Aspire Senior Living Pleasant Hill

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for three sampled residents (Resident #78, #139 and #102) out of three sampled residents who were discharged from Medicare part A services. The facility census was 80 residents. Record 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) was issued when all covered Medicare services end for coverage reasons. -If the skilled nursing facility (SNF) believed on admission or during a resident's stay that Medicare would not pay for skilled nursing or specialized rehabilitative services and the provider believed 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…

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 following resident rooms clean and free from a buildup of dust and food debris on the floors and walls: resident rooms 508, 207, 202, 201, 200, 301, 303, 302, 300, 403, 404, 401, 105, and 107. This practice potentially affected 24 residents who resided in those rooms. The facility census was 80 residents. 1. Observations with the Maintenance Director on 10/30/24, showed: -At 1:36 P.M., there was a heavy buildup of cobwebs (a web spun by certain spiders, often found in the corners of disused rooms) between the climate control unit and the night stand in resident room [ROOM NUMBER]. -At 2:37 P.M., there was a heavy buildup of cobwebs which stretched between the floor and the climate control unit. -At 2:40 P.M., there was a heavy buildup of food crumbs in he corner between the bed and the window in resident room [ROOM NUMBER]. -At 2:43 P.M., there was a buildup of dust on the fans in resident room [ROOM NUMBER]. -At 2:44 P.M., there was 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 maintain the hot water temperature at or below 120 °F (degrees Fahrenheit) in the room of Residents #2 and #76 and in the room of Residents #26 and #77; failed to use a gait belt when assisting one sampled resident to ambulate (Resident #19) who was unsteady on his/her feet; and failed to ensure an initial smoking assessment was completed to establish a baseline for the ability of one resident to smoke, determine assistance as necessary, and ensure safe smoking habits were in place for one sampled resident (Residents #61) out of 22 sampled residents. The facility census was 80 residents. 1. Review of the temperature log dated 10/14/24, showed the following hot water temperatures: -In the 100 Hall the temperature was 102 °F. -In the 200 Hall, the temperature was 102°F. -In the 300 Hall, the temperature was 104°F. -In the 400 Hall, the temperature was 105°F -In the 500 Hall, the temperature was 104°F. -The particular rooms on each hall were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with a diagnosis of sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep). Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Had a specialized treatment- a non-invasive ventilator (CPAP/bilevel positive airway pressure (BiPAP, a noninvasive breathing machine that helps people breathe when they have medical conditions that make it difficult). Review of the resident's POS dated 10/2024, showed physician's orders for: - CPAP/BiPAP setting and ensure distilled water is full in the reservoir at bedtime daily at 9:00 P.M. Review of the resident's Care Plan updated on 10/25/24, showed the resident had sleep apnea and used a CPAP/BiPAP at bedside. Interventions showed staff would: -Administer oxygen therapy as ordered. -Change the tubing per protocol. Observation on 10/28/24 at 8:39 A.M., showed the resident was not 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 interview, and record review, the facility failed to maintain documentation and ensure that Certified Nursing Assistants (CNAs), and licensed nursing staff had the appropriate competencies and skills check off completed annually and as needed. This had the potential to effect any resident care provided by care staff. The facility census was 80 residents. Review of the Facility Assessment dated 8/8/24 showed: -The facility has staff skills and competencies to address the current and future needs of the facility's resident. -The facility had reviewed staff training and inservices program and determined that it is appropriate to provide the level and types of care needed for the resident population outlined in this assessment. The facility also reviewed staff competencies and skills sets and determined that competencies and skills sets for both staff and contractors were appropriate. 1. During the entrance conference on 10/28/24 at 9:07 A.M., the Administrator said: -The facility does not currently have an Assistant Director of Nursing (ADON). -The facility had residents 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 and interview, the facility failed to maintain the covers of cleanouts (an access point which provides access to the sewer or other plumbing line so that blockages can be removed) in a tight-fitting manner so the covers would not be a hazard to facility residents or staff located on the 100 Hall and on the 400 Hall. This practice potentially affected 31 residents who resided on those halls. 1. Observations on 10/29/24 at 1:23 P.M. and on 10/31/24 at 10:29 A.M., showed the cleanout cover outside of resident room [ROOM NUMBER] was loose when it was stepped on. During an interview on 10/31/24 at 10:30 A.M., the Maintenance Director said there has not been any work completed around that cleanout since he/she started his/her tenure at the facility in April 2024. 2. Observations on 10/31/24 at 11:31 A.M., showed the cleanout cover between 107 and 108 was loose when it was stepped on. During a phone interview on 11/6/24 at 3:08 P.M., the Maintenance Director said he/she expected the housekeeping…

