Estates Of Perryville, Llc, The

Based on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one resident (Resident #1) with severe mental illness and behaviors, when Resident #1 displayed agitated behaviors and staff did not attempt to de-escalate. The census was 74. The facility did not provide a policy on behavioral health management. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head…

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

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 115. Review of the facility's Handwashing policy, undated, showed: - Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures; - Wash hands and exposed portions of arms immediately before engaging in food preparation; - When to wash hands: after handling garbage or garbage cans, dirty trays or dishes, or anything soiled; as often as necessary during food preparation to remove soil/contamination, and to prevent cross contamination when changing tasks; any time a contaminated surface is touched; - Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines; - To ensure safe and proper food handling during food preparation and service, the food code states that food items…

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 maintain infection control practices to prevent the development and transmission of infection during perineal (peri) care (cleaning the genital and anal areas of the body) for two residents (Resident #4 and #66) outside the sample. The facility failed to implement enhanced barrier precautions (EBP) during perineal and wound care for one resident (Resident #6) out of 23 sampled residents and failed in the prevention of communicable disease in regard to tuberculosis (TB-a communicable disease that affects the lungs and is characterized by fever, cough and difficulty breathing) screening/testing of two residents (Resident # 8 and #23) out of five sampled residents. The facility's census was 115. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-24-08-NH, dated 03/20/24, showed: - CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards; - EBP recommendations now…

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 maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 115. Review of the facility's policy, Pest Control, dated 08/24/24, showed: - This facility will ensure the facility remains clean and free from pests; - Daily cleaning of facility will be maintained; - Monthly contracted pest control company will treat inside and outside of facility; - Entry points to facility will be kept in good repair; - Residents will be provided bags for their snacks they keep in their rooms. Observation of the kitchen on 12/01/24 at 7:17 P.M. showed: - Approximately two dozen live cockroaches in the oven that scattered when the oven door was opened; - A live cockroach crawling up the wall near the coffee maker. Observation of the kitchen on 12/03/24 at 11:50 P.M. showed: - A live cockroach on a pair of oven mitts lying on a shelf next to the oven; - Multiple live cockroaches inside the oven; - A dead cockroach in the floor to the right of the oven.…

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 provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 115. Review of the facility's policy, Maintenance Repair Policy, dated 08/24/24, showed: - All team members are orientated to the Maintenance Work Order log located at each nurses' station; - Any team member can complete the Maintenance Work Order; - Maintenance personnel shall address routine maintenance work orders throughout the day, within 24 hours, or the next business day; - Emergency work orders shall be addressed upon notification; - In the event a work order has not been addressed within the timeframe specified, any team member will contact the Maintenance Director; - A log of these work orders shall be retained by the Maintenance Director; - In the event the Maintenance Director is unavailable, all concerns should be directed to the Administrator. Observations on 12/01/24 at 1:30 P.M. of the main entrance common area showed an overwhelming urine odor. Observation on…

