Nathan Richard Health Care Center

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer medications as ordered for one resident (Resident #41). The facility census was 59. Review showed the facility did not provide a policy regarding pharmacy services or obtaining medications for administration. Review of Resident #41's face sheet showed the following: -admission date of 03/1/24; -Diagnoses included chronic kidney disease stage 5 (damage to kidneys and less likely to filter waste and fluid out of the blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/8/24, showed the following: -Cognition intact; -Renal (kidney) failure; -On a diuretic medication (a medication that increases the production and excretion of urine by the kidneys). Review of the resident's current care plan, dated 03/06/24, showed staff to administer medications as ordered. Review of the resident's physician's orders showed an…

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

Based on interview and record review, the facility failed to ensure the physician responded in a timely manner to pharmacist recommendations during the monthly pharmacist review, when the physician did not address the pharmacist recommendation to discontinue one medication not recommended for use in the elderly due to its anticholinergic side effects (causing falls and confusion) for one resident (Resident #12) in a timely manner. The facility census was 59. Review showed the facility did not provide a policy regarding the pharmacy medication review and recommendation process. Review of Resident #12's face sheet showed the following: -admission date of 08/15/23; -Diagnoses that included cervical disc disorder with myelopathy (problems with the neck's bones, muscles, joints with symptoms of weakness, tingling, pain, and numbness in the neck or arms, and problems with coordination), heart failure, high blood pressure, chronic pain, arthritis, and retention of urine. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by…

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 a medication error rate not greater than 5%, when facility staff crushed extended release tablets for one resident (Resident #23) and when staff did not administer a medication for one resident (Resident #41). This resulted in two errors out of 36 opportunities and medication error rate of 5.56%. The facility census was 59. Review of the facility policy Medication Administration Policy, revised 6/26/24, showed medications that typically should not be crushed included sustained-release or extended-release medications. 1. Review of the Drugs.com warnings for Potassium Chloride, updated 02/29/24, showed the following: -Do not crush, chew, break, or suck on an extended-release tablet or capsule. Swallow the pill whole. -Breaking or crushing the pill may cause too much of the drug to be released at one time. Review of Resident #23's face sheet (a brief look at resident information), showed the following: -admission date of 10/15/20;…

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 maintain a complete medical record for all residents, when staff failed to document in the medical record a change in condition and transfer to the hospital for one resident (Resident #1). The facility census was 59. Review of the facility's policy titled, Resident Transfer, Discharge, Immediate Discharge and Therapeutic Leave Policy, dated 05/14/24, showed with the exception of ceasing to operate, the resident's medical record must be documented with the reason(s) for any facility-initiated transfer or discharge. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 02/05/25; -Diagnoses included essential hypertension (high blood pressure), edema (swelling caused by fluid building up in body tissues, and presence of cardiac pacemaker. Review of the resident's Facility Transfer Sheet, dated 02/19/25, showed the resident was discharged to the hospital on [DATE] for a medical reason, decreased level of function, 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 interview and record review, the facility failed to develop and implement policies to assure all residents were given the opportunity to receive pneumococcal vaccinations (pneumonia vaccines) when staff did not document offering the vaccine to two residents (Residents #11 and #31). The facility census was 59. Review of the Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccine, dated 10/26/24, showed the following: -There are two types of vaccines recommended to help prevent pneumococcal disease in adults; -One type of vaccine is the pneumococcal conjugate vaccines (PCVs): PCV15,PCV20,and PCV21; -One type of vaccine is the pneumococcal polysaccharide vaccine (PPSV23); -For older adults who received PCV13 and PPSV23, they have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they've already received both the PCV13 (but not PCV15 or PCV20) at any age or PPSV23 at or after the age of 65 years. These adults can talk with a vaccine provider and decide together, whether to get…

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 facility policy review, the facility failed to keep the light covers above the steam table and food preparation table clean; failed to seal opened bags of food; failed to discard dented cans of food; and failed to ensure food storage containers were clean. These failures had the potential to affect 57 residents who consumed food prepared from the facility's kitchen. The facility census was 58. Findings include: Review of the facility's policy titled, Receiving and Storing Food and Supplies, dated 10/12/21, revealed: Do not accept and return to the supplier, any item that is: In dented, rusty, damaged cans . Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids or Ziploc bags. Open products may also be sealed utilizing plastic film or tape. Review of the, undated, Dietary Manger's Job Description revealed the following duties: Inventories incoming food and supplies, . Inspects Dietary Department regularly to ensure…

