Bentleys Extended Care

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 47. Review of the facility's Staffing policy, revised, April, 2007, showed: -The facility provides adequate staffing to meet needed care and services of the resident population; -The facility maintains adequate staffing on each shift to ensure that the residents' needs and services are met; -Licensed RN and licensed nursing staff are available to provide and monitor the delivery of resident care services. Review of the facility's staffing sheets dated 10/1 through 10/21/24 showed no RN coverage for: 10/1, 10/2, 10/3, 10/4, 10/6, 10/8, 10/10, 10/11, 10/13, 10/14, and 10/19/24. During an interview on 10/23/24 at 9:05 A.M., the Assistant Director of Nursing (ADON) said she was aware that an RN is required eight hours a day, seven days a week. She is responsible for staffing. It was difficult to get RNs to work. She puts the request for an RN on the agency website, and no one picks up the shift. During 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 establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 47. Review of the facility's Controlled Substances policy, revised December, 2012, showed: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (a drug classification) narcotics and other controlled substances; -Nursing staff must count controlled medications at the end of each shift; The nurse coming on duty and the nurse going off duty must make the count together. Review of the Narcotic Count Sheets dated 10/1 through 10/19/24 on the 400 and 500 medication cart showed: -22 out of 57 shifts had no nurse initial on the shift change count; -28 out of 57 shifts only had one nurse initial on the shift change count. Review of the Narcotic Count Sheets dated 10/1 through…

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 have a system in place to ensure drugs and biologicals stored in the medication room refrigerator were being stored at a proper temperature for one out of one medication rooms observed. The medication room refrigerator also had food and nutritional supplements stored with the medications. The census was 47. Review of the facility's Storage of Medications policy, revised, April, 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation area in a clean, safe, and sanitary manner; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location; -Medication must be stored separately from food and must be labeled accordingly. During an interview and observation on 10/20/24 at 9:05 A.M., the medication room had a small refrigerator that contained a thermometer hanging on the inside of the door, two…

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

Based on observation, interview, and record review, the facility failed to ensure facility staff performed appropriate hand hygiene during meal service which effected 15 residents (Residents #21, #36, #11, #39, #20, #1, #13, #14, #35, #37, #9, #43, #19, #41, and #17). The sample was 12. The census was 79. Review of the facility's handwashing/hand hygiene policy, dated August 2015, Showed: -Policy statement: this facility considers hand hygiene the primary means to prevent the spread of infections; -Policy implementation: all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, before and after eating or handling food, before and after assisting a resident with meals. 1. Review of Resident #21's medical record, showed diagnoses included dementia, dystonia (involuntary muscle contractions that cause repetitive…

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 used good infection control practices for one resident when providing wound care (Residents #38). The facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs can spread that requires gown and glove use during high contact resident care activities for certain residents) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with urinary catheters (a tube that drains the bladder) and wounds requiring treatments (Residents #38 and #31). In addition, the facility failed to provide tuberculosis (TB) testing for five residents out of five residents reviewed for TB testing (Resident #38, #11, #12, #14, and #22). The sample was 12. The census was 47. An EBP policy was requested but not provided by the facility. Review of…

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

Based on interview and record review the facility failed to offer and vaccinate as desired, eligible residents for the pneumococcal (pneumonia) vaccine for 4 out of 5 residents sampled for immunizations (Resident #12, #11, #38, #22). The census was 47. Review of the facility's Pneumococcal Vaccine policy, revised August, 2016, showed; -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccination status will be conducted within 5 working days of the resident's admission if not conducted prior to admission; -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine;…

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 offer the COVID-19 vaccines for four out of five residents sampled for immunizations (Resident #11, #38, #22, and #14). The census was 47. Review of the facility's COVID -19 Vaccination of Residents policy, revised, May, 2023, showed: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated; -Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so; -The resident or the resident's representative has the opportunity to accept or refuse COVID-19 vaccine, and to change his/her decision; -COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his/her designee; -The individual who coordinates these responsibilities in the facility is the Assistant Director of Nursing (ADON); -The COVID-19 vaccine may be offered and provided directly by the facility or indirectly, such as through the arrangement with a pharmacy partner, local health department, or other…

