Pin Oaks Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly notify residents of potential non-coverage and beneficiary financial liability for two of three residents (Resident (R)225 and R227) reviewed for beneficiary notification out of a total sample of 24 residents. This had the potential to place undue financial liability on residents without their knowledge. The facility census was 71. Findings include: The facility did not provide a policy related to Advanced Beneficiary Notice (ABN). 1. Review of R225's undated Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R225 was admitted to the facility on [DATE] and discharged on 10/11/24. Review of a document titled Notice of Medicare Non-Coverage (NOMNC) for R225 revealed a NOMNC dated 09/03/24 indicating a coverage end date of 09/14/24. There was no ABN with a benefits end date of 09/14/24 when R225's coverage for skilled nursing was due to end and R225 remained in the facility. Review of R225's Progress Notes…

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 review of facility policy, record review, and interview, the facility failed to ensure one resident (Resident (R) R25) out of three residents reviewed for abuse was free from resident to resident verbal abuse. R25 was verbally abused by R49. This failure created the potential for further resident to resident abuse and for R25 to experience psychosocial harm related to the abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion; and examples include scolding, ignoring, ridiculing, or cursing a resident. 1. Review of R25's undated Face Sheet found in the Electronic Medical…

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 review of facility policy, record review and interview, the facility failed to ensure timely reporting of allegations of abuse related to three (Residents (R) R22, R25 and R49) out of a total of three residents reviewed for abuse. R22 reported an allegation of staff to resident abuse and R25 was verbally abused by another resident (R49) and neither incident was timely reported to the State Agency (SA), Ombudsman or local law enforcement. This failure created the potential for these and other residents to experience potential further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: The facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary…

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 review of facility policy, record review, and interview, the facility failed to ensure a thorough investigation was completed related to an incident of resident-to-resident verbal abuse involving two (Residents (R )25 and R49) out of a total of three residents reviewed for abuse. This failure created the potential for R25 and other residents to experience further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, Investigation: It is the policy of his facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. 1. Review of R25's Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, revealed the resident was admitted to the facility on [DATE]. 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 record review and staff interview, the facility failed to ensure three residents (R9, R48, and R53) of a total of 24 residents reviewed had comprehensive care plans in place to address all of their needs. R9 did not have a care plan with interventions to prevent the resident from experiencing another coffee burn. R48 did not have a care plan in place to address his behaviors or the administration of his psychotropic medications and R53 did not have a care plan in place to address the administration of her oxygen. This failure created the potential for comprehensive care to not be provided for the residents. The facility census was 71. Findings include: 1. Review of R53's Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnosis included chronic obstructive pulmonary disease (COPD). Review of R53's quarterly Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a final discharge summary was completed upon discharge for one resident (Resident (R) 17) of three residents reviewed for discharge out of a total sample of 24 residents. This deficient practice had the potential to contribute to a lack of continuity of care and lack of necessary treatment and services. The facility census was 71. The findings include: Review of the facility's policy titled, Resident Discharge/Transfer Policy dated March 2015, revealed, Complete discharge summary and post discharge plan of care form. Have resident and/or representative or person responsible for care sign discharge summary and post discharge care form. Place the original form in the record. Review of R17's Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included: sepsis, palliative care, morbid (severe) obesity, schizophrenia, peripheral vascular disease, pain,…

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 facility policy review, observation, record review, and interviews, the facility failed to implement their scheduled activities programs for residents. The facility also failed to ensure one (Resident (R)9) of two residents reviewed for activities was provided with a consistent activity program to meet their needs. The resident was not offered activities based on assessment of her activity preferences. This failure created the potential for the resident to experience isolation related to lack of participation in facility activities. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's Activity, Volunteer and Recreational Services Policy dated 03/2012 read, in pertinent part, The facility provides for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. 1. Review of the facility's activity calendars for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of Broda chair instructions, observation, record review, and interview, the facility failed to ensure one resident (R9) of two residents reviewed for pressure sores was provided with adequate care and treatment to prevent skin breakdown. This failure created the potential for the resident to experience further skin breakdown. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Wound Care and Treatment Policy read, in pertinent part, It is the purpose of this facility to prevent and treat all wounds; and There must be a specific order for the treatment; and The care plan should reflect the current status of the wound and appropriate goals and approaches. Review of the facility's undated Instructions for Use When Using a Broda Chair document, provided directly to the survey team, read, Are Additional Cushions Recommended or Required? Not necessarily. Our proprietary Comfort Tension Seating system…

