McCrite Plaza At Briarcliff Skilled Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing and water humidification bottles were exchanged out, and oxygen filters where changed (Resident #244, #28 and #11). This affected three of the 12 sampled residents. The facility census was 40. Review of the facility's Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment policy, undated, showed: - Non-Critical Equipment are those items that either touch only intact skin but not mucous membranes or do not directly touch the elder; - Reusable Equipment is a device designed and tested by the manufacturer, that is suitable for reprocessing prior to use on a elder; - All equipment must be cleaned immediately if visibly soiled; Review of the facility's Oxygen Administration policy, undated, showed: - Oxygen concentrators, cylinders and equipment will be kept and maintained in such a way as to be compliant with all relevant health…

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 staff administered medications with a medication rate of less than five percent when facility staff made two medication errors out of 25 opportunities for error resulting in a medication error rate of eight percent which affected two of the 12 sampled residents (Resident #19 and #16). The facility census was 40. Review of the facility's undated policy for medication administration showed, all medications will be administered to every resident by a licensed nurse or a Certified Medication Technician (CMT) and as ordered by a physician in a safe and sanitary manner. The facility did not provide a policy for administration of eye drops. Review of the website, https://webmd.com, for refresh eye drops showed: - To avoid contamination, do not touch the dropper tip to the eye or or any other surface; - Tilt your head back, look up, and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one…

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 store and label drugs and biological's in accordance with current accepted professional principles for three (Resident #12, #28, and #193 ) out of the 12 sampled residents when the facility failed to store medications in a locked storage area for Resident #28 and Resident #193. Additionally, the facilty failed to supervise Resident #12 while taking medications. The facility census was 40. Review of facility policy, right to self-administer medications, undated, showed: -A resident may self-administer medications only if approved in writing by the resident's physician and a licensed nurse has determined that the resident can perform the task safely and accurately. -A licensed nurse will assess the resident to determine the resident's ability to self-administer their medications. The findings of the assessment will be documented in the resident's medical record. -The medications that the resident self-administers, will be stored in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had a means of directly contacting caregivers when staff failed to identify and correct bathroom call light pull cords that had been wrapped around the handrail on the wall, leaving them inoperable and inaccessible to residents. The facility census was 40. The facility's Call Light, Bed Alarm System policy showed: -Call lights are to be present in all resident rooms and bathrooms. -The policy fails to address the issue of call lights being operable and accessible to a resident lying on the floor in need of help. The facility's Accident Prevention policy showed all staff members will ensure that each resident's environment remains as free from accident hazards as possible. The facility's Incident and/or Accident Protocol showed staff are to assess the environment for safety modifications, clear pathways and ensure the call light was within the resident's reach. The facility's Preventive Maintenance and Inspection policy…

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

Based on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition one resident and additionally failed to follow physician's orders for this resident to be laid down after lunch (Resident #14's ). This affected one resident out of twelve sampled residents. The facility census was 40. Review of facility policy, Safe Lift, Transfer, and Repositioning Policy, undated, showed: -Transfer and mobility assistance as well as other resident handling and movement tasks will be carried out in accordance with comprehensive nursing and therapy assessments, the Minimum Data Set (MDS) (a federally mandated assessment tool completed by facility staff) and individualized comprehensive care plan, and written instructions pertaining to each individual resident; -Lifting, transferring, or repositioning assistance will be provided in accordance with the resident's care plan absent emergencies or exceptional circumstances. 1. Review of Resident #14's Annual 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 observation, record review and interview the facility failed to provide a safe and comfortable home like environment when the facility's heating system was not able to maintain comfortable temperatures for the residents. The facility census was 82. Review of the facility's undated Environmental Control Failure policy., showed: -In the event of a system failure resulting in either warmer or cooler than desired temperatures the following process will be adhered to: -Notification of Administrator, Nursing On-Call, IT On-Call and Maintenance On-Call will be completed. -Department managers will attempt corrective action. -In the event temperatures cannot be raised with existing equipment, a contract with Sunbelt Heating and Cooling will be activated. -Sunbelt provides and maintains portable heat pumps. These devices are designed to produce a safe and controlled source of either cooling or heating. These devices contain no exposed heating elements as well as electrical safety systems with an electrical…

