Cedargate Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower, which put residents at an increased risk of injuries from exposure to the hot water. This practice had the potential to affect all the residents at the facility. The facility census was 49. Review of the facility's policy titled, Safety of Water Temperature, revised 12/2009, showed: - Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F; - Maintenance staff will be responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; - Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Review of the Burn Foundation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #6) out of nine sampled residents and one resident (Resident #19) outside the sample, exposed during care. The facility census was 49. Review of the facility's policy titled, Dignity, dated August 2009, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #6's medical record showed: - admission date of 08/30/22; - Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), atrial fibrillation (irregular heart rate), chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill…

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 a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 49. The facility did not provide a policy regarding the environment. Observations on 05/07/24 at 8:21 A.M., 05/08/24 at 11:18 A.M., and 05/09/24 at 08:32 A.M., showed water dripped on the floor beside a yellow caution cone beneath a heating ventilation and air conditioning (HVAC) ceiling vent near room [ROOM NUMBER] and the west wing nursing station. Observations on 05/09/24 at 9:12 A.M., 9:33 A.M. and 9:47 A.M., showed: -The east wing men's handicap shower room [ROOM NUMBER] with two 6 inch (in.) diameter piles of fecal material about 1/4 in. above the floor surface below the shower chair outside of the shower stall, the toilet with separated caulk seal and a black substance along the entire toilet base along the floor and 6 white 1 in. x 1 in. ceramic tile surfaces with 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 notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Residents #11 and #45) out of five sampled residents transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Emergency Transfer or Discharge, revised August 2018, showed: - Emergency transfers or discharges may be necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Did not address written notification to the resident or resident's representative. 1. Review of Resident #11's medical record showed: - admission date of 09/21/22; - The resident transferred to the hospital for medical evaluation on 01/11/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 02/04/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/18/24, 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 provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #11 and #45) out of five sampled residents. The facility census was 49. Review of the facility's policy titled, Bed Holds and Returns, revised 03/2020, showed prior to transfers, written information will be given to the residents and the resident representatives that explain in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non Medicaid residents), or to hold a bed beyond the state bed hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. Review of Resident #11's medical record showed: - admission date of 09/21/22; - The resident transferred to the hospital on [DATE], and readmitted to the facility 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.

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for three residents (Resident #5, #7 and #18) out of 13 sampled residents. The facility census was 49. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2020, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #5's medical record…

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

Based on interview and record review, the facility failed to ensure one resident (Resident #4) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility failed to provide needed care and services in accordance with professional standards of practice for one resident (Resident #23) out two sampled resident who required positioning due to an impairment. The facility census was 49. The facility did not provide a hospice policy. 1. Review of Resident #4's medical record showed: - admitted to hospice on 02/27/24; - No facility staff signatures for the hospice coordinated plan of care, dated 02/09/24; - The facility failed to provide a complete hospice coordinated plan of care for the resident. Review of the facility's policy titled, Repositioning, revised 05/2013, showed: - The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan 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.

Based on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for two residents (Resident #4 and #7) and failed to consistently use a dignity bag for one (Resident #7) out of 2 sampled residents. The facility census was 49. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014 showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; -If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered; - Infection Control, use standard precautions when handling or manipulating the drainage system, be sure the catheter tubing and drainage bag are kept off the floor. The facility did not provide a policy in regards to Foley catheter placement. 1. Review of Resident #4's medical record showed: - admission date of 09/12/23; - Diagnosis of unstageable (full thickness tissue loss in which actual…

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 proper storage of nasal cannulas when not in use for two residents (Resident #27 and #42) and failed to follow oxygen orders for one resident (Resident #42) out of four sampled residents. The facility census was 49. Review of the facility's policy titled, Oxygen Administration, revised, July 2010, showed: - Verify there is a physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - Assemble the equipment and supplies as needed; - The nasal cannula (plastic tubing placed in the nostrils to provide supplemental oxygen) is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head; - Check the tubing connected to the oxygen cylinder to assure that it is free of kinks; - Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter); - Adjust…

