Hickory Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #7) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility census was 39.Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, showed:- To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice;- To address the needs of trauma survivors by minimizing triggers and/or re-traumatization;- Trauma results from an event, series of events, or sets of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse…

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 the necessary behavioral health services and implement effective behavioral interventions for one resident (Resident #7) out of one sampled resident reviewed for behavioral health needs. The facility failed to assess, monitor, care plan, and intervene for ongoing verbally aggressive, disruptive, and maladaptive behaviors that affected other residents and staff. The facility census was 39.Review of the facility policy titled, Behavioral Assessment, Intervention, and Monitoring, revised February 2025, showed the facility would identify behavioral symptoms, evaluate the severity and safety risks of behaviors, develop individualized interventions, monitor the effectiveness of interventions, and document changes in resident behavior. 1. Review of Resident #7's medical record showed:- admitted on [DATE];- Own responsible party;- Diagnoses of bipolar disorder (mood disorder that can cause intense mood swings), anxiety (persistent worry…

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

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #6 and #9). The facility also failed to perform hand hygiene and change gloves during wound care for one resident (Resident #6) out of four sampled residents and during medication administration for one resident (Resident #11) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Enhanced Barrier Precautions, undated, showed:- EBP refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and gloves use during high contact resident care activities;- EBP will be initiated for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers,…

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 pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents. The facility census was 39.Review of the facility's policy titled, Pest Control, dated May 2008, showed:- Our facility shall maintain an effective pest control program;- This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of the facility's pest control invoice, dated 04/23/26, showed:- Services did not target flies;- An exit door didn't close/seal properly and required installation of weather stripping. 1. Observations on 04/27/26 of the dining room showed:- At 12:25 P.M., a visitor entered the dining room with a fly swatter in his/her hand and swatted flies at the resident's table;- At 12:38 P.M., three flies buzzed around Resident #3 and crawled on his/her back;- At 12:48 P.M., three flies crawled on a resident's dining table near the back of the dining room;- At 12:50 P.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 observation, interview, and record review, the facility failed to provide showers for one resident (Resident #1) out of four sampled residents. The facility's census was 39 Review of facility's policy titled, Bath, Shower/Tub dated 2001, showed: - The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Resident will have bath/shower per their request; - Documentation: the date, time the shower/tub bath was performed; name and title of who performed shower/tub bath; all assessment data (skin assessment) obtained during shower/tub bath; If resident refused the shower/tub bath and reasons; Notify supervisor if the resident refuses the shower/tub bath with reasons. Review of Resident #1's medical record showed: - An admission date of 02/04/25; - Diagnoses of hypertension (high blood pressure), Peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), chronic obstructive pulmonary disease (a group of lung diseases that…

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 follow their policy and procedure to complete Criminal Background Checks (CBC) for four of the ten sampled staff prior to hire and to check the Nurses Aide (NA) Registry for all new staff before the employment date to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for seven of the ten sampled staff. The facility census was 37. Review of the facility's policy titled, Abuse Prevention, dated September 2021, showed: - Background checks will be done at the time of hire in accordance with the facility background check policy. Staff will not be hired who have been found guilty, or plead nolo contendere (a plea of no contest) of abuse, neglect, mistreatment of residents, or misappropriation of resident property by a court of law. Such determination will not be limited to residents but shall include any known abusive acts against others; - The nurse aide registry will be checked prior to employment, nurse aides will not be hired whose name is…

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 implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #191) out of one sampled resident. The facility census was 37. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care is developed for each resident within 48 hours of admission to meet the resident's immediate health and safety needs; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care; - The resident and/or representative are provided a written summary of the baseline care plan that includes, but not limited to: stated goals and objectives of the resident, summary of the resident's medications and dietary instructions, any services/treatments to be administered by the facility, and any updated information based on the details of the comprehensive care plan, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Residents #4, #5, #12, and #38) out of 12 sampled residents. The facility census was 37. Review of the facility's policy titled, Care Plans - Comprehensive, revised September 2010, showed: - An individualized comprehensive care plan that includes measurable timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident; - The facility's Care Planning/Interdisciplinary Team (IDT - a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident), in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest functioning the resident may be expected to attain; - The comprehensive care plan is based on a thorough assessment that…

