Maryville Rehabilitation & Health Care Center

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected one of the 12 sampled residents, (Resident #3). The facility census was 46. The facility did not provide a policy for perineal care. 1. Review of Resident #1's urinalysis (UA, test to analyze urine contents), dated 2/20/25 showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine culture and sensitivity ( UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 2/20/25, showed the presence of organisms indicative of a possible UTI. Review of the resident's Physician Order Sheet (POS) dated 2/21/25 showed: - Ceftriaxone (broad spectrum antibiotic used to treat UTIs) Sodium injection solution, reconstituted one gram intramuscularly in the evening for infection…

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 four residents (Resident #1, #2, #3, and #4) out of five sampled residents were free from abuse when three staff members took photos of four residents (Resident #1, #2, #3, and #4) and one staff member took a video (Resident #2) and posted it to social media. Two of the pictures taken had a demeaning comment written on the pictures about the residents (Resident #1 and Resident #2). Three of the four residents had a diagnosis of dementia and all four residents were unaware that they had been recorded or had their pictures taken and posted to a social media platform. The facility census was 44. On 3/11/25, the Administrator was notified of the past noncompliance which began on 02/10/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected 02/28/2025. Review of the facility policy, Abuse Prevention, and Prohibition, revised January 2024, showed:…

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

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, failed to take food temperatures on the steam table before food service and when cooking items, failed to reheat foods to safe temperatures before serving, stored glasses with openings facing up, stored eggs on the floor, did not properly sanitize food preparation surfaces in kitchen, did not have a thermometer in refrigeration unit, did not ensure proper parts per million (PPM) sanitation levels were reached while using a 3 compartment sink, did not wash hands after contamination, did not have paper towels available at hand washing sink, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 59. 1. Review of facility policy, Receiving and storage of food, dated May 2015, showed: -Keep storage areas clean and dry. Review of facility policy, storage of dry food and supplies, dated May 2015, showed: -Storeroom must be neat…

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 respect resident rights of six residents out of the 15 sampled residents, when the facility failed to provide grooming for three residents ( #312, #36, #44) and failed to respect the privacy of three residents (#25, #40, #43). The facility census was 59. Facility did not provide a dignity policy. Review of facility policy, shaving the resident, undated, showed: To remove facial hair and improve the resident's appearance and morale. Review of facility policy, resident rights, undated, showed: -Residents will be provided the highest level of care and service; -Each resident shall be treated with consideration, respect a full recognition of his/her dignity, and individuality. -Right to dignified existence 1. Review of Resident #312's admission face sheet showed: Resident was admitted on [DATE] -Bipolar disorder (mental health disorder that alternates between depression and mania); -Macular degeneration (progressive loss of vision);…

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 that residents were offered a choice of when they would like to get up in the morning. This affected two of the 15 sampled residents (Residents #30, and #43). The facility census was 59. Review of the facility's Resident Rights Policy, dated 6/12/24 showed in part: -Each resident shall be treated with consideration, respect, and full recognition of his/her individuality; -Each resident shall not have the right to self determination which includes the right to a choice of schedules and accommodations for preferences. 1. Review of Resident #30's Quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 4/13/24 showed: -Moderate cognitive impairment; -Partial assistance with showers and personal hygiene; -Substantial assistance with dressing and transfers; -Dependent on staff for bed mobility; -Diagnosis included traumatic brain injury (TBI, injury to the brain from a violent blow or jolt to 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 interviews and record review, the facility failed to consider the views of resident council and act promptly upon grievances and recommendations made by the group concerning issues of resident care and life in the facility when the facility failed to demonstrate their response and rationale for such responses when they did not maintain documentation of resident concerns, facility's attempt to resolve concerns, or the facility's follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 59. Review of facility policy, resident rights, undated, showed: -Each resident shall be encouraged and assisted throughout his/her stay to exercise their rights as Resident and citizen, and may voice grievances and recommend changes in policies and services to facility staff or outside representatives of his/her choice. A staff person shall designated to receive grievances and Residents may voice their complaints and recommendations to staff designee, an ombudsman, or any person outside facility.…