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, record review, and tasting of foods on a requested test tray, the facility failed to provide food that was palatable and at an appetizing temperature for five (Resident (R) 26, R48, R50, R52, and R17) out of a total of 37 residents. This failure had the potential to affect residents on one of two halls who were served room trays. The facility census was 58. Findings include: 1. During an interview on 06/12/23 at 11:56 A.M., R26 stated he ate all his/her meals in his/her room. R26 specified that the evening meals were not hot. Review of R26's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/23, located under the MDS tab. The assessment recorded a Brief Interview for Mental Status (BIMS) score of 15 out of 15 for R26, which indicated the resident was cognitively intact. 2. During an interview on 06/12/23 at 12:40 P.M., R48 stated he/she ate his/her meals in his/her room. R48 specifically stated that the food was of poor quality. Review of R48's EMR revealed a quarterly MDS…

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 interviews, the facility failed to update the electronic medical record (EMR) and Nurse Aide (NA) reference book for one of one resident (Resident (R) 46) reviewed for Advance Directives to reflect the resident's choice to change from a full code(life saving measures including cardiopulmonary resuscitation (CPR) to a do not resuscitate(DNR) status out of a total sample of 37 residents. The failure to update the EMR and NA reference book increased the risk that R46's end of life wishes would not be honored and unwanted care and services would be provided. The facility census was 58. Findings include: Review of the EMR for R46, under the Census tab, revealed R46 had an admission date of [DATE] and diagnoses including hepatitis and diabetes. Under the Miscellaneous tab, the EMR banner indicated R46 was a full code. On [DATE], R46 created a new document titled, Out of the Hospital-Do Not Resuscitate orders indicating he desired to be No Code status. Review of the NA book at in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to provide a notice of bed hold to two (Resident (R) 46 and R29) of two sampled residents reviewed who were transferred to the hospital. The facility census was 58. Findings include: The facility policy titled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave, with a revision date of 07/12/22, directed III. Notice of Bed Hold . provide to the resident or their legal representative, a written copy of the bed hold policy . 1. Review of the Electronic Medical Record (EMR) for R46, under the Census tab, revealed an admission date of 10/22/22 and diagnoses including hepatitis and diabetes. Review of the Census tab of the EMR revealed R46 was transferred to the hospital on [DATE], 03/12/23, and 04/25/23. The EMR Miscellaneous tab lacked evidence that the facility provided R46 with the bed hold policy at these transfers to the hospital. During an interview with the Director of Nursing (DON) on 06/15/23 at…

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 develop and implement a comprehensive care plan for three of fifteen sampled residents (Resident (R) R9, R10, and R36) for oxygen usage, communication, and behavior management out of a total sample of 37 residents These failures created the potential for medical and psychosocial needs to be unmet. The facility census was 58. Findings include: Review of the facility policy titled, Comprehensive Care Plans and Baseline Care Plans, revised on 01/19/22 revealed, Purpose: The purpose of this policy is ensure that the facility must develops [sic] a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Review of R10's electronic medical record (EMR), revealed R10 admitted to the facility on [DATE] with diagnoses including deaf nonspeaking. Review of R10's quarterly Minimum Data…

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, record review, and policy review, the facility failed to ensure that a care plan for falls was updated for one of one resident (Resident (R) 38) reviewed for falls. After a fall there were no updates or interventions added to R38's care plan. The facility census was 58. Findings include: Review of the facility policy titled Focus Risk Assessment Plan Scope/ Severity for Falls (FRAPSS), with a revision date of 07/09/21, revealed, Purpose: To assess all residents for potential for falls in the facility . To identify precipitating factors for fall risk and be proactive in implementing interventions to prevent or reduce the incident of further falls . Review of the facility policy titled, Post Fall Protocol, with a revision date of 02/26/21, revealed Purpose: The purpose of this policy is to ensure that all residents who have had a fall have accurate assessment and follow through to prevent further injury and recurrence of falls. Procedures . 9. Update care plan to include individualized interventions with date . During an interview on 06/12/23 at 10:45 A.M., R38 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.

