Stonebridge Adams Street

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to store ice scoops in a manner to prevent contamination and failed cover resident meals in a manner to prevent contamination. Facility staff failed to maintain the ice machine drain air gap. The census was 53. 1. Review of the facility's Food Receiving and Sorage policy, revised July 2014, showed: -Food in desiganted dry storage areas shall be kept off the floor at least 18 inches; -All foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date; -Other opened containers must be dated and sealed or covered during storage; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated. 2. Observation on 12/01/24 at 9:29 A.M., showed the kitchen refrigerator #1 door contained a sign which read Record open and use by dates on all open items. Follow use by manufacturer's date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for six employees (Certified Nurse aide (CNA) I, Licensed practical nurse (LPN) J, Receptionist K, transporter M, Housekeeper N, and nurse aide (NA) B) out of ten sampled employees. Staff failed to perform hand hygiene and/or wash hands to prevent the spread of infection during perineal care for four residents (Resident #9, #14, #38, and #52) of four sampled residents. Failed to implement the Enhanced Barrier…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, facility staff failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet resident's needs for three residents (Resident #20, #49, and #56) out of 14 sampled residents.The facility census was 53. 1. Review of the facility's Comprehensive Care Plans policy, September 2022, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff used to assess the care needs of the resident, assessment. 2. Review of Resident #20's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to safely transfer two residents (Resident #14 and #52) of two sampled residents via mechanical lift, in a manner to prevent accidents. The facility's census was 53. 1. Review of the facility's policy titled, Using a Mechanical Lift Machine, dated July 2017, showed staff were directed as follows: -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Staff must be trained and demonstrate competency using the specific machines or devices used in the facility; -Gently support the resident as he or she is moved, but do not support any weight; -The policy did not contain direction for position of the base legs during the transfer. 2. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/14/24 showed staff assessed the resident as severe cognitive impairment and dependent on staff for transfers from chair to bed/bed to chair. Review of the resident's…

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

Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 27 opportunities observed, seven errors occurred, resulting in a 25.93% error rate, which affected two residents (Resident #16, and #36). The facility census was 53. 1. Review of the Facility's Administering Medications policy, dated 12/2012, showed: -Medications must be administered in accordance with the orders including any required time frame; -Individual administering the medication must check to verify right time; -The Expiration/beyond use date on the medication label must be checked prior to administering, when opening a multi-dose container, the date opened shall be recorded on the container; Review of the Facility's Medication Errors policy, dated 04/2017, showed: -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles or the professional providing services; -Example 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, facility staff failed to store medications in a safe and effective manner when staff failed to properly label, and/or discard expired insulin medications from two of two sampled medication carts. The facility census was 53. 1. Review of the facility's policy titled, Administering Medications, dated 12/2012, showed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 2. Observation on [DATE] at 9:26 A.M., showed the 100/200 hall medication cart contained two Lantus insulin Pens opened and undated. During an interview on [DATE] at 9:30 A.M., Certified Medication Technician (CMT) P said insulin pens are usually only good for 28 days. He/She said the person opening the insulin pen is responsible for putting the open date on the pen. He/She said the risk of not having an open date is you don't know when it expires, and insulin may not be…

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

Based on interview and record review, facility staff failed to contact one resident's (Resident #3) responsible party and physician when the resident had an unwitnessed fall. The facility census 54. 1. Review of the facility's Change in a Resident's Condition or Status Policy, dated 5/2017, showed staff are directed to promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Unless otherwise instructed by the resident a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 2. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated, showed: -Severe cognitive impairment; -Diagnosis of right sided paralysis and vascular dementia; -Dependant on two staff for transfers; -Two falls since prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete neurological checks for three residents (Resident #1, #2, and #3) out of three sampled residents who had unwitnessed falls. The facility census was 54. 1. Review of the facility's Fall Clinical Protocol Policy, dated 09/2012, showed falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such a sliding out of a chair or rolling from a low bed to the floor. Review of the facility's Post Fall Step by Step Policy, undated, showed staff are to complete post fall initial clinical assessment completed one time directly after each fall. Post fall 72- hour monitoring is completed after a no head injury fall once per shift for three days Post fall 72-hour monitoring with head injury is completed on a tapering scale for 72 hours. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete neurological checks and fall follow up documentation for three residents (Resident #1, Resident #2, and Resident #3) of three sampled residents who had un-witnessed falls. The facility census was 55. 1. Review of the facility's Post Fall step by step Protocol, undated, showed first post fall initial clinical assessment is completed one time directly after each fall. Review showed post fall 72 hour monitoring, with a head injury complete assessment is completed according to neurological timelines. 2. Review of Resident # 1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/20/24, showed staff assessed the resident as: -Cognitive impairment; -Dependent for mobility; -Resident at risk for falls with two falls since admission or prior assessment. Review of the resident's care plan, revised 5/15/24, showed staff assessed the resident at risk for falls related to dementia, poor safety awareness, and contractures to…

