Hubble Creek

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed for one resident (Resident #12) and failed to ensure a physician's order for oxygen with the use of a bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) was followed for one resident (Resident #195) out of two sampled residents. The facility census was 45. Review of the facility's policy titled, Oxygen Administration, undated, showed: - The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; - Prefilled disposable humidifiers may be changed when empty; - Set the flow meter to the rate ordered by the physician; - Label the humidifier with the date and time opened; - Change humidifier and tubing per cleaning guidelines; - At regular intervals, check and clean the oxygen equipment, masks, tubing and cannulas; - At regular intervals, check the liter flow contents of the oxygen cylinder, fluid level 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 ensure two nurse aides (NAs) (NA B and NA C) completed a nurse aide training program within four months of his/her employment in the facility out of two sampled NAs. This deficient practice had the potential to affect all residents in the facility. The facility census was 45. The facility did not provide a policy on the nurse aide training program. 1. Review of NA B's Training Record showed: - Hire date of 06/12/24; - NA B attended an online nurse aide program; - The facility failed to ensure the completion of the program within four months of the hire date. 2. Record review of NA C's Training Record showed: - Hire date of 06/25/24; - NA C attended an online nurse aide program; - The facility failed to ensure the completion of the program within four months of the hire date. During an interview on 11/07/24 at 9:30 A.M., the Director of Nursing (DON) said the currently employed NAs were taking nurse aide training through an online program. She thinks NA B and NA C had completed the program and were waiting on permission 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 interview and record review, the facility failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide annual in-service training based on the outcome of performance reviews for two Certified Nurse Assistants (CNAs) (CNA D and CNA E) out of two sampled CNAs. The facility census was 45. The facility did not provide a policy on CNA performance review and training requirements. 1. Review of CNA D's in-service record showed: - CNA D with a hire date of 02/22/22; - CNA D did not receive an annual individual performance review or evaluation; - No annual in-service training for February 2023 through February 2024. 2. Review of the CNA E's in-service record showed: - CNA E with a hire date of 02/18/15; - CNA E did not receive an annual individual performance review or evaluation; - No annual in-service training for February 2023 through February 2024. During an interview on 11/07/24 at 9:00 A.M., the Administrator said no employee performance reviews or evaluations had been done since she started in May 2024, and there was no…

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 an appropriate diagnosis for the use of an antipsychotic (medications that treat psychosis-related conditions and symptoms) medication for one resident (Resident #37) out of five sampled residents. The facility census was 45. Review of the facility's policy titled, Antipsychotic Medication Use, not dated, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record: schizo-affective disorder (a chronic mental illness that combines symptoms of schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and a mood disorder (a mental health condition that involves a persistent change in a person's emotional state)), mood disorders, depression (a mood disorder that causes a persistent feeling of sadness 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, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two errors made, for an error rate of 6.25%, which affected two residents (Residents #33 and #195) out of six sampled residents. The facility census was 45. The facility did not provide a medication error policy. Review of the insulin aspart manufacture guidelines for giving the airshot (prime) before each injection and administration, revised 02/2023, showed: - Turn the dose selector to select 2 units; - Hold the pen with the needle pointing up; - Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; - Keep the needle pointing upwards, press the push-button all the way in; - The dose selector returns to zero; - A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; - Select your dose. 1. Review of Resident #33's Physician Order Sheet (POS), dated November 2024,…

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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect the thirteen residents who were served food from the 400 Hall refrigerator. The facility census was 45. Review of facility policy titled, Receiving and Storage of Food, dated May 2015, showed: - All perishable items are stored in either refrigerators at a temperature of 40 degrees Fahrenheit (F) or below or freezers at a temperature of 0 degrees F or below. The facility did not provide refrigerator temperatures for the 400 Hall. 1. Observation on 11/07/24 at 12:10 P.M., of the 400 Hall unit refrigerator showed: - A temperature of 50 degrees F; - An opened container of milk, unlabeled and undated; - A pitcher of a purple liquid, unlabeled and undated; - An unopened container of yogurt. 2. Observation on 11/07/24 at 2:00 P.M., of the 400 Hall unit refrigerator showed: - A temperature of 50 degrees; - An opened container of milk, unlabeled and…

