Ignite Medical Resort Carondelet LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of practice when administering insulin (a hormone that regulates blood sugar), without cleansing the insulin pen rubber septum with alcohol prior to applying the pen needle and injecting insulin for two supplemental residents (Resident #75 and #115) out of 6 supplemental residents. The facility census was 105 residents. Review of the facility's Injections Policy last reviewed/revised in May 2023 showed there was no instruction given to clean pen septum prior to drawing up insulin.1. Review of Resident #75's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus (DM a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).Review of the resident's Physician's Order Sheet (POS) showed:-Humalog (a fast-acting insulin used to control high…

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 multiple shower refusals were reviewed and documented for a potential reason for the shower refusals, and failed to review and document preferences for bathing or shower days and preferred shower times, for one sampled resident (Resident's #19), who refused 5 out 5 showers since his/her admission; and failed to ensure one sampled resident (Resident #12) who required staff assistance with activities of daily living (ADL's) had the call light placed within his/her reach out of 21 sampled residents. The facility resident census of 105 residents. The facility's Bathing/Shower Program policy was requested and not received at time of exit. Review of the facility's Call Light-Ability to Use policy last revised/reviewed in January 2024, showed:-The call light system is provided as a tool for residents to communicate with staff.-Residents will be evaluated for ability to use call light on admission, quarterly and annually.-If residents are…

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 sampled resident (Resident #93) had access to an adaptive call light device and that the call light was within reach; and failed to implement ordered pressure injury prevention interventions, including the application of Prevalon boots while in bed. This failure placed the resident at risk for unmet needs, delayed assistance, and increased risk for pressure injury development out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Call Light-Ability to Use policy revised January 2024 showed:-The call light system was provided as a tool for residents to communicate with staff.-Residents would be evaluated for ability to use call light on admission, quarterly and annually.-If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) would be provided.-If residents are determined to be cognitively unable to use call lights, residents…

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 there were physician orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that treats sleep disorders by delivering a steady stream of air through a pressurized mask) for one sampled resident (Resident #18) out of 23 sampled residents. The census was 105 residents. Review of the facility policy titled Physician Orders revised dated May 2023 showed:-Orders may be called, handwritten, fax, or electronically generated by physician. -The physician's orders must be documented completely with sufficient content to clearly convey the provider's intent. Indication for PRN (as needed) orders should be included in the order.-After the authorized provider had completed the orders, the Registered Nurse (RN) or Licensed Practical Nurse (LPN) was responsible to promptly and accurately transcribe all written orders. The RN or LPN must include his/her signature, the date and time of the transcription and credentials.-Orders that were unclear must be clarified prior to implementation.1.…

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 dialysis (a medical treatment that filters waste products and excess fluid from the blood when the kidneys fail, acting as an artificial kidney to keep the body in balance) orders for monitoring the dialysis site were complete to show the thrill (the buzzing vibration felt on the skin over a vascular access (like an AV fistula) from rapid blood flow), and bruit (the whooshing sound heard with a stethoscope, both indicating the access was working properly) would be checked daily; failed to monitor the resident's dialysis site according to the facility protocol; failed to document that the monitoring was completed; and failed to develop a care plan that included how the facility would monitor the resident's dialysis site for one sampled resident who received dialysis (Resident #57) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Dialysis policy and procedure dated April 2023 showed:-Any line dressings will be done at dialysis unless specifically ordered to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure follow-up dental appointments were made, which resulted in delay in dental treatment for one sampled resident (Resident #77) who was at risk for dental pain and infection out of 21 sampled residents. The facility Census of 105 residents. Review of the facility's Physician Order Policy dated May 2023 showed:-To clarify requirement and assure that all physicians orders were valid and safe for resident care. -Licensed nursing staff were responsible to promptly and accurately transcribe all written order. Review of the facility's Dental Services policy revised on April 2023 showed:-The admitting nurse performs a dental assessment on each resident upon admission. -If dental care is needed the nurse informs the resident and responsible party. -If the resident would like to use the facility dentist, that dentist will be notified.If the feels that there is a dent emergency, then the attending physician is notified for possible transfer 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 failed to ensure a comfortable and homelike environment for 64 sampled residents out of 73 sampled residents with room temperatures ranging from 81.8 degrees Fahrenheit (°F) to 87.0 °F and halls A, B, C, D and F temperatures ranged from 81.5 °F to 82.8 °F. The facility had failed to have a comprehensive monitoring system including documentation for the air temperatures to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring. This had the potential to affect all residents in the building. The facility census was 116 residents. Review of the facility's Emergency Operations Plan policy dated 4/1/23 showed: -Temperature thresholds: --Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature as established by the National Oceanic and atmospheric Administration, inside the facility exceeds 80 degrees F. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain appropriate staffing numbers to adequately provide resident care and meet resident needs. This had the potential to affect all residents who resided at the facility. The census was 122 residents. A policy regarding staffing by acuity was requested and not received at time of exit. 1. Review of the working staff schedules, dated 1/1/24 to 1/30/24 showed: -The facility had seven halls where residents resided; A-D were long term care, F-H were rehabilitation. -Each hall was assigned one Certified Nursing Assistant (CNA) each shift. -Nurses were each assigned to two halls per shift. -On 1/1/24 (holiday), two halls (F and G) did not have a CNA assigned during the day, and one hall (G) did not have a CNA at night. -On 1/2/24, two halls (D and G) did not have a CNA assigned at night. -On 1/3/24, two halls (C and H) did not have a CNA assigned during the day, and one hall (F) did not have a CNA at night. -On 1/5/24, one hall (F) did not…