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 two residents (Resident #12 and #96) were free from physical abuse when one resident (Resident #27) struck Resident #12 on the right side of the face and later that day, struck Resident #96 in the face. The facility's census was 137. Review of the facility's Abuse, Neglect and Exploitation Policy, updated 04/08/24, showed: - Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion; - Resident must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident family members, legal guardians, friends or other individuals; - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; - Physical Abuse includes, but is not limited to hitting, slapping, pinching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for ten residents (Resident #8, #12, #15, #23, #26, #33, #35, #95, #111, and #315) out of 23 sampled residents and two residents (Resident #27 and #216) outside the sample. The facility's census was 115. Review of the facility's policy, Admission, Transfer and Discharge, revised 08/24/24, showed: - The facility may transfer or discharge the resident in compliance with facility standards and are as follows, but not limited to: the resident's welfare and needs cannot be met in the facility, the health or safety of individuals in the facility would otherwise be endangered, if the resident's health has improved sufficiently so the resident no longer needs the facility's services, or if the resident fails to pay any charges when due; - The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for nine residents (Resident #12, #15, #17, #23, #26, #33, #95, #111, and #315) out of 23 sampled residents, and three residents (Resident #5, #84, and #216) outside the sample. The facility's census was 115. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - It is the policy of this facility to notify the resident/responsible party of the bed hold policy. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; - The facility agrees to allow the resident to return to the facility at any time during the bed hold period, provided the facility can meet the resident's needs; - According to state regulations, a resident agreeing to the bed hold policies will have their bed held up 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.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #33 and Resident #57) out of 23 sampled residents and one resident (Resident #113) outside the sample. The facility's census was 115. Review of the facility's policy titled, MDS Policy, revised 08/02/24, showed: - Purpose: In Medicare, MDS stands for Minimum Data Set. It's a federally mandated process that involves a standardized assessment of each resident's health and functional capabilities in nursing homes certified by Medicare and Medicaid. The MDS assists nursing home staff identify health issues and potential problems, strengths, and preferences for residents. The assessment is completed electronically and transmitted to the state; - Procedure: The Resident Assessment Instrument (RAI) Manual serves as the policy by which the facility follows the process of completing MDS assessments. Review of the RAI Manual, revised October 2024, showed: - A significant change…

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 update and revise care plans with specific interventions to meet individual needs for six residents (Resident #9, #23, #33, #56, #57 and #87) out of 23 sampled residents. The facility's census was 115. Review of the facility's policy titled, Care Plan Policy, reviewed 08/24/24, showed: - A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents; - A comprehensive care plan will be generated through collaboration with the interdisciplinary team (IT), resident and responsible party, to be completed by the 21st day of admission; - The care plan will reflect a problem, goal and interventions to guide the IT team to assist the resident in achieving the desired outcome for a specific problem; - When goals and objectives are not achieved, the resident's medical record will be updated and the care plan will be modified accordingly; - The care plan will be reviewed quarterly and updated as needed. 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 observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #8, #15, #20, and #57) out of 23 sampled residents and one resident (Resident #5) outside the sample. The facility's census was 115. Review of the facility's policy titled, Physician Orders, updated 08/24/24, showed: - The purpose of this policy is to ensure our residents receive the care prescribed by their physician; - Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Medication Technicians (CMTs) are expected to review orders prior to administering medications and/or performing a treatment; - The RNs, LPNs, and CMTs are to follow the orders as written. Review of the facility's document titled, Scale/Weights Action Timeline, undated, showed on September 11, 2024, temporary scales purchased. All non-wheelchair bound residents weighed. 1. Review of Resident #5's medical record showed: - admitted on [DATE]; - Diagnoses of schizoaffective disorder (a 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 interview and record review, the facility failed to provide an ongoing program of activities to meet the interests and physical, mental, and psychosocial well-being of each resident. This practice affected three residents (Resident #8, #15, and #111) out of 23 sampled residents and four residents (Resident #5, #67, #82, and #102) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 115. Review of the facility's Activities Policy, reviewed 08/24/24, showed: - The purpose is to ensure that all residents of the facility have access to meaningful and engaging activities that enhance their quality of life, meet individual needs, and comply with state and federal regulations, including the Centers for Medicare & Medicaid Services (CMS) regulations; - The facility is committed to providing a comprehensive, person-centered activity program that promotes physical, mental, emotional, and social well-being for all residents. Activities will be designed 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.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) or contraindication for a GDR for two residents (Resident #15 and #20) out of 23 sampled residents. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility's census was 115. The facility did not provide a policy regarding GDRs. 1. Review of Resident #15's medical record showed: - An admission date of 04/23/21; - Diagnoses of paranoid schizophrenia (a type of schizophrenia characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), anxiety disorder (excessive and uncontrollable feelings of fear or worry that interfere with daily life), attention-deficit/hyperactivity disorder (ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness), major depressive disorder (MDD - persistently depressed mood or loss of interest in…