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 physician's orders for oxygen (O2) for two residents (Residents #3 and #14) out of three sampled residents and wound care for one resident (Resident #5) out of three sampled residents. The facility's census was 37. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed: - The purpose of the procedure is to provide guidelines for safe oxygen administration; - Verify that there is a physician's order for this procedure; - Review the the physician's orders or facility's protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - While the resident is receiving oxygen therapy, assess for cyanosis (blue tone to the skin), hypoxia (low level of oxygen in the tissues), oxygen toxicity (lung damage that happens from breathing in too much extra or supplemental oxygen) and vital signs. The facility did not provide a policy on following physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's order for a house supplement recommendation by the registered dietician (RD) and failed to ensure the RD completed a nutritional assessment due to significant weight loss for four residents (Residents #4, #24, #34 and #38) out of four sampled residents. The facility census was 37. Review of the facility's policy titled, Monthly Dietary Consultant Report, undated, showed: - A report of RD activities shall be made in writing or completed electronically and provided to the facility in hard copy or electronic format at the close of each consultation; - The monthly consultant report is to: serve as a communication tool between consultations, provide documentation that a consultation was provided according to state and federal regulations, avoid verbal misunderstanding of RD recommendations and findings, assist the consultant in planning for future consultations, assist the Dining Service Manager in correcting areas of…

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

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two sampled medication carts. This practice had the potential to affect all residents. The facility census was 37. Review of the facility's policy, titled, Controlled Substances, revised November 2022, showed: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; - Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; - The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) services. 1. Review of the 100 Hall Certified Medication Technician (CMT) Narcotic Count Log for Controlled Substances on 01/22/25 at 9:45 A.M., showed: - For the 5 A.M. - 11 P.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 interview and record review, the facility failed to monitor the drug regimen for unnecessary medications by not ensuring the as needed (PRN) psychotropic (medications that affect a persons mental state) medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #18) out of five sampled residents and one resident (Resident #19) outside the sample. The facility failed to ensure a gradual dose reductions (GDR) was attempted for four residents (Residents #7, #14, #18 and #24) out of five sampled residents. The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for one resident (Resident #24) out of five sampled residents. The facility census was 37. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction, revised July 2022, showed: - Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs; - The physician will order…

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

Based on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during wound care for two residents (Resident #5 and #191) out of three sampled residents and one resident (Resident #12) outside the sample. The facility census was 37. Review of the facility's policy titled, Enhanced Barrier Precautions, reviewed March 2024, showed: - Enhanced barrier precautions are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply; - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); h. wound care (any skin opening requiring a dressing); - EBPs…

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 comprehensive care plans in seven days after completion of the comprehensive assessment and no more than 21 days after admission to properly care for two residents (Residents #1 and #2) out of five sampled residents. The facility census was 36. Review of the facility policy, Care Plans; Comprehensive Person Centered, dated March 2022, showed: - A comprehensive person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The comprehensive person centered care plan is developed within seven days after completion of the required Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), and no more than 21 days after admission; - The comprehensive, person-centered care plan includes measurable objectives and time frames, describes the services that are to be furnished…

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

Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #1, #2, #3, and #5) out of five sampled residents. The facility census was 39. The facility did not provide a policy. 1. Review of Resident #1's medical record showed: - An admission date of 11/16/23; - Diagnoses of weakness, confusion, cerebral vascular accident (CVA (stroke), damage to the brain from interrupted blood supply), arteriosclerotic heart disease (ASHD, a thickening and hardening of the walls of the coronary arteries), congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs), orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), right abdomen mass, anxiety (persistent worry and fear about everyday situations), hypertension (HTN, high blood pressure), gastroesophageal reflux disease (GERD, stomach acid being forced back into the throat region), pain, and atrial fibrillation (a-fib, heart dysrhythmia); - An order, dated 05/28/24,…

