Lawson Manor & Rehab

Refer to Event ID NI0V12. Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46.

Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46. The facility did not provide an NA certification policy. Review of the NA employee list showed: -NA A employed since 6/24/24; -NA B employed since 4/26/24; -NA C employed since 7/15/24; -NA D employed since 7/16/24; -NA E employed since 6/7/24; -NA F employed since 2/12/24. During an interview on 12/4/24 at 11:29 A.M., NA A said: -He/She was not enrolled in any Certified Nurse Aide class; -He/She had worked in facility since July 2024, and worked in facility last year from July 2023-November 2023. During an interview on 12/4/24 at 12:48 P.M., NA B said: -He/She was not enrolled in CNA class after working for the facility for six months; -He/She was told several times that he/she would be put in the next CNA class but has never been enrolled in any class. During an interview on 12/4/24 at 1:40 P.M., NA F said: -He/She had worked in the facility for 10 months and 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.

Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46. Review of facility policy, employee screening for tuberculosis, revised March 2021, showed: -All employees are screened for latent tuberculosis infection and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. -Newly hired employee is screened for LTBI and active TB disease after an employment offer had been made but prior to employee's duty assignment. Observation on 12/4/24 at 1:00 P.M. showed Director of Nursing (DON) could not locate requested employee sample of TB tests for the following employees: -Dietary Aide A, date of hire 10/17/24; -Certified Nurse Aide (CNA) A, date of hire 10/16/24;…

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 one resident's visitation rights were not restricted when Resident #6 had a visitor that was asked to leave and not permitted to visit the resident. This affected one of six sampled residents (Resident #6). The facility census was 47. Review of facility policy, Resident Rights, undated, showed: -Resident has right to receive visitors of their choosing at time of their choosing and interact and participate with members of community and activities inside and outside facility, subject to resident's right to deny visitation, and in a manner that did not impose on rights of another resident. -Facility must provide immediate access, subject to resident's right to deny or withdraw consent at any time to any resident by: -Immediate family and other relatives of resident; -Facility must have written policies and procedures regarding visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction, and must inform each 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 interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46. Review of facility policy, Abuse Investigation and Reporting, Revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be thoroughly investigated by facility management. -Individual conducting the investigation will as a minimum: -Review the completed documentation forms; -Review the resident's medical record to determine events leading up to the incident; -Interview the person(s) reporting the incident; -Interview any witnesses to the incident;…

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 and interviews, the facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 40. The facility provided an undocumented time frame for when the facility had a DON working which showed: - A DON worked from 1/23/23 - 3/5/23; - A DON worked from 3/6/23 - 6/20/23; - A DON worked from 6/21/23 - 9/15/23; - A DON worked from 9/16/23 - 1/16/24; - A DON worked from 2/9/24 - 3/9/24. Observations from 3/12/24 through 3/15/24 and on 3/18/24, at various times showed the facility had charge nurses (CN) available, but did not have a DON. During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said: - He/she did not know who the DON was; - He/she was the ADON but did not think they had a DON. During the entrance conference on 3/12/24 at 8:35 A.M., the Administrator said: - They had a DON but he/she quit on 3/9/24; - They were in the process of finding another DON.

Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, temperature check food before it was served to residents, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 40 residents. 1. Review of facility policy, sanitation of dining and food service areas: -Dining service staff will uphold sanitation of the dining areas according to a thorough written schedule. -Dining services manager will record necessary cleaning and sanitation tasks for department -Tasks will be designated to specific departmental positions (cleaning schedule forms). -All staff will 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 they cared for residents in a dignified way, that any reasonable person would expect, when they failed to provide privacy by leaving window blinds open during a resident's morning care exposing the resident (Resident #8), Failed to respect privacy of a resident, when the facility posted personal information about a resident's daily care routine on wall above his/her bed for anyone to view, (Resident #20), and additionally failed to provide treat residents in a dignified manner when staff stood while feeding resident during meals (Resident #37) and when staff administered inhalers in the dining room, which affected one of 12 sampled residents, (Resident #17). The facility census was 40. Review of facility policy, dignity, revised February 2021, showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.…