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 identify, assess and provide supportive interventions for one resident (Resident #43) 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 two sampled residents. The facility's census was 49. Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care (TIC), dated 2019, showed: - Trauma informed activities of the facility include, but are not limited to care planning person centered approaches and interventions in response to the universal screening and/or periodic assessment of resident survivor needs including but not limited to honoring individual preferences and routines and responding to the emotional and psychosocial needs of resident survivors; - Collaborate with the treatment team to advocate for residents and reduce barriers to recovery; - Link resident…

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 error rate of less than five percent (%) when medications were administered. There were 32 opportunities with two errors made, for an error rate of 6.25%. This practice affected two residents (Resident #17 and #19) outside of the seven sampled residents. The facility census was 49. Review of facility's policy titled, Insulin Administration, revised 09/2014, showed staff to check the expiration date if drawing from a multi-dose vial. Review of facility's policy titled, Storage of Medications, revised 04/2019 showed nursing staff is responsible for maintaining the medication storage. Review of Novolog (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. 1. Review of Resident #17 medical record showed: - admitted on [DATE]; - Diagnosis of diabetes mellitus (DM - the body has…

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 opened, multi-use vials were discarded after the opened expiration date. The facility census was 49. Review of the facility's policy titled, Storage of Medications, revised 04/2019 showed the nursing staff is responsible for maintaining the medication storage. Review of Novolog (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. Review of insulin aspart (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. Review of Fiasp (type of insulin) manufacturer's instructions, revised 06/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. Review of lispro…

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 proper infection control practices during incontinent care for four residents (Resident #4, #5, #6 and #43) out of six sampled residents, catheter care for one resident (#4) out of two sampled residents, and wound care for two residents (Resident #4 and #303) out of three sampled residents. The facility census was 49. The facility did not provide a policy regarding infection control. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub or soap and water for: before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, after contact with a resident's intact skin, after handling used dressing or contaminated equipment,…

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 document pertinent education provided to the residents or the resident's representative regarding benefits, side effects or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for four residents (Residents #6, #23, #43, and #44) out of five sampled residents. The facility's census was 49. The facility did not provided policy regarding the influenza and pneumonia immunizations. 1. Review of Resident #6's medical record showed: - admission date of 08/30/22; - Influenza vaccine administered on 11/20/23; - No documentation the facility provided information and education to the resident or the resident's representative of the influenza vaccine. 2. Review of Resident #23's medical record showed: - admission date of 04/10/23; - Influenza vaccine administered on 10/20/23; - Pneumococcal vaccine administered on 11/26/23; - No documentation the facility provided information and education to the resident or the resident's representative of the influenza vaccine; - No…

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 a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 40. Record review of the facility's Maintenance Service Policy, revised 12/2009, showed: - Maintenance service shall be provided to all areas of the building, grounds and equipment; - The Maintenance Department will be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Functions of the maintenance personnel include maintaining the building in good repair and maintaining the building in compliance with the regulations; - The Maintenance Director will be responsible for maintaining the work order requests. Observation on 11/18/22 at 8:45 A.M., of the Men's shower room showed: - A six inch (in) area of a black substance in the corner of the shower; - An eight in area of brown and black discolored grout between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower, which put residents at an increased risk of injuries from exposure to the hot water. The facility also failed to ensure residents were transferred by staff with safe transfer techniques for one resident (Resident #4) out of two sampled residents, and one resident (Resident #10) outside of the sample. This practice had the potential to affect all the residents at the facility. The facility census was 40. Record review of the Safety of Water Temperatures policy, revised 12/2009, showed: - Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F; - Maintenance staff will be responsible for checking thermostats and temperature controls 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 observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of dependent residents by failing to keep the call lights within reach for two residents (Resident #8 and #36) out of 12 sampled residents. The facility census was 40. Record review of the facility's Call Lights policy, dated 5/2013, showed: - Each resident will have a readily accessible means to obtain needed assistance; - Each resident will be provided with a call light; - Call lights will be kept within reach of residents. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 8/3/22, showed: - Cognitively intact; - Diagnoses of diabetes mellitus (DM) (a disorder where the body does not produce enough or respond normally to the hormone insulin), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a loss of cognitive functioning), and 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.