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 sheets were posted daily, visible, and accessible to residents and visitors at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 122 residents. Review of the facility's policy, dated April 2023, titled Posting of Nursing Hours showed: -Each day staff were to post, at the facility entrance, the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) scheduled; the name of the facility; the census of the facility; and the total number of hours for each position. -Staff were to post the staffing sheet to be accessible for residents, family members, and visitors. -Staff were to instruct residents on the location of the daily staffing sheet at admission. 1. Observation on 1/23/24 at 11:25 A.M. showed: -No staffing sheet was posted at the main entrance. -One staffing sheet was found…

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 appropriate medication storage throughout the entire facility which had the potential to affect all residents within the facility. The facility census was 122 Residents. Review of the facility's policy titled Medication Storage dated January 2020 showed: -All drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements. -Each prescription medication label includes: --Resident's name. --Specific direction for use, indicating route of administration. --Medication name. --Strength of medication. --Physician's name. --Date medication was dispensed. --Quantity. --Expiration date if medication not used within 24 hours. --Expiration time if medication expires in less than 24 hours. -- Name, address, and telephone number of provider pharmacy. --Prescription number. -Upon opening of insulin pens, the licensed nurse will write the date of expiration. -Nonprescription medications not labeled by the pharmacy are kept in the manufacturer'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 and interview, the facility failed to maintain the floors under the automated dishwasher free of broken dishes, grime and debris; failed to prevent a buildup of dust on the fan blades in the dishwasher area; failed to repair a leak from one of the sinks of three-compartment sink across form the food preparation table; failed to maintain the floor under the convection oven and the six-burner stove keeping it free of grease, grime and food debris; failed to ensure there was an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the drainage hole in the floor; failed to ensure the mops and brooms were stored properly in the mop closet; failed to ensure three light fixtures in the kitchen area illuminated; failed to remove food debris from the upper nozzles of the automated dishwasher; failed to ensure two of three cutting boards were free from numerous nicks and grooves; failed to remove dust from the ceilings over the food preparation area; failed to ensure a bottle…

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 handwashing to prevent cross-contamination was completed prior to and during incontinence care for two sampled residents (Resident #90 and #69); failed to ensure appropriate hand hygiene was completed during medication administration for one sampled resident (Resident #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate); and failed to ensure appropriate hand hygiene was completed during wound care for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Administration of Medications via PEG Tube dated March 2023 showed no indication of when hand hygiene needed to be performed during the procedure. Review of the facility's policy titled Gloves dated April 2023 showed: -Gloves were worn when…

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 maintain the kitchen steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature in high-volume businesses such as kitchens) in a safe operating manner by not maintaining one well (a section of the steam table) in a working manner. This practice potentially affected 119 residents who ate food from the kitchen. The facility census was 122 residents. 1. Observation on 1/23/24 at 10:53 A.M., during the initial kitchen observation, showed one well of the steam table well not operating due to the burner of that steam table not properly connected and loosely hanging under the steam table. During an interview on 1/25/24 at 12:38 P.M., the Dietary Manager (DM) said: - A service technician came to the facility back in 11/23 to work on the steam table. - That service technician said he/she could not work on the steam table because the wires were not connected properly and were all over. During a phone interview on 2/7/24 at 12:19 P.M., the Service Manager from the service company said: -…

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 call light system operated as per the manufacturing guidelines and with the exception granted to the facility on [DATE], by failing to ensure that all Certified Nurse's Aide (CNAs) had pagers, failed to ensure the pagers operated properly, failed to ensure the call light activation devices in the resident rooms operated properly, and failed to ensure call lights were being answered timely for three sampled residents (Resident #23, #96 and #69) out of 33 sampled residents. This practice potentially affected all residents. The facility census was 122 residents. 1. Review of the Exception letter dated 10/13/21, showed: -19 CSR 30-85.012 paragraph (124) Facilities shall provide an electrically powered nurses' call system with indicator lights at the corridor entrance of each bedroom. - Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head…