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 resident was included on his/her care plan meetings and care plan meeting invitations for two sampled residents (Resident #59 and #75) out of 22 sampled residents. The facility census was 80 residents. Review of the policy Person Centered Care Plans effective date 8/15/18 showed: -Preparation for Care Plan Committee Meetings: --The Registered Nurse or other designee should provide a list of resident/guest(s) names, dates, and times for care plan meetings two weeks in advance to other team members. This list also includes information as to the type of care plan review for each resident/guest, admission, quarterly, annual, or significant change in status reviews. --The Social Service Director (SSD, or other designee, should inform the resident/guest and families of the scheduled meeting by mailing the Notice of Schedule Plan of Care Conference to family members or legal representatives, as meeting notice. Family members and legal representatives…

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 the correct code status was in place for one sampled resident (Resident #28) out of 22 sampled residents. The facility census was 80 residents. A policy related to advance directives was requested and was not received by the facility. 1. Review of Resident #28's face sheet showed he/she admitted to the facility on [DATE] with a diagnosis of Encounter for Other Orthopedic Aftercare. NOTE: The face sheet also showed that the resident did not have an advance directive or code status in place. Review of the resident's Physician Order Sheet (POS) dated [DATE] showed no order for an advance directive or code status. Review of the resident's care plan dated [DATE] showed the resident's advance directive or code status was not in the care plan. Review off the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident was cognitively intact. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when medication could not be obtained from the pharmacy for one sampled resident (Resident #61) out of 22 sampled residents. The facility census was 80 residents. Review of the facility Medication Shortages/Unavailable Medications, dated 1/1/13, showed: -When the facility discovers it has an inadequate supply of medication to administer to a resident then the facility staff should immediately initiate action to obtain the medication from the pharmacy. -If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage. 1. Review of Resident #61's Face Sheet showed the resident was admitted on [DATE] with the following diagnoses: -Alcohol-induced chronic pancreatitis (inflammation of the pancreas). -Alcohol abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident or resident representative was provided with the bed hold policy or educated on the bed hold policy when the resident was discharged to the hospital in a timely manner for two sampled residents (Resident #8 and #5) out of 22 sampled residents. The facility census was 80 residents. Review of the facility Transfer/Discharge and Therapeutic Leave policy and procedure updated June 26, 2019, showed: -A copy of the resident bed hold and admission policies/transfer to the hospital should be provided upon transfer by the assigned nurse to the resident or responsible party. 1. Review of Resident #8's Face Sheet showed the resident was initially admitted on [DATE]. Review of the resident's Nursing Notes showed: -10/26/24 at 11:19 A.M., showed the physician gave orders to send the resident to the hospital for further evaluation. The resident was unable to sign the bed hold. The nurse called the resident's responsible party again to notify 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 observation, interview and record review, the facility failed to provide an ongoing, person-centered activities program based on care planned and assessed resident interests and abilities in order to meet the interests and support a residents physical and psychosocial wellbeing for one of 22 sampled residents (Resident #25). The facility census was 80 residents. Review of a facility policy titled Delegation of Activity Program Duties, dated 3/1/08, showed: -The facility was to provide an ongoing activities program designed to meet the physical, mental and psychosocial wellbeing of each resident. -The activities program should have occurred within the context of each resident's comprehensive assessment and care plan. 1. Review of Resident 25's face sheet, dated 6/20/24, showed: -An admission date of 6/14/24. -Diagnoses of Down Syndrome (a genetic chromosomal disorder causing developmental and intellectual delays) and a cognitive communication deficit. Review of the resident's facility Activity Assessment, completed 6/14/24, showed: -Activity interests of games,…

