Maple Lawn Nursing Home

Based on interview and record review, the facility failed to ensure one nurse aide (NA) completed a state-approved training program within four months of hire. The facility census was 59. 1. Review of NA D's employee file showed a hire date of 02/18/25. Review of NA D's payroll showed the employee worked 205 hours as a NA from 11/12/25 to 12/15/25. Review of the facility's schedule for 12/11/25, showed NA D was scheduled for 11:00 P.M.-7:30 A.M. as a NA. During an interview on 12/16/25, at 4:00 P.M., NA D said he/she worked at the facility as an NA for since February 2025. He/She completed a training program but had not passed his/her test. During an interview on 12/09/25, at 11:30 A.M., the Administrator said NA D took the training course but failed the test twice. NA D was scheduled to test again. During an interview on 12/10/25 at 2:59 P.M., the Director of Nursing (DON) said NA D was not certified. NA D has worked as an NA since February 2025. NA D passed his/her class but failed the test. She did not know NA D could not work past four months if he/she was not certified.

Based on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program that monitored antibiotic use for two residents (Resident #2 and #32), in a review of 17 sampled residents. The facility had not had a designated Infection Preventionist or an active antibiotic stewardship program with tracking of infections or antibiotic use since November 2025. The facility census was 59. Review of the facility's policy, Antibiotic Stewardship, dated 10/15/24, showed the following: -Purpose: To ensure proper use of antimicrobials including appropriate treatment, duration of treatment and indication as well as ensuring that antibiotics are not used when contraindicated;-Policy: Nursing staff will not request antibiotics from attending physicians; -Culture shall be obtained when possible prior to antibiotics on all residents. Nursing will request cultures (for example, for urine or sputum) if a physician orders antibiotics without them; -When culture reports return to the facility, nursing…

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 inventories of schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule IV and V narcotic controlled substance medications, were reconciled by at least two qualified staff to ensure accountability for ten residents (Resident #4, 9, 5, 7, 8, 10, 6, 11, 12 and 13) that had narcotics held in the A-hall medication cart each shift per policy. The facility census was 61. Review of the facility policy, Accountability of Controlled Substances, revised 11/27/24, showed the following: -The controlled substance count is completed at the start of each shift; the charge nurse is responsible for counting all controlled substances and for signing the narcotic sheet;-Two nurse signatures (two Licensed Practical Nurses (LPN), two Registered Nurses (RN), or one LPN and one RN, or one nurse (LPN/RN and one Certified Medication Technician (CMT) must sign off on each narcotic count sheet;-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.

Based on interview and record review, the facility failed to follow their policy on reporting allegations of abuse to the state agency immediately, but no later than two hours after the allegation was made for one resident (Resident #1), in a review of eight sampled residents. Resident #1 reported an allegation of abuse to Certified Nurse Aide (CAN) A on 06/15/25. CNA A reported the allegation to his/her charge nurse, Licensed Practical Nurse (LPN) D, who also reported the allegation to Registered Nurse (RN) B. No staff reported the allegation to the Director of Nursing (DON) or the Administrator until four days later. Additionally, when the administrator became aware of the allegation on 06/19/25 at 10:45 A.M., she did not notify the state agency of the allegation until 1:12 P.M. (greater than two hours). The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from…

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

Based on interview and record review, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, per facility policy, for one resident (Resident #1), in a review of eight sampled residents. The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Investigations of Abuse/Neglect: a. The facility will ensure that all alleged reports of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property are investigated; b. The Human Resources Director is responsible for investigations of alleged abuse by an employee or staff member; h. The documented contents of the investigation will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility. The facility census was 62. Review of the most current Facility Assessment, dated [DATE], showed the following: -Licensed beds: 109; -Average daily censes: 53; -23 residents required extensive assistance of two or more staff for activities of daily living (ADLs); -Services required: assistance with ADLs, transfers, ambulation, restorative nursing, bowel and bladder training programs, incontinence prevention and care, catheter and colostomy care, pressure injury prevention and care, managing medical conditions and medication related issues, medication administration, pain assessment and management, physical, occupational, speech and respiratory therapy, management of braces and splints, nutrition, specialized diets, intravenous nutrition, tune feeding, person centered, directed care, psychosocial and spiritual support and dementia specialized care; -Administrative staff personnel…