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 submit a Third-Party Liability (TPL) form to Missouri (MO) Health Net, for three deceased residents (Resident #118, #117, and #166) within 30 days after the deaths of those three residents; and to submit a written notice to one resident (Resident #57) when his/her fund balance remained above the limit of $5,726.00 for three months. The facility census was 122 residents. 1. Review of the Closed Account Summary Report dated 9/23 through 12/23 showed: - Resident #118 passed away on [DATE], (a period of 56 days before the resident trust fund review on [DATE]) with a balance of $855.40 in his/her resident trust account. - Resident #117 passed away on [DATE], (a period of 75 days before the resident trust fund review on [DATE]) with a balance of $1,992.87 in his/her resident trust account. - Resident #166 passed away on [DATE], (a period of 133 days before the resident trust fund review on [DATE]) with a balance of $80.32 in his/her account. 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 maintain the floors of resident rooms D4 and C8, free of a buildup of tube feeding debris on the tube feeding poles and the floors in those rooms; to maintain the floors in many resident rooms, free of dust and debris on the floors; to maintain ceiling vents of resident rooms and showers free of a dust buildup and on those vents; to maintain the mattresses in resident rooms D4 and D11, and G3 in an easily cleanable condition; to maintain resident rooms B2 and B12, free of urine odors; to ensure that used adult briefs were picked up from the floors of resident room B7; and to ensure that trash containers in resident room D4 were cleaned to be free of a grime buildup. The facility census was 122 residents. Record review of the facility's undated policy entitled Room Cleaning procedure, showed: Pull trash recycle. - Remove liners, clean waste receptacles, place 5 liners on side of receptacles and one new one. - High dust everything above…

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 follow the screening section of the abuse prevention policy, by failing to conduct Federal Indicators (FI) through the Nurse Aide (NA) Registry and to ensure they were completed prior to hire in accordance with State requirements and facility policy to ensure potential employees did not have a history of abuse or neglect or a disqualifying crime against persons registry check on 6 of 10 employees selected for the background review. This practice potentially affected all residents in the areas the staff worked. The facility census was 122 residents. Review of the Screening section the facility's policy updated 11/23 showed the following: The facility will not knowingly employ any individual who has been found guilty of abusing, neglecting or mistreating residents. Prior to employment, all potential employees will be interviewed by a facility representative. Prior to employment, this facility will also run all required background checks, state required…

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 admission Minimum Data Set, (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) was accurate for four sampled residents (Resident #23, #96, #366, and #369) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Coordination and Certification of Assessments dated April 2023 showed each individual assessor was responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. 1. Review of Resident #23's Face Sheet showed he/she was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's POS 1/24, showed a physician…

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 an activity care plan for six sampled residents (Resident #23, #96, #75, #76, #366, and #369); and to establish a comprehensive care plan for two sampled residents (Resident #75 and #76) out of 33 sampled residents. The facility census was 122 residents. Review of the National Kidney Foundation's webarticle, dated 2015, titled Hemodialysis Access (hemodialysis-the process of removing excess water, solutes, and toxins from the blood of people whose kidneys can no longer perform these functions); access-a way to reach the blood to perform dialysis) showed the proper care of an arteriovenous fistula (AV fistula-a surgical connection between a vein and artery to allow for increased blood flow) included ensuring: -Blood pressures were not obtained using the arm with the access. -Blood was not to be drawn using the arm with the access. -No pressure was placed on the arm with the access (by laying on it, wearing tight-fitting clothing,…

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 8. Review of Resident #366's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Muscle weakness (generalized). -Need for assistance with personal care. -Metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's Care Plan dated January 2024 showed: -The resident had an Activities of Daily Living (ADL) self-care performance deficits and limitations in physical mobility related to his/her Metabolic Encephalopathy. -The resident was completely dependent on staff for showering/bathing. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was completely dependent on facility staff for showering/bathing. Observation on 1/24/24 at 12:10 P.M. of the resident showed: -He/she was in a hospital gown. -He/she had body odor. During an interview on 1/24/24 at 12:10 P.M. the resident said: -He/she had not received a bath since admitting to the facility. -He/she had not been…

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 4. Review of Resident #369's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Intertrochanteric Fracture of Left Femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), Subsequent Encounter for Closed Fracture with Routine Healing. -Metabolic Encephalopathy. -Need for Assistance with Personal Care. -Muscle Weakness (Generalized). Review of the resident's Care Plan dated January 2024 showed: -The resident had the potential for alterations in psychosocial well-being with an intervention to encourage the resident to spend time awake up and out of bed engaged in activity as tolerated and desired. -The resident had potential for poor activity involvement related to report of little interest or pleasure in doing things with the following interventions: --Enlarged monthly calendar provided in room. --The resident was to receive the Daily Chronicle packets (the facility's daily activity packet) from Activity Assistant three 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 failed to ensure appropriate care for three sampled residents (Resident #90, #94 and #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Administration of Medications via PEG Tube dated March 2023 showed: -Check placement of the tube by gently drawing back on the position of the syringe. -Medication should be administered separately with flushing of approximately 30 cc of water before and after each medication. -Verify that the medication cup were clear of any remnants of crushed pills or liquid medication. -Flush the G-tube after checking for placement, and before any medication are administered, between each medication, and following administration of all medications. -Check physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was documented on the Resident's Physician's Order Sheet (POS) that included the amount and duration oxygen should be administered, when tubing and supplies should be changed for one sampled resident (Resident #366); failed to ensure a physician's order for a Continuous positive airway pressure (CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or mouth during spontaneous breathing) device including the settings for the device, when tubing and mask should be cleaned for one sampled Resident (Resident #366); and failed to store oxygen supplies to prevent contamination when not in use for six sampled residents (Resident #23, #96, #366, #316, #317, and #318) out of 33 sampled residents. The facility census was 122 residents. Review of the facility Oxygen Storage policy revised 5/2023, showed the policy and procedure for storage of oxygen cylinders, but did not…

