Pearl's II Eden For Elders

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents when medications were left at bedside for three residents (Resident #15, #192, and #27) and when the medication cart was left unlocked and unattended. The facility census was 40. Facility provided no policy on medication storage. Review of facility policy, administering medications, dated 2001, showed: -Medications are administered in a safe and timely manner, and as prescribed. -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. -Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have decision-making capacity to do so safely. 1. Review of Resident #15's annual MDS, dated [DATE], showed: -He/She had moderately impaired…

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, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to label and date all foods, cover all foods being refrigerated, prepare food items from a menu, use proper hand washing and gloving, test the dishwasher for proper sanitation before running dishes, properly sanitize all food preparation surfaces in kitchen and dining room, failed to temperature check foods before serving food from steam table, and have a fully operational and working stove. The facility census was 40. 1. Review of facility policy, labeling and dating foods (date marking), dated 2020, showed: -All foods stored will be properly labeled according to following guidelines: -Dry storage food items: -Once case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the 'first in-first out' method of rotation.…

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 4. Review of Resident #30's annual MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required supervision or touch assistance from staff with eating; - Partial to moderate assistance from staff for transfers; - Diagnoses included high blood pressure, anxiety and depression. Review of the resident's physician order sheet (POS), dated August, 2024, showed: - Start date: 11/27/23 - Bupropion Hydrochloride (HCL), 100 milligrams (mg.), one tablet three times a day for anxiety; - Start date: 11/2/22 - Abilify tablet, 2 mg. daily for depression; - Start date: 3/30/23 - Celebrex 200 mg., one capsule twice daily for pain; - Start date: 2/28/24 - Fluoxetine HCL 10 mg. one tab daily for depression; - Start date: 12/4/23 - Famotidine 20 mg., one tab daily for gastroesophageal reflux disease (GERD, a chronic condition that occurs when stomach contents move back up into the esophagus); - Start date: 1/19/23 - Claritin 10 mg. tablet daily for seasonal allergies. Review of the resident's medication…

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 establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, for one deceased resident's account (Resident #92). When the facility charged the resident's account incurred bank fees from [DATE] to [DATE]. This affected one resident out of the sampled 12 residents. The facility census was 40. The facility was asked to provide a resident trust and banking policy, and the facility did not provide the policy. 1. Record Review on [DATE] at 1:35 P.M. showed: - The facility charged Resident #92 bank service fees of five dollars per month from [DATE] to [DATE] and applied that cost to the closed Resident account without reimbursement for a total cost of $20.00 to the Resident's guardian or responsible party. During an interview on [DATE] at 9:20 A.M., the Administrative Assistant said: -He/She mailed a check on [DATE] on behalf of the closed Resident Record's account since 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 interviews and record review, the facility failed to protect the residents right to be free from misappropriation of property for one of the 12 sampled residents, (Resident #28) when the resident reported missing $1300. The facility census was 40. Review of the facility's policy for abuse or neglect of a resident, dated 4/12/23 showed, in part: - The purpose is to establish protocol for reporting abuse (physical or verbal) or neglect of a resident, or misappropriation of funds; - Misappropriation of funds is any misuse of the resident's money; - Once the investigation is completed and the complaint has been validated, the Department of Health and Senior Services will be notified. Review of the facility's policy for reporting abuse, dated 2/5/13, showed, in part: - As established by Section 6703 (b) (3) of the Patient Protection and Affordable Care act of 2010, responsible suspicion of crime must be reported to both the State Agency and local law enforcement; - Centers for Medicare and Medicaid Services (CMS) recommends documenting your submission TO THE ADMINISTRATOR 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 interviews and record review, the facility failed to report an allegation of missaporpriation for one of the 12 sampled residents, (Resident #28) when staff did not notify law enforcement or the state survey agency after the resident reported missing $1,300. The facility census was 40. Review of the facility's policy for abuse or neglect of a resident, dated 4/12/23 showed, in part: - The purpose is to establish protocol for reporting abuse (physical or verbal) or neglect of a resident, or misappropriation of funds; - Misappropriation of funds is any misuse of the resident's money; - Once the investigation is completed and the complaint has been validated, the state survey agency will be notified. Review of the facility's policy for reporting abuse, dated 2/5/13, showed, in part: - As established by Section 6703 (b) (3) of the Patient Protection and Affordable Care act of 2010, responsible suspicion of crime must be reported to both the State Agency and local law enforcement; - Centers for Medicare and Medicaid Services (CMS) recommends documenting your submission 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.