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

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff also failed to wear hair restraints to protect food and food contact surfaces from potential contamination. The facility census was 53. 1. Review of the Food Safety Requirements policy, dated September 2022, showed the policy directed staff to label and date opened food items and to store foods covered or in air tight containers. Review also showed the policy directed staff to monitor foods so that it is used, frozen (where applicable), or discarded by its use-by date. Observation on 11/14/23 at 10:38 A.M., showed the cook's station contained: -Opened and undated one gallon bottles of red wine vinegar, white distilled vinegar, imitation vanilla…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to update the resident's care plan for one resident (Residents #7) who used oxygen, and for one resident (Resident #19) whose advanced directive changed from a full code to a Do Not Resuscitate (DNR). The facility census was 53. 1. Review of the facility's Care Planning - Interdisciplinary (IDT) team policy dated September 2013, showed: -The facility's care planning/IDT members are responsible for the development of an individualized comprehensive care plan for each resident; -The resident's care plan is based on the comprehensive assessment. Review of the facility's Comprehensive Care plan policy dated September 2022, showed: -The comprehensive care plan will describe, at a minimum, the following: a. services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; b. Any services that would otherwise be furnished, but are not provided due to the residents right 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 observation, interview and record review, the facility staff failed to maintain professional standards of documentation when staff failed to obtain a physician order for the use of assistive devices for four residents (Resident #7, #12, #30, and #37), failed to complete bed rail assessments to show the use of the assistive devices for three residents (Resident #30, #37, and #51) as directed in the facility policy, failed document one resident's skin weekly as ordered (Resident #53), and failed to consult with the physician on a dietary recommendation for a supplement on one resident (Resident #53). The facility census was 53. 1. Review of the facility's Proper Use of Side Rails Policy, dated September 2022, showed: -Facility will provide necessary treatment and care to the resident who has bed rails (assist bars) in accordance with professional standards of practice and the residents choice. That should be evidenced in the resident's records, including their care plan, including but not limited to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to to clean and store respiratory equipment and devices in a manner to prevent the spread of infection for nine residents (Residents #7, #10, #14, #17, #26, #34, #36, #46, and #51). The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for oxygen use, cleaning, and/or storage. Review of the facility's Infection Prevention and Control Manual General Policies Cleaning and Disinfecting Nebulizer Equipment, dated 2017, showed staff were directed to do the following: -Apply gloves; -Disassemble the nebulizer by removing the cup and mask or mouthpiece; -Thoroughly clean all visible soil or organic material from the cup, mask, or mouthpiece before disinfection; -Use warm water and mild dish detergent to was the nebulizer parts or follow manufacturers recommendations; -Shake an excess water off the cup and air dry on a clean surface, do not place directly on a contaminated surface; -Replace…