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 recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs during the breakfast meal on 1/29/24. This practice potentially affected 7 residents who had pureed diets. The facility census was 122 residents. 1. Review of the undated recipe for pureed scrambled eggs showed: -10 one ounce (oz.) serving of scrambled eggs. - 5 oz. of milk. Observation on 1/29/24 from 8:13 A.M. through 8:16 A.M., showed the following: - The Production Manager (PM) took 7 portions of eggs from the flat pan of scrambled eggs and placed those portions in the food processor. - The PM did not have a recipe book open during that time. - The PM did not add milk to the pureed eggs. - PM pureed the eggs and placed them in the pan and placed them back into the convection oven to keep them warm. During an interview on 1/29/24 at 9:44 A.M., the PM said he/she did not have the recipe open that morning, because the recipe was not available to him/her.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the hot foods of the breakfast meal on room trays for at least seven residents on the F Hall and at least six residents on the C Hall was served to residents at or close to a temperature of 120ºF (degrees Fahrenheit) including interviews with four residents sampled residents (Resident #23, #68, #317, and #65) out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #23's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/9/24, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 14 out of 15. During an interview on 1/23/24 at 11:21 A.M., the 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.

Based on observation, interview and record review, the facility failed to ensure that pureed (cooked food, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) versions of items such as sausage and French Toast on the breakfast menu was available for 7 residents with pureed diets. The facility census was 122 residents. 1. Review of the breakfast portion of the Week 2 At-a-Glance menu, dated 1/29/24, showed the following items for breakfast on 1/29/24: -Choice of hot or cold cereal. -Egg of choice. -Sausage or bacon. -Waffles (French Toast was substituted for waffles on that day). -Syrup. -Margarine. -2% milk. -Coffee. -Condiments. Observation on 1/29/24 from 7:06 A.M. through 7:40 A.M., during the breakfast meal preparation showed: - The Production Manager (PM) took eggs out of the steam table and pureed a portion of those eggs for the number of residents with pureed diets. - The PM cooked oatmeal cereal and pureed a portion of oatmeal cereal for the number of residents with pureed diets. - The PM took a portion of the sausage made…

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 inquire about or address the negative balance of one resident (Resident #37) who had a negative balance since from 1/27/23 through 1/23/24 on the facility statement document. The facility census was 122 residents. 1. Review of Resident #37's deposit receipt dated 1/15/23, showed the resident received a check for $237.54 from a pension organization. Review of the resident's statement document dated 1/25/23, showed the resident withdrew $40.00 for personal needs. Review of the resident's statement document dated 1/27/23 showed the check was returned for insufficient funds which created a $48.00 negative balance in the resident's account. Review of the resident's statement document dated 3/14/23, showed a deposit of $20.00 by the resident which caused the negative balance to decline to $28.00. Review of the resident's trial balance dated 1/23/24, 9 months later, showed a negative balance of $28.00. During an interview on 1/23/24 at 2:06 P.M., the Business Office Manager (BOM) said: -He/she has only been at that position for…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) for one sampled resident (Resident #1000) who was discharged from Medicare part A services out of three residents sampled for reviewing Medicare Beneficiary Notices and out of 33 sampled residents. The facility census was 122 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and 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 provide a bed hold form to the resident upon or during one sampled resident's (Resident #115) unplanned hospitalization out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility's undated Bed Hold policy and procedure showed: -Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. -Under certain conditions, we can reserve your existing bed for you at your request so when you return to the facility, you will have the same bed and room. -The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of 10 days when you are hospitalized . The facility must hold a bed for up to 10 days during a hospitalization. On the 11th day there is no requirement to hold a bed, but you are still a resident and will receive the next available bed when you are ready to return, even if there is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to appropriately discharge on e sampled resident (Resident #115), that was a closed record, by failing to provide the resident a 30 day discharge notice and inform him/her of his/her rights to appeal; and to discharge to a placement that was comparable to the skilled services the resident was receiving at the facility out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility undated admission Contract, Section D, showed the facility may transfer or discharge the resident in compliance with facility standards: -If necessary for the resident's welfare and the resident's needs cannot be met in the facility. -If appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. -If the health or safety of other individuals in the facility is endangered. -If the resident has failed, after reasonable and appropriate notice, to pay 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 complete a Level 1 Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) prior to admission for two sampled residents (Residents #76 and #91) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled PASRR Policy showed: -Staff were to review all potential admissions Level 1 PASRR to determine if the individual would need further screening. -Staff were to review the Level 1 screening and not admit any individual with a mental or intellectual disability until the Level 2 screening process had been completed. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: -Staff were screen all residents prior to admission using the Preadmission Screening and Resident Review (PASRR- a federally mandated screening…