Based on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for one resident (Resident #4) out of one sampled resident. The facility census was 40. Record review of Resident #4's medical record showed: - Diagnoses of intellectual disability, schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), bipolar disorder (a mental disorder that causes unusual shifts in mood), and difficulty walking; -Severely impaired cognitive status; - A Physical Restraint Assessment, dated 12/20/21, with benefits outweighing the risks for the use of the merry walker (an enclosed framed wheeled walker). The staff will reevaluate quarterly and as needed; - No other documentation of quarterly assessments for the reevaluation of the use of the merry walker. Record review of the resident's care plan, dated 12/20/21, showed: - Resident used a merry walker to ambulate due to a history…

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 staff failed to complete a comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframes for one resident (Resident #27) out of 12 sampled residents and one resident (Resident #28) outside the sample. The facility's census was 40. 1. Record review of Resident #27's MDS records showed: - admission to the facility on 9/5/20; - An annual MDS, dated [DATE]; - An annual MDS, dated [DATE], with a completion date of 9/28/22, and a submission date of 11/17/22; - The facility did not complete an annual MDS for the resident within 12 months of the last comprehensive MDS. 2. Record review of Resident #28's MDS records showed: - admission to the facility on [DATE]; - An annual MDS, dated [DATE]; - An annual MDS, dated [DATE], with a completion and accepted date of submission of 11/17/22; - The facility did not complete an annual MDS for the resident within 12 months of the last comprehensive…

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 to be completed by the facility staff, within 14 days of a discharge from hospice for one resident (Resident #22) out of three sampled residents. The facility census was 40. 1. Record review of Resident #22's medical record showed: - discharged from hospice on 4/7/22. Record review of the resident's MDS records showed: - No significant change MDS dated on or after 4/7/22; - The facility failed to complete a significant change MDS within 14 days of the resident's discharge from hospice. During a phone interview on 11/18/22 at 1:05 P.M., the MDS Coordinator said a significant change MDS should be completed within 14 days of a resident's discharge from hospice services. Resident #22 should have had a significant change MDS completed upon his/her discharge from hospice. If a significant change MDS wasn't completed, then he/she must have missed it. During an interview on 11/18/21 at 1:35 P.M., the Director of Nursing (DON) said she would…

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 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for five residents (Resident #13, #21, #29, #30 and #35) outside the 12 sampled residents. The facility's census was 40. 1. Record review of Resident #13's MDS records showed: - admission to the facility on 4/21/20; - A quarterly MDS, dated [DATE]; - An incomplete quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 2. Record review of Resident #21's MDS records showed: - admission to the facility on 6/8/19; - A quarterly MDS, dated [DATE]; - An incomplete quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 3. Record review of Resident #29's MDS records showed: - admission to the facility on 2/14/22; - A significant change MDS, dated [DATE]; - An incomplete…