Based on interviews and record review, the facility failed to follow facility policy and investigate an allegation of misappropriation when one of the 12 sampled residents, (Resident #28) reported missing $1,300. The facility census was 40. Review of the facility's policy for abuse prevention program, revised December, 2016, showed, in part: - Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; - As part of the resident abuse prevention, the administration will: protect our residents from abuse by anyone including, but not necessarily limited to : facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; - Develop and implement policies and procedures to aid our facility 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 observations, interviews, and record reviews, the facility failed to revise the comprehensive person centered care plans, when the facility failed to revise a care plan to reflect one resident (Resident #3) who had his/her left leg amputated above the knee. The facility census was 40. The facility did not provide a comprehensive care plan policy. 1. Review of Resident #3's Annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/19/24, showed: -He/She was cognitively intact; -He/She had impairment to one side of lower extremities; -He/She was dependent on wheelchair; -He/She required set up or clean up assistance with eating, oral hygiene; -He/She was dependent with toileting, showering, upper and lower body dressing, going from sitting to lying, lying to sitting on side of bed, tub transfers and wheelchair mobility; -He/She required substantial to maximal assistance with personal hygiene, rolling left and right -He/She had no current pressure ulcers, but had open lesions other than ulcers, rashes, cuts, and he/she had…

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, interviews and record review the facility failed to ensure an environment free of accident hazards when one resident (Resident #1) was not served a physician ordered mechanical soft diet and was served a regular hamburger on a bun, placing resident at risk for choking hazards. The facility census was 40. Review of facility policy, diet orders, dated 2020, showed: -Each resident will have a diet order prescribed by the physician and documented in health record; -Diet orders are checked for accuracy regularly, at the quarterly care plan meeting, by comparing diet orders on file in dining services with physician order sheet in health record. If diet order is not consistent, the dining services manager or designee will make the necessary changes to ensure the correct diet is on the physician order sheet and resident meal card. Review of facility policy, dental soft (mechanical soft), dated 2022, showed: -The consistency modified diet is for individuals with limited or difficulty in chewing…

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 Trauma Informed Care for one of the 12 sampled residents who had a diagnosis of Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock). The facility census was 40. The facility did not provide a policy for trauma informed care. 1. Review of Resident #6's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - Cognitive skill intact; - Upper and lower extremity impaired on one side; - Required substantial to maximum assistance from staff for toilet use, showers and transfers; - Occasionally incontinent of urine; - Always continent of bowel; - Diagnoses included hemiplegia (paralysis affecting one side of the body), depression, bipolar disorder ( episodes of mood swings ranging from depressive lows to manic highs), anxiety, psychotic disorder (mental illness…

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 observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime an insulin pen prior to administering insulin, which affected one of the 12 sampled residents, ( Resident #22). The facility census was 40. The facility did not provide a policy for administration of insulin or administration of medications. 1. Review of the website, https://humalog.lilly.com for Humalog (fast acting) (Lispro insulin) pen showed: - Wipe the rubber seal with an alcohol wipe and attach a new needle; - Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; - If you do not prime before each injection, you may get too much or too little insulin; - To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top; - Continue holing your pen with 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 record review and interviews, the facility failed to ensure they maintained a Department of Health and Senior Services (DHSS) approved surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 37. The facility did not have a policy for surety bonds. Review of the facilities approved escrow bond identified as number 122874 showed on 6/14/23 as an approved amount of $2,000.00 Review of the Resident Funds Bond Worksheet on 06/14/2023 showed: - An facility's average balance of the last 12 months as $ 4,145.09 - The required bond amount needed as $ 6,000.00 - The facility needed an additional bond amount of $ 4,000.00 to cover costs or loss. During an interview on 06/14/23 at 10:20 A.M. the Business Office staff member said: -He/She does not do anything with the bond. -The Administrator reviews the bond. -He/She did not know if the Administrator's Assistant had reviewed the bond. During an interview on 6/14/23 at…

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

Based on interview and record review the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency that was readily available and could be read by residents in the facility without assistance. The facility census was 37. 1. Reviewed the Resident Council notes from January, 2023 through May, 2023 which showed the staff did not document going over the location of the Ombudsman information or the State Survey Agency information. During a group interview on 6/13/23 at 10:18 A.M., the eight residents said: - They did not know where the information about the Ombudsman was located; - They did not know where the information about the State Survey Agency or hotline number was located. During an interview on 6/13/23 at 4:22 P.M., the Administrator said: - He/She thought the residents should know where the information was located. During an interview on 6/14/23 at 8:20 A.M., the Activity Assistant said: - He/She assisted with setting up the resident council meetings; - He/She had been doing the resident council…

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 interviews the facility failed to ensure residents received mail all days of the week that mail was delivered to the facility, including Saturdays. The facility census was 37. 1. During a group meeting on 6/13/23 at 10:18 A.M., the eight residents said they did not receive any mail on Saturdays but if it was delivered to the facility, they would like to have their mail. During an interview on 6/13/23 at 12:24 P.M., the Social Services Designee said: - The mail gets delivered to the facility on Saturdays but the staff do not pass the mail out until Monday. During an interview on 6/13/23 at 1:43 P.M., Licensed Practical Nurse (LPN) A said: - He/She worked every other weekend; - He/She did not deliver any mail to the residents on Saturdays. During an interview on 6/13/23 at 4:22 P.M., the Administrator said: - The mail is delivered to the facility on Saturdays; - She found that too many people handled the mail so they wait until Monday and have the mail sorted and delivered to the residents. During an interview on 6/14/23 at 8:20 A.M., the Activity Assistant said: - He/She 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.