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, record review, and review of facility policy, the facility failed to ensure residents were free from potential accident and hazards during smoking for one of one (Resident (R) 67) reviewed for safe environment out of a sample of 24 residents. This had the potential to place residents at risk of injury from a potential fire. The facility census was 71. Findings include: Review of the Oxygen Therapy Safety Guidelines from the National Institute of Health revealed the following: -Keep oxygen cylinders away from heat sources; -Keep oxygen delivery systems at least 5 feet from any heat source; -Oxygen supports combustion. No smoking is permitted around any oxygen delivery devices in the hospital or home environment. Review of the facility policy (undated) titled, Smoking-Resident revealed Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking. Review of a document titled Dependent Resident Smoking…

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 review of facility policy, record review, and interview, the facility failed to ensure comprehensive dialysis services were provided for one resident (R22) out of a total of one resident reviewed for dialysis. There were no orders in place related to the care and maintenance of the resident's intravenous (IV) dialysis catheter. This failure created the potential for R22 to receive incomplete and inconsistent care of her dialysis catheter. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Dialysis, Care of a Resident Receiving Policy read, in pertinent part, Care of a Subclavian or Femoral Vein Catheter: Treatment for cleaning as ordered by the physician .Nurses to maintain dressing to access site at all times. Site to be checked every shift and dressing reapplied or reinforced as needed. Review of R22's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, revealed the resident 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 record review, staff interviews, and facility policy review, the facility failed to ensure two residents (R9 and R53) of a total of nine residents reviewed for accidents was appropriately assessed for the use of side rails on their beds. The facility further failed to ensure both residents had an informed consent for the use of rails on their beds. This failure created the potential for the residents to be injured related to use of potentially unnecessary side rails installed and in use on their beds. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Bed Rails Policy read, in pertinent part, Prior to use of bed rails the facility should complete the Matrix Bed Rail Observation including the following: 1. Observation Detail 2. Clinical Assessment 3. Alternatives attempted prior to bed rail implementation 4. Bed Rail Details 5. Assessment of potential entrapment zones 6. Review of the risks and benefits with the resident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure the physical safety of bed rails for two (Residents (R)9 and R53) of a total of nine residents reviewed for accidents. Bed rails on both residents' beds were observed to be loose. This failure created the potential for the residents to be injured by improperly applied and unmaintained bed rails. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Bed Rails Policy read, in pertinent part, Staff will conduct regular inspections of all bedframes, mattresses, and bed rails, to identify areas of possible entrapment. 1. Review of R9's undated Resident Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included dementia and repeated falls. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment…

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 protect residents from misappropriation of property when 40 tablets of oxycodone/acetaminophen (narcotic pain medication used to treat moderate to severe pain) and five tablets of gabapentin (used to treat nerve pain) were determined missing for one resident (Resident #1), when in the possession of facility staff. A sample of seven residents was selected for review. The facility census was 68. Review of the facility's Abuse Prohibition Protocol, undated, showed the following: -It is the policy of this facility that reports of misappropriation of property are promptly investigated; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; -The staff will complete an active search of missing items including documentation of the investigation, and interview with staff members having contact with the resident during 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 interview, and record review, the facility failed to ensure narcotic counts were completed to ensure any missing doses could be readily detected, failed to label medications, and failed to store medications in a safe and effective manner. Licensed staff failed to complete on-coming and off-going controlled drug counts to verify the correct count of narcotics for one resident (Resident #1). Licensed staff also failed to follow the facility policy when accepting medications that were brought from home for the resident to ensure the medications were examined and positively identified by the pharmacist and approved for the resident's use. The facility census was 68. Review of the facility policy, Medications Scheduled II-V (drugs, substances, and certain chemicals used to manufacture them have been classified into categories based upon the drugs acceptable use and abuse or dependency potential), undated, showed the following: -To provide medication for residents as prescribed by facility medication personnel and to comply with State and Federal guidelines regarding these…