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

Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 45 residents who reside at the facility. The facility's census was 45. The facility did not provide a policy regarding the QAA Committee. The facility did not provide QAA Committee Attendance records prior to September 2024. Review of the QAA Committee Attendance record, dated September 2024, showed the IP did not attend the meeting as required. During an interview on 11/06/24 at 8:50 A.M., the Administrator said the IP did not attend the QAA meeting because he/she had been working as the charge nurse on the night shift. She did not have the QAA Committee Attendance records prior to September 2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment by not wearing source control (facemasks) during a Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 - a member of a large family of viruses called coronaviruses) outbreak. This deficient practice had the potential to affect all residents in the facility. The facility's census was 45. Review of the Infection Control Guidance, provided by the Centers for Disease Control and Prevention (CDC), updated on 05/08/23, showed: - Source control is recommended for those working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of a respiratory infection; - Universal use of source control could be discontinued once the outbreak is over; - Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility. Review of the facility's policy titled, Outbreak…

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 conduct at least twelve hours of certified nurse assistant (CNA) in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two CNAs (CNA D and CNA E) out of two sampled CNAs. The facility census was 45. The facility did not provide a policy on nurse aide training requirements. 1. Review of Certified Nursing Assistant (CNA) D's in-service record showed: - A hire date of 02/22/22; - Did not attend an annual competency in-service training on Dementia Care; - No annual in-service training for February 2023 through February 2024; - Less than twelve hours of in-service education for February 2023 through February 2024. 2. Review of CNA E's in-service record showed: - A hire date of 0218/15; - Did not attend an annual competency in-service training on Dementia Care; - No annual in-service training for February 2023 through February 2024; - Less than twelve hours of in-service education for February…

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 resident care for activities of daily living (ADLs) when residents did not receive scheduled showers for three residents (Residents #1, #2, and #3) out of three sampled residents. The facility census was 38. The facility did not provide a policy regarding shower frequency. 1. Review of Resident #1's medical record showed: - admission date of 10/23/23; - Diagnoses of osteoporosis (a decrease in bone mass and density) with fracture, muscle weakness, disc degeneration (a condition in which damaged disc causes pain), history of falling, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), lack of coordination, and frontotemporal neurocognitive disorder (a disorder when nerve cells of parts of the brain are lost, which can affect behavior, personality, language and movement). Review of the resident's quarterly Minimum Data Set (MDS, a federally…

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 protect one resident's (Resident #1) right to be free from physical abuse when Certified Nurse Assistant (CNA) C slapped Resident #1's hand in an effort to make him/her release items that did not belong to the resident. The facility census was 39. Review of the facility's policy titled, Abuse Prevention, not dated, showed: - The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; - Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone; - Ensure reporting of crimes against a resident or individual receiving care from the facility occurring in nursing homes within prescribed timeframes to the appropriate entities; - Ensure that all covered individuals, such as the owner, operator, employee, manager, agent or contractor report reasonable suspicion of crimes; -…

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 resident care for activities of daily living (ADL's) when the residents did not receive a minimum of two showers per week for three residents (Resident #1, #2, and #5) out of three sampled residents. The facility census was 39. The facility did not provide a policy related to shower frequency. Review of the shower list showed: - Resident #1 scheduled for showers two times weekly; - Resident #2 scheduled for showers two times weekly; - Resident #5 scheduled for showers two times weekly. 1. Review of Resident 1's medical record showed: - An admission date of 01/22/20; - Diagnoses of hypertension (high blood pressure), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (severe ongoing anxiety that interferes with daily activities). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the…

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

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 40. Review of the facility's policy titled, Nutrition and Dining Services Manual policy, dated May 2015, showed: - It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; - Develop detailed cleaning schedules to ensure sanitation is at acceptable standards. Review of the facility's Food Storage policy, undated, showed: - All foods will be considered as leftovers unless in the original container with an expiration date; - Leftovers will be discarded after third storage day; - All food will be stored in appropriate containers. 1. Observation on 08/01/23 at 9:45 A.M., of the dry food storage room, showed: - One 35 pound (lb.) cooking oil container sat on the floor; - One 7 lb. dented can with apple pie filling on the canned food…

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 the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 40. The facility failed to provide a policy regarding dumpster maintenance. 1. Observation of the dumpster area on 08/01/23 at 4:00 P.M., and 5:02 P.M., showed: - One 8 yard (yd.) dumpster partially filled with one plastic lid completely opened. 2. Observation of the dumpster area on 08/02/23 at 11:44 A.M., and 12:42 P.M., showed: - One 8 yd. dumpster partially filled with one plastic lid completely opened. 3. Observation of the dumpster area on 08/03/23 at 4:05 P.M., and 5:02 P.M., showed: - One 8 yd. blue dumpster partially filled with one plastic lid completely opened; - Three clear disposable gloves lay on the ground near the dumpster with other scattered debris. 4. Observation of the dumpster area on 08/04/23 at 9:43 A.M., and 10:32 A.M., showed: - One 8 yd. blue dumpster partially filled with one plastic lid completely opened; - A 12…