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 or record review, the facility failed to ensure the resident's care plan was updated to show the resident's current capability/capacity for participation in activities or limitations to participating in activities for two sampled residents (Resident #6 and #366) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Care Plans dated April 2023 showed: -The comprehensive care plan was developed within seven days of CAA completion. -The baseline care plan required the following: --Initial goals based on admission orders (services planned to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being including but not limited to: Activities of Daily Living (ADLs), nutrition, fall risk, skin integrity, and pain management) --Dietary orders. --Therapy services. --Social services (resident's goals and desired outcomes, advanced directives, preference and potential for future discharge from the…

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

Based on observation, interview and record review, the facility failed to ensure to have active physician order for use, monitoring/care and maintenance of a Peripherally Inserted Central Catheters (PICC) or Central Line Catheter (CVS) (is a long, thin, hollow, flexible tube that goes into a vein in your arm or chest and ends at the right side of your heart/right atrium. The PICC line is one type of catheter used to access the large veins in your chest, used to give intravenous (IV) therapy), and to document the flushing of the PICC line and dressing changes for one sampled resident (Resident #90) out of 33 sampled resident. Facility resident census of 122 residents. Review of the facility Policy for Physician Order revised on 5/2023 showed the facility will ensure all medication are administered as ordered by health professional in accordance with all state and federal guidelines. Review of the facility's Medication Administration policy revised on 4/2023 showed: -A physician or nurse practitioner order were required for the administration of all medication and treatments. -Read…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe transfer with a full body mechanical lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) for one sampled resident (Resident #69) and to ensure a comprehensive fall investigation and initial detail fall nursing note or incident note was completed for one sampled resident (Resident #49) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's Mechanical Lift Transfer policy revised 3/2023 showed: -At least two staff are required to transfer a resident with a mechanical lift. Review of the facility's Investigation policy revised 3/2023 showed: -Investigation will be completed by the Director of Nursing (DON) or designee. -Investigation may include if applicable: -Investigation summary, resident interviews, staff interview, any reports to state or local law enforcement…

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 resident's physician's orders for a catheter (a tube placed in the body to drain and collect urine from the bladder) were complete to include the catheter size and indication for the catheter, failed to assess and document the resident's ability to provide self-care of his/her catheter, failed to ensure the catheter bag was kept below his/her bladder, and failed to ensure the resident's care plan showed the resident performed self-care of his/her catheter for one sampled resident (Resident #12) out of 33 sampled residents. The facility census was 122 residents. Review of the facility Catheter policy and procedure revised 4/2023, showed: -The purpose of catheter care was to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. -Physician's orders should include the reason/indication for the catheter, frequency and type of irrigation if necessary.…

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 necessary mental and behavioral health treatment and services, consistent with professional standards of practice, to promote mental health wellness by not providing mental health counseling and therapy services for one sampled resident (Resident #91), who had a mental health diagnosis. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: -Staff were screen all residents prior to admission using the Preadmission Screening and Resident Review (PASARR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis). -Staff were to provide mental health and behavioral health services in accordance with state and federal laws. 1. Review of Resident #91's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Bipolar Disorder (a mental illness that causes unusual…

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 pharmacy failed to provide the correct anti-psychotic medication (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disorganized thinking) as ordered by the physician for one sampled resident (Resident #91), out of 33 sampled residents. The facility census was 122 residents. A written request for policies related to pharmacy services was requested and not received at time of exit. 1. Review of Resident #91's medical record showed he/she was admitted to the facility with an allergy to Seroquel (a brand name anti-psychotic medication, generic name of Quetiapine). Review of the resident's undated Order Summary Report showed the physician ordered Seroquel Extended Release 200 milligrams (mg) with a note that indicated name brand only on 12/19/23. Review of the resident's January 2024 Medication Administration Record (MAR) showed staff administered Quetiapine (generic version of Seroquel) 200 mg to the resident 21 times. During an interview on 1/26/24 at 12:24 P.M., Pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who admitted to the facility with infected pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure) received the ordered antibiotics (a drug used to treat infections caused by bacteria and other microorganisms) for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of Medlineplus.gov's article, dated 5/15/18, titled Ampicillin and Sulbactam (antibiotics) Injection showed: -Missed doses could cause the infection to not be fully treated and could allow the bacteria to become resistant to this medication. Review of Medlineplus.gov's article, dated 6/15/22, titled Vancomycin (an antibiotic) Injection showed: -Missed doses could cause the infection to not be fully treated and could allow the bacteria to become resistant to this medication. 1. Review of Resident #319's Face Sheet showed he/she was admitted [DATE] with the following…