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 staff treated three residents (Residents #7, #8 and #9), in a review of ten sampled residents, with dignity and respect when they refused to provide assistance and verbalized rude and disrespectful comments to the residents. The facility census was 71. Review of the facility undated policy Resident's Rights showed the following: -Long-term care residents have a right to care which maintains or enhances the quality of life; -Residents should be treated with consideration and respect, with full recognition of their dignity and individuality. Review of the undated facility admission packet showed the following: -As a nursing home resident, you have the right to privacy and respect; -You shall be treated with consideration, respect and full recognition of your dignity and individuality; -It is the intent of the facility to promote and ensure that highest standards of conduct and reliability by its employees and consultants to in turn produce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain exhaust vents, lighting, heating/ventilation units, walls, ceilings, and flooring in good repair and free of a buildup of debris. The facility census was 67. Observation and interview on 2/21/23 at 9:34 A.M. in occupied resident room [ROOM NUMBER] showed the brown wall paint was marred with exposed drywall behind the bed closest to the room door. A large patch of drywall compound was visible in the sink vanity area next to the mirror. Maintenance Staff C said the old soap dispenser had been removed and relocated. The area needed to be finished and painted. Observation on 2/21/23 at 9:42 A.M. in occupied resident room [ROOM NUMBER], showed the brown wall paint was marred behind the bed closest to the door. Observation on 2/21/23 at 9:47 A.M. in occupied resident room [ROOM NUMBER], showed a buildup of debris on the exhaust fan cover in the restroom. Observation on 2/21/23 at 9:50 A.M., in occupied resident room [ROOM NUMBER], showed the yellow…

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, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good personal hygiene for three residents (Resident #9, #32, and #370), who required assistance to perform their activities of daily living, in a review of 18 sampled residents. The facility census was 67. Review of the facility's undated policy, Bath (Shower), showed the following: -The purpose was to maintain skin integrity, comfort and cleanliness; -Wash face, upper extremities and body, lower extremities and feet, perineal area, and shampoo hair; -Dress resident, comb and style hair. (The facility's policy did not identify when staff were to bathe a resident.) Review of the facility's undated policy, Shaving the Resident, showed to remove facial hair and improve the resident's appearance and morale. (The facility's policy did not identify when staff were to shave a resident.) 1. Review of Resident #9's care plan, dated 10/4/22, showed the following: -The resident 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 observation, interview, and record review, the facility failed to safely transfer three residents (Residents #4, #53, and #62), in a review of 18 sampled residents; failed to utilize a gait belt when repositioning two residents (Residents #6 and #62); and failed to safely transport one resident (Resident #4) in a wheelchair. The facility census was 67. Review of the facility's undated policy for wheelchair use showed footrests should be lowered and the resident's feet placed on them if used. The resident's feet and legs should be placed in good body alignment. Review of an undated facility policy for gait belt use showed the following: -Purpose: To provide better control and balance while assisting resident with ambulation and transfer. -Resident transfers: -Assist resident to a sitting position; -Apply belt to resident's waist; tighten to fit snugly with the buckle at the side; -Face the resident; -Bend your knees and place your hands around the gait belt on each side of the resident's waist; -Bring…

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 respiratory and oxygen interventions and monitoring and maintain continuous positive airway pressure (CPAP; machine that uses mild air pressure to keep breathing airways open while you sleep) equipment according to the facility's policy for four residents (Resident #1, #4, #9 and #24), in a review of 18 sampled residents. The facility census was 67. Review of the facility's undated policy, Cleaning Guidelines-Oxygen Equipment, showed tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and as needed (PRN), and marked with date and initials. Review of the facility's Oxygen Administration policy, undated, showed the following: -A reserve oxygen tank should be available to provide continuity of care; -Label reusable humidifiers with date and time opened; -Change humidifier and tubing per cleaning guidelines; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -At regular…

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

Based on observation and interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 67. Observation on 02/21/23 of the noon meal preparation and service showed the following: -At 9:22 A.M., the Dietary Manager and Dietary Aide B prepared food for the noon meal. Both staff had hair hanging out of the sides of their hairnets; -At 10:18 A.M., the Dietary Manager helped prepare the lunch meal, and did not have the top of his/her hair covered with a hairnet; -At 10:22 A.M., the Dietary Manager made cornbread and the sides and top of his/her hair were not covered with a hairnet; -At 11:33 A.M., the Dietary Manager cut corn bread and the sides and top of his/her hair was not covered with a hairnet; -At 11:34 A.M., Dietary Aide B made drinks for the noon meal and the sides of his/her hair were not in the hairnet; -At 11:57 A.M., Dietary Aide B helped serve lunch plates and the sides of his/her hair were…