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 to have a comprehensive physician's order for colostomy (or ostomy is a surgical procedure that creates an opening in the large intestine, or colon, through the abdominal wall. The opening, called a stoma, allows stool to drain into a bag or pouch attached to the abdomen) care to include type and size of ostomy supplies needed, failed to have a comprehensive care plan for colostomy care and type of supplies needed for one sampled resident (Resident #3) out of 22 sampled residents. The facility census was 80 residents. Review of the facility's Colostomy Care policy dated 10/1/10 showed: -Care of the colostomy site helps prevent skin irritation around the sire and leakage of the drainage bag. 1. Review of of Resident #3's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/29/24 showed: -Was cognitively intact, able to make his/her needs and wants known. -Had a colostomy upon admission. Review of the resident's care plan…

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 appropriate care for one sampled resident (Resident #60) with a Percutaneous Endoscopic Gastronomy (PEG) tube (a tube that is passed into a person's stomach through the abdominal wall, most commonly used to provide a means of feeding when oral intake is not adequate) out of 22 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Tube Feeding-Kangaroo E-Pump dated 2/1/18 showed: -Staff were expected to label the feeding formula including rate, time, and initials. -Staff were expected to label the flush bag with the date, time, and initial amount of water. -Staff were expected to follow the manufacturer guidelines related to hang times for the tube feeding. 1. Review of Resident #60's face sheet showed he/she admitted to the facility with the following diagnosis: -Gastrostomy Status. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/19/24 showed: -The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician's orders for assessing the resident's dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) shunt (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for dialysis) site twice daily, failed to ensure dialysis communication was received and documented after each dialysis treatment for continuum of care, and failed to include in the care plan the location and type of dialysis access and complete interventions on dialysis care needs for two sampled residents (Resident #68 and #75) out of 22 sampled residents. The facility census was 80 residents. Review of the facility Hemodialysis policy and procedure dated 11/1/01, showed: -Physician's orders for care of the hemodialysis resident should include information regarding visits to a dialysis center, along with care of the access site. -Process…

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

Based on observation and interview, the facility failed to have a regular system of checking food temperatures to ensure that hot foods (scrambled eggs) were maintained at or close to a temperature of 120°F (degrees Fahrenheit) on five trays for residents on the 500 Hall. This practice potentially affected five residents who were yet to receive breakfast room trays on 11/1/24. The facility census was 80 residents. 1. Observation on 11/1/24 showed: -At 7:31 A.M., the cart with trays for the residents in the 500 Hall left the kitchen. -From 7:34 A.M. through 7:38 A.M., trays were passed to residents who were in the 500 Hall dining room. -From 7:40 A.M. through 7:45 A.M. trays were delivered to residents who wanted trays in their rooms. -At 7:44 A.M., with Certified Nursing Assistant (CNA) A watching, the temperature of the eggs on one of the trays was measured at 113 °F . During an interview on 11/1/24 at 7:46 A.M., CNA A said he/she had not seen anyone from the dietary department at the 500 Unit to check food temperatures. During an interview on 11/1/24 at 7:49 A.M., Registered Nurse…

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 one sampled resident (Resident #1) was treated with dignity and respect when on 3/25/24 Registered Nurse (RN) A cursed and yelled at the resident in the dining room out of three sampled residents. The facility census was 81 residents. On 3/25/24 the Administrator was notified of Past Non-Compliance which occurred on 3/25/24. RN A was suspended pending investigation immediately. Upon completion of the investigation, RN A was terminated for violating facility policy on 3/26/24. Facility training for abuse, neglect, dignity and customer services was completed for all staff 3/26/24 prior to the start of their shift. Review of the facility Resident Rights Policy dated 5/1/23 showed: -Purpose: --This policy is concerned with all incidents and accidents involving residents. --All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. --Abuse is the willful infliction of injury,…