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 report an injury of unknown origin for one resident (Resident #1), in a review of five sampled residents. The census was 52. Review of the facility policy, Abuse/Neglect and Reporting Reasonable Suspicion of a Crime, last revised 1/5/17 showed: -It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect and injuries of unknown sources; -All allegations of mistreatment, abuse or neglect, and injuries of unknown sources will be reported and thoroughly investigated; -It is the responsibility of each covered individual who is an owner, operator, employee, manager, agent or contractor of the facility to report an incident or situation which may be considered a reasonable suspicion of a crime; -There are two specific time period limits which will be followed, depending on the seriousness of the event that leads to the reasonable suspicion report: -Serious Bodily Injury-within two hours; -All others-within 24 hours: If the events do not result in serious bodily injury to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent cross contamination to other food items. Staff failed to discard food that was expired or showed visible signs of deterioration, failed to store and handle food products to maintain quality and free from potential contaminants, and failed to label and date opened food items. Staff failed to ensure foodware and drinkware was handled appropriately and protected from moisture, debris, and other contaminants and surfaces and equipment were properly cleaned and sanitized. Staff failed to ensure hygienic practices when preparing and serving food and beverages to residents and employ proper hand hygiene and surface sanitization practices. Staff failed to ensure an adequate air gap was present at the drain for three of the facility's five ice machines to prevent possible backflow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Resident #8), in a review of 15 sampled residents and for two additional residents (Resident #23 and #52). Staff failed to correctly apply a splint per physician's orders for Resident #8, failed to follow medication administration guidelines for Resident #23, and failed to follow physician's orders and medication guidelines to rinse the mouth following administration of an inhaled medication for Resident #52. The facility census was 51. 1. Review of Resident #8's physician orders, dated 6/15/23, showed the resident was to have both hand splints/palm protectors on while in bed, off when the resident was out of bed, apply and monitor each shift. Review of the resident's care plan, dated 6/22/23, showed the following: -Provide gentle passive range of motion of both hands; -Put both hand splints/palm protectors on the resident while he/she was in bed, remove the resident's hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to check two dependent residents (Residents #5 and #32) for incontinence according to their plan of care, and failed to provide complete incontinence care to one resident (Resident #17) in a review of 15 sampled residents,. The facility census was 51. Review of the facility policy, Perineal Care, dated 01/26/11, showed the following: -Perineal care is the washing of the genital and rectal areas of the body. Perineal care is usually called peri care; -Peri care prevents skin breakdown of the perineal area, itching, burning, odor and infections. Peri care is very important in maintaining the resident comfort. -All areas that have been touched by the attends/pad (adult protective brief or the cloth pad under the resident) must be washed; -Wash across the abdomen, be sure to lift and wipe all folds, rinse then dry; -Gently wash the inner legs and outer peri areas, rinse and pat dry; -Turn the resident to the side and wash across lower back,…

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 adequately document appropriate diagnoses residents or resident behaviors to justify the implementation or continued used of antipsychotic medications for three residents with a diagnosis of dementia (Residents #11, #17, and #32), in a review of 15 sampled residents. The facility census was 51. A review of the facility policy, Psychotropic Medication, dated 10/10/13, showed the following: -Policy: the facility will make every effort to comply with state and federal regulations to the monitoring and use of psychopharmacological medication, this will include regular review for the continued need, appropriate dosage, side effects, risks and/or benefit. The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness; -General statement: -No psychopharmacologic medication will be administered without a physician order that includes the diagnosis,…

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

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the diet spreadsheet menu. Staff also failed to have recipes readily available for staff to utilize when preparing food items listed on the diet spreadsheet menu. The facility census was 51. The facility did not have a policy related to preparing and serving food according to the diet spreadsheet menu or availability of recipes. 1. Review of the Diet Orders, obtained 10/30/23, showed the following: -Thirty-four residents with a physician-ordered regular diet; -Twelve residents with a physician-ordered mechanical soft diet; -Five residents with a physician-ordered heart healthy diet; -Two residents with a physician-ordered consistent carbohydrate (CCHO) diet; -Two residents with a physician-ordered no concentrated sweets (NCS) diet; -Four residents with a physician-ordered low concentrated sweets (LCS) diet. Review of the Diet Spreadsheet, for 10/30/23 (Day 2, Monday) Lunch, showed…

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

Based on observation, interview, and record review, the facility failed to ensure residents with a physician order for a mechanical soft diet (a texture-modified diet that restricts foods that are difficult to chew or swallow) received food items with the proper texture. The facility census was 51. Review of the facility policy, Dental Soft (Mechanical Soft) Diet, dated 2022, showed the following: -The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods; -The diet consists of food of nearly regular textures but excludes very hard, crunchy, or hard to chew foods; -Foods should be moist and fork tender; -Dry, hard crusty breads are excluded; -Vegetables are cooked soft, moist, and fork tender with no large chunks or pieces; -All vegetables should be chopped or diced into bite-size pieces (0.5 inches or smaller). Review of the Diet Orders, obtained 10/30/23, showed 12 residents with a physician-ordered mechanical soft diet. Review of the Diet Spreadsheet, for 10/30/23 (Day 2, Monday) Lunch, showed staff was to serve…

