure ulcers and monitors progress weekly; -Staff development/Orientation for Licensed Nurse included how to stage pressure ulcers and classify wounds by depth and description; -Weekly skin assessments were to be completed and documented by licensed staff; -Weekly wound rounds were…

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 pharmacy recommendations were acted upon in a timely manner and a rationale was provided for a Gradual Dose Reduction (GDR) recommendation when the physician declined to reduce an antipsychotic, (medication used to manage disordered thoughts, delusions (altered reality or beliefs despite evidence to the contrary) and/or hallucinations (perceptions of having sensed something that wasn't actually there) for one sampled resident (Resident #14) out of 13 sampled residents. The facility census was 49 residents. Record review of the facility's Drug Regimen Review (DRR) Policy, dated 6/10/19, showed: -A licensed Pharmacist will review the resident drug regimen including the resident chart at least monthly or more frequently depending on the resident condition. The licensed Pharmacist will report in writing any irregularities to the Primary Care Physician (PCP), Medical Director and the Director of Nursing (DON) to be acted upon; -The Pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to educate all staff as to the readily accessible whereabouts and complete contents of a single, written, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 49 residents with a licensed capacity of 56 residents. During an interview on 10/1/19 at 8:56 A.M., the Dietary Manager said that there was a policy for outside food brought in for residents by family or visitors and subsequently provided a copy. Record review on 10/1/19 at 12:47 P.M. of the policy entitled Foods Brought in by Family/Visitors, provided by the Dietary Manager at 9:34 A.M. showed an eight-point document that included: - Foods brought in must be checked against the resident's diet orders; - If a…

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