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 electronically transmit significant change and quarterly Minimum Data Set assessments (MDS), a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for four residents (Resident #21, #29, #30, and #35) outside of the 12 sampled residents. The facility's census was 40. 1. Record review of Resident #21's medical record showed: - A quarterly MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, dated [DATE], completed 10/23/22, and not submitted; - The facility failed to submit the resident's quarterly MDS, dated [DATE], within 14 days of the completion date. 2. Record review of Resident # 29's medical record showed: - A significant change MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, dated [DATE], completed on 10/18/22, with an acceptance date for submission of 11/17/22, and over 120 days from the last MDS, dated [DATE]; -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 ensure the baseline care plan (the initial plan for delivery of care and services) included specific interventions and the resident and/or representative received a written summary of the baseline care plan for one resident (Resident #196) out of one sampled resident. The facility census was 40. Record review of the facility's Care Plans - Preliminary policy, revised 8/2006, showed: - A preliminary plan of care to meet the resident's immediate needs should be developed for each resident within 24 hours of admission; - The interdisciplinary team (team members from different disciplines working together) will review the attending physician's orders and implement a nursing care plan to meet the resident's immediate care needs; - The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 1. Record review of Resident #196's medical record showed: - The resident admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to include the residents and/or the representatives during care plan meetings for five residents (Resident #4, #8, #22, #33, #36) out of 12 sampled residents. The facility also failed to ensure the care plan showed the most current Activities of Daily Living (ADL) requirement for one (Resident #4) out of 12 sampled residents. The facility census was 40. Record review of the facility's Care Plans - Comprehensive, revised 9/2010, showed: - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs will be developed for each resident; - The care planning/interdisciplinary team (team members from different disciplines working together), in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to coordinate a plan of care with hospice (supportive comfort care to people in the final phase of a terminal illness) for one resident (Resident #196) out of two sampled residents. The facility census was 40. 1. Record review of Resident #196's medical record showed: - admitted to the facility on [DATE]; - Diagnosis of chronic respiratory failure; - admitted to hospice on 7/1/21, prior to the admission to the facility; - No documentation of a hospice coordinated plan of care to identify the specific hospice staff, the specific days for the hospice staff visits, any wound care services, any treatments with the responsible provider and the frequency provided, any medical supplies provided by the hospice, any medical equipment provided by the hospice, and communication between the facility and hospice staff. During an interview on 11/17/22 at 3:34 P.M., Licensed Practical Nurse (LPN) A said he/she did not know what a hospice coordinated of care was used…

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 the physician's order for supplemental oxygen therapy for one resident (Resident #196) out of three sampled residents. The facility census was 40. Record review of the facility's Oxygen Administration policy, undated, showed: - Verify the physician's order for oxygen therapy; - Review the physician's orders or the facility protocol for oxygen administration; - Document the rate of the oxygen flow, route and rationale. 1. Record review of Resident #196's medical record showed: - admitted to the facility on [DATE]; - Diagnosis of chronic respiratory failure; - admitted to hospice on 7/1/21, prior to the admission to the facility; - An order for oxygen at 2 liters/min (L/min) via nasal cannula (NC) (supplemental oxygen through tubing into the nostrils) continuously, dated 11/14/22. Observations of the resident showed: - On 11/15/22 at 9:56 A.M., the resident lay in the bed with oxygen on at 2.5 L/min per a NC that lay outside 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 document accurate immunization status, provide information and education to each resident or the resident's representative of the pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for five residents (Residents #6, #8, #26, and #39), and failed to provide and document the pneumococcal vaccinations for one resident (Resident #22) out of five sampled residents. The facility's census was 40. Record review of the facility's Pneumoccoccal Vaccine policy, revised 10/2014, showed: - All residents will be offered pneumococcal vaccines to aid in the prevention of pneumonia/pneumococcal infections; - Prior to or upon admission, the residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 day of admission to the facility unless medically contraindicated or the resident previously vaccinated; - Assessments of pneumococcal vaccination status will…

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

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide the required annual competency of Dementia Care, (care of a resident with an impaired ability to remember, think, or make decisions). This effected two out of two sampled certified nurse aides (CNA) (CNA G and CNA L) and had the potential to effect all staff and residents. The facility's census was 40. Record review of the facility's Nurse Aide In-service Training Program, revised September 2011, showed: - All personnel required to attend regularly scheduled in-service training classes; - The facility will complete a performance review of the nurse aides at least every 12 months; - In-service training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews; - Annual in-services must ensure the continuing competence of nurse aides, be no less than 12 hours per employment year, address areas…

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.