Legendary Health Care Center

Based on observation, interview, and record review, the facility failed to ensure staff provided one resident (Resident #9's), in a review of 14 sampled residents, with an appropriately sized wheelchair that did not impede his/her ability to self-propel in his/her wheelchair. The facility census was 31. Review of the facility's policy, Accommodation of Needs, dated March 2021, showed the following: -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -Needs are evaluated upon admission and reviewed on an ongoing basis; -Provides a variety of types (for example, chairs with or without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position. 1. Review of Resident #9's Care Plan, dated 04/16/25, showed the resident was independent in using a wheelchair. Review of resident's admission Minimum Data Set (MDS), a federally…

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 gradual dose reductions (GDR's) were attempted, or document clinical contraindications for all psychotropic medications for one resident, (Resident #4 ), in a review of five residents sampled for unnecessary medications. The facility census was 31. Review of the facility policy, Tapering Medications and Gradual Drug Dose Reduction, revised June 2022, showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; -All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions; -Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; -Periodically, the staff and practitioner…

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 meet professional standards of quality for one resident (Resident #9), in a review of 14 sampled residents, when staff failed to follow physician's orders. The facility census was 31. 1. Review of Resident #9's undated Face Sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had private insurance and Medicaid was pending. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/17/25, showed the following: -admission diagnosis of fracture and other multiple traumas; -Orthopedic surgery to repair fractures of the pelvis, hip, leg, knee or ankle; -Cognition was intact; -Independent with transfers; -Upper and lower extremity impairment on one side; -Independent with a wheelchair. Review of the resident's nursing progress notes, dated 4/22/25 at 8:11 P.M., showed the resident returned from an orthopedic appointment. The resident…

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

Based on interview and record review, the facility failed to ensure one nurse aide (NA B), completed a nurse aide training program within four months of employment with the facility. The facility census was 31. 1. During an interview on 05/13/25 at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of the facility staff title listing, dated 05/12/25, showed the facility hired NA B on 09/20/24. 3. Review of NA B's employee file showed a hire date of 09/20/24 as a nurse aide. His/Her employee file did not include documentation he/she had completed his/her certification for a nurse assistant. 4. Review of NA B's nurse aide registry check showed no documentation to show NA B had a Certified Nurse Assistant (CNA) certification. Review of the facility May 2025 schedule, dated 05/12/25-05/20/25 (duration of survey), showed NA B scheduled to work as a nurse assistant on 05/12/25 day shift, 05/13/25 day shift, 05/15/25 day shift, 05/17/25 night shift, 05/18/25 night shift and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one staff, Nurse Assistant (NA) J, in a review of five NA employee files, had completed a new training and competency evaluation program or a new competency evaluation program on hire. NA J, a former Certified Nurse Assistant (CNA), who did not continue working as a CNA for 24 consecutive months, had let his/her CNA certification expire. NA J had not completed the required retraining and had not been accepted to challenge the CNA exam or have any other approval to work as a CNA. The facility census was 31. 1. During an interview on [DATE] at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of NA J's nurse aide registry check showed his/her CNA certification expired [DATE]. 3. Review of NA J's employee file showed the following: -Date of hire [DATE]; -No documentation to show he/she was in a training and competency evaluation…

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 Refer to Event ID 0T6H13 Based on interview and record review the facility failed to ensure safe transfer techniques and prevent falls for two residents (Resident #1 and #3) in a review of six residents when staff failed to prevent Resident #1, who the facility identified as a fall risk and who was dependent on staff for all transfers and care needs, from rolling out of bed while staff provided care and failed to prevent the resident from falling to the floor when the mechanical lift (a device used to lift a resident from one surface to another with the use a sling) tipped over during a transfer. Staff also failed to use a gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair) and provide adequate staff assistance during a transfer for Resident #3 with a known increased fall risk following a total hip replacement surgery. The facility census was 37. Review of the facility policy, Transferring a Resident, dated February 2018, 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.