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, interviews and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety and follow proper sanitation and food handling practices to prevent the possibility of foodborne illness when staff placed their thermometer, used to obtain internal food temperatures prior to serving to the residents, directly into their red bucket filled with sanitizer water after they used the water to wash their food preparation table, placed gloved hands into oven mitts repeatedly without removing their gloves and washing their hands, and kept staff's personal drinks in food preparation areas. The facility's census was 44. Review of the food preparation and handling policy on 3/23/23 shows: - Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances. - All food handlers will perform handwashing regularly in a designated hand washing sink during each shift and for the following reasons: *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 record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). The facility also failed to ensure facility staff were informed on the facility's Water Management Plan and on safe water temperatures to maintain for the hot water. The facility census was 44. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow 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 record review and interviews, the facility failed to ensure they established and maintained a system that ensured a full, complete and separate accounting according to accepted accounting principles and failed to establish a system that precludes any commingling of resident funds with facility funds. This affected 23 residents (Residents #292, #294, #7, #296, #297, #298, #299, #300, #256, #302, #303. #304, #305, #21, #306, #23, # 308, #309, #41, #310, #13, #319, and #313). The facility's census was 44. Review of the facility's undated Resident Funds Policy showed the facility will, upon written authorization of the resident or their legal representative, manage, safeguard and account for personal funds or money in trust for the resident. The record keeping and other requirements of this section apply only to those personal possessions and funds which the facility accepts to hold in trust for the resident as provided in the facility's policy. The policy directed the following: - An individual record of…

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

Based on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential the affect all residents in the affected areas. The facility had a census of 44. The requested cleaning policy was not provided. A review of the undated Public Bathroom Cleaning Instructions showed: - Clean the sink and the vanity; - Clean all handles and rails; - Empty trash cans; - Replace toilet paper if low; - Sweep and mop the floor. A review of the undated Cleaning Check list showed: -Ground floor restrooms: o Wipe down walls; o Refill paper products; o Sweep and mop the floor. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed: -The vent on the ceiling caked with dirt and debris; -Three lights above the mirror covered in dust and debris; -The top of the baseboard around the entire bathroom floor covered with dirt and debris; -The hand rails on the left and back side of the toilet covered in dust; -The wall on the left side of the sink covered with a white substances running…

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 dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected four out of 12 sampled residents, (Resident #4, #7, #13, and #18) and when the facility failed to keep Resident #1, #7, #9, and #14 shaved. The facility census was 44. Review of the facility's undated policy for perineal care, showed: - Perineal care is very important in maintaining the residents' comfort and should be done after an incontinent episode; - Perform hand hygiene; -Explain procedure to the resident; -provide privacy; For female residents: - Separate the labia and wash with wipe, moving from front to back on each side of the labia and in the center over the urethra and vaginal opening, using a clean wipe for each stroke For male residents: -Cleanse the penis from the urethral opening to the tip of the penis;…

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, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring four of 12 sampled residents, ( Resident #4, #7, #13, and #18) during the use of a mechanical lift transfer. The facility census was 44. Review of the facility's undated policy for mechanical lift transfers, showed in part: - At least two nursing staff will assist in the transfer of a resident when utilizing the mechanical lift; - Roll the lift frame into position with legs in the open position. Legs may be closed to navigate corners or small spaces, but should be in the open position to counter balance resident weight when actively in use with resident; - One staff member operates the lift and the the second staff member guides the movement of the resident while in the lift; - One staff member stands behind the wheelchair to guide the resident's hips back into the seat while the other staff member operates the lift; - The policy did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, causing residents to become incontinent, which affected seven of 12 sampled residents, (Resident # 3, #5, #7, #9, #12, #18 and #253) and call light concerns brought up during resident council. The facility census was 44. Review of the facility's undated policy for silversphere call light system, showed in part: - The facility uses many tools to provide a safe, homelike environment. One took in use is a fully electronic call light system called Silversphere by [NAME]. This system runs through a mobile app, providing privacy and comfort through reduced noise pollution for every resident; - It is the responsibility of every nursing staff member to acquaint themselves with this system, and to respond urgently to all alarms; - Upon arrival for shift, direct care staff must login to the Silversphere system on either a facility provided phone or their own…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the exhaust system to remove bathroom odors. The facility census was 44. The requested vent cleaning policy was not provided. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed the vent on the ceiling caked with dirt and debris. 2. Observation of the bathroom in the basement by the resident salon on 03/22/23, at 4:16 P.M., showed the vent on the ceiling caked with dirt and debris. 3. Observation of the bathroom in the basement by the salon on 3/23/23, at 8:11 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 4. Observation of the bathroom the 2nd floor by the social services office on 3/23/23 at 10:31 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 5. Observation on 3/22/23 at beginning at 8:30 A.M. showed the following vents on the ceiling were caked with dust, lint and debris: - Bathroom by Director of Nursing office 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.

