Northwood Hills Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was served was palatable and at temperatures that were appetizing for resident including four residents (Resident #36, #71, #72, ad #45) who often ate in their rooms. The facility census was 90. Review of the facility policy titled, Food Temperature Control, revised 06/28/24, showed the following: -Food temperatures are maintained during mealtimes to ensure residents received safe food served at acceptable temperatures; -Hot foods are held at a minimum of 135 degrees Fahrenheit (F) per state requirements; -Cold foods are held at or below 41 degrees per federal guidelines, unless the state requirements are more stringent; -Food should not be placed on the steam table more than 30 minutes before meal service begins; -Maximum length of time food is held on the steam table is four hours; -Food reheated in the microwave is heated so that all parts of the food reach 165 degrees F and food is rotated, stirred, covered, and allowed to…

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

Based on observation, record review, and interviews, the facility to maintain an effective infection control program when the facility failed to screen all staff for tuberculosis (a contagious infection that usually attacks the lungs) as required when the facility failed to ensure the first step of the two-step Tuberculin (TB) skin test was completed prior resident contact for four staff member (Registered Nurse (RN) D, Licensed Practical Nurse (LPN) E, Speech Therapist (ST) F, and RN G) of 10 sampled staff members; and when staff counted resident cigarettes eight times per day by touching the cigarettes with their bare hands for eight residents (Resident #13, #18, #22, #23, #41, #52, #59, #79) out of fifteen sampled residents that were on the smoking list. The facility had a census of 90. 1. Review of the facility policy, Tuberculosis - Testing and Screening (associates and Volunteers), dated dated 09/24/24, showed the following: -The facility will evaluate each associate and volunteer for tuberculosis in accordance with current Centers of Disease Control and Prevention (CDC)…

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, observation, and interview, the facility failed to ensure each resident was treated with dignity and respect when staff spoke to one resident (Resident #72) in a threatening manner. The facility had a census of 90. Review of the facility policy titled Resident Rights, dated 09/10/24, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident; -The resident has the right to be treated with dignity and respect. 1. Review of Resident #72's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 03/03/23; -Diagnoses included chronic post-traumatic stress disorder (PTSD - disorder in which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide trauma-informed care in accordance with standards of practice when staff failed to identify, assess, care plan, and provide supportive interventions for two residents (Resident #72 and #6) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 90. Review showed the facility did not provide a policy related to Trauma Informed Care (a model of care that acknowledges the impact of trauma on people's lives and aims to provide effective services). Review of the facility's policy titled Resident Rights, dated 09/10/24, showed the following: -At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care per standards of practice when the facility failed to complete timely assessments/reassessments of side rail use, failed to obtain physician's orders for side rail use prior to side rail use, and failed to obtain full informed consent prior to side rail use for two residents (Resident #77 and #70). The facility also failed to care plan the use of side rails and failed to document risk/benefits and alternatives attempted prior to side rail use for one resident (Resident #77). The facility census was 90. Review of the facility policy titled Bed Rails - Safe and Effective Use of Bed Rails, dated 11/16/21, showed the following: -The facility must attempt to use appropriate alternatives prior to installing a side or bed rail; -The facility must ensure correct installation, use, and maintenance of bed rails; -The facility should assess the resident for risk of entrapment prior to installation; -Risks and benefits should be reviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide all residents food that accommodated each residents' allergies, intolerances, and preferences, when staff served one resident (Resident #36) food items containing an ingredient identified as an allergen/dislike on the resident's meal ticket and when staff served one resident (Resident #38) food items the guardian had requested not be served to the resident. The facility census was 90. Review of the facility policy titled, Food Allergies and Intolerances, revised 04/25/23, showed the following: -The Director of Food and Nutrition Services obtains food preferences, including any food allergies and intolerances upon admission; -Each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences; -Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; -Facilities should be aware of each…

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

Based on interview and record review, the facility failed to maintain an effective system of records and disposition of controlled medication when staff could not locate three cards of controlled medications and documented administration of the medication when it was not available for administration one resident (Resident #1). The facility census was 81. Review of the facility policy titled, Administration of Medication, last revised 02/23/23, showed the following: -The facility will ensure medications are administered safety and appropriately per physician order to address resident's diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration, right drug, right resident, right does, right route, right time and frequency, right documentation, right assessment, right to refuse, right…