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 provide acceptable accommodation of needs for two (Resident #23 and #192) of 12 residents sampled when they did not provide Resident #23 access to toileting options in his/her room and when Resident #192's leg was secured to the leg rest of his/her wheel chair with a gait belt to keep it immobilized when the foot pedal was not long enough. The facility census was 40. Review of facility policy, accommodation of needs, dated March 2021, showed: -Facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. -Resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. -Adaptations will be made to the physical environment, including the resident's bedroom and bathroom, as well as common areas 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, interviews, and record review, the facility failed to promote self-determination for four of 12 sampled residents when the facility failed to allow two sampled residents to be toileted per their request (Resident #18 & Resident #8), failed to allow resident to stay in bed per his/her request (Resident #8), failed to honor residents preferences for AM showers (Resident #11), and failed to offer meal choices. (Resident #192). This impacted four of 12 sampled residents (Resident #8, #11, #18, and #192). The facility census was 40. Review of the facility policy, Resident Rights, revised February 2021, showed: -Resident's have the right to self-determination -Be supported by the facility in exercising his or her rights; -Right to privacy and confidentiality. Facility did not provide requested policy regarding self determination. 1. Review of Resident #18's Annual MDS, a federally mandated assessment tool completed by facility staff, dated 12/15/23, showed: -He/She had a Brief Interview Mental…

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

Based on interview and record review, the facility failed to establish and maintain a system that assures a full and complete separate accounting, according to generallly accepted accounting principles when the facility allowed the petty cash balances to have a negative balance for two months. The facility census was 40. Facility did not provide a policy regarding resident funds accounts. Review of the facility petty cash log showed: -May 2023 a negative cash balance of $-92.93 -June 2023 a negative cash balance of $-73.73 Review of the facility Resident Trust Fund (RTF) bank reconciliation report showed: -May 2023 month ending: Note at bottom of page showed petty cash starting balance was off by $100.00. Business Office Manager will take this from facility Petty Cash to refund the RTF account. Additionally, some residents accounts are negative due to surplus being deducted twice this month. -June 2023 month ending: Check order and deposit slip order showed a shortage of RTF petty cash. Will take from regular petty cash and make deposit. During an interview on 3/13/24 at 11:33 A.M.,…

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 record review and interviews, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond amount covering the Resident Trust Fund (RTF) account. The facility census was 40. Review of the DHSS database, which tracks the most up to date information regarding approved bonds for RTF accounts for all facilities that hold resident monies, on 3/13/24 at 1:07 P.M showed an approved bond amount of $65,000. Review of the Resident Funds Bond Worksheet, a form used by DHSS to determine the facility's bond should be and if they have the appropriate approved amount for their bond, showed: -The average balance for the previous twelve months in the facility's RTF bank account of $51,292.59 -After multiplying this amount by 1.5, the approved bond amount should be $76,500. During an interview on 3/12/24 at 11:33 A.M., the business office manager said: -The bond rider was increased on 3/12/24 to $110,000; -He/She did not know if bond increase had been submitted to DHSS for approval. 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 record review and interviews, the facility failed to ensure that two sampled resident's (Resident #10 and #37) advance directive (a legal document which allows resident to plan and make their own end-of life wishes known in the event they are unable to communicate) were clear and placed in the resident's medical record when the facility failed to show that one resident (Resident #10's) physician's orders did not show his/her code status and when one resident (Resident #37) did not have a letter of enacted incapacitation when the resident's durable power of attorney (DPOA) had a signed an Out of Hospital Do Not Resuscitate Order (OHDNR). The facility census was 40. Facility did not provide a requested policy regarding advance directives. 1. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure 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, facility staff failed to provide a comfortable and homelike environment for all residents when they did not repair gouges in walls and missing paint in resident rooms (Resident #29 and #20), repair broken lights at resident's beds (Resident #11 and #20), fix and repair peeling ceiling paint in kitchen, when they did not repair a clogged sink in the memory care unit, clean vents in the ceiling of the memory care unit, clean base boards, repair large holes in parking lots, and maintain repairs in resident rooms. The facility census was 40. Facility did not provide an environmental policy. 1. Review of Resident #11's quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 13, (a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care), showed resident was cognitively intact. -He/She had clear…

