Gardens Health And Rehab, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or resident's representative, and the facility failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for two residents (Resident #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on side rails. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); - On 11/16/24, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - An order 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 interview and record review, the facility failed to ensure that three nursing assistants (NAs) completed a nursing assistant training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 87. Review of the facility's policy, Nurse Aide Training Program, Purpose of, last revised December 2006, showed: - The primary purpose of the nurse aide training program is to prepare the individual for employment in a long-term care facility; - Provide each individual presently employed in the long-term care facility with an in-depth training program; - Provide each student with instructions on how to perform basic long-term care nursing procedures; - The policy did not address time frame in which NAs must become certified. 1. Review of Nursing Assistant H's personnel file and schedule showed: - Hire date of 09/11/24; - Not currently enrolled in a Certified Nursing Assistant (CNA) class; - Scheduled to work day shift on 03/01/25, 03/02/25, 03/05/35, 03/07/25, 03/10/25, 03/11/25,…

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 procedures to ensure medications were accurately administered, documented, and reconciled for one resident (Resident #29) of 18 sampled residents and failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for two of three narcotic count books checked. The facility's census was 87. Review of the facility's policy titled, Controlled Substances, revised December 2012, showed: - The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; - Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report…

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

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 87. Review of the facility's policy titled, Cleaning Rotation, dated 2011, showed: - Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; - Items cleaned daily: stove top, grill, exterior and large appliances, kitchen and dining room floors; - Items cleaned weekly: hoods, filters, storerooms. Review of the facility's policy titled, Steam Table Serving Temperatures for Hot and Cold Foods, dated 2011, showed: - Staff will follow the guidelines below when serving hot and cold beverages and food; - Foods will be served at the following temperatures to ensure a safe and appetizing dining experience; - Meat and casseroles at 135 degrees Fahrenheit (F) to 170 degrees F; - Dairy products 41 degrees F or below. 1. Observation on 03/09/25 at 9:58 A.M. and 03/12/25 at 12:40…

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

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for ten residents (Resident #6, #14, #19, #37, #38, #57, #70, #72, #78, and #79) out of the 14 sampled residents. The facility's census was 87. Review of the facility's policy titled, Hand Hygiene Policy and Procedure, dated 2025, showed: - The purpose is to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment, and comply with CMS (Centers for Medicare and Medicaid Services, CDC (Centers for Disease Control), and state infection control guidelines. This policy includes specific hand hygiene practices related to peri care (the cleaning of the the genitals and anal area) to minimize the risk of urinary tract infections (UTIs) and other infections; - This policy applies to all facility staff, including nurses, Certified Nurse Aides (CNAs), therapists, dietary staff, housekeeping, and any personnel with direct or indirect resident contact;…

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 resident 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 two residents (Residents #36 and #47) out of five sampled residents. The facility's census was 87. The facility did not provide a policy regarding influenza or pneumococcal vaccination. 1. Review of Resident #36's medical record showed: - admission date of 04/24/20; - No documentation the facility provided information and education for influenza or pneumococcal vaccinations; - No documentation of consent or refusal; - No documentation the influenza or the pneumococcal vaccinations had been administered. 2. Review of Resident #47's medical record showed: - admission date of 06/17/24; - An incomplete Pneumococcal and Influenza Immunization consent form, signed by the representative on 06/17/24, that did not state whether or not the resident was to receive vaccinations; - 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.

Based on interview and record review, the facility failed to ensure the Covid-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Resident #36, #47 and #56) out of five sampled residents. The facility's census was 87. Review of the facility's Immunization Policy, undated, showed: - The Centers for Medicare and Medicaid Services (CMS) mandates that all long term care facilities develop and implement policies to ensure that all staff are fully vaccinated against Covid-19. This includes educating residents and staff about benefits and potential side effects of the Covid-19 vaccine and offering the vaccine to them; - Facilities are expected to have processes in place to track and securely document the vaccination status of all staff and residents. 1. Review of Resident #36's medical record showed: - admission date of 04/24/20; - Diagnoses of schizoaffective disorder (a condition that includes…