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 have a Facility Assessment updated annually and as needed to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment updated annually and complete to show the current resident population and needs. A total of 14 residents were sampled. The facility census was 55 residents. Facility policy for facility assessment was requested from the facility and no policy was provided. 1. Record review of the Facility Assessment dated 12/17/2021 showed: -Casper Report dated 10/31/21 was used for information for the assessment. -Facility Census and Condition report competed 10/31/21 was used for the report. -Facility Matrix dated 10/31/21 was used for the assessment. -Provider Rating Report Nursing Home Compare Five-Star Rating 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 interview and record review, the facility failed to ensure resident funds were placed in an account separate from the facility's operating account whereby, not providing and returning residents' their personal refunds from the operating account in a timely manner for 34 residents (Resident #190, #18, #160, #161, #162, #163, #41, #202, #164, #165, #166, #167, #203, #168, #29, #192, #170, #13, #171, #172, #173, #174, #177, #178, #179, #180, #181, #182, #183, #184, #186, #187, #188 and #189). The facility had a census of 55 residents at the time of survey. 1. Record review of the facility's maintained Interim Aged Analysis Summary (Accounts Receivable Aging Report) for the period 3/1/22 through 3/31/23, showed the following residents with personal funds held in the facility's operating account. Resident Amount Held in Operating Account #190 $ 323.99 #18 $ 81.00 #160 $ 164.61 #161 $ 26.92 #162 $ 32.88 #163 $ 166.78 #41 $ 130.00 #202 $ 2,154.35 #164 $ 4,305.23 #165 $ 633.00 #166 $ 2,472.78 #167 $ 1,308.54 #203 $ 906.00 #168 $ 905.32 #29 $ 2,911.97 #192 $ 394.00 #170 $ 6.50 #13 $…

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 Nurse Aide (NA) Registry checks, Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) checks, Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees) checks, Employee Disqualification List (EDL) checks, and/or Criminal Background Check (CBC) checks were completed prior to hire for three sampled staff (Employees A, D, and F) out of 10 sampled staff. The facility census was 55 residents. Record review of the facility's Employment policy and procedure 10/22/98 showed: -An offer of employment may be made by the department head/supervisor only after the following checked: --Applicable registry, licensing board, etc. has been contracted and checked. --The criminal background check completed and are satisfactory. --The policy did not address specific to checking EDL, CBC, FCSR, or the NA registry. 1. Record review of Employee A's file…

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 have a correct code status for a one sampled resident (Resident #261) out of 14 sampled residents. The facility census was 55 residents. Record review of facility policy Advance Directives and Refusal of Treatment-Missouri dated [DATE] showed: -The resident had the right to refuse treatment, to refuse to participate in experimental research and to formalize and advanced directive for the management of his/her care. -The resident might have refused medical treatment to the extent permitted by law. -Only when the resident's medical status and the resident's or family's wishes indicated can a Do Not Resuscitate (DNR) be completed. -This could be at any point in the resident's care. -This form would be placed in the front of the medical record housed in a plastic sheath. -Orders would be written in the physician section of the medical record. -The physician have to enter the order personally, no orders for DNR can be taken via telephone, but fax or email…

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 notify the resident's responsible party after a fall occurred for one sampled resident (Resident #10) out of 14 sampled residents. The facility census was 55 residents. On 3/13/23 the Administrator was notified of the past noncompliance which occurred on 2/18/23. On 2/19/23 the facility administration was notified of the change of condition/notification not being completed and a grievance was started. Facility staff were educated on change of condition and notification to the responsible party. All changes of condition were monitored daily for notification. The deficiency was corrected on 2/20/23. Record review of the facility policy Change in Medical Condition dated 11/28/16 showed: -Notification of the resident's family member should occur promptly when there is a change in the resident's medical condition. -Example of a change of condition was a fall. 1. Record review of Resident'#10's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed but facility staff for care planning…