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 interviews and record review the facility failed to ensure residents were aware of how to file a grievance or complaint. This affected any resident who wanted to file a grievance. The facility census was 40. The facility did not provide a policy related to grievances. 1. Review of the resident's council meeting minutes showed: - 11/14/23 - the minutes did not indicate if the residents knew how to file a grievance; - 12/14/23 - the minutes did not indicate if the residents knew how to file a grievance; - 1/4/24 - the minutes did not indicate if the residents knew how to file a grievance. During a group meeting on 3/14/24 at 2:56 P.M., five out of five residents who were alert and oriented said they did not know how to file a grievance or who the grievance officer was. During an interview on 3/14/24 at 1:55 P.M., the Activity Director said: - He/she had only been in that position for three weeks; - He/she had not had a resident council meeting yet. During an interview on 3/15/24 at 7:35 P.M., the Administrator said: - She always thought Social Services was the one who…

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 reviews, the facility failed to ensure staff provided a written notice of transfer of discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic nail) and telephone number of the Office of the State Long-Term Care Ombudsman, and for residents with a metal disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with metal disorders established under the Protection and Advocacy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to inform residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for three of 12 sampled residents, (Resident #1, Resident #10 and Resident #192) and failed to have the resident or family/legal representative sign the bed hold which affected Resident #1. The facility census was 40. The facility did not provide a policy regarding bed holds. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/24 showed: - Cognitive skills intact; - Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing; - Occasionally incontinent of urine; - Continent of bowel; - Diagnoses included anxiety, high blood pressure, coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart). Review of the resident's medical record, dated…

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 develop and implement a comprehensive person-centered plan of care to include measurable objectives and appropriate timeframe's for two of 12 sampled residents (Resident #33 and Resident #36). The facility census was 40. The facility did not provide the requested comprehensive care plan policy. 1. Review of Resident #33's Quarterly MDS dated , 1/7/24, showed: -Severe cognitive impairment; -The resident has delusions (false beliefs or judgments about reality); -Limited assistance with ADLs; -Diagnosis included, Dementia, diabetes mellitus (a metabolic disease, involving elevated blood sugar levels), and heart failure. Review of the resident's POS, dated March 2024, showed: - Activities - per care plan - Start date: 4/26/23 - Novolog( rapid-acting insulin), 5 units three times before meals for diabetes mellitus. Call the physician if blood sugar is less than 60 or greater than 400. Review of the resident's undated care plan showed: -Limited assistance…

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 utilized an Inter Disciplinary Care Team to developed and updated a care plan consistent with resident's specific conditions and needs which affected two of 12 sampled residents, (Resident #10 and #1) when they did not update care with interventions regarding unexpected weight loss for (Resident #10) and when they did not include residents (Resident #1) in his/her care planning. The facility census was 40. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed: --He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact. -He/She had clear speech, was able to make self-understood, and usually understood others; -He/She used walker for mobility; -He/She was independent…

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 failed to administer medications with food, which affected three of 12 sampled residents, (Resident #7, Resident #15 and Resident #33). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24 showed: - Cognitive skills intact; - Independent with eating, personal hygiene, toilet use, dressing and transfers; - Diagnoses included high blood pressure, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood flow 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 residents who required assistance with Activity of Daily Living (ADL) received the necessary assistance with grooming, bathing and incontinent care when the facilty staff failed to ensure three residents (Resident #36, Resident #142, and Resident #20) received regular showers, failed to provide complete incontinence care for one resident (Resident #37), and when staff failed to provide oral care to two resident (Resident #8 and #20). The facility census was 40. Review of the facility's Activities of Daily Living (ADL) policy revised March 2018, showed: -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good grooming, oral care and personal hygiene; -Appropriate care and services that will be provide include bathing, dressing, grooming, oral care and toileting. The facilty staff did not provide a policy regarding incontinence care. 1. Review of Resident #142's admission Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected four residents (Residents #2, #30, #36 and #142) out of 12 sampled residents. The facility census was 40. Review of the facility's Activities Programs, revised June 2018, showed: -Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well being of each resident; -The activities is provided to support the well-being of resident's and to encourage independence community interaction; -Activities are based on the comprehensive resident-centered assessment and the preferences of each resident; -The activities program is ongoing and includes facilty organized group activities, independent individual activities and assisted individual activities;…