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 inform residents how to file a grievance or complaint, take prompt efforts to resolve resident grievances voiced in resident council meetings when the same problems were voiced multiple months with no resolutions and failed to follow up with one resident's family member (Resident #43) with resolution regarding a grievance made to the facility. The facility census was 59. Review of nursing home resident right's, undated, showed: -Right to raise grievances: -Present grievances without discrimination or retaliation, or fear of it; -Prompt efforts by the facility to resolve grievances, and provide a written decision upon request. Review of facility policy, resident grievances, undated, showed: -Resident has the right to exercise his or her rights as a resident of the facility; -A complaint must be in writing and contain the name and address of the person filing it; -The grievance coordinator (or designee) shall conduct an investigation of the complaint to determine its validity; -The grievance coordinator will…

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 individualized person centered comprehensive care plans for two residents (Resident #15 and #44) to address dehydration and falls (resident #15) and code status (Resident #44). The facility census was 59. Review of facility policy, care plan comprehensive, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. 1. Review of Resident #15's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/22/24, showed: -He/She was severely cognitively impaired; -He/She was dependent on a walker for mobility; -He/She had fall history prior to admission, but no falls the last 2-6 months; -He/She 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 observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to administer medications within the appropriate time frame, which affected three of the 15 sampled residents, (Resident #21, #28 and #29). The facility census was 59. Review of the facility's undated policy for the medication administration guidelines showed: - It is the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose tot he proper resident, and promptly recording the information; - Medications may not be prepared in advance and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) received the necessary assistance with bathing, incontinent care. This affected four out of the 17 sampled residents, when the facility staff failed to ensure two residents (Resident #4 and #43) received regular showers, failed to provide complete incontinence care for two residents (Resident #33 and #40) The facility census was 59. Review of the facility's undated Perineal Care policy showed: -Wash hands and apply clean gloves; -Using a clean wipe separate and cleanse all skin folds that have came in contact with urine or feces; -Wash from front to back. Review of the facilty's undated Resident Rights policy showed; -Residents have the right to dignified existence; -Residents have the right to be treated with consideration, respect and dignity, recognizing each residents individuality; -Residents have the right to a quality of life that is maintained 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the staff failed to ensure residents remained free from accident hazards and failed to provide adequate supervision to prevent accidents. Staff failed to ensure one resident was served the accurate therapeutic ordered diet (Resident #27) and staff failed to ensure medication was administered when a controlled medication was left on a resident's card table for two days (Resident #49). This affected two of fifteen sampled residents. Additionally, the facility failed to ensure staff used proper techniques to reduce the possibility of injuries during the use of sit to stand (a lift that allows residents who can bear weight to transfer from a sitting position to a standing position) transfer, which affected Resident #43. The facility census was 59. Facility did not provide a policy regarding prevention of accidents. Review of facility policy, diet orders, undated, showed: -Diet orders prescribed by the attending physician shall be reviewed monthly by the dietary…

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 sufficient staffing to provide services to residents to maintain highest practicable physical, mental, and psychosocial well-being when residents did not receive showers which affected one of the 15 sampled residents, (Resident #43), meal service was late which affected all the residents, activities were not offered due to activity director being pulled to cover the floor, and medications were late which affected Resident # 21, #28 and #29. The facility census was 59. The facility did not provide a policy for staffing. The facility did not provide a policy for showers. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; - Required substantial to maximal assistance with toilet use, dressing and transfers; - Had a Suprapubic catheter (a catheter which…