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 provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 40. Observation on 08/04/23 at 11:05 A.M., of the building showed: - Water dripped from a light fixture into a 6 inch (in.) puddle on the floor in front of the admissions office; - A 6 in. brown stain on the ceiling near the speaker by the business office; - A 1 in. by 6 in. brown stain to the left and right of the light fixture located in the ceiling outside the business office; - A 4 in. dark brown ring on the ceiling near room [ROOM NUMBER]; - An approximately 8 to 10 in. brown stained area on the dining room ceiling; - Multiple brown rings on the ceiling in the dining room near the window; - Damage to five ceiling tiles in the hallway outside of rooms [ROOM NUMBERS]; - Five brown streaks down the wall approximately 8 feet long between rooms [ROOM NUMBERS]; - Damage to the edges of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for six residents (Residents #4, #7, #9, #10, #36 and #40) out of 12 sampled residents. The facility census was 40. Review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered, undated, showed: - An individualized comprehensive care plan will include measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment; - Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; - A well developed care plan will: Be developed within seven days of the completion of the Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff; Prevent avoidable decline in function; Manage risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently document residents' code status with Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for two residents (Residents #7 and #40) out of 12 sampled residents. The facility census was 40. Record review of the facility's policy on Advance Directives, undated, showed: - Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical surgical treatment and the right to formulate an advance directive. - The social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive. - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for two residents (Residents #7 and #35) out of two sampled residents. The facility census was 40. Record review of the facility's policy titled, Use of Restraints, undated, showed: - Restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; - Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; - The definition of a restraint is based on the functional status of the resident 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 the accuracy of the Minimum Data Set (MDS) assessments, a federally mandated assessment to be completed by the facility staff, for two residents (Residents #9 and #35) out of 12 sampled residents. The facility census was 40. The facility did not provide an accuracy of the MDS assessment policy. 1. Review of Resident #9's annual MDS, dated [DATE], showed: - The resident did not receive antidepressant (a medication used to treat depression) medication; - The resident received antipsychotic (medication used to treat psychotic disorders) medication seven out of seven days; - The resident required total assistance of one staff for transfers. Review of the resident's Physician Order Sheet (POS), dated August 2023, showed: - A diagnosis of depression (a constant feeling of sadness and loss of interest); - An order, dated 07/19/23, for sertraline (an antidepressant) 25 milligram (mg) one tablet by mouth once a day at 6:00 P.M.; - No order…

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 closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #41) out of one sampled discharged resident. The facility census was 40. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Complete a discharge summary and post-discharge plan of care form, include the list of medications, the post-discharge care, the person responsible for the care to sign the discharge summary and the post-discharge care form, give a copy to the resident and/or representative, and place in the medical record. DEFINITIONS §483.21(c)(1) states: Discharge planning begins at…

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

Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #41) out of one sampled discharged resident. The facility census was 40. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Complete a discharge summary and post-discharge plan of care form, include the list of medications, post-discharge care, the person responsible for the care to sign the discharge summary and the post-discharge care form, give a copy to the resident and/or representative, and place in the medical record. 1. Review of Resident #41's closed medical record showed: - The resident discharged on 07/25/23; - The Managed Care Discharge to Long Term Care Summary, dated 07/25/23, showed the planning and recommendations for post-discharge section not completed, and the recapitulation section not completed; - No documentation of a comprehensive discharge summary. 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.

Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #4) out of 12 sampled residents. The facility census was 40. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #4's Physicians Order Sheet (POS), dated August 2023, showed: - Diagnoses of multiple sclerosis (a disease that results in nerve damage disrupting the communication between the brain and body), contracture (a condition of shortening or hardening of the muscles) of the left ankle, and contracture of right ankle; - An order, dated 04/13/21 for Dynasplint (a stretching device that helps increase joint range of motion) braces to be worn eight hours a day while supine (on back with face and abdomen facing up) in bed; - An order, dated 04/13/21, to monitor for skin breakdown when doffing (removing) the braces. Review of the resident's medical record showed: - No documentation of the application of the braces; - No documentation of the monitoring of the skin on removal of the braces; - No documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in two occupied resident room sinks (Residents #23 and #35), which put the residents at an increased risk of injuries from exposure to the hot water. The facility failed to assess three of three sampled residents who were identified as residents who smoke (Residents #4, #36 and #40) to ensure they were able to smoke safely. The facility also failed to ensure staff utilized safe transfer techniques for two of eight sampled residents (Residents #7 and #9). These practices had the potential to affect all the residents at the facility. The facility census was 40. The facility did not provide a policy regarding water temperatures. Review of the Burn Foundation website showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting 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 ensure one resident (Resident #3) out of seven sampled residents who were incontinent of bowel and bladder received appropriate treatment and services after an incontinent episode. One resident was left without personal care for over six hours, resulting in the resident's brief being saturated with urine. The census was 40. The facility did not provide a policy. 1. Review of Resident #3's Significant Change MDS, dated [DATE] showed: - Transfer and bed mobility to be total dependant with assist of two plus staff; - Toilet use to not have occurred; - Personal hygiene to be total dependant with assist of one staff; - Totally incontinent of bowel and bladder; - At risk of pressure ulcer development with intervention of a pressure reducing cushion for bed/chair; - Stage one pressure ulcer. Review of the resident's current care plan, date 07/21/23, showed: - Staff to assist with ADLs, incontinent care, and transfers with use of hoyer lift; -…