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

Based on observation, interview, and record review, facility staff failed to store and label medications and biologicals in a safe effective manner for one of two medication carts, one treatment cart, one of two medication storage rooms, one crash cart, and two resident's (Resident #12 and #37) rooms. The facility census was 53. 1. Review of the facility's policy titled, Storage of Medications, revised April 2007, showed staff were directed to do the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed; -Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff failed to announce themselves and wait for permission before entering the room for one resident (Resident #34), hung visible care signs for one resident (Resident #21) fluid consistency, and failed to provide privacy by ensuring the door was closed during a medication injection and blood glucose test for one residents (Resident #20). The facility census was 53. 1. Review of the facility's Nursing Home Residents' Rights pamphlet and Resident and Family Handbook, undated, showed the residents have a right to a dignified existence and be treated with consideration, respect, and dignity, recognizing each residents individuality and to privacy during treatment and care of personal needs. Review of the facility's Dignity policy, dated September 2022, showed: -All staff members are involved in providing care to residents to promote and maintain resident dignity 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, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when a staff member did not release the resident's wrists during a transfer, and then forcefully pushed the resident in the stomach with closed fists, resulting in a bruise to the resident's arm. The facility census was 54. The administrator was notified on 8/09/23 of Past Non-Compliance which occurred on 7/27/23. On 7/27/23, the administrator identified Certified Nursing Assistant (CNA) A physically abused the resident. Upon discovery, staff suspended the employee, conducted an investigation, notified the appropriate parties and agencies, and terminated the CNA. Facility staff reviewed their abuse and neglect policies, and inserviced all employees on abuse and neglect. Staff corrected the deficient practice on 7/27/23. 1. Review of the facility's Abuse/Neglect/Exploitation Compliance and Overview Policy, dated 9/2022, showed the purpose is to assure the facility is doing all within its control to prevent occurrences of abuse, neglect, or exploitation 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 interview and record review, facility staff failed to maintain a surety bond sufficient to ensure protection of resident funds for 18 of 18 sampled residents. The facility held funds for a total of 18 residents. The facility census was 53. 1. Review of the facility's Resident Trust Fund Account Policy and Procedure, dated 11/28/16, showed the facility has a current surety bond in the amount equal to at least one and one-half times the average total of the monthly balances and will be reviewed annually. Review of the facility's resident fund account bank statements from May 2021 through April 2022, showed an average monthly balance of $29,324, which would require a bond of $43,986. Review of the Department of Health and Senior Services (DHSS) approved bond list, dated 4/17/18, showed the facility had a bond for $30,000. During an interview on 6/1/22 at 10:05 A.M., the Business Office Manager (BOM) said he/she is new to the position and is still learning. He/she said he/she was unaware the bond needed to be an average of one and a half times the amount for the preceding 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, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical, and nursing needs when they failed to address the code status for two residents (Resident #30 and #203), failed to address falls for one resident (Resident #21) and failed to address oxygen use for one resident (Resident #38). The facility census was 53. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated [DATE], showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan will: -Describe the services that are to be furnished to attain or maintain the resident's highest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to revise the care plan for two residents (Resident #26 and Resident #29) who had a change in code status, and one resident (Resident #35) who received an anticoagulant (medication used to thin the blood to reduce the risk of blood clots). Additionally, staff failed to follow the care plan for two residents (Resident #26 and Resident #43) one of which was at risk for falls and required the use of fall mats. The facility census was 53. 1. Review of the facility's Comprehensive care plan policy, dated [DATE], showed: -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes; -The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. 2. Review of the facility's Advanced Directives policy,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide care consistent with professional standards of practice when they failed to document assessments, and contact the physician for two residents (Residents #27 and #210) who sustained falls at the facility, failed to obtain a physician's order for one residents (Resident #21) code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) and one residents (Resident #38) oxygen. Additionally, staff failed to clean and maintain oxygen concentrator filters for one resident (Resident #44) who was dependant on oxygen. The facility census was 53. 1. Review of the facility's Clinical Protocol for Falls, dated [DATE], directed staff: -Staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events, etc.; -The staff, with the physician's guidance, will follow up on any fall 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to obtain a physician's order for an indwelling urinary catheter (tube inserted into the bladder to drain urine) and an indication for the use of the catheter for one resident (Resident #21). Additionally, staff failed to obtain orders for catheter care, and catheter/balloon size for two residents (Resident #21 and #203), one of which had a Urinary Tract Infection (UTI). The facility census was 53. 1. Review of the facility's Physician Services policy, dated April 2013, showed it did not contain direction for staff in regards to catheter orders or care of catheters. Review of the facility's Catheter Care, Urinary policy, dated September 2014, showed the purpose of the procedure is to prevent catheter-associated urinary tract infections (CAUTI) and directed staff to document: -The date and time catheter care was provided; -The name and title of the individual providing the catheter care; -All assessment data obtained while providing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to complete ongoing assessments to assure bed rails were used to meet the resident's needs, for three residents (Resident #7, #10, and #50). The facility census was 53. 1. Review of the facility's Proper Use of Side Rails Policy, dated October 2017, showed: -The facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need and determination when the side rail/bed rail will be discontinued; -The use of side rails/bed rails as an assistive device will be addressed in the residents' care plan and Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. 2. Review of Resident 7's Quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Diagnoses of Heart failure and chronic Atrial Fibrillation (irregular and fast heart rate); -Required extensive assistance from one staff member for bed mobility; -Did not use bed rails.…

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 interviews, the facility staff failed to store food in a manner to prevent cross-contamination and out-dated use. The facility census was 53. 1. Review of the facility's Food Receiving and Storage policy, dated 2001, showed: -Foods shall be received and sstored in a manner that complies with safe food handling practices; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system; -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -Uncooked and raw animal products and fish will be stored separately in drip-prood containers and below fruits, vegetables and other ready-to-eat foods. Observation on 05/31/22 at 9:18 A.M., showed six clear containers on a three-tier cart with dry cereal, not labeled or dated. Obervation on 05/31/22 at 9:24 A.M., showed the dry storage area contained a clear bag of dry ceral not labeled or dated. Further observation showed a clear container with a teal lid, not dated or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #11) had an appropriate indication and diagnoses for the use of an anitpsychotic medication (medication that alters brain activity) and failed to contact the physician with pharmacy recommendations for Gradual Dose Reductions (GDRs) (a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for psychoactive medications for two residents (#32 and #38). The facility census was 53. 1. Review of the facility's Medication Regimen Review (MRR) policy, dated 10/17, showed: -A review of psychotropic drug use will occur with every MRR. A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. These drugs include but are not limited to, drugs in the following categories, anti-psychotic, anti-depressant, anti-anxiety and anti-hypnotic; -The pharmacist should report…

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.