Rehabilitation Center Of Independence, The

Based on interviews and facility policy, the facility staff failed to protect the rights of a resident whose room was changed without notice prior to the change for one (1) of one (1) resident reviewed for room changes. Resident #65 left the facility for an appointment and returned to learn his/her belongings had been moved to another room. The findings include: Review of facility policy titled Room or Roommate Change Version 1.0, Revised 8/2020 revealed the policy's Purpose -To ensure that a resident is able to exercise their right to change rooms or roommates .Procedure -III. Prior to changing a room assignment, the resident, the resident's representative (if available), the resident's new roommate, will be given timely advance notice of such change according to state and federal regulations. A. When the resident is being moved at the request of the Facility, the notice of a change in room assignment will be in writing and will include the reason(s) for the change. B. Social Services Staff will assist in orienting the resident to his or her new room and/or roommate. 1. 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, interviews and record review, the facility failed to ensure appropriate notification following a fall during a transfer for one (1) of 36 residents sampled (Resident #39). Resident # 39 reported falling while being transferred from a wheelchair to the bed by Restorative Nursing Aide (RNA) AA and Maintenance Supervisor. The staff involved did not notify the nurse or physician of the incident, as required. This deficient practice compromised the resident's right to prompt assessment and care and potentially placed the resident at risk for unrecognized or untreated injuries. The findings included: 1. Record review of Resident #39's admission Minimum Data Set (MDS) dated [DATE], revealed an admission date of 12/24/24, and a Brief Interview for Mental Status (BIMS) summary score of 13 which indicated the resident was cognitively intact. Resident #39 was coded as dependent for a chair/bed to chair transfer. Continued review revealed diagnoses which included Diffuse Traumatic Brain Injury with…

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 provide documentation of appropriate notification of pending benefit changes to Medicare services for one (1) of three (3) residents sampled for beneficiary notices (Resident #90). The findings include: 1. The 1/10/25 review of the notices given to three (3) residents selected from the form entitled Beneficiary Notice - Residents discharged Within the Last Six Months (provided to the facility during the Entrance Conference) revealed none was available for 1 of 3 sampled residents, Resident #90. In an interview, the Social Worker (SW) on 1/10/25 at 2:28 p.m. reported not being in the position until August 2024 and the SW was unable to provide proof of notification letters sent to Resident #90.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify the resident and the resident's representative of a facility-initiated emergency transfer to an acute care hospital. This deficient practice affected one (1) of two (2) residents reviewed for hospitalizations from a total of 36 residents sampled (Resident #101). The findings include: The facility's policy governing resident transfer and discharge processes was reviewed. The policy, titled Transfer and Discharge was dated 10/24/22. The policy directed staff from Social Services (or a designee) to prepare a written transfer notice to send with the resident in the event of an emergency transfer. 1. A review of Resident #101's medical record revealed an admission date of 10/28/24. His/her medical history included metabolic encephalopathy, hemiparesis affecting his/her left side, and history of CVA. A comprehensive minimum data set (MDS) was not completed as the resident was admitted on [DATE] and discharged on 10/29/24. Resident #101 did not return…

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 review, the facility failed to provide the resident and the resident's representative with a written notice of the facility's bed-hold policy upon transferring a resident to an acute care hospital. This deficient practice affected one (1) of two (2) residents reviewed for hospitalizations from a total of 36 residents sampled (Resident #101). The findings included: The facility's policy governing resident transfer and discharge processes was reviewed. The policy, titled Transfer and Discharge was dated 10/24/22. The policy directed staff to provide a resident and a resident representative with a written notice which specified the duration of the resident's bed-hold at the time of transfer. 1. A review of Resident #101's medical record revealed an admission date of 10/28/24. His/her medical history included metabolic encephalopathy, hemiparesis affecting his/her left side, and history of CVA. A comprehensive minimum data set (MDS) was not completed as the resident was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure the accuracy of a skin assessment when the corresponding assessment did not reflect the actual condition of the skin for one (1) of 36 residents sampled (Resident #39). Inaccurate documentation compromised the facility's ability to provide appropriate and timely care, potentially putting the resident at risk for further complications. The findings included: 1. A review of Resident #39's electronic health record revealed an admission date of 12/24/24, with diagnoses that included Diffuse Traumatic Brain Injury with Loss of Consciousness, Cerebral Infarction due to Occlusion of Stenosis of Small Artery, Morbid Obesity, Muscle Weakness and Repeated Falls. A further review of Resident #39's admission Minimum Data Set (MDS) dated [DATE], noted a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated the resident's cognition was intact. Section M of the MDS noted Moisture Associated Skin Damage (MASD), and no other…