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 rate of less than five percent (5%). Facility staff made nine medication errors out of 28 opportunities for error, resulting in a medication error rate of 32.14%. This affected five of 15 sampled residents, (Resident #3, #4, #12, #48 and #53). The facility census was 59. Review of the manufactures guidelines for Novolog insulin FlexPen dated July 2023 showed: -Clean the area with an alcohol swab and let dry; -Hold the needle in the skin for at least 6 seconds before removing the needle. Review of the manufactures guidelines for Levimir FlexTouch insulin pen dated March 2024 showed in part: -Clean the area with an alcohol swab and let dry; -Hold the needle in the skin for at least 6 seconds before removing the needle. The facilty did no provide the requested policy on insulin administration. 1. Review of Resident #3's Physician's Order Sheet (POS), dated June 2024 showed: -Start date: 3/2/20 - Novolog insulin FlexPen (fast-acting) 100 units/millilliter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. Additionally, the staff failed to discard a vial of the Influenza Vaccine after it had expired and failed to ensure medication had had a pharmacy label on it. The facility census was 59. Review of facility policy, storage of medications, undated, showed: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medicaiton carts. -All mobile medication carts must be under visual control of the staff at all times when not stored safetly and securely. Carts must be either in a locked room or otherwise made immobile. -All controlled substances must be stored under double lock and key. -An unattended medication cart must remain locked at all times. In the event the nurse 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure the cleanliness of the kitchen, and meals were served to residents in a timely manner. This has the potential to affect all residents of the facility. The facility census was 59. Facility did not provide a policy regarding dietary staffing. 1. Review of Resident # 40's Significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/7/24, showed: - Cognitive skills intact; - He/She was independent with eating - Diagnoses included high blood pressure, gastroesophageal reflux disease (GERD) (A digestive disease in which stomach acid or bile irritates the food pipe lining), and anxiety. Review of the resident's care plan, revised 4/25/24 showed: -Resident was at nutritional risk for having strong food preferences and personal choices on not leaving his/her room for meals; -Regular diet; -Dietary to provide…

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 three (resident #40, #43, and #312) of fifteen sampled residents. The facility census was 59. Review of facility policy, food temperatures, dated April 2015, showed: -Hot foods should be at least 120 degrees Fahrenheit when served to the resident. 1. Review of Resident # 40's Significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/7/24, showed: - Cognitive skills intact; - He/She was independent with eating - Diagnoses included high blood pressure, gastroesophageal reflux disease (GERD) (A digestive disease in which stomach acid or bile irritates the food pipe lining), and anxiety. Review of the resident's care plan, revised 4/25/24 showed: -Resident was at nutritional risk for…

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

Based on observations, interviews, and record review, the facility failed to ensure the call light system was accessible for residents in their rooms when call lights were out of reach for two of the 15 sampled residents, (Resident # 43 and #44). The facility census was 59. Review of facility policy, use of call light, undated, showed: -When providing care to residents, be sure to position the call light conveniently for the resident's use. -Tell the resident where the call light is and show him/her how to use the call light. -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; - Required substantial to maximal assistance with toilet use, dressing and transfers; - Had a Suprapubic catheter (a catheter which enters the bladder through the lower abdomen; - Frequently incontinent of bowel; - Diagnoses included…

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 the facility failed to protect the resident's right to personal privacy when a nurse left the medication cart computer screen unattended, unlocked, and visible with resident personal information accessible to anyone near the computer screen. The facility census was 59. Review of facility policy, electronic medical records, undated, showed: -Only authorized persons who have been issued a password and a user identification (ID) code will be permitted access to the electronic medical records system. -The facility electronic medical records system has: -safeguards to prevent unauthorized access; -individual password and user ID codes and permission is established to ensure only authorized persons enter appropriate data; -will not permit a change on the record once it had been locked without the approval of the person that completed the assessment. Review of facility policy, resident rights, undated, showed: -All information contained in resident's medical, personal, or financial record and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to identify, assess and document a pressure ulcer (an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) for one of the 15 sampled residents, (Resident #43). The facility census was 59. Review of the facility's undated policy for wound care and treatment showed, in part: - The purpose of the facility is to prevent and treat all wounds; - There must be a specific order for the treatment; - Prevention strategies - On - going skin assessment with weekly documentation of status. Minimize dry skin. Apply house moisturizer to areas of dry skin, after and as needed. Avoid massage over bony prominence's. Minimize friction and sheer through proper positioning transferring and turning. Develop and implement method of communicating position changing; - Incontinence management - Minimize skin exposure to incontinence, perspiration and /or wound drainage. Use cloth clothing protector…