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

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on inspection of side rails. 1. Review of Resident #29's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/10/25 at 10:30 A.M., Resident lay in bed, grab bar up on left side of bed, right side of bed against the wall; - On 03/11/25 at 2:40 P.M., Resident out of room, grab bar up on left side of bed, right side of bed against the wall; - 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 provide the required annual competency training for dementia care (care of a resident with an impaired ability to remember, think, or make decisions) and/or have staff attend at least twelve hours of in-service education per year for two of three sampled Certified Nursing Assistants (CNAs). This deficient practice had the potential to affect all residents. The facility's census was 87. The facility did not provide a policy. 1. Review of CNA E's in-service record showed: - A hire date of 07/12/89; - A total of twelve hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. 2. Review of CNA F's in-service record showed: - A hire date of 03/28/23; - A total of four hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. During an interview on 03/12/25 at 3:50 P.M., the Director of Nursing (DON) said she provides some in-service videos on the staff's communication app. There are no written in-services on dementia…

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 resident (Resident #1) out of five sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 62. The administrator was notified of the Past Non-Compliance (PNC) on 08/23/24. The PNC started on 07/28/24 and was removed on 07/30/24, when the incident was reported to the Administrator who immediately began an investigation and removed the housekeeper from the facility then completed the facility policy and procedure on misapprorpiation, reporting and retraining staff The PNC was removed on 07/30/24. Review of the facility's policy titled, Standards of Conduct, dated May 2023, showed violation of the Conduct Standards include, but are not limited to: stealing from a resident, visitor, other employee of facility showed the first offense to be a discharge. 1. Review of Resident #1's face sheet showed: - admitted on [DATE]; -…

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, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. Review of the facility's policy titled, Quality of Life - Homelike Environment, undated, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary and orderly environment. Observations of room [ROOM NUMBER] showed: - On 10/24/23 at 11:59 A.M., the top right corner of the heating and air unit pulled away from the wall with daylight showing through a one inch (in.) open crack across the corner; - On 10/26/23 at 9:20 A.M., the bed rolled a few in. across the floor as the resident tried to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) for three residents (Resident #23, #45 and #48) out of 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, 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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Review of the Residents' Smoking List, dated 10/11/23, showed: - Resident #23 smoked while supervised by staff. - Resident #45 and #48…

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 implement a care plan with specific interventions tailored to meet individual needs of three residents (Resident #15, #45, and #48) out of 16 sampled residents and one resident (Resident #35) outside the sample. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, 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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 1. Review of Resident 15's medical record showed: - admission date of 10/25/21; - Diagnoses of chronic obstructive pulmonary…

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 obtain physician's orders for one resident (Resident #2) out 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Physician's Orders, undated, showed: - Our facility shall promptly obtain physician orders for accident, discovery of injuries of an unknown source, an incident involving the resident and specific instruction to notify the physician of changes in the resident's condition; - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; - The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; - The policy did not address a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) and/or urostomy (a surgical procedure that creates an opening for the urinary system) care. Review of…

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

Based on observation, interview and record review, the facility failed to maintain infection control practices during incontinent care for one resident (Resident #38) out of six sampled residents, and for the disinfection of a glucometer (a device for measuring the concentration of glucose in the blood) used for glucose (the main type of sugar in the blood) monitoring for three residents (Resident #24, #30, and #47) out of three sampled residents. The facility census was 65. Review of the facility's policy, titled, Handwashing/Hand Hygiene, dated 10/11/22 showed: - The facility considers hand hygiene the primary means to prevent the spread of infection; - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or…

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 protect one resident's (Resident #1) right to be free from verbal abuse when Registered Nurse (RN) C yelled, cursed, and threatened to withhold cigarettes from the resident in order to force the resident's compliance with incontinence care. The facility census was 64. The Administration was notified on 09/12/23 of the Past Non-Compliance citation on 09/06/23. On 09/06/23, facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered abuse and neglect. The deficiency was corrected on 09/06/23. Review of the facility's policy titled, Resident Freedom from Misappropriation of Property and Exploitation and Procedure, not dated, showed: - Enable any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others working for the facility to do all that is within their power to ensure that residents are free from abuse, neglect,…