Based on observation, record review and interviews, the facility failed to store cookware and dishes in a sanitary area, properly monitor sanitizer buckets and dishwasher temperatures, failed ensure they refrigerated foods that recommended refrigeration after opening, and failed to ensure facility staff used utensils or gloves when filling a cooler with ice that was used for filling residents' cups. The facility census was 56. Review of an undated facility policy titled Food Preparation and Handling Policy included the following: - All food items and products served to residents will be prepared or served from a central kitchen and/or unit kitchen serving area according to standardized recipes. Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances; - The kitchen and equipment will be kept clean, neat, orderly and well maintained; - All food items, while being prepared, will be protected against contamination from dust, flies, rodents and other vermin, unclean utensils…

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, interviews and record review, the facility failed to assure staff used the comprehensive assessment to develop, implement and review a comprehensive person-centered plan of care consistent with the resident's specific conditions, needs and risks, which affected three of 14 sampled residents (Resident #31, #45 and #41). The facility census was 56. 1. Review of Resident #45's care plan, revised 11/27/19, showed: - The resident required activities of daily living (ADL) assistance related to generalized weakness and brain cancer; - Extensive assistance of one staff for toileting; - The care plan did not address the resident's indwelling catheter (sterile tube inserted into the bladder to drain urine). Review of the resident's significant change in status Minimum Data Set (MDS), dated [DATE], showed: - Cognitive skills moderately impaired; - Required extensive assistance of one staff for bed mobility, transfers, and toilet use; - Had a Foley catheter; - Diagnoses included cancer. Observation 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 observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care when staff did not administer Flonase (used to treat seasonal allergies) correctly and failed to administer Restasis eye drops (used to treat dry eyes caused by inflammation, which affected one of 14 sampled residents (Resident #24), failed to obtain an order for oxygen therapy for one sampled resident (Resident #15), failed to date an opened insulin pen for one sampled resident (Resident #201), and failed to provide wound care according to physician orders for one sampled resident (Resident #31). The facility census was 56. 1. The facility did not provide a policy for administration of eye drops or administration of nasal sprays. Review of the facility's undated medication administration policy showed, in part: - All medications will be administered to every resident by a licensed nurse or a certified medication technician (CMT) and as ordered by a physician in a safe and sanitary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, causing residents to become incontinent, which affected four of 14 sampled residents (Resident #1, #31, #41 and #203), and failed to provide wound care according to physician orders for one resident (Resident #31). The facility census was 56. The facility did not provide a policy regarding call light response times. 1. Review of Resident #31's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement, and chronic kidney disease; - Required extensive assistance with bed mobility, transfers, dressing, and toilet use; - Was always continent of bowel and bladder; - Was at risk for pressure ulcers. Review of the resident's care plan, dated 1/28/20, showed: - The resident had skin…