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 review, the facility failed to obtain a physician ordered urinalysis (UA) sample in a timely manner for Resident #5, one (1) of one (1) resident reviewed for laboratory results from a total of 36 residents sampled. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses including but not limited to cellulitis, heart disease, anemia, morbid obesity, infection of unspecified joint, pain and diabetes with diabetic neuropathy. Review of the clinical health record for Resident #5 revealed a physician's order dated 1/3/24 for a UA. On 1/9/25 the laboratory results were requested from the Director of Nursing Services (DON) with reminders provided as other requests were completed. In an interview on 1/10/25 at 5:10 p.m., the DON reported that the 1/3/25 physician's order was executed on 1/10/25 and the sample was earlier that day. There was no reason provided for the delay in obtaining the sample.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and policy review, the facility did not provide meaningful activities on the weekends for two (2) residents (Resident #58 and Resident #78), and did not get one (1) resident out of bed for activities that they wanted to attend (Resident #39) out of 36 residents sampled. The findings include: The facility's policy Activities Program, revised 6/2020, documented under Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. Listed under Policy: The facility provides an Activity Program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests identified through the assessment process. The Activity Program may address areas including but not limited: A. Social Activities: B. Indoor ad…

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 ensure the environment was as free from accident hazards by failing to 1) Ensure residents smoked only in the areas designated by the facility's safety committee in accordance with the facility's policy; and 2) Supervise residents while they smoked in accordance with the facility's policy. This deficient practice affected two (2) of four (4) residents reviewed for accident hazards related to smoking from a total of 36 residents sampled (Resident #13 and Resident #20). The findings include: The facility's policy governing practices for residents who smoke was reviewed. The policy, titled Smoking by Residents contained a revision date of November 2023. The policy's purpose read, To respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. Section II of the policy read, The facility permits smoking only in the area(s) designated by the Facility's Safety Committee. Line X of the procedure read, All smoking sessions will be supervised by Facility Staff members.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure that perineal care was provided in a manner to prevent urinary tract infection for one (1) of 36 residents sampled (Resident #82). The finding included: Review of the facility policy titled, Perineal Care revised 6/2020 revealed the procedures for performing Perineal care, as follows: .A. For female residents: i. Separate the labia. Wash with soapy washcloth/cleansing wipe, moving from front to back, on each side of the labia and in the center over the urethra and vaginal opening, using a clean washcloth/cleansing wipe for each stroke. ii. Rinse area, moving from front to back, using clean washcloth/cleansing wipe for each stroke. iii. Dry area moving from front to back, using a blotting motion with towel. 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included Ventricular Tachycardia, Overactive Bladder, Major Depressive Disorder and Chronic Pain Syndrome. 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 observations, interviews, and record review, facility staff failed to ensure residents fed by enteral means receive the appropriate treatment and services to maintain the resident's nutritional status by failing to monitor the resident's intake and administer supplemental tube feedings for meal intakes less than 50%. This deficient practice affected one (1) of two (2) residents reviewed for tube feeding from a total of 36 residents sampled. (Resident #73) The findings included: 1. A review of Resident #73's medical record revealed an initial admission date of 11/18/24. His/her medical history included dementia and presence of a gastrostomy tube. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 02 from a total of 15 possible points indicating the resident's cognition was severely impaired. The assessment identified the presence of a feeding tube. On 1/8/25 at 1:44 p.m. Resident #73 was observed during the lunch meal sitting in his/her wheelchair at a table in the memory 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.