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 Certified Nursing Assistants (CNA) received a minimum of 12 hours on ongoing education annually for five out of five sampled CNAs. The census was 47. A policy related to CNA 12-hour training was requested and not provided by the facility. 1. Review of CNA M's employee file showed hire date: 1/15/20. No in-service training records provided upon request. 2. Review of CNA N's, employee filed showed hire date: 9/28/22. No in-service training records provided upon request. 3. Review of CNA O's employee file showed hire date: 9/10/21. No in-service training records provided upon request. 4. Review of Certified Medication Technician (CMT) F's employee file showed hire Date: 12/12/22. No in-service training records provided upon request. During an interview on 10/23/24 at 12:15 P.M., CMT F said he/she the facility provides in-services, but he/she is not aware of any formal tracking or training system. 5. Review of CMT P's employee file showed hire Date: 4/2/22. No in-service training records provided upon request. 6. During…

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 immediately notify the physician of abnormal lab results for one resident (Resident #11) and to notify the resident and the resident's representative of abnormal lab results and new orders for medications to treat a urinary tract infection (UTI). The sample was 12. The census was 47. Review of the facility's Change in a Resident's Condition or Status policy, revised December 2016, showed: -Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -Policy Interpretation and Implementation: -The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): --Need to alter the resident's medical treatment significantly; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: --There is a significant change in the resident's physical,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or resident representative with emergency written notices of transfer/discharge for two residents transferred to the hospital for acute medical reasons (Residents #31 and #19). The sample was 12. The census was 47. Review of the facility's Transfer or Discharge Notice policy, revised December 2016, showed: -Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a 30-day written notice of an impending transfer or discharge; -Policy Interpretation and Implementation: -A resident and/or his or her representative (sponsor) will be given a 30-day advance notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: --An immediate transfer or discharge is required by the resident's urgent medical needs; -The resident and/or representative will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or resident representative with written information on the facility's bed hold policy at the time of transfer for two residents transferred to the hospital for acute medical reasons (Residents #31 and #19). The sample was 12. The census was 47. Review of the facility's Bed Holds and Returns policy, revised March 2017, showed: -Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Policy Interpretation and Implementation: -Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: --The rights and limitations of the resident regarding bed-holds; --The reserve bed payment policy as indicated by the state plan (Medicaid residents); --The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold…

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

Based on interview and record review, the facility failed to ensure one resident received an accurate assessment, reflective of the resident's status at the time of assessment, by failing to identify the resident's unplanned significant weight loss, unhealed pressure ulcers (injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), and other skin problems (Resident #31). The sample was 12. The census was 47. Review of Resident #31's medical record, showed diagnoses included bullous pemphigoid (an autoimmune skin disorder that causes blisters on the skin). Review of the resident's weights, showed: -On 2/19/24, weighed 147.2 pounds (lbs); -On 8/19/24, weighed 120.0 lbs; -Significant weight loss of -18.48% in six months. Review of the resident's nutrition quarterly review, dated 8/20/24, showed: -Greater than 10% weight change in 180 days; -Additional information: Significant weight loss of -25 pounds in six months. Continues with trend down. Poor appetite continues. Stability continues to be guarded with declining condition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's care needs for four residents (Residents #38, #46, #22, and #32) of 12 sampled residents. The facility census was 47. Review of facility's, undated, Care Plans, Comprehensive Person-Centered policy, showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implanted for each resident; -Policy Interpretation and Implementation: Areas of concern that identified during the resident assessment will be evaluated before intervention are added to the care plan. The comprehensive, person-centered care plan is developed with seven (7) days of the completion of the required comprehensive assessment. Assessments of resident are ongoing and care plans are revised as information about the residents and the residents' condition change. 1.…