Based on interview, record review, and policy review, the facility failed to ensure an incident report and investigation was completed following a fall for one of one resident (Resident (R)38) reviewed for falls. This failure placed the resident at greater risk of more falls and not know the reason for the falls. The facility census was 58. Findings include: Review of the facility policy titled Focus Risk Assessment Plan Scope/ Severity for Falls (FRAPSS), with a revision date of 07/09/21 revealed, Purpose: To assess all residents for potential for falls in the facility . To identify precipitating factors for fall risk and be proactive in implementing interventions to prevent or reduce the incident of further falls . Procedure: Focus Risk Assessment Plan Scope/Severity for Falls: 1. Resident will be assessed using the FRAPSS form for fall risks upon admission, quarterly and in an acute situation where resident has fallen. The FRAPSS assessment guide measures areas of precipitating factors such as age, use of assistive devices, diagnoses, medical antecedents, history of previous…

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 infection control measure for the storage and changing of oxygen tubing for two of two (Residents (R) 9 and R52) residents reviewed for respiratory care. Oxygen tubing was stored without being placed in a bag and was not changed weekly. The facility census was 58. Findings include: 1. Review of R9's ''Profile'' tab in the electronic medical record (EMR) revealed an undated ''admission Record'' which indicated R9 was admitted to the facility on [DATE] with diagnoses including shortness of breath and wheezing. Review of the EMR ''Orders'' tab revealed a ''Physician Order,'' dated 12/08/20, for ''O2 [Oxygen] at 2 LPM [liters per minute] per nasal cannula as needed for shortness of breath.'' During observation and interview on 06/13/23 at 9:10 A.M., R9's nasal cannula was wrapped up with the tubing and placed on the water bottle attached to the oxygen concentrator. The date 06/04/23 was written on humidification (water) bottle. R9…

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, record review, and policy review, the facility failed to ensure pharmacist recommendations were acted upon for two of five residents (Residents (R)38 and R41) reviewed for unnecessary medications. The pharmacist made recommendations to discontinue medication and to add some direction to another for R38 and R41. This deficient practice had the potential to allow residents to continue medications may have adverse consequences. The facility census was 58. Findings include: Review of the facility policy titled, Monthly Drug Regimen Review, with a revision date of 07/05/22, revealed Purpose: The purpose of this policy is to monitor the resident's medication on a monthly basis to ensure any irregularities are corrected to protect the resident. Procedure. 6. The. Director of nursing will forward the pharmacists' recommendations to the attending physician within 48 hours of receiving the recommendation. The DON will document the date and time that the physician was notified of the recommendation. 7. lf the attending physician does not respond to the recommendation within…

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, document review, and policy review, the facility failed to ensure the medication error rate was less than 5% due to two medication errors (Resident (R) 46 and R31) out of 27 medications observed delivered to residents. The facility's medication error rate was 7.4%. The facility's failure to follow the manufacturer's instructions to prime the insulin pens resulted in incorrect insulin dosing and failure to follow physician orders. The facility census was 58. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring and Insulin Administration, with a revision date of 07/09/21, revealed the policy lacked instruction to the staff of how to administer insulin using a pre-filled insulin pen with needle set. Review of the manufacturer's instructions for the use of the Novalog insulin pen, dated 02/2023, directed that the insulin pen needle set required an air shot of two units of insulin to prime the needle set. Priming the needle set removes air bubbles from the needle set and ensures the dose ordered is administered. 1. Review…

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 protect food from possible contamination when staff failed to ensure the air gap for two ice machines in the facility had the required two inch gap between the drain in the floor and the tubing from the ice machine. The facility had a census of 38 residents. 1. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. Observation on 11/03/2020, at 12:23 P.M., showed the ice machine in the kitchen had the following: -Ice machine located near the kitchen door had two drain pipes below the floor level; -One pipe was less than two inches from the drain with approximately one inch air gap; -The second pipe had fallen loose and touched the drain with no air gap. Observation on 11/04/2020, at 1:15 P.M., showed the ice machine in a small storage room behind the nurses'…