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 the nurse aide's annual individual performance review or evaluation for one certified nursing assistant (CNA) out of two sampled CNAs. The facility census was 40. The facility did not provide a policy for nurse aide annual individual performance review or evaluations. Review of the facility's employee records for July 2022 through August 2023, showed: - CNA D had a hire date of 01/18/10; - No documentation that CNA D received an annual individual performance review or evaluation. During an interview on 08/03/23 at 3:30 P.M., CNA D said he/she had worked at the facility for 14 years and had not received any annual performance reviews. During an interview on 08/04/23 at 8:45 A.M., the Administrator said they did not perform performance reviews on nurse aides annually.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two medication carts and one medication storage room. This had the potential to affect all residents. The facility census was 40. Review of the facility's policy titled, Narcotic Count, undated, showed: - The purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies; - The narcotic supply is to be kept under two locks at all times; - One Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify the accuracy of the narcotics supply for each individual resident at each shift change; - Narcotic records are reconciled by physical count of the remaining narcotic supply at each shift change by incoming and outgoing licensed nurse. Emergency kits containing narcotics will be checked at the same time 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 interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) of a psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) for three residents (Resident #3, #23 and #30) out of five sampled residents. The facility's census was 40. The facility did not provide a GDR policy. 1. Review of Resident #3's medical record showed: - admission date of 08/01/03; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations), bipolar disorder (a mental disorder that causes unusual shifts in mood), and Alzheimer's disease (progressive mental deterioration), and intellectual disabilities; - An order, dated, 02/26/21, for Trileptal (a mood stabilizer) 600 milligram (mg) one tablet twice a day, for bipolar disorder; - An order, dated, 06/09/22, for mirtazapine (an antidepressant) 7.5 mg one tablet daily for depression; - No documentation of an attempted GDR for Trileptal since 06/14/22; - No documentation of an attempted GDR for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility also failed to ensure one resident (Resident #13) outside of the sample of 12 residents had a physician's order to keep an inhaler (hand-held portable device that delivers medication to the lungs) at the bedside and to store medications in a safe and effective manner when staff left the medications cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents The facility census was 40. Review of the facility's policy titled, Bedside Medication Storage,dated 3/2015, showed: - If a resident expresses a desire to self-administer medication, the interdisciplinary team (team members from different disciplines who actively coordinate to work toward shared treatment goals) must assess the resident's cognitive, physical and visual ability to carry out this responsibility. The mental…

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 quarterly Quality Assurance Assessment (QAA) Committee (those responsible for identifying and responding to quality deficiencies that are identified in the facility) meetings with the required members. The facility's census was 40. Review of the facility's 2023 Quality Assurance and Performance Improvement (QAPI) (a program to improve processes for the delivery of health care and quality of life for the resident) Plan showed: - The purpose will be to take a proactive approach to continually improve the way staff care for and engage with the residents, caregivers, and other partners. To do this, all employees will participate in the ongoing QAPI efforts which support the facility's vision and mission; - Key monitors are measured and trended on a quarterly basis; - At minimum, the leadership will report annually on the status of the current QAPI plan as well as the proposed plan and goals for the coming year; - In addition, the QAPI Steering Committee will implement any Performance Improvement Projects (PIP) topics…

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 and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects, or warnings of those immunizations for four residents (Residents #7, #10, #36 and #40) out of five sampled residents. The facility census was 40. Review of the facility's policy titled, Immunizations, undated, showed: - Resident's physician will be consulted and determine the level of risk and need for vaccinations; - A physician order is required to administer any medication/vaccination; - Influenza (flu) is recommended annually for all residents; - Pneumococcal (an infection caused by a type of bacteria that can cause pneumonia) vaccination in persons ages 65 years and older, unless contraindicated - Adults 65 years or older who have not already received a Pneumococcal conjugate vaccine should receive either a single dose of Pneumococcal…

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.