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 all staff certified in cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) received their CPR certification through a provider whose training includes hands-on practice and in-person skills assessment. The facility identified 10 CPR-certified staff and problems were found with three. The sample was 12. The census was 47. Review of the facility's Advance Directives policy, revised [DATE], showed no guidance for ensuring staff received CPR certification through a provide whose training includes hands-on practice and in-person skills assessment. Review of the facility's resident code status report, reviewed [DATE], showed 22 residents with full code status. Review of the CPR certification for CPR-certified facility staff, showed Licensed Practical Nurse (LPN) A, Registered Nurse (RN) Q, and the Assistant Director of Nurses (ADON) through a provider that offers online CPR certification.…

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 services consistent with acceptable standards of practice for one resident when staff failed to accurately assess the appropriate wheelchair size, resulting in skin irritation and indentations to the resident's legs, and failed to reposition the resident for six hours (Resident #41). In addition, the facility failed to date when a dressing was completed for one resident (Resident #16). The sample size was 12. The census was 47. Review of the facility's undated admission Assessment and Follow Up: Role of the Nurse, showed: -Purpose: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff). 1. Review of Resident #41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foot care was maintained for two of 12 sampled residents (Resident #44 and Resident #21) resulting in long nails and dry feet. The census was 47. Review of the facility's activities of daily living (ADL) Policy, dated march 2018, showed: -Policy statement: residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Policy Implementation: appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking),…

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 physician orders were followed for a resident with an order for continuous oxygen usage (Resident #44). In addition, the facility failed to ensure oxygen masks were properly stored while not in use and the facility had a process to ensure routine changing of the oxygen tubing for infection control purposes, for two sampled residents (Resident #44 and Resident #14). The sample was 12. The Census was 47. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration; -The policy failed to address storage of oxygen supplies to prevent contamination, or frequency and process to change out oxygen tubing. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated…

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

Based on interview and record review, the facility failed to ensure Nursing Assistants (NAs) that were employed by the facility were certified within 4 months of hire for five out of five NA's, who worked in the facility for more than 4 months. The census was 47. Review of the Facility Assessment, reviewed 7/21/23, showed: -Staff training and education that are necessary to provide level and types of support and care needed for the resident population included certification and licensure requirements, yearly in-services, and additional education provided when needs are trends are identified. Record review the hire dates for of all NAs, reviewed on 10/23/24, showed: -The facility hired NA R on 5/5/21; -The facility hired NA J on 8/2/23; -The facility hired NA S on 4/3/24; -The facility hired NA C on 4/26/24; -The facility hired NA T on 5/20/24; -The five NAs were not certified within the required 4 month period. During an interview on 10/21/24 at 8:07 and 8:55 A.M., NA C said he/she has worked at the facility since April, 2024 and was waiting to test out. He/She has completed 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 ensure residents were free from unnecessary psychotropic medications when one resident (Resident #19) was prescribed Haldol (haloperidol, antipsychotic medication) without appropriate documentation in the resident's medical record to support the clinical need for the medication. The facility failed to appropriately monitor for adverse consequences and medication effectiveness when the resident had an increase in falls after the adjustment to his/her psychotropic medications, and no improvement with his/her psychiatric symptoms. The sample was 12. The census was 47. Review of the facility's Antipsychotic Medication Use policy, revised [DATE], showed: -Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Policy Interpretation 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 provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week; and failed to hire, maintain or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. This deficiency had the potential to affect all residents. The census was 50. Review of the facility's undated list of Department Heads, provided on 7/1/24, showed no DON employed within the facility. Review of the facility's daily assignment sheets, dated 6/17/24 through 7/2/24, showed no DON for all 16 days and no RN in the facility on 6/17, 6/18, 6/19, 6/20, 6/26, 6/28, 6/29 and 7/1/24, for a total of 8 out of 16 days. During an interview on 7/1/24 at 12:54 P.M., Certified Nursing Assistant (CNA) A said they had not had a DON in a couple of months. The Assistant Director of Nursing (ADON) is the person everyone went to and who handled all DON duties. He/She did not know if the ADON was an RN or Licensed Practical Nurse (LPN). The facility had a couple RNs, but they mainly work evenings or overnight. He/She…