Based on observation and interview, it was determined the facility failed to ensure the pureed diets were followed according to the menu. This failed practice affected two (2) residents with pureed diets out of 93 residents who received meals from the kitchen. The findings include: Review of the facility policy, Therapeutic Diets, with a revision date of 12/2020, documented under Purpose,- To ensure that the Facility provides therapeutic diets to residents that meet nutritional guidelines and physicians' orders. The policy listed under Procedure, - IV. The Nutrition Services Manager and Dietitian will observe meal preparation and serving to ensure that: A. Each food item, served separately in the regular diet, is pureed and served separately for a pureed diet per the menu spreadsheet and pureed diets. 1. Review of the noon menu, dated 1/9/25, revealed residents with pureed diets were supposed to receive pureed BBQ meatballs, mashed potato and gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread with a beverage. Observation of the preparation of the noon meal…

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 provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week in the first quarter of the fiscal year for October 2022 and November 2022. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The census was 91 residents. Review of the facility's Nursing Department - Staffing, Scheduling & Postings dated 12/2020 showed: -The facility must use the services of a RN for at least eight consecutive hours a day, seven days per week, unless a waiver applies. -The facility will designate a RN to serve as the Director of Nursing (DON) on a full-time basis. -The facility will submit to the Center for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditabel data in a uniform format according to specifications established by CMS. 1. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based…

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 keep the walk-in refrigerator and walk-in freezer floors clean; to maintain sanitary utensils and food preparation equipment; to properly document hot food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 91 residents with a licensed capacity for 130 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 6/5/23 between 9:04 A.M. and 11:53 A.M. showed the following: -On a can dispenser rack in the Dry Storage room there was a 6 pound (lb.) 8 ounce (oz.) can of irregular sliced peaches that was dented on the top rim. -Numerous maroon and gray plastic…

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 establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility; and failed to follow acceptable infection control practices to prevent the spread of infection by not putting proper infection control measures for staff and visitors in place for three days for one sampled resident (Resident #28) who returned from the hospital with an infection, out of 19 sampled residents. This had the potential of affecting all residents in the…

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

Based on interview and record review, the facility failed to provide 12 hours of training/in-services in the last 12 months, from June 2022 to May 2023, to include abuse/neglect prevention, behaviors, resident rights, and training areas of weakness as determined in the nurse assistants performance reviews for three out of three sampled Certified Nursing Assistants (CNA) and abuse/neglect prevention, behaviors, resident rights for two out of two sampled Licensed Practical Nurses (LPN). This had the potential to affect all residents. The facility census was 91 residents. Review of the facility's Care Standards policy dated 6/2020 showed: -Ensure all residents receive necessary care and services that are evidence-based and in accordance with accepted professional clinical standards of practice. -The Administrator or designee maintains copies of current license and/or certification documentation for staff providing direct care to residents. -The Director of Nursing (DON) or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs. -The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) was provided to the resident or their representative for one sampled resident (Resident #355) and to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for three sampled residents (Resident #355, #74 and #20) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 91 residents. Review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -The NOMNC, form…

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 notify in writing the reason for a transfer for three sampled residents, (Resident #42, #71, and #87) who were sent to the hospital out of 19 sampled residents. The facility census was 91 residents. Review of the facility's policy, Transfer and Discharge dated October 24, 2022 showed the facility may transfer a resident for the following reason: -The transfer was necessary for the resident's welfare. -The resident's needs could not be met in the facility. -Documentation relating to the resident's transfer would be maintained in the resident's medical record. -Prior to transfer the Social Services Staff or designee would have provided the resident or responsible party with reasonable notice that the resident was going to be transferred. -The Notice of Transfer would include the following information: -The reason the resident was transferred. -The effective date of the transfer. -The name, complete address and telephone number to which the resident was…