Refer to Event ID 0T6H12. Based on observation, interview, and record review, the facility failed to follow a physician ordered diet when staff provided the resident with orange juice and failed to provide nectar thickened liquids for one resident (Resident #33) in a review of seven sampled residents. The facility census was 36. Review of the facility policy, Therapeutic Diets, revised October 2017, showed a therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example, altered consistency diet. 1. Review of Resident #33's undated face sheet showed the resident's diagnoses included dementia, end stage renal disease, oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat) and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 9/3/23, showed the following: -Moderately…

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 store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to store food products to maintain quality and free from potential contaminants. Staff failed to maintain appropriate holding temperatures of cold food items. Staff failed to store and handle utensils and kitchenware in a sanitary manner. Staff failed to ensure proper hand hygiene and sanitization practices were employed. Staff failed to ensure food storage and preparation equipment and surfaces were clean and maintained. Staff failed to ensure the facility's ice machine drain contained an air gap. The facility census was 37. 1. Review of the facility policy, Guidelines for Staff Preparing Food Fundamentals to Prevent Food Borne Illness, dated 2011, showed food should be protected during storage, preparation, and service. Review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, showed the following: -Food shall be stored on shelves in a clean, dry area, free from…

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 changed gloves and washed hands as indicated during the provision of care for one resident (Resident #12), in a review of 14 sampled residents, and failed to ensure proper infection control was utilized for respiratory care supplies for one resident (Resident #16). The facility also failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 37. Review of the facility's Handwashing/Hand Hygiene policy, dated August 2019, showed the following: -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a.When hands are visibly…

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 create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two additional residents (Resident #17 and #19) who both had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking. Four additional residents (Resident #5, #6, #10 and #30) voiced concerns of staff awakening them between 4:00 A.M. and 6:00 A.M. when getting other residents up or getting them up when it was convenient for staff. The facility census was 37. Review of the facility's Resident Rights policy, dated December 2016, showed Federal and State laws guarantee certain basic rights to all residents of this facility, including self-determination. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated…

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

Based on interview and record review, the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 37. Review of the facility's Mail and Electronic Communication policy, dated May 2017, showed mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries). 1. During a group interview on 8/9/23 at 10:05 A.M., Resident #30 and Resident #2 said residents do not receive mail on Saturdays. During an interview on 8/11/23 at 9:45 A.M., Transportation/Activities O said the following: -During the week, Activities Staff P brings mail into the facility from the mailbox; -He/She distributed the residents' mail around the building to residents' rooms; -He/She did not deliver mail on Saturdays. During an interview on 8/11/23 at 11:06 A.M., Activities Staff P said the following: -He/She did not not pass mail to residents on Saturdays; -Any mail that was delivered to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean and comfortable environment for residents when the facility failed to ensure resident's rooms and living spaces were clean and in good repair. The facility census was 37. Review of the facility's Maintenance Service policy, dated December 2009, showed the following: -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to: -Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; -Maintaining the building in good repair and free from hazards; -Providing routinely scheduled maintenance to all areas. 1. Observations on 8/8/23 between 10:23 A.M. and 4:15 P.M. showed the following: -A ceiling tile, located by the smoke barrier doors between the front nurses station and the 300 hallway, was water damaged, bowed, and was stained brown with…

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

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 37. Review of the facility policy, Director of Nursing Services, dated August 2006, showed an RN is on staff eight hours each day between the hours of 6:00 A.M. to 8:00 P.M. 1. Review of the January 2023 Nurse Schedule, dated 01/01/23 through 01/31/23, showed no RN coverage on 01/20/23. Review of the February 2023 Nurse Schedule, dated 02/01/23 through 02/28/23, showed no RN coverage on 02/05/23, 02/12/23, 02/25/23 and 02/26/23. Review of the March 2023 Nurse Schedule, dated 03/01/23 through 03/31/23, showed no RN coverage on 03/02/23, 03/07/23, 03/08/23 and 03/09/23. Review of the May 2023 Nurse Schedule, dated 05/01/23 through 05/31/23, showed no RN coverage on 05/13/23, 05/14/23 and 05/27/23. Review of the June 2023 Nurse Schedule, dated 06/01/23 through 06/30/23, showed no RN coverage on 06/03/23, 06/04/23, 06/17/23, 06/18/23 and 06/24/23. Review of the July 2023 Nurse Schedule, dated 07/01/23 through 07/31/23,…