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 facility document review, interviews, and facility policy review, the facility failed to ensure nursing assistants (NAs), who were full-time employees, completed the required competency exam for certification within four months of hire for 6 (NAs #3, #4, #8, #11, #16, and #20) of 13 nursing assistants reviewed for competencies. This had the potential to affect all residents. The facility census was 42. Findings included: Review of the facility's staffing schedule for June 2023 revealed the facility employed non- certified nursing assistants (NAs #3, #4, #8, #11, #16, and #20) on a full-time basis. The schedule further indicated for the evening shift, there were no certified nursing assistants (CNAs) scheduled to work, only NAs were scheduled to work. Review of an untitled and undated facility document with staff credentials and hire dates revealed the following hire dates for 6 of 13 nursing assistants. -NA #3: 07/02/2021 -NA #4: 09/28/2022 -NA #8: 02/01/2022 -NA #11: 09/10/2021 -NA #16: 02/03/2023 -NA #20: 05/05/2021 Review of personnel files for nursing assistants (NAs…

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, interviews, and facility document and policy review, the facility failed to maintain proper kitchen sanitation in 1 of 1 kitchen when Dietary Aide (DA) #1 and the [NAME] did not know how to ensure proper sanitizer concentration for a low temperature dish machine. The facility census was 42. Findings included: A review of the facility's undated policy titled, Dishwashing, revealed, Check chemical dispensers for proper operation and adequate supply of chemical. A review of the facility's Chemical Sanitizing Dish Machine Log, dated June 2023, revealed the chemical concentration of chlorine was to be 100 parts per million (ppm). Entries were to be entered on the Dish Machine Log once a day. Further review revealed, Corrective action must be taken if the chemical concentration requirement is not met. Although requested, facility staff did not provide manufacturer's instructions for the dish machine. A review of the facility's Chemical Sanitizing Dish Machine Log, dated June 2023, indicated the chemical concentration for chlorine at 5:50 AM on 06/13/2023 was 100 ppm.…

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

Based on interviews and facility document and policy review, the facility failed to ensure the facility was administered in a manner that effectively and efficiently attained or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility failed to: - Thoroughly investigate falls to determine causal factors, implement and evaluate interventions to prevent falls, and provide sufficient supervision. - Assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on residents' beds. - Complete and transmit Minimum Data Set (MDS) data within the required time frames - Review, update, and implement comprehensive care plans within the required time frames; and - Ensure nursing assistants (NA), who were full-time employees, completed the required competency exam for certification within four months of hire. -Failed to employ 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 interviews and facility document and policy review, it was determined that the facility failed to conduct and accurately document a facility-wide assessment to determine what resources were necessary to competently care for its residents and failed to review this assessment at least annually. This had the potential to affect all residents. The facility census was 42. Findings included: Review of a facility policy titled, Facility Assessment, revised in 07/2017, specified, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. 1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The policy further indicated, 4. The facility assessment also includes a detailed review of the resources available to meet the needs of the…

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

Based on interviews and facility document and policy review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program that obtained feedback, used data, took action to conduct structured, systematic investigations and analyzed underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life and, resident safety. Specifically, the facility QAPI program failed to: - Identify that the facility did not investigate falls to determine causal factors, implement and evaluate interventions to prevent falls, and provide sufficient supervision to residents. - Identify the facility did not assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on residents' beds. - Identify the facility was not completing and transmitting Minimum Data Set (MDS) data within 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 observations, interviews, record review, facility document review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. Certified Nursing Assistant (CNA) #17 followed the steps for hand hygiene when providing incontinent care for 1 (Resident #145) of 2 residents reviewed for incontinence care; 2. Certified Medicine Technician (CMT) #19 did not touch medication with her bare hands when administering medication for 1 (Resident #96) of 6 residents reviewed for medication administration; and 3. Measures were in place, such as by having a documented water management program, to minimize the risk of Legionella and or other waterborne pathogens, which had the potential to affect all residents. Findings included: 1. A review of a facility policy titled, Infection Control Guidelines for All Nursing Procedures revised…