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, failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled residents (Residents #6 and #50) who remained in the facility but were discharged from Medicare part A services for beneficiary notices. The facility census was 55 residents. A policy was requested from the facility but not received. 1. Record review of Resident #6's SNF ABN Protection Notification Review showed: -The resident went on hospice (end of life care) per family request on 3/12/23. -A SNF ABN was not provided to the resident or resident's responsible party. 2. Record review of Resident #50's SNF ABN Protection Notification Review showed: -The resident was discharged off Medicare Part A services on 12/2/22. -A SNF ABN was not provided to the resident or resident's responsible party. 3. During an interview on 3/16/23 at 8:53 A.M. the Financial Analyst said: -He/she was responsible for completing all notices when a resident discharged off of Medicare Part A services. -He/she had not been providing the SNF ABNs to the residents or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for one closed record resident (Resident #58) of his/her discharge from the facility out of three closed record sampled residents. The facility census was 55 residents. A policy was requested and no policy was received related to notification of the ombudsman. 1. Record review Resident #58's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 12/22/22 showed the resident: -Was severely cognitively impaired. -Was admitted for skilled rehabilitation services. Record review of the resident's Discharge summary dated [DATE] showed: -The resident was being transferred to another facility. -The resident was sent to the other facility with all medications. During an interview on 3/16/23 at 1:40 P.M. the Social Services Designee (SSD) said: -He/she was responsible…

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

Based on interview and record review, the facility failed to ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR) recommendations and to integrate the recommendations into the care plan for one sampled resident (Resident #50) out of 14 sampled residents. The facility census was 55 residents. A policy was requested but not received. 1. Record review of Resident 50s admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/24/22 showed the resident: -Was severely cognitively impaired. -Had the following diagnoses: --Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety) --Depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). --Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, 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 interview and record review, the facility failed complete a recapitulation upon discharge form the facility for one closed record resident (Resident #58) out of three closed record sampled residents. The facility census was 55 residents. Record review of facility policy entitled Discharge Summary and Plan of Care dated November 28, 2016 showed: -Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident from the facility, help the new care provider to understand the resident's goals and needs. -When the facility anticipated the discharge of a resident, a discharge plan summary would be developed. -Upon discharge of a resident a discharge summary was provided to the receiving care provider. 1. Record review Resident #58's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 12/22/22 showed the resident: -Was severely cognitively impaired. -Was admitted 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 ensure physician's order for oxygen tubing changes were on the Physician's Orders Sheet (POS) and to ensure oxygen nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and tubing was stored to prevent contamination when not in use for two sampled residents (Resident #49 and #51); to ensure nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) equipment was maintained and stored to prevent contamination when not in use for one sampled resident (Resident #49); and to ensure an oxygen care plan was completed for one sampled resident (Resident #51) out of 14 sampled residents. The facility census was 55 residents. Record review of the facility's Nebulizer policy dated 5/1/04 showed: -The staff were to obtain physician's orders for the nebulizer. -After use of the nebulizer and cleaning of the nebulizer, store the equipment in a plastic…

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 bed rails were assessed on an on-going basis, to try other assistive devices before placing the side rails, to have a consent signed by the resident to notify them of the risks and/or benefits of the use of side rails and to care plan the use side rails for one sampled resident (Resident #43) out of 14 sampled residents. The facility census was 55 residents. Record review of the facility policy Bed Rail Use dated 10/26/22 showed: -Bed rails may be used to enable a guest to become more functionally independent and when their medical condition required to use of a bed rail. -Bed rails may be used to help turn themselves in bed. -Possible hazards and clinical benefits of the bed rail use should be explained to the resident during the admission process and upon initial implementation of the bed rails. -The bed rail evaluation should be completed upon admission, readmission, when implementing the side rail, with significant change 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 interview, and record review, the facility failed to ensure documentation of coordination of care with hospice (end of life care) services by not ensuring a current hospice comprehensive resident medical record was maintained with a current certificate of care, nursing summary, and plan of care for two sampled residents (Resident #29 and Resident #6) out of 14 sampled residents. The facility census was 55 residents. A policy related to hospice services was requested and not received at the time of exit. Record review of the facility and specific Contracted Hospice Agency Agreement dated 10/13/22 showed: -Each party shall prepare and maintain complete and detail clinical record concerning each hospice resident receiving hospice services under this agreement in accordance with it usual record -keeping procedures and as required by applicable federal. -Each record shall have document that the specified services are furnished in accordance with this agreement and shall be readily accessible 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 the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for three sampled residents (Resident #7, #277, and #278) out of three sampled residents who were discharged from Medicare part A services. The facility census was 68 residents. Record 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) was issued when all covered Medicare services end for coverage reasons. -If the skilled nursing facility (SNF) believed on admission or during a resident's stay that Medicare would not pay for skilled nursing or specialized rehabilitative services and the provider believed 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…