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 washed their hands and changed their gloves after each direct resident contact and when indicated by facility policy during personal care for four residents (Residents #21, #24, #30, and #44), in a review of 18 sampled residents, and for one additional resident (Resident #3). The facility failed to ensure sanitary practices when handling wound care supplies during and after wound care for one resident (Resident #120), and failed to ensure proper infection control practices were utilized for respiratory care supplies for two residents (Residents #4 and #370). The facility failed to ensure all procedures were implemented to address prevention, development, and transmission of Tuberculosis (TB) as directed by facility policy. The facility failed to ensure Tuberculin Skin Tests (TST; a small injection in the top layer of skin in the forearm that contains purified protein derivative, PPD) were completed and documented as directed…

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 call lights were in reach for two residents (Residents #4 and #62), in a review of 18 sampled residents. The facility census was 67. Review of facility's undated call light policy showed the following: -Purpose: To respond promptly to resident's call for assistance; -When providing care to residents, be sure to position the call light conveniently for the resident's use; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #4's Face Sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD) (a condition involving constriction of the airways and difficulty or discomfort in breathing), orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying position), depression, hallucinations (an experience involving the apparent perception of something not present), muscle weakness, and unspecified visual loss. Review of the resident's admission Minimum Data Set (MDS), 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 observation, interview, and record review, the facility failed to evaluate one resident's (Resident #41's) wheelchair as a restraint, in a review of 18 sampled residents. The resident's wheelchair was positioned so the resident's legs were in front of him/her (horizontal with the floor). Staff documented the resident had poor safety awareness and impulsive behavior, and frequently attempted to get out of his/her wheelchair. The facility census was 67. Review of undated facility policy, Physical Restraints, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. -Purpose: -To restrict movement to protect the resident during treatment and diagnostic procedures; -To prevent the resident from injuring himself/herself or others; -To improve the resident's mobility and independent function; -To treat the resident's medical symptoms -Guidelines: -Assess…

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 physician orders for one resident (Resident #4), in a review of 18 sampled residents. Staff failed to administer three doses of ordered medication and to obtain laboratory testing as ordered following the resident's return from the hospital. The facility census was 67. Review of the undated facility policy, Physician Orders, showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Physician orders must be reviewed and renewed. 1. Review of Resident #4's Face Sheet showed the resident's diagnoses included hypokalemia (a blood level that is below normal in potassium, which can result in fatigue, muscle cramps, and abnormal heart rhythms). Review of the resident's progress note, dated 2/1/23 at 2:40 A.M., showed the following: -The resident arrived back to facility from the hospital emergency room; -Abnormal lab was potassium of 2.9 (normal blood potassium level is 3.6 to 5.2 millimoles per liter); -Additional instructions from 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 one resident (Resident #120), in a review of 18 sampled residents, received necessary care/treatments to prevent and/or heal pressure ulcers. Staff failed to ensure the resident, who had a pressure ulcer on his/her left heel, had heel protectors on while he/she was in bed. The facility census was 67. Review of facility's undated policy, Pressure Ulcer Care and Prevention, showed the following: -The purpose was to prevent and treat further breakdown of pressure ulcers; -The nurse was responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Staff should use heel protectors if needed. 1. Review of Resident #120's Braden skin assessment for pressure ulcer risk (an assessment tool for evaluation pressure ulcer risk), dated 2/9/23, showed he/she was at high risk for developing pressure ulcers. Review of the resident's wound documentation, dated 2/9/23 at 6:00 P.M., showed the resident had a 1 centimeter (cm) by 0.4 cm pressure…