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

Based on interviews and facility policy review, it was determined the facility failed to ensure an antibiotic stewardship program was in place. The facility's failure to develop, promote, and implement a facility-wide system to monitor the use of antibiotics had the potential to affect all 43 residents living in the facility. Findings included: A review of an undated facility policy titled, Antibiotic Stewardship, revealed Purpose: The purpose being to ensure that residents are not subjected to the inappropriate use of antibiotics [nd] therefore the residents have improved outcomes with fewer adverse events. Note: Antibiotic Stewardship is part of the Infection Prevention and Control Program within the facility. During an interview on 06/21/2023 at 1:21 PM, the Director of Nursing (DON) stated she did not know anything about the antibiotic stewardship program. During an additional interview on 06/23/2023 at 10:43 AM, she stated the facility was not tracking or trending the antibiotic use in the facility. During an interview on 06/24/2023 at 12:32 PM, the Assistant Director of…

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

Based on interviews and facility policy review, it was determined the facility failed to employ a qualified infection preventionist. The facility's failure to employ a qualified infection preventionist to be responsible for the infection prevention and control program had the potential to affect all 43 residents living in the facility. Findings included: A review of an undated facility policy, titled Infection Preventionist, revealed the IP is responsible for the effective direction, management, and operation of the infection prevention program, including the education of facility staff members and independent practitioners, and consulting with the county and state department of health. The IP utilizes evidence-based practices such as those published by the Centers for Disease Control and Prevention (CDC). Additionally, the IP ensures compliance with regulations and requirements from the Centers for Medicare and Medicaid Services (CMS), other accrediting healthcare organizations and state regulations. The IP is responsible for the facilities activities aimed at preventing…

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

Based on record review and interview, the facility failed to establish and maintain a process to follow Generally Accepted Accounting Principles (GAAP) to reconcile the Resident Trust Fund (RTF) Account monthly. The facility census was 42. Record review of the facility maintained RTF Cash Reconciliation Statement for the period 6/2022 through 5/2023, showed the facility did not follow GAAP, and did not investigate (identify or detail) why there were several outstanding transactions (old checks) from 2017 - 2019. Record review of the facility maintained RTF attempted reconciliation for the period 6/2022 through 5/2023, showed the facility carried over a difference each month for transactions from 2017 - 2019, for the following months, without identifying or detailing the outstanding transactions. Month RTF Ledgers RTF Bank #1 Statement Balance 6/2022 $38,604.05 $43,405.53 Difference of old, outstanding checks: $4,801.48 7/2022 $39,251.60 $44,053.08 Difference of old, outstanding checks: $4,801.48 8/2022 $40,127.00 $45,260.48 Difference of old, outstanding checks: $5,133.48 9/2022…

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 interviews, record review, facility document review, and facility policy review, the facility failed to transmit a Minimum Data Set (MDS) within the required 7-day time frame for 5 (Residents #96, #10, #27, #23, and #36) of 29 residents reviewed for MDS transmission. The facility census was 42. Findings included: Review of a facility policy titled, Electronic Transmission of the MDS, dated 09/2010, specified, All MDS assessments (for example (e.g.), admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Process (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. 6. The MDS Coordinator is responsible for ensuring the appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes…

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 interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for 3 (Residents #6, #10, and #14) of 29 residents for whom MDS assessments were reviewed. Specifically, falls were not accurately coded on the assessments completed for Resident #10 and Resident #14 and administration of anticoagulant medication was inaccurately coded for Resident #6. The facility census was 42. Findings included: Review of the facility policy titled, MDS [Minimum Data Set] Error Correction, dated 2001 and revised in September 2010, indicated, 5. If an error is discovered after the encoding period and the record in error is an OBRA Assessment [Omnibus Budget Reconciliation Act] assessment, determine if the error is major or minor. a. A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to the QIES [Quality Improvement Evaluation System] ASAP [Assessment Submission and Processing] system. b. 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 observations, interviews, and facility policy reviews, the facility failed to ensure 2 (nurses' medication cart and 400/500 Hall medication cart) of 3 medication carts were maintained in a safe manner. Specifically, the facility failed to ensure narcotics were secured in a separately locked compartment, drugs were not expired, and that there were no loose medications in the med cart; and medications were not repackaged. The facility census was 42. Findings included: Review of a facility policy titled, Storage of Medications, dated [DATE], indicated, 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The policy continued, 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.…