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 provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected two residents (Resident #111 and #315) out of 23 sampled residents and three residents (Residents #61, #77, and #83) outside the sample and had the potential to affect all residents in the facility. The facility's census was 115. The facility did not provide a food temperature policy. Observation of the lunch meal on 12/03/24 at 1:15 P.M. showed: - Macaroni salad with a temperature of 60 degrees Fahrenheit (F); - Pears with a temperature of 55 degrees F; - Deviled egg with a temperature of 51 degrees F; - Tomato with a temperature of 58 degrees F. Review of the steam table temperature logs for October and November showed: - No logs provided for the month of October; - Logs provided for November did not have dates listed, so the Dietary Manager (DM) listed November dates at the top of the logs. During an interview on 12/01/24 at 4:56 P.M., Resident #83 said the food is getting better, but it's horrible 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 have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 97. The facility did not provide a policy. Review of the facility's current employee list, dated 09/24/23, showed a hire date of 09/16/22 for the Dietary Manager (DM). During an interview on 09/26/23 at 10:59 A.M., the Administrator said she did not know the DM had been in her position for almost a year. She was aware the DM was not certified. The employee will be enrolled in an online course to start the certification process to meet the dietary manager requirement. During an interview on 09/27/23 at 11:19 A.M., the DM said he/she was not aware of the requirement to become a Certified Dietary Manager (CDM) until the Administrator informed him/her of it a couple of days ago. The Administrator enrolled…

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 implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to maintain proper infection control practices for glucose monitoring for one resident (Resident #15) out of 20 sampled residents and five residents (Resident #5, #7, #34, #38, and #65) outside of the sample, and failed to perform hand hygiene during medication administration for one resident (Resident #15) out of 20 sampled residents and two residents (Resident #34 and #65) outside the sample. The facility census was 97. 1. The facility failed to provide a policy regarding Legionella. During an interview on 09/28/23 at 3:15 P.M., the Maintenance Assistant said he/she was not aware if any routine checks for Legionella were being performed, as he/she just started a couple of weeks ago. During an interview on 09/28/23 at 3:25 P.M., the Maintenance Supervisor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected ten residents (Resident #15, #22, #31, #43, #52, #55, #73, #86, #87, and #89) out of 20 sampled residents, five residents (Resident #28, #58, #71, #88, and #303), outside the sample, and had the potential to affect all residents. The facility's census was 97. Review of the facility's Pest Control Policy, last revised March 2022, showed: - The facility will remain clean and free from pests; - Daily cleaning of facility will be maintained; - Monthly contracted pest control company will treat inside and outside of facility; - Entry points will be kept in good repair; - Residents will be provided bags for snacks they keep in rooms. 1. Observation of Resident #15 showed: - On 09/27/23 at 3:05 P.M., the resident sat in a wheelchair and a fly was observed on the right leg, then onto left leg. The fly buzzed around again and landed on his/her…

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 the residents' environment was free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and a community shower, which put residents at increased risk for burns caused by scalding water. This practice affected five residents (Resident #15, #47, #56 #67, and #77) out of 20 sampled residents and seven residents (Resident #1, #26, #9, #53, #65, #75, and #90) outside the sample. This practice could have potentially affected all residents. The facility census was 97. Review of the Burn Foundation website showed hot water causes third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: - In 1 second at 156 degrees F; - In 2 seconds at 149 degrees F; - In 5 seconds at 140 degrees F; - In 15 seconds at 133 degrees F. Review 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 interview and record review, the facility failed to provide personal funds and a final accounting of resident personal funds with the balance of those funds within thirty days of discharge for one resident (Resident #203) out of two closed records sampled in the resident fund review. The facility also failed to notify one sampled resident (Resident #15) out of 20 sampled residents and four residents (Resident #7, #13, #45, and #59) outside the sample and/or the responsible parties of the resident's fund balances remaining above $5,762.00 (the limit which should trigger a notification) for the months of August 2023 and September 2023. The facility census was 97. Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/23, showed: - The facility shall furnish the resident with a written receipt for all expenditures and deposits regarding any of the resident's funds deposited with the facility; - A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted…