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 as needed (PRN) psychotropic medications were limited to 14 days for two residents (Resident #34 and Resident #3), in a review of 14 sampled residents. The facility also failed to ensure one resident's (Resident #18) physician provided a rationale when he disagreed with the pharmacist's recommendation for a gradual dose reduction (GDR). The facility census was 37. Review of the facility's Antipsychotic Medication Use, dated December 2016, showed the following: -Residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; -The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order; -PRN orders for antipsychotic medications will not be renewed beyond 14 days unless 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 remove and destroy outdated resident medications and failed to remove and destroy expired stock medications (over-the-counter medications used for more than one resident) from medication carts and medication rooms. The facility failed to destroy or return one discharged resident's medications and facility failed to document an open date on medication that the manufacturer suggested be destroyed 30 days after opening. The facility census was 37. Review of the facility policy, Labeling of Medication Containers, dated 4/2019, showed all medication will be destroyed according to the expiration date. Review of a Tubersol (injectable medication used in the diagnoses of tuberculosis (infectious bacterial disease that mainly affects the lungs)) package insert showed it said a vial of Tubersol which has been entered (punctured) and in use for 30 days should be discarded. 1. Observation on 08/10/23 at 7:38 A.M., of the stock medications 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.

Based on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the facility's diet spreadsheet menu. The facility census was 37. Review of the facility policy, Therapeutic Diets, dated 2001, showed the following: -Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences, the attending physician may delegate this task to a registered or licensed dietitian as permitted by state law; -Diet order should match the terminology used by the food and nutrition services department; -A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Review of the facility policy, Menu Planning (Serving Requirements), dated 2011, showed the following: -Diet spreadsheets will be planned…

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 food items at a safe and appetizing temperature. The facility census was 37. Review of the facility policy, Guidelines for Staff Preparing Food Fundamentals to Prevent Food Borne Illness, dated 2011, showed the following: -Cold, under 41 degrees Fahrenheit (F), stops bacteria from growing; -Heat, over 135 degrees F, halts most bacteria; -Cold foods should be kept chilled, hot foods should be kept hot. Review showed the facility did not have a policy related to food holding temperatures or temperatures to be achieved at time of service to residents. Review of email correspondence, dated 08/10/23, from the facility's Registered Dietitian, showed point of service temperature for hot food was 120 degrees F and the holding temperature for cold food was 41 degrees F. 1. During a group interview on 8/9/23 at 10:05 A.M., eight of eight residents in attendance said the food was cold. They just leave the food on the table and don't eat it. During an interview on 08/09/23 at 12:33, Resident #3 said he/she liked…

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 treat one resident (Resident #139) in a review of 14 sampled residents, with dignity and respect. Staff failed to assist the resident to use either a commode or toilet and directed the resident to urinate in his/her brief. facility census was 37. Review of the facility's Dignity policy, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -When assisting with care, residents are supported in exercising their rights, including allowing the resident to choose when to conduct activities of daily living; -Staff are expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance. 1. Review of Resident #139's baseline care plan, dated 08/1/23, showed the following: -Can communicate easily with staff; -Toilet use: two or more person physical assist; -Always incontinent of bladder and bowel. Review of the resident's undated care plan showed the following: -The resident requires pretty much total care with two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when one resident (Residents #18), in a review of 14 sampled residents, and one additional resident (Resident #13), were transferred to the hospital. The facility census was 37. During an interview on 08/11/23 at 2:45 P.M., the Director of Nursing (DON) said she was unable to find a Discharge/Transfer Policy. Review of the Bed Hold/Agreement Policy, revised December 2006, showed it did not address discharge transfer information. 1. Review of Resident #18's face sheet showed his/her family member was his/her responsible party. Review of the resident's progress notes, dated 03/26/23 at 7:42 A.M., showed the resident continues with inappropriate sexual behaviors. Review of the resident's progress notes dated 03/26/23 at 12:17 P.M., showed the following: -Resident sent to psychiatric facility for psychiatric issues; -Resident being transported by staff in facility vehicle;…