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 residents who were sent to the hospital received a written bedhold policy for three sampled residents, (Resident #42, #71, and #87) out of 19 sampled residents. The facility census was 91 residents. Record review of the facility's policy Transfer and discharge date d October 24, 2022 showed: -Before the Facility transfers a resident to a hospital the Facility would provide written information to the resident or his/her personal representative which specifies: -The duration of the bed-hold during which the resident was permitted to return and resume residence in the nursing facility. -The Facilities policies regarding bed-hold periods permitting a resident to return. -At the time of transfer, the Facility would provide to the resident and a family member or personal representative written notice which specifies the duration of the bed-hold policy, and would inform the resident of his/her right to exercise a bed hold provision. 1. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit Minimum Data Sets (MDS-a federally mandated assessment tool completed by facility staff for care planning) to the Centers for Medicare & Medicaid Services (CMS) system for three sampled residents (Resident #31, #86 and #43) out of 19 sampled residents. The facility census was 91 residents. 1. Review of the CMS System showed that an MDS had not been transmitted for Resident #31 for over 120 days. Review of the CMS System showed no entry tracking form for 6/6/19 for Resident #31. During an interview on 6/12/23 at 11:31 A.M., MDS Coordinator B said: -Resident #31's assessment was completed on 5/9/23 also due on 5/9/23. -It was transmitted on 6/5/23 by the corporate office staff. -Corporate staff were responsible for submission and transmitting. 2. Review of the CMS System showed that an MDS had not been transmitted for Resident #86 for over 120 days. Review of the CMS System showed no entry tracking form for 6/6/19 for Resident #86. During an…

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 oxygen tubing and equipment was stored in a sanitary means, kept clean, and changed out per physician's order for three sampled residents, (Resident #7, #62, and #87) out of 19 sampled residents. The facility census was 91 residents. Review of the facility's policy titled Oxygen Administration, dated 6/20 showed: -All oxygen tubing, humidifiers masks, and cannulas used to deliver oxygen: -Would be changed out weekly and when visibly soiled, or as indicated by state regulation. -Oxygen items would be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #7's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). -Sleep apnea (a potentially serious sleep disorder in which breathing repeatedly…

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 staffing information was posted daily in a prominent place, readily accessible to residents and visitors of the daily resident census, or the number of nursing staff for each shift. This practice had the potential to affect all residents and visitors who were inquiring about the facility staffing hours. The facility census was 91 residents. Review of the facility's Nursing Department-Staffing, Scheduling & Postings policy dated October 24, 2022 showed: -To ensure an adequate number of nursing personnel are available to meet resident needs. -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. --Registered Nurses (RN). --Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN) (as defined under state law). --Certified Nurse Aides (CNA). -Posting requirements: --The Facility will post…

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 sign out a narcotic medication before administering it to one sampled resident (Resident #100), to have two signatures for each shift, resulting in four signatures each day, when counting narcotic medications at the beginning and end of each shift; to ensure the narcotic count sheet was not presigned by one nurse prior to counting narcotic medications; to ensure the narcotic count was accurate and to report a discrepancy of a narcotic count for one sampled resident (Resident #77) out of 19 sampled residents; and to ensure the signature page for the narcotic count sheet had the accurate number of narcotic medication cards for the 500 hall medication cart. The facility census was 91 residents. Review of the facility's policy Storage of Controlled Substances, dated 8/2020 showed: -Medications classified as controlled substances (also known as a narcotic medication- a drug or other substance that is tightly controlled by the government because it may be abused or cause an addiction) are subject to special…