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

Based on observations, interviews, and record review, the facility failed to discard expired medications and biologicals stored within the medication cart and medication room, failed to date an opened vial of tuberculin purified protein derivative (skin test used to help diagnose tuberculosis infection), failed to properly label opened, multi-dose medications with dates to indicate when they were opened, which affected one of 14 sampled residents (Resident #45), failed to date opened insulin pens which affected two sampled residents (Residents #31 and #201), and failed to ensure there were no loose pills in the medication cart. The facility census was 56. 1. Review of the facility's destruction of medications by facility, revised 5/13/15, showed, in part: - Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law; - All discontinued and expired medications shall be disposed of and documented appropriately by the facility nursing staff; - All discontinued medications will be immediately located and removed from the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not change their gloves or wash their hands between dirty and clean tasks, failed to clean the drainage port correctly and failed to disinfect the stool riser and toilet when it became soiled with fecal material, which affected one of 14 sampled residents (Resident #45) and when staff failed to provide a clean barrier to place a urinal on which affected one sampled resident (Resident #48). The facility census was 56. 1. Review of the facility's undated hand hygiene policy showed, in part: - The staff will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections; - Indications for hand washing: when hands are visibly dirty or contaminated with blood or other body fluids, wash hands with either a non-antimicrobial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to honor residents' dignity when staff did not answer call lights timely, causing two of 14 sampled residents (Resident #31 and #203) to become incontinent. The facility census was 56. The facility did not provide a policy regarding call light response times or a policy regarding treating a resident with dignity and respect. 1. Review of Resident #31's comprehensive Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement and chronic kidney disease; - Required extensive assistance with bed mobility, transfers, dressing, and toilet use; - Was always continent of bowel and bladder. During an interview on 2/11/20 at 8:19 A.M., the resident said he/she: - Has had two bowel incontinence accidents waiting for staff since being admitted to the facility; - Has to wait 15 minutes for call lights 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 observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected two of 14 sampled residents (Residents #1 and #42), and failed to ensure facility staff did not rely solely on Hospice (end of life care) staff to provided showers for Resident #42. The facility census was 56. Review of the facility's undated perineal care protocol showed, in part: - Perineal care is very important in maintaining the resident's comfort and should be done after an incontinent episode and as a part of the bathing; - Separate the perineal folds and wash with a soapy washcloth/wipe, moving from front to back, on each side of the perineal folds and in the center over the skin folds; - Cleanse from the tip of the skin folds and clean all the skin folds; - Wash the buttocks and peri -anal area without…

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

Based on observations, interview, and record review, the facility failed to ensure staff provided complete catheter (sterile tube inserted into the bladder to drain urine) care in a manner to prevent infection or the possibility of infection which affected one of 14 sampled residents (Resident #45). The facility census was 56. 1. Review of the facility's undated indwelling catheter protocol showed, in part: - A physician must order the placement of an indwelling catheter including the appropriate and approved indication for use of the catheter with an estimation of the stop date; - Because of the danger of infection when a catheter is introduced, the equipment used must be sterile and should be sterile and should be handled aseptically; - Wash hands immediately before and after any manipulation of the catheter site or drainage bag; - Never allow the bag or tubing to touch the floor; - Empty the Foley bag every shift or when the drainage bag is 2/3 full, to prevent infection and to avoid traction on the catheter from the weight of the drainage bag. - Perform hand hygiene and apply…

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, interviews and record review, the facility failed to assure staff provided proper respiratory care when staff failed to ensure the oxygen concentrator had humidified sterile water, which affected one of 14 sampled residents (Resident #15), failed to properly clean oxygen concentrator filters and failed to date the oxygen tubing, which affected two sampled residents (Resident #15 and #31). The facility census was 56. 1. Review of the facility's undated oxygen administration policy showed, in part: - Oxygen therapy is the administration of oxygen to treat or prevent signs and symptoms of hypoxemia (abnormally low concentration of oxygen in the blood), or medical conditions that are known to clinically improve with oxygen; - Oxygen concentrators, cylinders and equipment will be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines; - Oxygen therapy will be administered or supplied with a prescription from the resident's primary care physician 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 observations, interviews, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent (%). Staff made four medication errors out of 25 possible errors for an error rate of 16%. These errors affected one of 14 sampled residents (Resident #32). The facility census was 56. 1. Review of the facility's undated gastrostomy tube feedings policy showed, in part: - Gastrostomy feedings will be administered in a safe sanitary manner to provide nourishment in the form of liquid, through a tube into the stomach; - Aspirate for gastric residual, then re-insert gastric contents; - The gastric residual of residents fed continuously will be checked every four hours. Review of the facility's undated medication administration policy showed, in part: - All medications will be administered to every resident as ordered by a physician in a safe and sanitary manner; - The only exceptions are those medications to which the physician has placed specific times; - If 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.