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 update and revise care plans with specific interventions tailored to meet individualized needs for three residents (Residents #33, #51, and #40) out of 16 sampled residents. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) a group of lung diseases that block air flow making it difficult to breathe, tracheostomy (trach, tube surgically inserted into the trachea for breathing) . Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care while a resident marked. Review of Resident #33's Physician's Order Sheet (POS), dated November 2021, showed: - An order to clean tracheostomy and change inner cannula every two days. Review of the resident's comprehensive care plan, last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to follow physician orders for two residents (Resident #22 and #214) out 16 sampled residents. The facility census was 64. 1. Record review of Resident #22's medical record, showed: -An admission face sheet, admission date of 2/22/17; -Diagnoses included morbid obesity due to excess calories and major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/21, showed: -Alert and oriented; -No behaviors for rejection of care; -Required extensive to total assistance from one to two staff for activities of daily living (ADLs); -Non-ambulatory; -No impaired range of motion affecting upper/lower extremities. Review of the resident's Physician Order Sheet (POS), dated October 2021, showed: -An order dated 10/5/21, for physical therapy to evaluate the resident one time…

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 a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain adequate grooming, bathing and nail care had been completed for three residents (Resident #21, #22, and #38) out of 16 sampled residents. The facility census was 64. 1. Record review of the facility's Shower/Tub Bath Policy/Procedure, dated October 2020, showed: -Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the residents and to observe the condition of the resident's skin; -Documentation: The following information should be recorded in the resident's ADL record and/or in the resident's medical record; 1. The date and time the shower/tub bath was performed. 2. The name and title of the individuals who assisted the resident with the shower/tub bath; 3. All assessment data (any redness and/or sore on the resident's skin) obtained during the shower/tub bath; 4. How the 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 recognize, evaluate and address the nutritional needs of one resident (Resident #3) out of 16 sampled residents. The facility's census was 64. Record review of the facility's policy titled Weight Assessment and Intervention, dated September 2008, showed: - The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter; - Each weight will be recorded in each unit's Weight Record chart; - Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The Dietician will respond within 24 hours of receipt of notification; - The Dietician will review the Weight Record by the 15 th of the month to follow individual weight trends; - Negative trends will be evaluated by the…

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

Based on interview, and record review the facility failed to provide tracheostomy (trach, tube surgically inserted into the trachea for breathing) care consistent with professional standards of practice by failing to change the inner cannula (IC) every other day as ordered by the physician for one resident (Resident #33) out of one sampled resident. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block air flow making it difficult to breathe) and Tracheostomy. Record review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care. Record review of Resident #33's Physician's Order Sheet (POS), dated November 2021, showed: - An order to clean tracheostomy and change the IC every two days. Record review of the resident's Treatment Administration Record (TAR), showed: - The September 2021 TAR…

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 thorough assessments, orders, monitoring and on-going communication with dialysis (process for removal of waste and excess water from the blood due to kidney failure) center for one resident (Resident #40) out of a sample of two residents receiving dialysis treatments. The facility census was 64. Review of the facility's Dialysis-General Guidelines and Management Policy/Procedure, dated May 2017, showed: -Policy: -It is the policy of this home that dialysis residents will receive services as per physician's orders and will be monitored accordingly; -Hemo-Dialysis involves shunting the resident's blood from the body through a dialyzer (machine used in dialysis treatments) in which diffusion and ultrafiltration occur and back into the resident's circulation. To perform hemo-dialysis there must be access to the resident's blood, a mechanism to transport the blood to and from the dialyzer, and a dialyzer (area in which the exchange of fluid electrolytes and waste products occurs). This dialysis access is…

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 ensure staff dated insulin vials and Flexpens (prefilled injectable insulin) once they were opened and discard outdated insulin vials for two of two medication carts checked and failed to store all drugs under proper temperature controls in the medication refrigerator on the B hall. The facility census was 64. 1. Review of the facility's Insulin Administration Policy, dated September 2014, showed: -Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes mellitus (DM, condition that affects the way the body processes blood sugar); -Preparation: The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to use; -Steps in the procedure (insulin injections); -Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record the expiration date and time on the vial (follow manufacturer recommendations for expiration after opening); -The facility's policy did not address…

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.