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

Based on observation, interview, and record review, the facility failed to provide one sampled resident (Resident #65) with his/her stated food preferences as documented on his/her meal ticket out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #65's breakfast meal ticket showed the resident wanted wheat farina (a form of milled wheat popular in the United States which was often cooked as a hot breakfast cereal), grits, raisin bran, fruit loops, and rice krispies with breakfast. -The resident wanted cottage cheese and fruit for a snack. Observation on 1/29/24 at 7:08 A.M., during the breakfast meal preparation showed the Production Manager (PM) cooked a large pot of oatmeal cereal. Further observation showed there were no other cereals cooked at that time. Observation on 1/30/24 at 8:45 A.M., showed the resident was served oatmeal cereal as part of his/her breakfast. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 12/13/23, showed 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 observations and interview, the facility failed to maintain a comfortable environment and safe environment by failing to ensure the temperature was comfortable and to prevent a draft from the window in the room for two sampled residents (Residents #23 and #42) which caused the relative (Family Member E) of Resident #42 to bring in portable heaters to maintain a comfortable temperature in the room and to maintain one sampled resident's (Resident #317) toilet in good repair our of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #23's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/9/24, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information. These items are crucial…

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 there were enough nursing staff available to provide resident cares for 121 residents in the facility. The facility sample was 13 residents. The facility census was 121 residents. 1. Review of the facility's Facility Assessment updated on 5/17/23 showed: -The facility was licensed for 162 beds and the average daily census was 110 residents. -The average census on the long term care unit was 75 residents and the average census on the rehabilitation unit was 30. -Of the residents in the facility who required 1-2 staff assistance or were totally dependent, 97 residents needed assistance with dressing and bathing, 89 residents needed assistance with transfers, 48 residents needed assistance with eating and 87 needed assistance with toileting. -Of the residents in the facility 17 residents used an assistive device to ambulate and 83 residents were in the wheelchair most of the time. -The budgeted hours per payroll for 2 weeks (7 day week) showed the facility budgeted 672 hours for Registered Nurses (RN); 672…

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 call light display monitor was working properly on one hall, and to ensure call lights were answered timely for three sampled residents (Resident #5, #8 and #11) out of 13 sampled residents. The facility census was 121 residents. Review of the facility Daily Device Activity Report showed documentation that showed each time a call light was turned on. Documentation showed the date, time it was turned on, hall, bed and how long the call light was on before it was answered/turned off. Documentation from 8/29/23 to 8/31/23 showed: -On 8/29/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 12 call lights that were on longer than 20 minutes. The longest call light was on for 55 minutes. On the evening shift (6:00 P.M. to 6:00 A.M.) there were 5 call lights that were on longer than 20 minutes. The longest call light was on for 41 minutes. -On 8/30/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 26 call lights that were 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, interview and record review, the facility failed to observe, monitor and assess one sampled resident (Resident #5) as he/she self-administered his/her medication, and to ensure an order for self-administration of medication was on the physician's order sheet out of 13 sampled residents. The facility census was 121 residents. 1. Review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, difficulty walking, kidney disease, heart failure, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), hypotension (low blood pressure) and anemia (low iron). Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 8/12/23, showed the resident: -Was alert, oriented and cognitively intact. His/her Brief Interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to administer the correct form of insulin to one sampled resident (Resident #2) out of three sampled residents for insulin administration. The facility census was 121 residents. On 9/7/23 the Administrator was notified of the past noncompliance which occurred on 8/20/23. Chief Nursing Officer (CNO) provided immediate education to nursing staff on medication administration, including accessing the emergency medications, two person verification process added to all insulin orders and education on the five rights of medication administration. All education to nursing staff was done prior to the start of shift. The deficiency was corrected on 8/21/23. Review of the facility policy titled Insulin Administration Procedure, dated November, 2018 showed: -Insulin is only given with a physician or nurse practitioner order. -The standard insulin syringe needle is 5/8 inch and 27 gauge. -Wash hands.-Draw up the insulin in and and remove any air bubbles.…

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 the area under the automated dishwasher free of dishes and debris; to maintain the wall mounted fan free of a heavy dust buildup in the dishwashing area; to maintain two out of three cutting boards without numerous grooves, indentations and stains, which made the cutting boards not easy to clean; to remove food debris such as a discarded sausage patty, jelly packets from under the steam table towards the front of the kitchen; to label a container which contained a white powdery substance; to take and record a temperature of unpasteurized eggs, a potentially hazardous food (PHF-a term used by food safety organizations to classify foods that require time-temperature control to keep them safe for human consumption) before placing them in a pan to be sent to the C and D hall kitchenette; and to ensure the light fixtures and vent covers on the ceiling of the kitchen, were free of a dust buildup. This practice potentially affected 97 residents who ate food from the kitchen. The facility census was 103…