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 (Resident #139), in a review of 14 sampled residents, received care based on professional standards of practice. The resident had a diagnosis of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should) and received diuretic medication (medications that help reduce fluid buildup in the body). Staff catheterized (the placement of a tube in the bladder to drain urine) the resident for a urine specimen and received a residual amount of 1000 milliliters (ml) (in adults, 100 ml of residual urine is considered to be an abnormal level) . Facility staff emailed the physician's nurse but, did not attempt to contact the physician again regarding the large residual amount. The resident repeatedly complained of needing to urinate. Facility staff also failed to report to the physician when the resident experienced a 14 pound weight loss in seven days. The facility census was 37. Review of the facility policy, Nutrition (Impaired)/Unplanned Weight…

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

Based on observation, interview and record review, the facility failed to ensure staff safelytransferredd one resident (Resident #8), in a review of 14 sampled residents, who was unable to fully bear weight. The facility failed to ensure chemicals, stored in the dementia unit, were secured in a locked storage area. The facility census was 37. Review of the facility policy SafeLiftingg and Movement of Residents revised July 2017 showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 1. Review of Resident #8's undated care plan showed the following: -The resident is dependent on staff for his/her cares; -He/She can help some, using his/her right arm;…

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 adequately address one resident's (Resident #139's), in a review of 14 sampled residents, expressions and complaints of pain during cares. Staff failed to notify the resident's physician when the resident's pain was unrelieved by as needed (PRN) pain medication. The facility census was 37. Review of the facility policy, Pain Assessment and Management, dated 3/2020 showed the following: -The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -The 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 plan, and the resident's choices 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; -Acute pain (or…

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

Based on observation, interview, and record review, the facility failed to follow a physician ordered diet when staff provided the resident with orange juice and failed to provide nectar thickened liquids for one resident (Resident #33) in a review of seven sampled residents. The facility census was 36. Review of the facility policy, Therapeutic Diets, revised October 2017, showed a therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example, altered consistency diet. 1. Review of Resident #33's undated face sheet showed the resident's diagnoses included dementia, end stage renal disease, oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat) and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 9/3/23, showed the following: -Moderately impaired cognition; -Required…

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

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality by not obtaining a apical pulse prior to Digoxin (used to improve the strength and efficiency of the heart or to control the rate and rhythm of the heartbeat) administration and failed to obtain a physician ordered blood test for one resident (Resident #21) in a review of 13 sampled residents. The facility census was 26. 1. Review of facility policy Administering Medications, updated December 2012, showed the following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 2. Review of facility policy Anticoagulation- Clinical Protocol, updated November 2018, showed the following: -The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; -Nurse shall assess and document/report the following: Recent labs, including therapeutic dose monitoring. 3. Review of online drug resource, www.drugs.com,…

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

Based on interview and record review, the facility failed to maintain a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), by failing to implement their policy or to complete a risk assessment to determine susceptible locations for the growth of such organisms. The facility census was 26. 1. Review of the facility's Legionella Water Management Program Policy, dated 2017, showed the following: -The purpose of the water management program was to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; -The water management program used by the facility should be based on the Centers for Disease Control and Prevention and The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations for developing a Legionella water management program; -The water management program includes and interdisciplinary water management team, a detailed…

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.