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 observation, interviews, and record review, the facility staff failed to provide repositioning and incontinent care according to professional standards of practice for three residents (Resident #3, #18, and #37) who were dependent upon staff for mobility and assistance with cares. This affected three of twelve sampled residents. The facility census was 40. Facility did not provide the requested policy regarding positioning. 1. Review of Resident #3's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 7, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was severely cognitively impaired. -He/She had clear speech, usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time; -He/She usually understands but misses some part or intent…

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 nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 40. Review of the facility's policy for nurse aide qualifications and training program, revised August, 2022 showed, in part: - Nurse aides must undergo a state-approved training program; - The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state. 1. Review of the NA employee list showed: - NA D employed since 9/5/23; - NA F employed since 7/26/23. During an interview on 3/15/24 at 7:35 P.M., the Administrator said: - The NAs have to be through the training by the end of their four month hire date; - They will send the NAs to their sister…

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

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent (5%). Facility staff made seven medication errors out of 25 opportunities for error, resulting in a medication error rate of 28%. This affected four of 12 sampled residents, (Resident #6, Resident #9, Resident #15 and Resident #17). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders); - The individual administering the medications checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; - Staff follows…

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 did not leave medications unattended in the resident's rooms and in the dining room, which affected three of 12 sampled residents, (Resident #7, Resident #9 and Resident #11). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders); - The individual administering the medications checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; - Staff follows established facility infection control procedures (e.g. hand washing,…

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 interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to five of twelve sampled residents (Resident #192, #36, #7, #9, and #11) The facility had a census of 40. Review of facility policy, serving temperature for hot and cold foods, dated 2016, showed: -Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. These are minimum serving/holding temperatures and may vary based on state regulations. Hot foods served at higher temperatures, based on resident preference, must be done cautiously because foods served too hot may potentially decrease food quality and possibly contribute to resident burns. -Meats and casseroles, vegetables, potatoes,…

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 follow acceptable infection prevention and control practices to help prevent the development and the transmission of communicable diseases as well as infections, when staff failed to administer medication in a safe manner, when staff used their bare fingers to administer medications to one resident (Resident #15), and when staff failed to wash or sanitize their hands and change gloves between dirty and clean tasks. Additionally, staff failed to follow infection prevention measures when staff placed soiled linens directly on the floor when providing incontinent care for one resident (Resident #37) and when facility staff failed to follow their Employee Screening for Tuberculosis policy for three of 10 sampled new hires. The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications 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.

Based on interviews the facility staff failed to ensure residents had timely access to their personal funds after business hours and on the weekend. This affected one of 12 sampled resident's. Resident #11, was not able to access personal funds after hours. The facility census was 40. The facility did not provide policy on funds access. Review of facility policy, Resident Rights, revised February 2021, showed: -Access personal records pertaining to him or herself. -Manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes). 1. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 13, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact. -He/She had clear speech, was able to make self understood and understand others; -He/She used walker and wheelchair for mobility; -He/She required set up or clean up…

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 adequate pain control for one of 12 sampled residents (Resident #192). The facility census was 40. Review of facility policy, administering pain medications, showed: -Pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care pan, and the resident's choice related to pain management. -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. -Pain management is a multidisciplinary care process that includes the following: -assessing the potential for pain; -Recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of the pain; -Developing and implementing approaches to pain management; -Identifying and using specific strategies for different levels 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, facility staff failed to provide appropriate incontinence care for two residents who required assistance.(Resident #4 and #5) of seven sampled residents. The facility census was 46. The facility provided policy, Dementia Care, dated November 2018 showed in part: -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. 1. Review of Resident #4's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/24/23 showed: -Brief Interview of Mental Status (BIMS) of 99; indicated significant cognitive loss. -No behaviors -Partial to moderate assistance by staff for Activities of Daily Living (ADL's: general activities necessary for one to function and live independently, such as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence.) -Always incontinent of bladder. (the inability to control the passage of urine)…