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, observation, and interview, the facility failed to provide a sanitary environment for all residents, staff, and the public, when staff failed to keep the wall behind the dirty dish sink clean and failed to repair the missing caulking between the sink an wall. The facility census was 91. Review of the facility's Cleaning Schedule Policy, revised 04/25/23, shows the following information: -The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietician, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times; -The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned; -Designated cleaning tasks are assigned to each position; -The cleaning schedule is posted in a location where it can be easily read; -The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately. Review of the facility's Kitchen Cleaning Schedule, undated, showed…

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

Based on interview, observation, and record review, the facility failed ensure all food was protected from possible contamination during storage, preparation, and distribution when staff stored dented cans with other cans of food to be used in food service; stored dishes in a manner that trapped moisture; had unpasteurized eggs purchased and in the cooler for use; and failed to keep food free of contaminates when foil was stirred into noodle. The facility had a census of 88. 1. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: - Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination; - Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. - Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and…

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

Based on observation and interview, the facility failed to ensure a clean and homelike environment when staff failed to adequately clean resident bathroom floors for ten residents (Resident #5, #8, #19, #21, #29, #37, #45, #47, #48, and #51); failed to adequately clean resident bathroom ceiling for two residents (Resident #5 and #51); failed to adequately clean and maintain the resident room sinks for five residents (Resident #8, #21, #29, #37, and #47); failed to maintain toilets in good working order for three residents (Resident #49, #63, and #69); failed to maintain the shower floor tile in one facility shower room; and failed to maintain the tiles and mop board areas for five residents (Resident #8, #19, #29, #37, and #48). The facility census was 88. Record review of the facility policy titled Housekeeping Services, dated 8/9/22, showed the following information: -The facility will provide a safe, clean, comfortable and homelike environment; -Keep housekeeping surfaces visibly clean on a routine basis and clean spills promptly; -The environmental supervisor will maintain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for a mental disorder or intellectual disability prior to admission) for two residents (Resident #28 and #51) and failed to complete a level two screening for one resident (Resident #68), prior to or upon admission to the facility, to ensure the resident received appropriate care and service. The facility census was 88. Record review showed the facility did not provide a policy regarding PASARRs. 1. Record review of Resident #28's face sheet (brief information sheet about the resident) showed the following information: -admission date of 3/20/2018; -Diagnoses included traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), delusional disorder (belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when staff made seven errors out of 25 opportunities, resulting in an error rate of 28%, when staff failed to hold insulin injectable pens in place for for the recommended time following administration for two residents (Residents #73 and #67), failed to administer medication with orange juice for one resident (Resident #29), and failed to crush medications for one resident (Resident #61). The facility census was 88. Record review of a facility policy entitled Insulin Pen Administration, dated 8/10/2022, showed the following: -The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards of practice and manufacturer's guidance; -To verify that all insulin is injected, keep the pen needle in the subcutaneous fat layer for six to ten seconds after the injection with the thumb on the push button plunger. Record review of manufacturer's current guidelines regarding…

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 follow acceptable standards of practice for infection control when staff did not perform appropriate hand washing before, during, or after incontinent care for four residents (Resident #6, #40, #48, and #51) and when staff failed to properly clean and disinfect glucometers (machine used to test blood glucose levels) between use for four residents (Residents #8, #29, #67 and #73). The facility had a census of 88. 1. Record review of the facility policy, Perineal (the skin in between the genitals (external reproductive organ) and anus (opening through which solid waste leaves the body)) Care of the Female Patient, dated 8/22/2022, showed the following information: -After cleaning the perineum, perform hand hygiene, apply new gloves, and apply moisture-barrier skin protectant as needed; -Discard soiled articles in the appropriate receptacle; -Remove and discard gloves; -Perform hand hygiene. Record review of the facility policy, Perineal…