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

Based on observation and interview, the facility failed to provide proper care to a urinary catheter (a tube inserted in to the bladder to excrete urine out of the body) for one resident (Resident #120), in a review of 18 sampled residents, by failing to keep the catheter drainage bag and catheter tubing from touching the floor. The facility identified two residents with a urinary catheter. The facility census was 67. Review of the facility's undated policy, Catheter/Emptying a Urinary Drainage Bag, showed to keep the drainage bag and tubing off of the floor at all times to prevent contamination and damage. 1. Review of Resident #120's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 8/22/22, showed he/she had a urinary catheter. Review of the resident's physician's orders, dated 2/9/23, showed the resident had a urinary catheter. Review of the resident's care plan, dated 2/10/23, showed the resident's diagnoses included history of urinary tract infections (UTI). (The resident's care plan did not identify the resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement trauma informed care for one resident (Resident #307), in a review of 18 sampled residents. The resident had a diagnosis of post traumatic stress disorder with a history suicidal ideations. The facility census was 67. Review of Resident #307's Preadmission Screening and Resident Review (PASRR) II (evaluation on a resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms), dated 1/30/21, showed the following: -The resident was admitted in 1993 in a hospital with suicidal gesture, cut wrists, inpatient for a month; -The resident's parent passed away from brain aneurysm (weakness in a blood vessel in the brain that can leak or rupture, causing life-threatening bleeding) from the motor vehicle accident when the resident was 14 or l5 years old; -The resident was molested by his/her step parent as a child; -Diagnoses of bipolar disorder (brain disorder that causes changes in a person's mood, energy, 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.

Based on observation, interview, and record review, the facility failed to act promptly upon the grievances and recommendations of the resident council concerning resident care in the facility; and failed to provide the resident council with responses, actions and rationale taken regarding their concerns. The facility census was 76. 1. Review of the facility's policy, Resident Council, dated March 2012, showed the following: -The resident population will elect a resident council annually in the facility. Monthly meetings will be held with minutes of the meetings documented. Recommendations for changes by the council will be given to the administrator who will evaluate the recommendations. The resident council serves as a liaison between the employees, residents and others who interface with the facility; -Concerns and needs are addressed as voiced by members of the council; -All department leaders are encouraged to attend the meeting for problem resolution. 2. Review of the facility Resident Council Minutes, dated 5/23/19, showed the following: -Eight residents, including Residents…

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 keep the floors and walls in good repair, and failed to maintain comfortable temperatures in the facility. The census was 76. 1. Observation on 8/6/19 at 3:34 P.M. showed black marls on the bathroom floor and around the toilet in the bathroom for room [ROOM NUMBER]. The soap dispenser on the wall by the sink had been removed leaving holes in the wall from where it had been attached. Observation on 8/6/19 at 10:45 A.M. showed the wall behind the bed in room [ROOM NUMBER] was marred with multiple areas of chipped and missing paint. Observations on from 8/6/19 to 08/09/19 showed the following: -Multiple areas of chipped paint on the wall behind bed 1 in room [ROOM NUMBER]; -Multiple areas of chipped paint on the wall behind bed 2 in room [ROOM NUMBER]; -Multiple areas of chipped paint on the wall behind bed 2 in room [ROOM NUMBER]; -Multiple areas of chipped paint on the wall behind bed 1 and 2 in room [ROOM NUMBER]; -Multiple areas of chipped paint on 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 follow standards of practice and physician orders for three residents (Residents #11, #31, and #54), in a review of 22 sampled residents. The facility failed to provide one resident (Resident #54) with honey thickened (liquids thickened to honey consistency) water in his/her room; failed to ensure oxygen administration was set at prescribed level as physician ordered for three residents (Residents #54, #31, and #11). The facility census was 76. 1. Review of the facility policy Physician Orders, dated March 2015, showed the following: -Current list of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -Oxygen orders: Specify the rate of flow, route, and rationale (i.e., 2-3 liters/minute per nasal cannula as needed (PRN) for shortness of breath); -PRN medications:…