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 meals were served to meet the needs of the residents when staff failed to serve food items for each diet type when staff failed to prepare food according to the menu and failed to serve the correct portion sizes per the menu. This had the ability to affect all residents. The facility census was 59. Review of facility policy, menus, dated May 2015, showed: -Menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the recommended dietary allowances; -Any unusual or complex diet not printed on the menu or listed in the Manual shall be written by the consulting dietician based on physicians orders. Review of facility menus, day 16 lunch, showed: -Regular baked chicken: portion size 3 ounces (oz); -Pureed baked chicken: portion size/serving utensil #8 scoop; 5 servings recipe showed : -3 oz chicken,1/2 cup + 2 tablespoons stock chicken soup based,1 Tablespoon + 3/4 teaspoon food thickener; -Minced and moist chicken: portion size #8 scoop, 5 serving…

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 prepare food in a form designed to meet individual needs when residents were served food not consistent with their dietary orders (Resident #27). This affected one of fifteen sampled residents. The facility census was 59. Review of facility policy, menus, dated May 2015, showed: -Menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the recommended dietary allowances; -Any unusual or complex diet not printed on the menu or listed in the Diet Manual shall be written by the consulting dietician based on physicians orders. Review of facility policy, diet communication form, dated April 2006, showed: -It is the responsibility of the nursing department to communicate all information associated with the residents diet order to the dietary department via the dietary communication form; -A dietary communication form will be completed when there is a change in diet. 1. Review of Resident #27's quarterly minimum data set (MDS), a federally mandated assessment tool…

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 provide care in a manner to prevent infection or the possibility of infection when staff failed to wash hands between dirty and clean tasks which affected one of the 15 sampled residents, (Resident #43). The facility census was 59. Review of the facility's undated policy for handwashing showed: - The purpose is to reduce transmission of organisms form resident to resident, nursing staff to resident and resident to nursing staff; - The policy did not indicate when staff should wash or sanitize their hands. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; - Required substantial to maximal assistance with toilet use, dressing and transfers; - Had a Suprapubic catheter (a catheter which enters the bladder through the lower abdomen; - Occasionally incontinent of bowel; - Had a Stage II pressure ulcer (a partial thickness loss of…

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

Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. The facility census was 51. Review of policy, storage of medications, undated, showed: -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. Observation on the C hall used as the COVID isolation unit, on 11/30/23 at 1:02 P.M., showed the medication cart lock was sticking out from medication cart and the drawers were not locked. No facility employees were found on the C wing hall. Five residents were residing on the COVID unit. Observation on the C hall wing, 11/30/23 at 1:15 P.M., showed the regional nurse entered unit and locked the medication cart. During an interview on 11/30/23 at 4:47 P.M., the Director of Nursing (DON) said: -Medication…

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

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to label food when it was opened, failed to temperature check foods, and failed to ensure staff washed their hands when contaminated. The facility census was 51. Review of the facility policy, Sanitizing the three-compartment sink, dated 5/15 showed: -Ensure the sanitizing water is at the appropriate level, is being monitored, documented, and used correction, according to the instruction below: - Fill third compartment of 3-compartment sink with water to the line as indicated on the sink. - Dip test paper into solution and hold for 10 seconds. - Compare color on strip to chart on container (desired reading is 200 ppm) - If not at desired reading, report to dietary services manager immediately. - Document test strip completion on log provided. - Dishes should be submerged in sanitizing solution for 1 to 2 minutes and allowed to air dry. -The sanitizing solution should 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff failed to follow acceptable standards of practice for the 2019 Novel Coronavirus Disease COVID-19 (COVID-19,(an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)), when staff failed to apply personal protective equipment (PPE) upon entering the room and failed to remove PPE when exiting the room of SARS-Covid-19 positive residents (Residents #1 and #2), reused disposable gowns (Residents #1, #2 and #5), did not sanitize hands after applying reused disposable gowns (Resident #5), when used disposable gowns were left hanging in hallway of non-isolation unit (Residents #1 & #2). This affected three of five sampled residents. The facility census was 51. Review of facility policy, COVID-19…