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, observation, and record review, the facility failed to maintain a sanitary environment when staff failed to maintain vents and non-food contact surfaces clean and free of debris. The facility census was 88. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -Non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris. 1. Observation of the kitchen on 2/26/2023, at 9:30 A.M., showed the following: -The ice machine filter, which covered a vent on the front of the machine, was covered in a black, fuzzy substance; -In some places the black, fuzzy substance was moving with any motion of air. Observation of the kitchen on 2/26/2023, at 9:35 A.M., showed the following: -Four ceiling vents above the doors to enter the kitchen and the ice machine; -The four vents were covered in a black, fuzzy substance with some dangling downward. Observation of the kitchen on 2/26/2023, at 9:50 A.M., showed the following: -Six ceiling vents in the dishwasher room; -These six vents had…

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

Based on observation, interview, and record review, the facility staff failed to treat each resident with dignity and respect when staff incorrectly spelled one resident's name (Resident #8) on the room name tag causing him/her to be called by the wrong name. The facility census was 88. Record review of the facility policy entitled Area of Focus: Resident Rights, dated 11/21/22, showed the following information: -A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. 1. Record review of Resident #8's face sheet (brief information sheet about the resident) showed the following information: -Most recent admission date of 3/4/22; -The resident's name spelled correctly on the face sheet. Record review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment instrument), dated 1/6/23, showed the resident's name spelled correctly and moderate cognitive impairment. Record review of…

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

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards possible, when staff attempted to place one resident (Resident #5) on a scale in a unsafe manner. The facility census was 88. Record review of the facility policy titled Weight Monitoring, Long-Term Care, dated 8/19/22, showed the following: - Staff should gather equipment including a scale (a type that is appropriate for the resident's condition, such as standing, wheelchair, lift, or bed), gloves, and facility-approved disinfectant; -Staff should follow the facility guidelines for obtaining weight measurements (for example, time of day, before meals, with or without shoes) to ensure consistency among staff members; -Explain the procedure to the resident according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation; -Weigh the resident according to the scale manufacturer's instruction for use; -If the resident requires assistive equipment (for example, a wheelchair, walker, 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, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff administered insulin to two residents (Residents #67 and #73) without holding the insulin pen in place the recommended time after injection. The facility census was 88. Record review of a facility policy entitled Insulin Pen Administration, dated 8/10/2022, showed the following: -The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards of practice and manufacturer's guidance; -To verify that all insulin is injected, keep the pen needle in the subcutaneous fat layer for six to ten seconds after the injection with the thumb on the push button plunger. Record review of manufacturer's current guidelines regarding administration using an insulin aspart (rapid acting insulin) pre-filled pen showed the following: -Put the needle into the skin all the way; -Press and hold the button to give the dose; -Keep the button pressed and slowly count…

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, observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards when staff failed ensure the range hood and range hood extinguishing system located over the stove where staff prepared and cooked resident food did not have a buildup of grease and lint; failed to ensure the sides, legs, and bottom shelves of prep tables and steam table did not have a buildup of grease and lint; and failed to protect food from possible contamination when staff failed to follow proper handling of dishes while serving food items. The facility census was 96. Record review of the 2013 Food and Drug Administration (FDA) Food Code showed: -Non-contact food surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials; -Mats and duckboards shall be designed to be removable and easily cleanable; -Single-service and single-use…