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 check the Certified Nursing Assistant (CNA) Registry to ensure individuals did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for four sampled employees (Employees A, C, D, and E), out of six sampled employees hired since the last annual survey. The facility census was 68 residents. Record review of the facility Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injury of Unknown Source, and Exploitation policy dated 11/28/17 and revised on 2/18/18 showed: -The facility will not knowingly employ or otherwise engage any individual who has been found guilty by a court of law of abusing, neglecting, or mistreating resident. -In addition, the facility will not knowingly employ any individual who had a finding entered into the state nurse aide registry or disciplinary action against his or her professional license, concerning abuse, neglect, and mistreatment of resident, exploitation or misappropriation of resident property. -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 observation, interview and record review, the facility failed to ensure residents who were unable to carry out bathing needs received showers or baths to maintain good personal hygiene for two sampled residents (Resident #64 and #62) out of 17 sampled residents and for one closed record resident (Resident #271) out of three closed records. The facility census was 68 residents. Record review of the facility's Bath-Shower or Tub policy dated 10/1/10 showed: -Showers and baths promote cleanliness and comfort for the resident. -Residents should receive a shower or tub bath as needed. 1. Record review of Resident #64's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Major depressive Disorder (a state of intense…

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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident out of 17 sampled residents. The facility census was 68 residents. 1a. Record review of the facility's Facility assessment dated [DATE] showed: -There was no documentation that showed the residents' diseases, conditions, physical and cognitive disabilities or the facility acuity level. -The facility did not vary staffing levels according to a prospective resident's acuity or care needs. -Staffing: --Current staffing was stable from day to day and shift to shift based on normal and expected care needs of the residents. --When residents with extensive care needs are considered for admission, the administrator, admissions director, and Director of Nursing (DON) determine whether additional staffing was required or whether the admission should 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.

Based on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) was serving as a DON only when the facility had an average occupancy of fewer than 60 residents. The facility census was 68 residents. 1. Record review of the facility's Census Report dated 10/19/20 showed the facility census was 68 residents. Record review of the facility's Resident Census and Condition of Residents report dated 10/19/20 showed the facility census was 68 residents. During an interview on 10/26/20 at 12:59 P.M. the DON said he/she was the charge nurse today for the unit. Observation on 10/26/20 at 1:06 P.M. showed the DON was passing medications to the residents on the 500 hall. During an interview on 10/26/20 at 2:36 P.M. the DON said he/she started acting as a charge nurse on the 500 hall unit at 12:00 P.M. Observation on 10/26/20 at 2:37 P.M. showed the DON was passing medications to the residents on the 500 hall. During an interview on 10/27/20 at 10:54 A.M. the Administrator and the Regional Nurse Consultant (previously the interim DON) said the DON…

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 the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 68 residents. Record review of the facility's Inventory Control of Controlled Substances dated 12/1/07 and revised on 1/1/13 showed: -The facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances (narcotics) and other medications with a risk of abuse or diversion at the change of every shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet. -The facility should ensure that staff count all Schedule III - V controlled substances in accordance with facility policy and applicable law. 1. Record review of the facility's Controlled Drug Count sheet dated 5/15/20 - 6/6/20 showed: -The document did not identify which hall the narcotic count sheet was for. -17 out of 44 opportunities were not signed by either the oncoming or offgoing staff. -One shift (6/5/20 day shift)…

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 the medication refrigerator temperatures were monitored and maintained within appropriate limits; to ensure insulins and eye drops were dated when they were opened and to ensure expired medications were removed from the medication delivery system in two medication carts and one medication room. The facility census was 68 residents. Record review of the facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/1/07 and revised on 10/28/19 showed: -Facility should ensure that medications and biologicals that have an expired date on the label are stored separately from other medications until destroyed or returned to the pharmacy or supplier. -Facility should ensure that food is not to be stored in the refrigerator or general storage areas where medications and biologicals are stored. -Once a medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration…