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 nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for three residents (Residents #8, #17, and #32), in a review of 15 sampled residents. The facility census was 51. Review of the facility's undated hand hygiene policy showed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves; Review of Infection Control Guidelines for Long-Term Care Facilities emphasis on Body Substance Precautions, dated July 1999, showed the following: -Handwashing…

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 inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #3, #33, #37 and #40), in a review of 15 sampled residents, and for two additional residents (Residents #11 and #27) who used bed rails. The facility census was 51. Review of the Food and Drug Administration (FDA) document titled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients,…

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 turn and reposition two residents (Resident #5 and Resident #32), who were identified as at risk for developing pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. It can present as intact skin or an open ulcer and may be painful. It occurs as a result of intense or prolonged pressure or pressure in combination with shear), in a review of 15 sampled residents, according to facility policy and the residents' plan of care. The facility census was 51. Review of the facility policy Resident Turning and Repositioning, last reviewed on 9/4/23, showed the following: -Those residents who are unable to address the need to turn and reposition themselves independently will be turned every two hours and as needed (PRN) by the trained nursing department; -Lay the resident on one side of the body for two hours. A foam wedge may be used behind the resident and…

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

Based on observation, interview, and record review, the facility failed ensure the areas within the rangehood, the wall behind the range, griddle and deep fat fryer, the metal backspash for the range and griddle, and the suppression nozzle over the deep fat fryer were free from a buildup of grease and debris. The facility also failed to ensure the wall behind the range, griddle, and deep fat fryer was maintained with an easily cleanable surface. The facility census was 69. Observation on 2/24/20 at 10:08 A.M. showed the wall behind the deep fat fryer, griddle, and range had a heavy buildup of yellow grease. The wall was constructed with drywall, covered with paint. The drywall compound and paint was cracked and peeling in areas above the deep fat fryer. The metal backsplash behind the range and the griddle had a heavy buildup of grease and debris. The baffle filters within the rangehood, located over the range, griddle, and deep fat fryer, and the areas within the hood below the filters, had a buildup of clear grease. The fire suppression nozzle and piping, located over the deep fat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the residents' environment clean and in good repair. The facility census was 69. Review of the facility Housekeeping Cleaning Policy dated 4/30/18 showed the following in part: -Primary purpose was to perform day-to-day activities of housekeeping and assure the facility was maintained in a clean, safe and comfortable manner; A. Follow cleaning schedule; B. Clean floors. Inspect furnishings for wear or defects and report to supervisor; C. Cleans all bathrooms in facility. Disinfect all walls, floor, fixtures; J. Curtains or drapes that were soiled need to be removed cleaned and replaced. Check for wear and defects and report to supervisor. 1. Observation on 2/24/20 at 2;40 P.M showed a section of missing tile in the hallway between rooms #114 and #113 on Walnut Lane. Observation on 2/24/20 at 2:45 P.M. showed broken tile in the door way between the hallway and room [ROOM NUMBER] on Walnut Lane. Observation of the C hall shower room on 2/25/20 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.

Based on interview and record review the facility failed to develop and implement written policies consistent with the requirements for reporting. The facility census was 53. 1. Review of the document Abuse /Neglect and Reporting Reasonable Suspicion of a Crime Policy and Procedures dated, 1/5/17 showed the following: Policy: It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect, injuries of unknown origin and misappropriation or stealing of resident property or money. Abuse/Neglect Procedures: The facility will not permit residents to be subjected to abuse or neglect by anyone, including staff members, other residents, consultants, volunteers, vendors and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. Abuse/Neglect Definitions of Reportable Issues- To assist our facility in defining incidents of abuse and neglect, the following information is provided. All issues listed below are considered reportable issues and staff should begin the investigation…

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 complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #27, #17 and #162) in a review of 18 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition (improvement or decline) which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 69. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the facility followed the Resident Assessment Instrument (RAI) User's Manual while completing the MDS assessment. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:…