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 staff failed to provide privacy, dignity, and respect for all residents when staff performed blood glucose testing on two residents (Resident #28 and #78) and an insulin injection on one resident (Resident #28) in the main dining room with random residents observing the procedures and when staff completed catheter (a sterile tube inserted into the bladder to drain urine) care with the room door open and privacy curtain not closed for one resident (Resident #71). A sample of 21 residents was selected and the facility census was 96. 1. Record review of Resident # 78's face sheet (general resident information) in the medical record showed the following: -admission dated of 3/9/16; -Diagnosis of diabetes mellitus (a disease that affects how a person's body handles insulin and glucose levels in the blood). During an observation on 11/01/19, at 11:35, Registered Nurse (RN) O entered the main dining room, went to a table, and performed a blood glucose test on the resident by puncturing a finger with a needle and obtaining a blood sample.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a clean and homelike environment when staff failed to clean shower rooms and a clean shower chair, failed to ensure one shower room was in good repair, failed to ensure one shower room door was free of scuff marks, and failed to ensure the kitchen floor was kept clean. The facility census was 96. 1. Observation on 11/05/19, at 3:21 P.M., of the shower room on the special care unit (SCU) showed black grime along the base of the tile and wall to the shower. The surveyor used a paper towel and the black grime came off the wall when wiped with a paper towel. The black grime appeared to be mold-like. The shower chair in the SCU shower had a build up of orange substance on the back of the chair and on various parts of the chair. The shower chair had a black substance on the chair between the back rest and the seat of the chair. Observation on 11/06/19, at 9:10 A.M., of the shower room on the SCU showed the black grime along the base of the tile and wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital for seven residents (Resident #15, #61, #69, #71, #79, #90, and #242). A sample of 21 residents was selected out of a facility census of 96. Record review of the facility's policy titled Transfers and Discharges, dated 5/06/19, showed the following information: -The facility ensures systems are implemented to provide written notification to the resident and resident representative prior to transfer. This written notification is provided on the Notice of Transfer or Discharge form. This information will be presented in a language and manner that the resident/resident representative can understand; -Obtain physician's order for the transfer unless it is a 911 emergency; -Explain transfer and reason to the resident and/or representative and give a copy of signed transfer or discharge notice to the resident and/or representative or person(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, the facility failed to inform residents and families/legal representatives of the facility bed hold protocol at the time of a transfer to the hospital for seven residents (Resident #15, #61, #69 #71, #79, #90, and #242). A sample of 21 residents was selected out of a facility census of 96. Record review of the facility's policy, titled Bedhold/Reservation of Room, dated 5/02/19, showed the following information: -The bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or if the resident goes on therapeutic leave of absence; -The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the resident's return to the facility to ensure that resident's are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital or when taking therapeutic leave of absence from the facility;…

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

Based on observation, interview, and record review, the facility failed to follow up and notify the physician of low blood sugar levels for three residents (Resident #27, #38, and #61) and failed to document interventions of and responses to the residents' abnormal blood sugar levels for two residents (Resident # 27 and # 38). A sample of 21 residents was selected for review out of a facility census of 96. Record review of the facility's Hypoglycemia (low blood sugar) Policy, dated 10/4/19, showed the following: -Decreased levels of blood glucose (sugar) to the brain can lead to seizures, coma, and death; -Follow hypoglycemia prevention and management protocol as directed; -Monitor blood glucose levels as ordered; -Recheck glucose levels within 15 minutes of treatment, and continue or monitor glucose as ordered; -Document blood glucose levels and treatment provided, as well as the resident's response to treatment. Record review of the facility's Hypoglycemic Reaction Policy, dated 9/9/19, showed the following: -The policy is intended to provide directions and guidelines for the 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 adhere to professional standards when staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose (sugar) levels for residents) while collecting blood glucose samples on residents with a diagnosis of diabetes mellitus (a disease that affects how a person's body handles insulin and glucose levels in the blood). This practice affected four residents, Resident # 65, # 78, # 241, and # 242. The facility failed to administer the two-step tuberculin (TB) test timely and failed to document results in millimeters three residents (Resident #70, #71, and #90). The facility census was 96. 1. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. The CDC investigated multiple outbreaks of viral hepatitis (disease affecting the liver) among residents in long-term care (LTC)…

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's licensed staff failed to ensure the Emergency Kit (E-Kit) and the pharmacy form titled Security Lock Register matched the lock tag number on the E-Kit. The facility census was 96. 1. Record review of the document from the pharmacy titled Security Lock Register showed the following information: -On 9/18/19, staff signed the register that lock number 6260356 was taken off and a new lock number 6500499 was put on the E-Kit; -On 10/8/19, staff signed the register that lock number 6228305 was taken off and a new lock number 6500637 was put on; -On 10/14/19, staff signed the register that lock number 6228618 was taken off and a new lock number 6500637 was put on; -On 10/15/19, staff signed the register that lock number 6500637 was taken off and a new lock number 6500633 was put on; -On 10/23/19, staff signed the register that lock number 6500500 was taken off and a new lock number 650049 was put on; -On 10/25/19, staff signed the register that lock number 6500492 was taken off and a new lock number 6500448 was put on; -On…

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