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 sanitary food serving utensils; to ensure plastic cutting boards were in good condition to avoid food safety hazards; and to refrigerate open foodstuffs that stated to do so on their labels. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 68 residents with a licensed capacity for 90. 1. Observations during the kitchen inspection on 10/19/20 between 8:57 A.M. and 11:43 A.M. showed the following: -An open 1-gallon jug of Teriyaki sauce approximately 3/5 full located on the upper shelf of a rack in the dry storage stated Refrigerate After Opening on the label. -One red and one green cutting board on a lower shelf under a microwave both were heavily scored to the point of plastic bits hanging off them. -An open 1-gallon jug of soy sauce approximately 1/4 full located on the bottom shelf of a cart by the 3-sink area stated Refrigerate After Opening for Quality on the label. -A blue handled scoop in a plastic 3-drawer cart…

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 Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment. A total of 17 residents were sampled. The facility census was 68 residents. 1. Record review of the facility's Facility Assessment, dated 9/9/20, showed: -There was no documentation that showed the residents' diseases, conditions, physical and cognitive disabilities or the facility acuity level. -The facility did not vary staffing levels according to a prospective resident's acuity or care needs. -Staffing: --Current staffing was stable from day to day and shift to shift based on normal and expected care needs of the residents. --When residents with extensive care needs are considered for admission, the administrator, admissions director, and Director of Nursing (DON) determine whether additional staffing was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed to prevent cross-contamination by not performing appropriate hand hygiene (wash or sanitize hands) between glove changes, during incontinent care and during urinary catheter (a tube passed through the urethra into the bladder to drain urine) care for two sampled residents (Resident #31 and #62), during wound care for two sampled residents (Resident #34 and #62), during blood glucose monitoring for one sampled resident (Resident #13) and two supplemental residents (Residents #46 and #67), and not sanitizing the blood glucometer (a machine to measure blood sugar levels) between residents for one sampled resident (Resident #13) and two supplemental residents (Resident #46 and #67), not ensuring isolation precautions were maintained for newly admitted residents for one sampled residents (Resident #31), failed to ensure one sampled resident's (Resident #62) linens were properly handled, failed…

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 one sampled resident (Resident #54) was afforded an opportunity to formulate advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Advance Directives and Refusal of Treatment policy date 10/1/10 showed: -The resident has the right to refuse treatment and to formulate an advance directive for the management of his/her care. -The resident will be given information and the opportunity to formulate Advance Directives, including but not limited to a Living Will and/or an attorney-in-fact appointed pursuant to a Durable Power of Attorney for Health Care. -The resident shall have a copy of his/her Advance Directive(s), if any, made a part of his/her medical record. -Prior 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 interview and record review, the facility failed to ensure a resident being discharged from the facility to the hospital received a discharge notification for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 68 residents. 1. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] and was readmitted on [DATE]. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/20 showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. -Required extensive staff assistance for dressing and bathing. -Required total staff assistance for toileting. Record review of the resident's electronic medical record showed: -He/She was sent to the hospital for abdominal pain and not having a bowel movement for several days despite treatment on 10/15/20. --No documentation 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 interview and record review, the facility failed to ensure a resident being discharged from the facility to the hospital received a bed hold notice for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 68 residents, 1. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] and was readmitted on [DATE]. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/20 showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. -Required extensive staff assistance for dressing and bathing. -Required total staff assistance for toileting. Record review of the resident's electronic medical record showed: -He/She was sent to the hospital for abdominal pain and not having a bowel movement for several days despite treatment on 10/15/20. --No documentation a bed hold notice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a base line care plan was developed and reviewed with the resident or the resident's responsible party, and to provide a copy of the base line care plan to the resident/responsible party within 48 hours of the resident's admission to the facility for two sampled residents (Resident's #13 and #62) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Person Centered Care Plan policy dated 7/17/18 showed: -Person centered plans of care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals of the resident consistent with the residents rights. -The facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident. -The baseline plan of care should be initiated by the Minimum Data Set (MDS - a federally mandated assessment tool…