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 Medication Regimen Review (MRR)s were reviewed monthly by a pharmacist, were included in the medical charts, were acted upon and maintained the physician's response to the MRRs for four sampled residents (Residents #47, #40, #28 and #47) out of five residents sampled for unnecessary medications. This practice had the potential to effect each resident's physical and mental well-being. The facility census was 91 residents. Review of the facility's Medication Regimen Review policy, dated August 2020, showed: -The consultant pharmacist was responsible for performing a comprehensive review of each resident's medication regimen and clinical record at least monthly. -The MRR included evaluating the resident's response to medication therapy to determine that the resident maintained the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. -The MRR also involved a thorough 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 the medication refrigerator was checked daily to ensure the temperature was within range. The facility census was 91 residents. Review of the facility's policy, Refrigerator/Freezer Temperature Records dated 12/20 showed: -A daily temperature record was to have been kept for the refrigerated and frozen storage areas. -The services manager or designee was to have recorded daily all refrigerator temperatures on the Refrigerator Temperature Log during A.M. and P.M. shifts. -The refrigerator temperature must be 41 degree Fahrenheit (F) or below. -Temperatures above this should be reported to the service manager. -Corrective action should have been taken to correct the temperature, or the items should have been moved to another storage area to maintain acceptable temperature. 1. Observation on 6/9/23 at 7:47 A.M. of the 500 hall medication refrigerator with Licensed Practical Nurse (LPN) B showed: -The temperature inside the medication refrigerator was 50 degrees F. -The temperature was verified by LPN B to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines, assessments and education for three sampled residents (Resident #355, #28 and #71) out of five residents sampled for immunizations. This practice had the potential to effect all residents. The census was 91 residents. Review of the facility's Pneumococcal Disease Prevention policy, dated 12/1/2017, showed: -The purpose of the policy was to ensure the facility prevented and controlled the spread of pneumococcal disease in the facility. -The facility offered training to facility staff upon hire and inform residents on precautions and best practices to prevent and control the pneumococcal disease in the facility. -The pneumococcal vaccine was recommended for: --All adults [AGE] years of age or older. --Anyone through [AGE] years of age who had long-term health problems such as heart disease, lung disease, and diabetes. -Before offering the pneumococcal vaccine each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one sampled resident's (Resident #25) responsible party when the physician made medication changes, ordered tests, and when the resident had a change in condition out of 19 sampled residents. The facility census was 91 residents. Review of the facility's Change of Condition Notification policy dated 6/2020 showed: -Residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. -The facility will promptly inform the resident, consult with the resident's Attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: --A significant change in the resident's physical, cognitive, behavioral or functional status. --A significant change in treatment. -The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a quarterly review assessment for one sampled resident (Resident #40) out of 19 sampled residents. The facility census was 91 residents. 1. Review on 6/9/23 of Resident #40's most recent Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) showed it was a quarterly MDS dated [DATE]. Review during the survey conducted 6/1/23-6/13/23 of the Centers for Medicare & Medicaid Services (CMS) System showed that an MDS had not been transmitted for the resident for over 120 days. Observation on 6/5/23 at 1:46 P.M. showed: -The resident self-propelling himself/herself out of his/her room in a wheelchair. -The resident asking how to get out said he/she wondered if he/she could go out the window. -The resident went back into his/her room, went to his/her window and tried pulling it up but could not move it. Observation on 6/6/23 showed: -At 10:18 A.M., the resident was lying in bed. -At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately reflect wandering on the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #43) out of 19 sampled residents. The facility census was 91 residents. 1. Review of Resident #43's annual MDS dated [DATE] showed the following staff assessment of the resident: -The resident did not wander (the act of moving from place to place with or without a specified course or known direction and it may or may not be aimless). -An occupation was not listed for the resident. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -The resident did not wander. -An occupation was not listed for the resident. Review of the resident's care plan dated 4/5/23 showed: -The resident was an elopement risk and wandered related to dementia (a progressive mental disorder characterized by memory problems, impaired…