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 the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 35. Review of the facility's policy titled, Food-Related Garbage and Refuse Disposal, revised October 2017, showed the outside dumpsters provided by the garbage pickup services will be kept closed and free of surrounding litter. 1. Observations on 01/08/24 at 11:00 A.M., 01/09/24 at 10:45 A.M., 01/10/24 at 2:00 P.M., and 1:53 P.M., and 01/11/24 at 9:03 A.M., of the outside trash dumpster located near the kitchen entrance showed one 6-yard (yd.) dumpster partially filled with the one plastic lid completely opened. During an interview on 01/11/24 at 9:00 A.M., the Dietary Manager said the dietary staff removed the trash at the end of their shifts daily. Trash bags were usually tossed in the dumpster, and it was left open for the next time it needed to be filled, but it should be closed. During an interview on 01/11/24 at 9:04…

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 document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility) for two residents (Resident #3, and #18) out of 12 sampled residents. The facility's census was 35. Review of the facility's Resident Assessment policy, revised March, 2022, showed: - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews; - A comprehensive assessment includes a completion of the MDS. 1. Review of Resident #3's medical record showed: - An admission date on 07/17/23; - Diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia (BPH) (an enlargement of the prostate causing difficulty in urination); - No documentation of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement care plans with specific interventions tailored to meet individual needs for three residents (Resident #2, #9, and #28) out of 12 sampled residents. The facility census was 35. Review of the facility's policy titled, Care Plan, revised 03/2022, showed: - A comprehensive, person centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident; - Builds on the resident's strength; - Reflects currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), Parkinson's (a disorder of the central nervous system that affects movement), aggression, and agitation; - An order for haloperidol (an antipsychotic medication) 2 milligram (mg) by mouth every 12 hours as…

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 obtain a physician's order and failed to complete a resident assessment and safety evaluation for the use of a trapeze (a device designed to assist residents in changing positions) for one resident (Resident #27) out of one sampled resident. The facility census was 35. The facility did not provide a policy regarding trapeze use. 1. Review of Resident #27's Physician's Order Sheet (POS), dated January 2024, showed: - admission date of 08/31/22; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety (persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), bipolar disorder (a mental disorder that causes unusual shifts in mood) and morbid obesity; - No order for a trapeze. Review of the resident's…

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

Based on observation, interview, and record review, the facility failed to follow physician's orders for two residents (Resident #18 and #27) out of 12 sampled residents. The facility census was 35. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #18's Physician Order Sheet (POS), dated January 2024, showed: - Diagnoses of benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), hearing loss, and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow); - An order to change the Foley catheter (a tube inserted into the bladder to drain urine) size 16 french with 10 milliliter (ml) balloon monthly (on the 19th) and as needed for obstructive uropathy, dated 09/23/22; - An order to change hearing aid batteries every Friday, dated 03/24/23. Review of the resident's Treatment Administration Record (TAR), dated December 2023, showed: - No documentation of the Foley catheter changed with one out of one opportunity missed; - No documentation of the hearing aids…

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 assess residents for the use of bed rails prior to installation and use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #18 and #27) out of 12 sampled residents. The facility's census was 35. Review of the facility's policy titled, Bed Safety and Bed Rails, revised August 2022, showed: - The resident's sleeping environment is evaluated by the interdisciplinary team; - Bed frames, mattresses, and bed rails are checked for compatibility and size; - Bed dimensions are appropriate for resident's size; - The use of bed rails or side rails is prohibited unless the criteria for the use if bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.; - Alternatives to the use of bed or side rails that are attempted include roll guards, foam bumpers, lowering the bed, and/or use of concave…