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 train staff to adequately care for one resident (Resident #7) with behavioral health care needs. The facility census was 46. Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022 showed in part: -Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work rules or occupational functions successfully. Staff must meet the skills and techniques necessary to care for resident needs including (but not limited to) Behavioral health, Psychosocial care, Dementia care, Person centered care, and Communication. Review of the facility policy Dementia-Clinical Protocol dated November 2018 showed in part: -Nursing assistants will receive training in the care of residents with dementia and related behaviors. Performance reviews will be conducted annually and in-service education will be based on the results of the reviews. 1. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly investigate falls and put interventions in place for Resident #3 who had multiple falls. The facility census was 45. A review of the facility's Accidents and Incident Policy with a revision date of July 2017, showed: - All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator; -The nurse supervisor/charge nurse and/or the department or supervisor shall promptly initiate and document investigation of the accident or incident; -The following data shall be include on the report: o The date and time of the incident; o The nature of the injury; o The circumstances surrounding the incident; o The time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions; o The dated and time the injured person's family was notified; o Other pertinent information; o The signature and title of the person completing 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 nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 43. Review of facility policy, Nurse Aide Qualifications and Training Requirements, dated May 2019 showed: -Nurse aides must undergo a state-approved training program. -Facility will not employ any individual as a nurse aide for more than four months unless that individual is competent and has completed a training program or a program approved by the state. -Facility will not employ any individual as a nurse aide for less than four months unless the individual is participating in a state-approved training program. Review of the NA employee list showed: -NA A employed since 10/2022. -NA B employed since 10/2022. -NA C employed since 10/2022. -NA D employed since 07/2022. -NA E employed since 05/2021. -NA F employed since 11/2022. During an interview on 12/5/22 at 9:37 A.M. the Interim Administrator, Interim Director of Nursing (DON), and DON said: -Nurse…

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 effective, comprehensive, data-driven QAPI program that focused on outcomes of care and quality of life when the facility failed to provide documentation and evidence of its ongoing Quality assurance and performance improvement (QAPI) program. Facility census was 43. Review of the facility QAPI plan showed: -Meet monthly. During the entrance conference interview on 12/5/22 at 9:37 A.M., the Interim Administrator said: -He/she started in November 2022. -He/she could not find any QAPI documentation for 2022 and only one meeting for 2021. -QAPI is monthly. During a follow up interview on 12/08/22 at 11:56 A.M. the Interim Administrator was not able to provide any documentation from 2021.

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 and did not review it annually. The facility also failed to ensure facility staff were informed on the facility's Water Management Plan. The facility was 43. 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 spread in the facility water system. -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 staff treated residents with dignity and respect when staff stood while assisting two sampled residents with eating (Residents #1 and #10) and failed to provide assistance with grooming for seven residents (Residents #3, #7, #9, #20, #23, # 30 and #41). The facility census was 43 residents. Review of facility policy, dated 2001 and revised February 2021, showed: - Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth an self-esteem; - When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.); e. provided with a dignified dining experience. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/9/22, showed: - Requires…

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, observation, and interview, the facility failed to ensure four of four sampled residents (Residents #1, #2, #26, and #28) who were dependent on staff for activities of daily living, consistently had access to a call light or other means of summoning staff when needed. The facility census was 43. Review of facility policy, Call System, Resident, dated September 2022, showed: - Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor - If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/22, showed: - A Brief Interview for Mental Status (BIMS) score of 99; which indicates a Staff Assessment for Mental Status…