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 provided six residents (Residents #11, #28, #47, #54, #55, and #65), in a review of 22 sampled residents, and two additional residents (Residents #8 and #66), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal and oral hygiene. The facility census was 76. 1. Review of the facility's policy, Perineal Care, dated March 2015, showed the following: -Purpose: to cleanse the perineum and to prevent infection and odor; -Female perineal care: Put on disposable gloves. Wet washcloth and make a mitt with it. Apply soap lightly, use one gloved hand to stabilize and separate the labia. With the other hand, wash from front to back, rinse and pat dry; -Male perineal care: Put on disposable gloves. Wet washcloth and make a mitt with it. Apply soap lightly, wash pubis and penis. If uncircumcised, pull back foreskin of penis and wash. Carefully dry and return foreskin to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oversight to prevent one additional resident (Resident #61) from wandering outside the facility in a wheelchair. The resident left the facility through an unlocked and unalarmed door. The facility failed to safely transfer three residents (Residents #24, #54 and #65), in a review of 22 sampled residents. The facility census was 76. 1. Review of the facility policy Elopement-Missing Resident from the Nursing Guidelines Manual, dated March 2015, showed the guidelines discussed a resident missing, who to notify, thorough search, notifying law enforcement, and when located, to assess for injuries. The policy did not address assessing residents for elopement/wandering risk and prevention measures. 2. Review of the facility's [NAME] 3000 Arjo (a standing and raising aide used for transferring residents) instructions for stand-up lift, dated August 2013, showed the following: -A mobile raising aid for raising to a standing position 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 provide sufficient nursing staff to meet residents' needs for seven residents (Residents #11, #17, #24, #31, #33, #54, and #65), in a review of 22 sampled residents, and three additional residents (Residents #8, #38, and #100). The facility census was 76. 1. During interview on 8/9/19 at 2:30 P.M., the director of nursing said the facility had no policy regarding facility staffing. 2. During interview with the facility's resident council on 8/6/19/19 at 1:24 P.M. showed the following: -Residents #33 said he/she has had to wait 30 to 40 minutes for staff to answer his/her call light and doesn't feel there are enough staff to get the showers done. He/she feels all three shifts need more help; -Residents #100 said he/she had to wait up to an hour for staff assistance; -Resident #11 said staff come to see what he/she wants when they answer his/her call light, but staff do not return from going to get help. He/she has had to relieve…

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 food at an appetizing temperature. The facility census was 76. 1. Review of the facility policy, Food Temperatures, dated May 2015, showed hot food should be at least 120 degrees Fahrenheit (F) when served to the resident. 2. During interview on 8/6/19 at 1:37 P.M., Resident #5 said the food served was always cold. The dietary staff brought a cart of trays to the dining room (located by the 400 and 500 hall) for each meal. Staff did not get those trays served for over 15 to 20 minutes. When staff finally got around to passing out the meal trays, the food was cold. 3. Observation on 8/7/19 at 1:14 P.M. of the test tray, obtained after staff served the last resident in the 400/500 hall dining room, showed the temperature of the ground chicken was 92 degrees Fahrenheit, the temperature of the pureed carrots was 94 degrees Fahrenheit, the temperature of the fried chicken was 112 degrees Fahrenheit, and the regular consistency carrots were 92 degrees Fahrenheit. The food was cool to taste.…

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

Based on observation and interview, the facility failed to offer residents a daily bedtime snack. The census was 76. During group interview on 8/6/19 at 1:24 P.M., the residents said the following: -Resident #2 said he/she had to get bedtime snacks at the nurses station. Staff do not bring bedtime snacks to the residents; -Resident #5 said staff bring a bowl of snacks to the nurses station but they do not normally bring the snacks to the residents' rooms. He/she would like a snack at night; -Resident #4 said staff will eventually bring a snack if he/she asks for it. Observation on 8/7/19 at 8:00 A.M., showed a blue bowl sat on the nurses station containing various snacks. Observation on 8/8/19 at 5:30 A.M., showed a blue bowl sat on the nurses station containing various snacks. During interview on 8/9/19 at 8:22 A.M., Licensed Practical Nurse (LPN) A said the dietary staff bring out a snack bowl in the evening and staff are to offer the residents a snack and document the intake or refusal in the computer. During interview on 8/9/19 at 8:29 A.M., the dietary manager said bedtime…

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 washed their hands after each direct resident contact and when indicated by professional standards of practice during personal care for four residents (Residents #28, #37, #47 and #54), in a review of 22 sampled residents Facility staff failed to transport clean linens in such a way as to prevent cross-contamination. The facility census was 76. 1. Review of the facility's policy, Gloves, dated March 2015, showed the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. Gloves must be changed between residents and between contacts with different body sites of the same resident; -REMEMBER: Gloves are not a cure-all. They should reduce the likelihood of contaminating the hands, but…

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, maintain, and update a plan of care consistent with residents' specific conditions, needs, and risks based on their comprehensive assessment for one resident (Resident #65), in a of 22 sampled residents. The facility census was 76. 1. Review of the facility policy Care Plan Comprehensive, dated March 2015, showed the following: -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff); Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; -The interdisciplinary care plan team is responsible for periodic review and updating of care plans when a significant change 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.