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 laboratory (lab) services as ordered for two sampled residents (Residents #40 and #61) out of 19 sampled residents. The facility census was 91 residents. Review of the facility's undated policy titled Laboratory, Diagnostic and Radiology Services showed: -Lab services would be coordinated pursuant to an order by a physician. -The facility was responsible for the quality and timeliness of services provided by the lab. -Lab results would be maintained as part of the resident's medical record. 1. Review of Resident #40's current orders showed a physician's order dated 4/11/22 for the following labs every three months: -Complete Blood Count (CBC-a test that gives information about blood cells) with differential (CBC with differential-measures the amount of each type of white blood cell in the body which are part of the immune system that helps prevent infections). -Comprehensive Metabolic Panel (CMP-a panel of labs that give information 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 complete a dietary preferences/screen/assessment for one sampled resident (Resident #2) who had ethnic preferences for food out of 19 sampled residents. The facility census was 91 residents. Review of the facility's undated policy titled Resident Preference Interview showed: -The Nutrition Services Manager or designee would meet with the resident within 72 hours of admission or readmission to review the resident's diet, the types of food served at each meal and review the weekly menu and the locations where it was posted. -A Nutrition Screen would be completed upon admission, readmission and no less than annually to capture the resident's preferences. -Resident preferences would be reflected on the tray card and updated in a timely manner. -The Nutrition Services Manager or designee would review the Nutrition Screen with the resident quarterly or more often if requested by the resident to determine if the information is still accurate.…

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 maintain sanitary food serving utensils and preparation equipment; failed to ensure plastic cutting boards were in good condition to avoid food safety hazards; failed to separate damaged food stuffs and keep others free from contamination; failed to refrigerate food stuffs when needed; and failed to keep all kitchen floor areas clean. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 95 residents with a licensed capacity for 130 residents. 1. Observations during the kitchen inspection on 4/5/21 between 9:22 A.M. and 12:18 P.M., showed the following: -In the Dry Storage room the floor felt sticky when walked upon. -There was a 6 pound (lb.) 12 ounce (oz.) can of cut sweet potatoes heavily dented on one side and a 5 lb. 13 oz. dented can of spinach on a can dispensing rack. -There was a sign on the dispensing rack that read, Please Bring All Dented Cans to the Manager's Office. -On a top shelf there was a tub of bran flakes, a tub…

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 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, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. 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 95 with a licensed capacity for 130 residents. 1. Record review of the facility's disaster manual entitled Emergency Preparedness Plan, last reviewed and updated on 2/13/19 and obtained from the north nurse station, showed a 13-page document with the heading Legionella Management Policy that did not include the following requirements: -A facility-specific risk assessment that considers the American…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain physician's orders for an electronic cardiac device for two sampled residents (Resident #61 and #69), and failed to accurately and consistently document the resident's vital signs (temperature, pulse rate, respiration rate, and blood pressure), right and left lung sounds, and respiratory status (e.g. shortness of breath or even respirations) for the resident's COVID (a new disease caused by a novel (new) coronavirus) respiratory assessments and to consistently document symptoms of COVID on the resident's Treatment Administration Record (TAR). The facility also failed to document administration of medications on the Medication Administration Record (MAR) for one sampled resident (Resident #77), out of 22 sampled residents. The facility census was 95 residents. Record review of the Centers for Disease Control and Prevention (CDC) Interim Infection and Control Recommendations for Healthcare Personnel During the Coronavirus, 2019…

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 2. Record review of Resident #7's Face Sheet showed: -He/she was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. -He/she had the following diagnoses: --Polyneuropathy (a condition involving damage to multiple nerves throughout the body outside of the brain and spinal cord; symptoms can include temporary or permanent numbness, tingling, pricking or burning sensations, increased sensitivity to touch, and pain). --Spinal stenosis (narrowing in the spine which puts pressure on the nerves and spinal cord which can cause pain and numbness). Record review of the resident's quarterly MDS, dated [DATE] showed: -Was cognitively intact. -Received as needed pain medication. -Had occasional moderate pain. Record review of the resident's POS showed an order dated 2/2/21 for Norco tablet 5-325 (a prescription medication that combines hydrocodone 5 mg, an opioid pain reliever, with acetaminophen(Tylenol) 325 mg, which is given to relieve moderate to severe pain), one tablet every six…