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 revise a resident's care plan to reflect the resident's current condition to include the resident's Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) code status for one sampled resident (Resident #29), and after one resident's fall with a fracture for one sampled resident (Resident #63), out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Person Centered Care Plan policy dated 7/17/18 showed: -Person centered plans of care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals of the resident consistent with the residents rights. -The facility develops a comprehensive person centered plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review , the facility failed to develop a discharge plan according to residents needs for one sampled closed record (Resident # 72) out of 17 sampled residents and three closed records. Facility census was 68 residents. Record review of the facility's Discharge Summary and Plan of Care policy dated November 28 2016 showed: -Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident from the facility, help the new care provider understand the resident goal and needs. -A post discharge plan of care developed with the resident and his/her family, to assist the resident to adjust to his/her new living environment. -The planned discharge review should be initiated upon determination that the resident planned to discharge and should be updated on-going, to be completed before the resident's discharge. -Discharge to home instructions should be completed prior to the resident's discharge, preferably on the date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive discharge summary which included a recapitulation of stay for one sampled closed record (Resident #72) out of 17 sampled residents and three closed records. The facility census was 68 residents. Record review of facility's Discharge Summary and Plan of Care policy dated November 28, 2016 showed: -If the facility anticipated the discharge of a resident, a discharge plan summary should be developed. -Upon discharge of a resident, a discharge summary is provided. -The discharge summary should include a recapitulation of residents stay, a final summary of the residents status at time of discharge, a post discharge plan of care developed with the resident and his/her family to assist the resident to adjust to his/her new living environment,and a reconciliation of pre and post discharge medications. -Planned discharge review should be imitated upon determination that the resident planned to discharge and should be updated on-going,…

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 meaningful activities to meet the interests of and support the physical, mental, and psychosocial well-being of two sampled residents (Resident #48 and #64) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Activity Program Management policy updated 3/1/2008 showed: -The purpose of the policy was to help activity staff understand aging complications experienced by the elderly, and the federal and state requirements affecting long term care practice. -The quality of care section of the activity program manual was dedicated and a resource to the activity program staff regarding program management related to medical and nursing care needs of the residents. -No other parts of the activity program manual were provided by the facility. 1. Record review of the facility's activity calendar dated 10/2020 showed: -10/19/20: Daily handouts, riddles, 100 hall cupcakes, and door decorating.…

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, notify the physician, obtain treatment orders and complete an incident report and investigation for one sampled resident (Resident #18) who had right lower leg abrasions; to ensure one sampled resident (Resident #51) had a hospice (end of life care) book with a clear integrated plan on how to care for the resident at his/her end of life; and to monitor a resident's non-pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for one sampled resident (Resident #62) out of 17 sampled residents. The facility census was 68 residents Record review of the facility's Terminally Ill - Caring For policy updated 11/1/2001 showed: -The resident's family, friends and clergy should be encouraged to play an active role in the psychosocial plan of care for 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 monitor a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for one sampled resident (Resident #62) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility's Protocol for Certified Nursing Assistant (CNA) and Licensed Nurse Skin Inspections policy dated 10/1/10 showed: -CNA's will conduct body inspections of residents at risk for pressure ulcers on a daily basis. -Licensed Nurses will conduct body inspections of residents at risk for pressure ulcers on a weekly basis. -CNAs will conduct a body inspection on all assigned residents. -Results of inspection will be documented on the body audit sheet or in the electronic charting beside the resident's name. -Any skin concern identified by the CNA 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 observation, interview and record review, the facility failed to maintain communication between the facility and the dialysis center and to develop a dialysis policy that instructed staff regarding communication between the facility and the dialysis center for one sampled resident (Resident #58) who received dialysis (use of a machine to purifying the blood of a person whose kidneys are not working adequately to sustain life) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Hemodialysis (removing waste products from a person's blood) Care policy dated 11/1/01 showed: -Obtain dry weights from the dialysis center. -Obtain lab work from the dialysis center. -The policy did not include specific instruction regarding how to maintain communication between the facility and the dialysis center. 1. Record review of Resident #58's Face Sheet showed he/she was readmitted to the facility on [DATE] with a diagnosis of end stage renal failure (the last stage of chronic…

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.