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 post the nurse staffing data with all the required components in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis. The facility's census was 35. The facility did not provide a nurse staffing policy. Observations of the facility showed: - On 01/08/24 at 11:45 A.M., and 2:30 P.M., no documentation of the nurse staffing posted; - On 01/09/24 at 9:10 A.M., and 1:05 P.M., no documentation of the nurse staffing posted; - On 01/10/24 at 10:30 A.M., no documentation of the nurse staffing posted. During an interview on 01/10/24 at 10:30 A.M., Registered Nurse (RN) A said the nurse staffing sheets were completed and placed into the hanging folder on the door across from the nurse's station. The nurse staffing sheets were not visible to the residents or visitors. They were completed at the start of each shift but one had not been completed for 01/10/24. During an interview on 01/10/24 at 10:35 A.M., the Administrator said the staffing sheets should be posted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the pharmacy consultant identified an appropriate diagnosis for the use of an antipsychotic (a medication used to treat psychosis or the loss of connection to reality) medication during the pharmacist's monthly Medication Regimen Review (MRR) for three residents (Resident #2, #9, and #18) out of three sampled residents. The facility's census was 35. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat a specific condition for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate diagnosis for the use of an antipsychotic (a medication used to treat psychosis or the loss of connection to reality) medication for three residents (Resident #2, #9, and #18) out of three sampled residents and failed to limit the use of an as needed (PRN) psychotropic (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) medication to 14 days or to document the rationale for extending the order for three residents (Resident #2, #14, #25) out of 12 sampled residents during the pharmacist's monthly Medication Regimen Review (MRR). The facility's census was 35. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat a specific condition for which they are indicated and effective; - The attending physician and other staff will gather and document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information and education to the resident or the resident's representative of the pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus) and influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) vaccines, and offer the pneumococcal and influenza vaccines to four residents (Resident #2, #3, #18, and #22) out of five sampled residents. The facility census was 35. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, revised on 09/22/23, showed the CDC recommends pneumococcal vaccination for adults [AGE] years old and older and adults 19 through [AGE] years old with certain underlying medical or risk conditions. Review of the United States Department of Health and Human Services Centers for Disease Control (CDC) Pneumococcal Vaccine Timing for Adults, dated 03/15/23, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 resident vaccinations were offered, administered, or refused by the resident and/or the resident representative for four residents (Residents #2, #3, #18, and #22) out of five sampled residents. The facility census was 35. Review of the facility policy titled, COVID-19 Vaccination of Residents, revised June 2022, showed: - Residents eligible to receive the COVID-19 vaccine are strongly encouraged to do so; - Resident or representative has the right to accept, refuse, and change his/her decision about taking the COVID-19 vaccine; - Resident is provided with education regarding the benefits, risks, and potential side effects associated with the each vaccine and booster; - Residents are screened for contraindications to the vaccine; - Residents must sign a consent to vaccinate form prior to receiving the vaccine; - When COVID-19 vaccines are administered in two does, the second dose is automatically scheduled if first dose is received; - 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.

Based on interview and record review, the facility failed to provide the required annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions) or the abuse and neglect training and 12 hours of training for two Certified Nurse Aides (CNA) (CNA B and CNA C) out of two sampled CNAs, which had the potential to affect all residents. The facility's census was 35. The facility failed to provide a policy regarding the required annual nurse aide training. 1. Review of CNA B's in-service record showed: - A hire date of 03/30/20; - No documentation of the annual dementia care training provided for March 2022 through March 2023; - No documentation of 12 hours of training provided for March 2022 through March 2023. 2. Review of CNA C's in-service record showed: - A hire date of 12/12/22; - No documentation of the annual abuse and neglect training provided for December 2022 through December 2023; - No documentation of 12 hours of training provided for December 2022 through December 2023. During an interview on 01/11/24 at 1:20 P.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one resident's (Resident #1) responsible party after the resident fell and sustained injuries on two separate occasions, one of which resulted in the resident going to the emergency room for evaluation. The facility census was 32. Review of the facility policy titled, Change in Resident's Condition or Status, revised on February 2021, showed the following: -The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: The resident is involved in an accident or incident that results in an injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status; or it is necessary to transfer the resident to the hospital. 1. Review of Resident #1's face sheet showed the following:…

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