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 properly contain waste in a garbage can in the kitchen, and in close-lidded dumpsters, to prevent the harboring and/or feeding of pests. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 95 residents with a licensed capacity for 130 residents. 1. Observations during the kitchen inspection on 4/5/21 at 3:45 P.M. outside the Service Hall showed there were two dumpsters side-by-side, both facing northward, with the left lid of the east dumpster left completely open. 2. Observations during a follow-up kitchen inspection and the facility outer perimeter inspection on 4/6/21, showed the following: -At 8:18 A.M., both lids of the east dumpster were completely open. -At 8:40 A.M., a silver trash can with foot pedal next to a sink in the kitchen had its lid propped up approximately 9 inches by the trash piled too high inside. -At 9:43 A.M., the left lid of the east dumpster was completely open. -At 2:23 P.M., the left lid of the east dumpster was…

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 promote dignity when one cognitively impaired sampled resident (Resident #9) was exposed in an incontinence brief and hospital gown visible to the hallway and not dressed daily in appropriate clothing out of 22 sampled residents. The facility census was 95 residents. Record review of the facility's Privacy and Dignity policy revised 6/2020 showed: -The facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect, in full recognition of each residents' individuality. -The staff were to assist the resident in maintaining self-esteem and self-worth. -Residents were dressed appropriate to the time of day and season as well as individual preferences. 1. Record review of Resident #9's admission Record showed the resident was admitted on [DATE] and had the following diagnoses: -Femur fracture (broken thigh bone). -Need for assistance with personal care. -Attention and concentration deficits.…

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 develop an individualized plan and provide an activity program based on the resident's comprehensive assessments and activity preferences to meet the resident's interests and needs for one cognitively impaired sampled resident (Resident #9) and one cognitively intact sampled resident (Resident #72) out 22 sampled residents. The facility census was 95 residents. Record review of the facility's Activities Program policy revised 6/20/20 showed: -The purpose was to encourage residents to participate in activities to make life more meaningful, to stimulate and support mental and physical capabilities to the fullest extent and to enable the resident to maintain the highest social, physical and emotional functioning. -The facility provided an activity program designed to meet the needs, interests, and preferences of the residents. -A variety of activities should be offered on a daily basis which included weekends and evenings. -Activities 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 observation, interview, and record review, the facility failed to ensure tracheostomy care was performed in a manner to reduce the potential for complications for one sample resident (Resident #72), when staff failed to ensure appropriate supplies were available for tracheostomy care, and failed to follow physician's orders and administer oxygen via a tracheostomy shield. As a result, the resident was without his/her correct size inner cannula (the inner trach tube that acts as a liner that can be removed and replaced to prevent the build-up of mucus inside the trach tube) for 59 minutes. The facility also failed to transcribe physician's orders for one closed record sampled resident (Resident #501) for the use of a Bilevel Positive Airway Pressure (BiPAP - a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) out of 22 sampled residents and 16 closed records. The facility census was 95 residents. Record review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received required physician's visits with an alternating personal visit in a rotation of the resident's physician and nurse practitioner for one sampled resident (Resident #61) out of 22 sampled residents. The facility census was 95 residents. Record review of the facility's Physician Services and Visits policy revised 8/2020 showed: -The purpose was that the facility would provide residents with care under an attending physician. -The physician must evaluate the resident at least every 60 days unless there was an alternate schedule or state specific requirement. 1. Record review of Resident #61's admission Record showed the resident was admitted to the facility on [DATE] and had the following diagnoses: -Cerebrovascular Accident (CVA, stroke). -Hemiplegia/hemiparesis (paralysis/weakness affecting one side of the body) -Chronic Kidney Disease (CKD-moderate kidney damage). -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication regime was free of psychoactive medications without adequate indications, and to ensure behaviors were identified for each psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication used to address the resident's psychosocial needs, for use for one sampled resident (Resident #68), failed to ensure a Pro Re Nata (PRN - as needed) antianxiety (a drug that is used to prevent and treat anxiety (an emotion characterized by feelings of tension and worry) medication was limited to a 14 day duration or to indicate a specific duration if the medication was extended beyond that time period, and to ensure nurses documented specific behaviors and non-pharmacological interventions used prior to using a PRN antianxiety medication for one sampled resident (Resident #78) out of 22 sampled residents. The facility census was 95 residents. Record review of the facility Psychotherapeutic Drug…

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.