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 interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #96) was treated with respect and dignity and in an environment that promotes quality of life when a staff member used foul language in front of them while providing assistance. The facility census was 42. Findings included: Review of a facility policy titled, Bentleys Extended Care Abuse Policy, with a revision date of 07/27/2021, indicated verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of Resident #96's admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. A review of the admission Minimum Data Set…

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 interviews, record review, and facility policy review, the facility failed to notify the physician about a significant change in status for one (Resident #17) of two residents reviewed for weight loss. Specifically, the facility did not notify the physician when Resident #17 lost 11.4 pounds (8.06%) in seven days, and 21.0 pounds (14.85%) in 28 days. The facility census was 42. Findings included: Review of a facility policy titled, Change in a Resident's Condition or Status, dated 2001 and revised in December 2016, indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a: d. significant change in the resident's physical/emotional/mental condition: e. need to alter the resident's…

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

Based on record review, interview, and facility policy review, the facility failed to complete an admission comprehensive Minimum Data Set (MDS) assessment for 2 (Resident #145 and Resident #44) of 29 residents reviewed for resident assessments. The facility census was 42. Findings included: Review of a facility policy titled, Electronic Transmission of the MDS, with a revision date of September 2010, indicated, All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS [Centers for Medicare and Medicaid Services] QIES [Quality Improvement Evaluation System] Assessment Submission and Process (ASAP) system in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of MDS data. 1. A review of Resident #145's admission Record indicated the facility admitted the resident on 05/24/2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy…

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

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) level I screening for two (Resident #35 and Resident #23) of three residents reviewed for PASARRs. Specifically, the facility failed to submit an updated PASARR level I screen when Resident #35 was diagnosed with unspecified psychosis on 01/14/2022 after admission and when Resident #23 was diagnosed with bipolar disorder on 03/04/2019. The facility census was 42. Findings included: Review of an undated facility policy titled, Preadmission Screening and Resident Review, indicated, Preadmission Screening and Resident Review (PASRR) [sic] is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long term care. 1. A review of Resident #23's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, it was determined the facility failed to ensure physician orders were obtained for dialysis treatment and failed to ensure the facility's communication forms were completed for the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (Resident #36) of two sampled residents who received dialysis. The facility census was 42. Findings included: Review of a facility policy titled, Care of a Resident with End-Stage Renal Disease (ESRD), revised in 09/2010, indicated, 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. A review of Resident #36's admission Record indicated the facility admitted the resident on 04/18/2023 with diagnoses including chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate…

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 reviews, and facility policy review, it was determined that the facility failed to maintain a medication error rate less than 5%. There were two errors in 25 opportunities, which resulted in an 8% medication error rate for 2 (Resident #96 and Resident #33) of 6 residents observed for medication pass. The facility census was 42. Findings included: Review of a facility policy titled, Administering Oral Medications, revised in 10/2010, indicated, Check the label on the medication and confirm the medication name and dose with the MAR (Medication Administration Record). The policy continued, Check the medication dose. Re-check to confirm the proper dose. 1. A review of an admission Record indicated the facility admitted Resident #96 on 04/22/2023 with diagnoses that included essential hypertension (abnormally high blood pressure). A review of Resident #96's Order Summary Report with active orders as of 06/13/2023 revealed an order, dated 04/21/2023, for metoprolol succinate ER (extended release) 50 milligrams (mg) by mouth every 12 hours related…

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 facility policy review, it was determined the facility failed to ensure a resident was free of significant medication error for 1 (Resident #33) of 6 residents observed during medication administration. Certified Medicine Technician (CMT) #19 failed to hold blood pressure medication when the resident's blood pressure was outside parameters established by the resident's physician orders. The facility census was 42. Findings included: Review of a facility policy titled, Adverse Consequences and Medication Errors, revised in 04/2014, indicated, A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications or accepted professional standards and principles of the professional(s) providing services. A review of an admission Record indicated the facility admitted Resident #33 on 09/29/2020 with diagnoses that included essential hypertension and heart failure. A review of Resident #33s Order Summary Report with active orders as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for three of three sampled residents (Resident #20, #31, and #105) who remained in the facility upon discharge from Medicare A services for rehabilitation. The facility census was 58. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential…