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 complete a risk assessment to include alternative interventions attempted prior to the use of side rails, obtain informed consent for the use of side rails, and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Resident #1, #2, #5 and #36) out of a sample of 16 residents. The facility census was 38. Record review of the facility's policy entitled, Bed Siderails (last revised 11/2017) showed the policy included the following information: -Purpose: To ensure all bed side rails in use have been evaluated for safety; -All residents using any size siderail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly, and as needed if there is a significant change in the resident's condition; -If the 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 observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made four errors out of 25 opportunities resulting in an error rate of 16% when staff failed to prime the insulin pens for three residents (Resident #9, #14, and #25). The facility census was 38. Record review of the Novolog Flexpen (name brand for insulin aspart [rDNA origin] injection) manufacturer's website, dated May 2016, showed the product is a man-made insulin used to control high blood sugar in adults and children with diabetes. Instruction for use included the following: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle, pull of the paper tab, push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen - Turn the dose selector to select two units. Press and hold the dose button. Make sure a drop appears; -Select the dose - Turn the dose selector to select the number of units you need 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, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for three residents (Resident #9, #14, and #25) during random medication pass observations. The facility had a census of 38. Record review of the Novolog Flexpen (name brand for insulin aspart [rDNA origin] injection) manufacturer's website, dated May 2016, showed the following information: -This product is a man-made insulin used to control high blood glucose levels (sugar) in adults and children with diabetes mellitus; -Instruction for use include; -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen. Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears; -Select the dose. Turn the dose selector to select the number of units you need 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 store medications according to professional standards and manufacturer's guidelines when staff failed to note when a vial of insulin was opened for three residents (Resident #11, #25, and #26 ) and failed to discard expired or discontinued insulin for one resident (Resident #11). The facility census was 38. Record review of the facility's policy titled, Administering Medications, dated [DATE], showed the policy included the following information: -Medication must be administered per physicians' orders. All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. -The nurse or certified medication technician (CMT) will check each medication to the MAR noting correct name of medication, correct resident name, correct dose, correct time, and correct route of administration; -For all medications, except for pre-packaged bubble cards or pre-packed unit dose…

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 use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants, when staff failed to use appropriate hand hygiene during incontinence care for two residents (Resident #2 and #40), failed to perform hand hygiene when assisting multiple residents and failed to wear facemasks appropriately with meal trays and meal assistance, including seven residents (Resident #1, #4, #12, #14, #16, #18, and #34) in the dining room, failed to use appropriate hand hygiene during blood glucose testing and/or failed to properly disinfect glucometers (small hand-held devices that check blood glucose levels in residents) between resident use for eight residents (Resident #9, #11, #14, #15, #21, #24, #25, and #40) and failed to complete appropriate hand hygiene during medication administration for two residents (Resident #14 and #25). Additionally, staff failed to pre-clean the rubber…

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 treated residents with dignity and respect when they did not provide a dignity bag for one resident (Resident #5) with an indwelling urinary catheter (tubing placed internally to drain the bladder). A sample of 12 residents was selected for review; the facility census was 38. Record review of the facility's (undated) policy titled, Nursing Urinary Catheter Care, showed the following information: -Resident with indwelling catheters will receive catheter care every shift or as ordered by the physician; -Catheter bags are to be placed in privacy bags to promote the resident's dignity. 1. Record review of Resident #5's face sheet (general information at a quick glance) showed the following information: -admission date of 10/19/2015; -Diagnoses included: End stage renal disease (last stage of kidney disease); neuromuscular dysfunction of bladder (dysfunction of the bladder due to disease or injury of the central nervous system (brain and spinal cord) involved in the control of urination); benign…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for two residents (Resident #31 and #36). A sample of 16 residents was selected for review out of a facility with a census of 38. Record review of the facility's policy entitled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy (last revised 5/2018), showed the following information: -Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected; -Before any resident is transferred or discharged under a Facility-Initiated Transfer or Discharge, the facility must: -Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; -Notify a representative of the Office of the State Long-Term Care Ombudsman; -The written notice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Resident #31 and #36). A sample of 16 residents was selected for review out of a facility with a census of 38. Record review of the facility's policy entitled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy (last revised 5/2018), showed the following information: -When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy. This notice must be given at the time of transfer, or within 24 hours of emergency transfers; -Documentation that the bed hold policy was provided must be put in the resident's medical record. This documentation shall include how and when the notice was issued; -The bed hold policy must provide information 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.