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 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), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how will facility account for changes in water quality such as water main breaks and construction and specific actions that would be taken in response to a legionella positive water sample. This deficient practice had the potential to affect all residents and staff who reside in or work in the facility. The facility census was 103 residents with a licensed capacity of 162 residents. Record review of page 3 of Centers for Disease Control 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 its call light system was maintained in compliance with the stipulations outlined in their state approved exceptions letter dated 10/13/21. This practice potentially affected all residents. The facility census was 103 residents. Record review of the exception letter regarding call lights showed: -The facility had an approved exception for complying with state regulation 19 CSR 30-85.012 (124) Facilities shall provide an electrically-powered nurses' call system with indicator lights at the corridor entrance of each bedroom. Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. -The following stipulations were spelled out in the exception letter: --The exception applies only to the omission of indicator lights at the corridor entrance of each bedroom door and omission of audible…

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 resident's bed fit him/her properly for one sampled resident (Resident #194); failed to ensure resident needs were met by facility staff not answering call lights in a timely manner for five sampled residents (Residents #62, #194, #80, #26, and #88) and three supplemental residents (Residents #4, #68 and #12); and to ensure call lights were within reach for one sampled resident (Resident #17) and two supplemental residents (Residents #302, and #303) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's call light policy dated November 2018 showed: -The call light system was provided as a tool for residents to communicate with staff. -Staff members would ensure the call lights were within reach of the resident who is able to use it each time they leave the room. 1. Record review of Resident #194's admission nursing evaluation dated 6/21/22 showed the resident: -Verbalized/demonstrated…

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 authorization forms for three sampled residents (Resident's #30, #43 and #63) out of five sampled residents selected for the resident trust fund review portion of the survey. The facility census was 103 residents. 1. Record review on 6/24/22, of authorization forms for the five residents selected, showed: - The absence of authorization forms for Resident's #30 and #43. - Resident #63 did not sign the authorization forms. During an interview on 6/24/22 at 11:43 A.M., the Business Office Manager (BOM) said Resident #30 had been at facility since 5/31/19 and has had a guardian since 5/28/19. During an interview on 6/24/22 at 11:45 A.M., the BOM said Resident #43 had been at facility since 11/20/20, and has had a guardian since 6/27/19. During an interview on 6/24/22 at 11:49 A.M. the Regional BOM said the facility had approval from the guardians to manage funds for Resident's #30 and #43, but they were not able to find the authorization forms.

Based on interview and record review, the facility failed to reconcile (to account for) the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis and to ensure there were resident signature approved withdrawals which accurately reflected the amount of money in the petty cash in the account at the beginning of June 2022. This practice potentially affected 48 residents who had resident trust accounts. The facility census was 103 residents. 1. Record review of the monthly accounts for the months of June 2021 through May 2022 showed the absence of documentation of the ending balances for petty cash for the months of June 2021 through May 2022. During an interview on 6/24/22 at 11:04 A.M., the Business Office Manager (BOM) said: -The facility did not calculate the total amount of petty cash on hand at the end of the months, while he/she was at the facility from March 2022 until the present. -Prior to his/her start of employment and there were not any records of the petty cash totals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige--the residents who are a part of the resident trust)) that was one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 48 residents who allowed the facility to manage their resident funds. The facility census was 103 residents. 1. Record review of the instructions for determining what a surety bond amount should be, showed: -The monthly reconciled bank statements and the monthly ending petty cash (the amount of cash that the facility keeps to be accessible to the residents) are added together for each of the previous (usually 9-12) months since the last survey. -The total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the floor in the restroom of Resident #193's room free of a sticky substance; to maintain a shower chair in resident room H9 without a crack; to maintain commode risers (a device which fit over a commode seat which adds some height to the seat, making it easier for a person to sit or stand without bending) in resident rooms H12 and F4 without rust; to maintain shower chairs in resident rooms G4 and G6, without rust; to maintain the trash container in resident room D12 without a black/brown substance which had a white substance on the black/brown substance and to maintain the floors of resident rooms C12, B9, B12, B5, A11, A7, A10, without food crumbs and debris. This practice potentially affected at least 20 residents who resided in or used those rooms. The facility census was 103 residents. 1. Record review of Resident #193's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care…

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

Based on interview and record review, the facility failed to ensure they completed a check of the Employee Disqualification List (EDL) and/or Criminal Background Check (CBC) prior to hire for four out of 10 staff sampled. The facility census was 103 residents. Record review of the facility's background checks and pre-hire process policy dated November 2020 showed background checks should be completed prior to hire. 1. Record review of the facility's list of employees hired since their last annual survey showed employee A was hired on 2/8/22. Record review of employee A's employee files showed the EDL was requested for employee A on 2/25/22 (27 days after date of hire). 2. Record review of the facility's list of employees hired since their last annual survey showed employee B was hired on 2/15/22. Record review of employee B's employee files showed the EDL was requested for employee B on 2/25/22 (10 days after date of hire). 3. Record review of the facility's list of employees hired since their last annual survey showed employee D was hired on 3/15/22. Record review of employee B's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going staff; to verify the correct count of narcotics; and to ensure the narcotic count sheet was not pre signed before the end of a shift and to administer the correct dose of Lidocaine Cream (an anesthetic [a substance that induces insensitivity to pain] causing loss of feeling in the skin and surrounding tissues to prevent and treat pain from some procedures) for one supplemental resident (Resident #4) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. -Remove medication from (medication) drawer and read label three times. -If there is a discrepancy between the Medication Administration Record (MAR) 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 interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations (DRR) were reviewed and acted upon by the physician for five sampled residents (Resident #39, #49, #24, #62, and #80) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's Pharmacy Services policy dated April 2022 showed: -The Pharmacy Services guideline purpose was: --To maintain accurate and timely medication records. --To minimize medication-related adverse consequences or events. --The overall goal is to ensure the safe and effective use of medications. --The Interdisciplinary Clinical Team is the responsible party. -The facility will employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. 1. Record review of Resident #39's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Alcoholic Cirrhosis…