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 four of four randomly selected certified nurse aides (CNA) received the required annual 12 hour resident care training. The census was 58. Review of the CNA individual in-service records, showed the following: -CNA A hired 9/12/13, with 0 hours of in-service education; -CNA B hired 3/9/01, with 0 hours of in-service education; -CNA C hired 8/1/05, with 0 hours of in-service education; -CNA D hired 3/3/17, with 0 hours of in-service education. Review of the facility assessment, showed the facility is required to develop, implement and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified. During an interview on 11/5/19 at 3:07 P.M., the Assistant Director of Nursing (ADON) confirmed that there were four CNAs who have been employed for more than one year and was not able 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 ensure complete perineal care (peri-care, cleansing from the front of the hips, in between the legs and buttocks to the back of the hips) was provided for two of two care observations (Residents #38 and #28). The census was 58. Review of the facility's undated peri-care procedure, showed: -Procedure: Expose the perineal area. Start at the top of the groin and wash down one side of the outer groin tissue, turn the wash cloth and wash the other side of the outer groin. Turn the wash cloth again and wash down the middle of the peri area in a downward motion and front to back manner. Obtain a clean wash cloth and continue cleaning down the legs as needed. Dry the peri area. Roll the resident onto one side and continue washing soiled and wet areas from front to back. 1. Review of Resident #38's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 9/10/19, showed: -Severe…

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 resident monthly pharmacy drug regimen recommendations were followed up on, for one out of six residents sampled for medication regimen review (MRR) (Resident #39). In addition, the facility medication review policy failed to include the appropriate time frames for the different steps in the MRR process. The sample was 15. The census was 58. Review of the facility's undated Medication Regimen Review policy, showed: -The consultant pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for the review; -The review of the medication regimen will include all medications, including medications that are ordered on an as needed basis. The consultant pharmacist will report any apparent irregularities in writing to the attending physician, the director of nursing and the medical director; -In addition to the written communication to the attending…

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 complete and accurately documented medical records for one of 15 sampled residents (Resident #28) identified as receiving one to one activities. The facility did not provide documentation of individualized one to one activities, what kind of activity was provided and length of time the activity was provided. The census was 58. Review of the facility's activity assessment policy, revised 10/2009, showed: -Policy: In order to promote the physical, mental and psychosocial wellbeing of residents, an activity assessment is conducted and maintained for each resident; -Policy interpretation and Implementation: -The resident's assessment will be conducted by the activity department personnel, in conjunction with other staff who will assess related factors such as functional level, cognition and medical conditions that may affect activities participation. The resident's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences will be included in the assessment; -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 develop a coordinated plan of care for residents receiving hospice services and maintain required hospice records onsite at the facility. The facility identified five residents who elected hospice services and all five were included in the sample. Issues were found with two of the five residents (Residents #28 and #225). The census was 58. 1. Review of Resident #28's hospice binder, showed: -admitted to hospice services on 3/12/16; -Hospice admission diagnosis: Malignant melanoma (cancer) of the face. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/19, showed: -Severe cognitive impairment; -Diagnoses of melanoma and dementia; -Received hospice services. Review of the resident's hospice aide care plan, located in the hospice binder and updated on 9/11/19, showed: -The resident is dependent on staff for all activities of daily living (ADLs) and is unable to make any needs known, receives a shower every Tuesday and Friday. Hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to follow the hand hygiene policy and prevent the potential spread of contaminates during personal care by failing to change gloves and wash hands for two of two care observations (Residents #28 and #38). The census was 58. Review of the facility's handwashing/hand hygiene policy, revised 10/2009, showed: -Purpose: To provide guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infections; -Objective: To prevent and control the spread of infectious diseases; -General Guidelines: Approximate 10 to 15 second handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: When hands are visibly dirty, before and after resident contact (for which hand hygiene is indicated by acceptable professional practice), before and after assisting resident with personal care (oral care, bathing), before and after assisting a resident 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.