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 hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected eleven residents. The facility's census was 43. Review of facility policy titled 'conveyance of Resident Funds' showed: -Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death, as applicable -The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate) jurisdiction per state law), as applicable, within thirty days from the date of the resident's discharge or eviction from the facility, or death. Review of Interim Aged Analysis Summary, dated 12/5/22, showed: -Resident #145 (discharged [DATE]) had a negative balance of -4,104.00 -Resident #146 (discharged [DATE]) had 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 observation, interview, and record review the facility failed to notify the resident and/or resident representative of transfers and the reason for transfer in writing. This affected three of three sampled residents (Resident #6, #14, and #34). Facility census was 43. Review of facility policy, Transfer or Discharge Notice, dated March 2021, showed: -The resident and representative are notified in writing of the following information: specific reason for transfer or discharge, effective date of the transfer or discharge, and the location to which the resident is being transferred or discharged . 1. Review of Resident #6's 5 day Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/24/22, showed: -No Brief Interview for Mental Status (BIMS) score. This indicates the resident is never/rarely understood. -Diagnosis include: coronary artery disease (damage in the heart's major blood vessels), heart failure, urinary tract infection, Alzheimer's Disease, and depression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement resident centered care plans when the facility did not have a care plan that addressed seizures or anticoagulants for Resident #18, did not implement the repositioning care plan for Resident #34 and failed to implement the oxygen, falls, and contractures care plan for Resident #1. Facility census was 43. Review of facility policy, Care Plans, Comprehensive Person-Centered, dated March 2022 showed: -A care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The interdisciplinary team (IDT), in conjunction with the resident and family, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The care plan includes measurable objectives 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 assure staff provided assistance to dependent residents with grooming and showers by failing to provide at least two showers a week to six residents (Resident #1, #30, #26, #7, #20, and #3). The facility also failed to provide shaving for one dependent resident (Resident #41). The facility census was 43. Review of the facility's policy on Supporting Activities of Daily Living (ADL) Policy, March 2018, showed: -Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. -Policy Interpretation and Implementation: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meaningful activities, facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected two sampled residents (Residents #12 and #41). The facility census was 43. Review of facility policy, Activity Programs, dated June 2018, showed: -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. -Activities are considered any endeavor, other than routine Activities of Daily Living (ADLs),…

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 record review, observation, and interview, the facility failed to ensure staff prepared foods in a form designed to meet each resident's individual needs when they did not ensure the pureed foods were of smooth consistency. This had the potential to affect all six residents on the pureed diet. The facility census was 43. Review of the International Dysphagia (Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all.) Diet Standardization Initiative (IDDSI), dated 2022, showed: - The IDDSI Pureed level 4 (formerly known as Dysphagia Pureed) is designed for individuals who have moderate to severe dysphagia with poor oral phase abilities and decreased ability to protect their airway. - The diet follows the regular diet planned with foods pureed which are of a smooth, homogenous and cohesive consistency. - All foods to be served may be audited with standardized testing procedures including Fork Drip Test (used to check the correct thickness and cohesiveness in Levels 3-5 foods by assessing whether they flow through or how…

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 record review, observation, and interview, the facility failed ensure staff stored, prepared, distributed and served food to residents in accordance to professional standards for food service safety when they failed to label and date foods after opening, failed to ensure stored dishes were clean and free from dust and food particles, and failed to maintain kitchen tiles and ceiling in good repair and in a sanitary condition to prevent food contamination. This affects all residents who received food from the facility's kitchen. The facility census was 43. Review of an undated Daily Aide Checklist showed: - Properly date and label all items. Review of an undated Daily [NAME] Checklist showed: - All items in fridge properly labeled and dated; - All dishes clean and put where they belong. Must be dry. Observation on 12/5/22 at 9:25 A.M., showed: - Food on the floor under a dish rack by the exit door; - A yellow lid on the floor under the stove; - A glass platter with dust and food particles on a shelf under the can opener; - An open package of bacon in the refrigerator 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review, the facility failed to maintain a surety bond that was equal or greater [NAME] one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive moths from December 2021 through November 2022. This has the potential to affect all residents who had money in the trust account. The census was 43. Review of the facility Surety Bond Policy dated March 2021 showed: -Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility. -Policy Interpretation and Implementation -Surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages. -This facility holds a surety bond to guarantee the protection of residents' funds managed by the…

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