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 maintain the surety bond (a purchased bond for security of resident's personal funds) for at least one and one half times the average monthly balance of the resident's personal funds for the last 12 consecutive months from September 2022 through August 2023. The facility census was 97. Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/2019, showed the facility has a surety bond to assure the security of the resident's personal fund deposited with facility. Review of the resident's personal funds account for the last 12 consecutive months from September 2022 through August 2023 showed: - The facility's approved bond amount equaled $100,000.00; - The average monthly balance of the resident's personal funds equaled $85,598.03; - An average monthly balance of $85,598.03 rounded to the nearest thousand equaled $86,000.00, at one and one half times will equal the required bond amount of at least $129,000.00. During an interview on 09/27/23 at 9:07 A.M., the Business Office Manager…

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 complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames for 13 residents (Resident #14, #15, #17, #18, #21, #29, #31, #34, #48, #54, #55, #68, and #89) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment, 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 interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for ten residents (Resident #14, #17, #18, #21, #29, #31, #34, #35, #47, and #55) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment, a subset of items upon 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 interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner and in accordance with guidelines for nine residents (Resident #14, #18, #31, #34, #35, #47, #54, #55, and #89) of 20 sampled residents. The facility census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #47) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Physician/Medication Order Policy, last reviewed 12/2018, showed: - For written transfer orders, implement if signed and dated by the resident's current attending physician; - If not signed by the current attending physician, the receiving nurse should verify the order with the current attending physician. Review of Resident #47's medical record showed: - Latest admission date of 09/08/2023; - Diagnoses of impairment of speech following a stroke, hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), dementia (the loss of cognitive thinking, remembering, and reasoning that interferes with a person's daily life and activities), anemia (lack of blood), Wernicke's encephalopathy (a type of brain injury), gastro-esophageal reflux disease (digestive disease 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 obtain an order for a Foley catheter (a flexible tube inserted into the bladder to drain urine), catheter care, and provide a diagnosis for the use of a catheter for one resident (Resident #47) out of 20 sampled residents The facility census was 97. Review of the facility's policy titled, Catheter Care Protocol, updated on 02/2021, showed: - Skin care guidelines should be followed once a day and more often as needed. Review of Resident #47's medical record showed: - An admission date of 03/24/21; - admitted to the hospital on [DATE] and returned to the facility on [DATE] with a Foley catheter; - No diagnosis for a Foley catheter; - The September 2023 Physician's Order Sheet, (POS) showed no order for the Foley catheter or for catheter care; - The facility failed to obtain a diagnosis, an order for the catheter placement, and for catheter care. Observation of the resident on 09/26/23 at 10:15 A.M. showed the resident with an indwelling…

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 identify, assess and provide supportive interventions for one resident (Resident #14) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 20 sampled residents. The facility's census was 97. The facility did not provide a policy. Review of Resident #14's electronic medical record (EMR) showed: - admitted on [DATE]; - Diagnoses of PTSD, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (MDD, a long-term loss of pleasure or interest in life), and generalized anxiety disorder (GAD, severe, ongoing anxiety that interferes with daily activities); - An order for the resident to see the dentist, psychiatry, and podiatrist as needed, dated 08/06/21; -…

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 drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 97. Review of the facility's policy titled, Storage and Labeling of Medications, updated 2/13/23, showed: - Medications and biologicals are stored safely, securely and properly, following the manufacturer's recommendations or those of the supplier; - The facility receives medications dispensed by the provider pharmacy in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medication from one container to another or return partially used medication to the original container; - All medications dispensed by the pharmacy are stored in the container with the pharmacy label; - Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according 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.