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 complete entrapment assessments, obtain informed consent and physician orders for use of side rails for three of 15 sampled residents. (Residents #10, #26, and #38). The facility census was 50. Review of the undated facility provided policy regarding physical restraints showed: -Equipment: side rails (bed rails) -Guidelines: assess residents need for use; obtain physician's order. -Side Rails: involve the resident and the resident's representative in planning for side rail use. - The policy did not include direction for staff regarding assessment, obtaining consent or obtaining a physician order. 1. Review of Resident #10 Quarterly Minimum Data Set (MDS a federally mandated assessment completed by facility staff) dated 7/10/22 showed: -Brief Interview of Mental Status (BIMS) of 0. This indicates severe cognitive deficits. -Extensive assistance with bed mobility (movement of body while in bed), dressing, and personal hygiene. -Dependence…

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 prepare and serve foods that were attractive and palatable to residents at or above 120 degrees Fahrenheit (F). The facility census was 50. Review of facility Food Temperature's policy, dated May 2015, showed: -Hot food should be at least 120 degrees F when served to the resident. Observation on 10/11/22 at 12:06 P.M. showed: -The hot box (A hot box is an improvised appliance to heat up food) was not plugged in as the hall trays were beginning to be dished up and placed inside to be sent to the Dementia unit. -One tray was sitting on top of the hot box instead of being inside. It was covered with an insolated top with no insolated or heated bottom. Observation on 10/12/22 at 12:31 P.M. showed: -Sample hall tray contained Parmesan chicken with green beans, red bliss potatoes, and dinner roll. -Temperature of chicken 140.5 degrees F; The chicken tasted bland. -Temperature of green beans 116.2 degrees F; no flavor and needed seasoning. -Temperature of red bliss potatoes 106.1 degrees F; no seasoning; and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff cared for residents in a dignified manner, when they failed to ensure that two residents received facial grooming for the removal of unwanted facial hair (Resident #43, and Resident #253) and failed to ensure that one resident (Resident #45) was able to sit at an appropriate sized table height to accommodate independent eating during meals in the main dining. The facility census was 50. Review of the facility's posted Resident Rights policy showed: Each resident has the right to be treated with dignity and respect. All staff activities and interactions with residents must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's preferences and choices. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/24/22 showed: -Diagnosis: Intact cognition, osteoarthritis, diabetes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assure staff provided necessary care and services in accordance with professional standards of practice for two residents (Resident #12 and #31) out of the sampled thirteen residents when the staff failed to place a hand roll in the contracted hand of one resident to prevent further contractures and failed to apply heel protectors for Resident # 12 and staff failed to apply compression socks every morning before the resident was out of bed for Resident #31. The facility census was 50. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 7/15/22 showed: -Dementia; -Extensive assistance of two staff members for Activities of Daily Living (ADL's); -Incontinent of bowel and bladder; -Diagnoses of anemia, heart failure (HF), hypertension (HTN), and cerebral vascular accident with left hemiplegia(CVA-Stroke with partial paralysis), contracture of the left hand (hand…

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 appropriate treatment and services to maintain the ability to communicate for one resident (Resident #38) of 15 sampled residents. Facility census was 50. The facility did not provide a policy on communication. 1. Review of Resident #38 Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 9/16/22 showed: -BIMS of 14, indicates no cognitive impairment -Hearing highly impaired -No hearing aide -Extensive assistance with bed mobility and dressing. -Dependent on staff for transfers and toilet use. -Limited assistance with personal hygiene. - Diagnosis of heart failure, Diabetes (a disease where the pancreas doesn't produce enough insulin to control the amount of glucose, or sugar,in the blood.),Depression and Chronic Obstructive Pulmonary Disease (COPD: a group of diseases that cause blocked airflow into the lungs and breathing difficulty) -Resident admitted [DATE] Review of the Care Plan for impaired…

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.