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 within range of 36 degrees Fahrenheit (F) to 46 degrees F for one out of two sampled refrigerators which stored residents' prescribed medications and failed to ensure that two medication carts were locked during medication pass. The facility census was 103 residents. Record review of the facility's policy, Refrigeration Medication Storage, dated June 2022 showed: -The facility will assure that all refrigerators and freezers were clean, contents were properly stored, and the temperatures were monitored in accordance with all state and federal regulations. -An accurately calibrated thermometer would be kept in each refrigerator at all times. -Temperatures at which drugs were stored will be maintained between 36 degrees F to 46 degrees F. -If the temperatures registered above or below the appropriate temperature all stored items would be removed, the viability of the items stored would be determined and non-viable items would be discarded. -Environmental Services would 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 observation, interview, and record review, the facility failed to maintain the area under the automated dishwasher and resident rooms B 12, A 12 and A 3, free of gnats (small flies). The facility also failed to maintain the floors of resident rooms B 8 and B 5 free of food crumbs as to not provide harborage for ants. This practice potentially affected at least eight residents. The facility census was 103 residents. 1. Observation during the initial kitchen observation on 6/22/22 showed: -At 9:17 A.M., gnats flew around in the kitchen around the automated dishwasher area. -At 9:25 A.M., gnats flew around the area next to the breaker box on the east side of the kitchen. 2. Observation with the Maintenance Director on 6/23/22, showed: -At 2:33 P.M., many gnats flew around a cup with a brown colored drink in it, in resident room B 12. -At 2:51 P.M., there were numerous ants and food crumbs on the floor of resident room B 8. -At 2:53 P.M., there were numerous ants and food crumbs on the floor of resident room B 5. -At 3:18 P.M., numerous gnats flew around in the area under 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 have a physician's order to keep medications at the resident's bedside and to assess the resident's ability to self administer for one supplemental resident (Resident #4) and one sampled resident (Resident #297) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -If medication was ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication. -Remain with the resident to ensure that the resident swallows the medication. -Once the resident took the medication hit save on the Electronic Medication Administration record (eMar). -NOTE: This policy did not address resident's having medications at bedside. The facility did not provide a policy to include keeping medications at a resident's bedside. 1. Record review of the Resident #4's Quarterly Minimum Data Set (MDS…

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 pain medications were administered as ordered for one supplemental resident (Resident #10) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's pain management policy dated November 2018 showed: -If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the elder's care providers. -Healthcare providers that have implemented a pain control mechanism, will reassess the resident to determine amount of pain control or relief achieved. -Pain control mechanisms may include administering medications for the control or relief of pain. 1. Record review of Resident #10's face sheet showed he/she was admitted to the facility on [DATE] and some of his/her diagnoses included: -Diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance 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 failed to ensure the medication error rate was less than 5%. The facility had two errors out of 25 opportunities making the facility error rate 8%. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. -Remove medication from (medication) drawer and read label three times. -If there is a discrepancy between the Medication Administration Record (MAR) and the label, check orders before administering medications. Record review of the facility's Pharmacy Services dated April 2022 showed: -Assure that the correct medication is administered in the correct dose, in the correct dosage form. 1. Observation on 6/24/22 at 5:25 A.M. of the resident's medication pass, showed Licensed Practical Nurse (LPN) D: -Told the resident that his/her Lidocaine Cream (an anesthetic causing loss of feeling in the skin and surrounding…

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 air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the floor drain on the floor next to the ice machine and failed to place a grate over an 8 inch (in.) diameter drainage hole for the washing machines in the laundry area. This practice affected two non-resident use areas. The facility census was 103 residents. 1. Observations on 6/22/22 at 9:22 A.M. and on 6/27/22 at 1:31 P.M., showed: -The absence of an air gap between the ice machine drainage pipe. -The ice machine drainage pipe resting on top of a white padding over the drainage hole under the ice machine with a black substance around the drainage pipe. During an interview on 6/27/22 at 1:32 P.M., the Dietary Manager (DM) said the drainage pipe needed to be lifted from the drainage area so there could be an air gap. Observation on 6/27/22 at 1:33 P.M., showed Maintenance Director B lifted up the drainage pipe from the floor drain next to the ice…

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.