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 staff failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for six of 18 sampled residents (Resident #7, #8, #11, #17, #27, and #162). The facility census was 69. During interview on 3/26/20 at 6:15 P.M. the MDS Coordinator said the facility followed the RAI 3.0 process for completion of all MDS assessments. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -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 staff performed Activities of Daily Living for seven dependent residents (Resident #27, #59, #7, #36, #41, #60 and #162) of 18 sampled residents. The facility census was 69. During interview on 2/26/20 at 6:60 PM the Director of Nursing (DON) said they did not have a policy regarding staff providing residents' morning and bedtime ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the facility policy Perineal Care dated 1/26/11 showed the following: -Perineal care is washing of the genital and rectal areas of the body. Perineal care was usually called peri care. Peri care prevented skin breakdown of the perineal area, itching, burning, odor, and infections. Pericare was very important in maintaining the resident's comfort; -Gather your equipment,necessary for completion of care. Remember to take two disposable bags, one for linen and one for trash. Wash your hands and put on gloves. Explain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foot pedals were in place on wheelchairs during transportation for three residents (Resident #60, #162 and #41), failed to ensure staff used proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair) transfers for two residents (Resident #7 and #41) and failed to consistently implement, evaluate and modify care plan interventions to prevent falls, in accordance with current standards of practice, for one resident (Resident #59) who had a history of repeated falls in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Fall Prevention Program dated 7/13/12 showed the following: This is to be used as a guideline for the preventions of falls/injuries related to falls. All fall reports are routed to the combined resident committee. All new admissions are assessed for fall risks, care plans are reviewed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately assess, obtain informed consents, and reassess the safety and effectiveness of cane rails, one-quarter length bedrails and one-half length bedrails in use for five residents (Resident #11, #27, #36, #40, and # 55) of 18 sampled residents who had bedrails in place on their beds. The facility census was 69. Review of the facility's Bed Rail Checks, Installation and Removal policy dated 6/22/17 showed the following: -Bedrails were defined as any device that could be attached to one or both sides of a bed for the purpose of fall restraint or mobility assist; -All bedrail installations would be monitored and checked monthly by support services staff to eliminate hazards or entrapment of any kind, and review quarterly by support services supervisor and/or administrator; -Support services would be in-serviced at least annually; -A log would be maintained with a record of date of inspection, resident's last name, room/bed number and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medications were stored/destroyed appropriately. The facility census was 69. Review of the facility policy Destruction of expired/opened and used medication (not controlled) dated [DATE] showed : All medication will be collected weekly from the units and given to the nursing office for destruction or credit. Controlled medications are destroyed on site- see policy. Destruction and Returned for Credit: 1.) Medication will be counted and logged into Omniview web portal; 2.) Record are available on web site. Boxes are kept in the nursing office and pharmacy transporter picks them up weekly. Review of the facility policy Destruction of controlled substances dated [DATE] showed the following: This is a guideline for use in the destruction of all controlled substances for our facility: 1.) All unused controlled substances will be destroyed in the nursing office by two licensed nursing staff; 2.) All medication counted and logged on controlled substance…

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 residents' medications were secured in a locked cart or cabinet when left unattended during a medication pass. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 showed the following in part: -Read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident; -Medication carts should not be left unattended. If you needed to step away, make sure the cart was locked and the computer screen was on lock out. 1. Observations on 2/24/20 showed the following: -At 3:41 P.M. Licensed Practical Nurse (LPN) R parked the medication cart against the C-hallway wall and obtained and prepared Resident #300's medications from the medication cart for administration. The medication cart was full of resident medications and contained a locked cabinet of narcotic medications inside one of the unlocked drawers. LPN R did not lock the medication cart, walked away from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for eight residents (Resident #41, #60, #162, #27, #59, #7, #34 and #36) in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Handwashing/Hand Hygiene undated, showed the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage complainace with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to pull the privacy curtains and close the door leading to the hallway to allow for privacy while providing toileting, incontinence care and dressing for two of 18 sampled residents (Resident #7 and #162). The facility census was 69. Review of the facility policy Quality of Life, Dignity and Privacy dated 3/13/12 showed the following: Each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality; 1. Residents would be treated with dignity and respect at all times; 3. Residents would be groomed as they wished as long as adequate hygiene was maintained; 9. Staff would promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #7's face sheet showed the following: -admission dated 9/17/18; -Diagnosis of stroke and suicidal ideations. Review of the resident's care plan dated…

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, facility staff failed to ensure one additional resident (Resident #21) was free from significant medication errors. Staff failed to prime (remove the air) from the Humalog Kwikpen (prefilled pen of fast acting insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration), needle as instructed by the manufacturer prior to administration of the physician prescribed dose resulting in administration of less than the ordered dose of Humalog. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 directed staff to read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident. Review of the Humalog Kwikpen package insert showed the following in part: -Humalog KwikPen was a disposable single-patient-use prefilled pen containing 300 units of Humalog insulin. Each turn (click) 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.