Based on observations and interviews, the facility failed to post the most recent survey results in a prominent place readily accessible to residents. This had the potential to affect all the residents. The facility census was 37. 1. Review of the Federal regulations 483.10 (g) (10) showed: - The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. During the resident council meeting on 6/13/23 at 10:18 A.M., eight of the residents said: - They did not know where the State survey book which contained the most recent survey results was located. Observation on 6/13/23 at 4:15 P.M., showed: - A three legged wooden table in the entry way with a sign which said the State survey book was in the drawer; - When attempting to open the drawer the table wobbled and it was difficult to open the drawer where the survey book was located. During an interview on 6/13/23 at 4:22 P.M., the Administrator said: - The State survey book is located in the front…

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 follow acceptable standards of practice when they failed to obtain a physician's order for foley catheter care and to ensure that foley catheter care was provided and documented on one resident (Resident #12) out of the 12 sampled residents. The facility census was 37. Review of the facility's urinary foley catheter policy, dated August of 2022., showed: - Urinary catheters should be evaluated, assessed, and documented for ongoing need and clinical use. - Assess and maintain unobstructed urine flow, monitor urinary output. - Documentation to support urinary catheter care should include name, title, and date that catheter care was done. No policy regarding professional standards of practice provided. Review of Resident #12's Quarterly Minimum Data Set (MDS), A federally mandated comphrensive assessment completed by facility staff, on 4/5/23 showed: - (BIMS) A Behavior Interview for Mental Status, with a score of 15, indicating cognitively intact. - Diagnoses: neurogenic bladder, (The bladder is unable to…

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

Based on observation, interviews and record review, the facility failed to ensure staff provided showers or baths for those residents who are unable to carry out their own activities of daily living (ADL's) for two out of 12 sampled residents (Resident #35 and Resident #12). The facility census was 37. Review of the facility's Shower/tub bath policy, revised February 2018 showed its purpose is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. - Documentation: - Date and time the shower/tub bath was performed; - Names of those who assisted; - All assessment data obtained during the shower/tub bath; - How the resident tolerated; - If the resident refused, the reasons why and interventions taken; - Signature and title of person recording data. Review of the facility's bed bath policy, revised March 2021 showed its purpose is to promote cleanliness, provide comfort and to observe the condition of the resident's skin. - Documentation: - Date and time the bed bath was performed; - Name and titles of those who performed the bed…

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 interviews and record review, the facility failed to follow policy to assure staff evaluated the cause of residents' falls and implement measures to prevent reoccurrence of falls which affected three of 12 sampled residents, (Resident #9, #30, #34). The facility census was 37. Review of the facility's policy for assessing falls and their causes, revised March 2018, showed, in part: - The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; - Review the resident's care plan to assess for any special needs of the resident; - Identify the resident's current medications and active medical conditions; - After a fall: if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. If an assessment rules out significant 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 observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for two of 12 sampled residents (Residents #9 and #88) when staff failed to: properly maintain oxygen concentrator humidifier water levels, properly label and date oxygen concentrator oxygen tubing, and maintain proper observation of resident's oxygen levels. The facility census was 37. Review of the facility's oxygen administration policy, dated October 2010, showed: - Oxygen is administered per a physician's order; - Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Arterial blood gases and oxygen saturation; - Assemble the equipment and supplies as needed, including: nasal cannula, humidifier bottle, etc.; - Periodically re-check water level in humidifying jar; - The policy did not direct staff to verify the equipment in the room belonged to the resident; - The procedures did not include direction on dating and labeling when…

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 observations, interviews and record review, the facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis and failed to ensure they employed an RN for eight consecutive hours per day, seven days per week. The facility census was 37. Review of the facility's policy for Director of Nursing Services (DNS), revised August 2022, showed, in part: - The nursing department is under the direct supervision of an RN; - The director is an RN, licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing; - The director is employed full time (40 hours per week) and is responsible for, but is not necessarily limited to: developing and periodically updating the nursing service objectives and statements of philosophy; overseeing standards of nursing practice; developing and maintaining nursing policy and procedure manuals; developing and maintaining written job descriptions for each level of nursing personnel; providing direct resident care when needed; coordinating…

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 observations, interviews and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent. Staff made three medication errors out of 29 opportunities for error, which resulted in a medication error rate of 10.34%, which affected two of 12 sampled residents, (Resident #15 & Resident #12). The facility census was 37. Review of the facility's policy administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions. Review of the facility's policy for insulin administration, revised September 2014, showed, in part: - The purpose is to provide guidelines for the safe administration of insulin to residents with diabetes; - Did not address the use of insulin pens. Review of the Novolog flexpen ( a fast acting insulin contained in a pen that should be given five to ten minutes before a meal ) guidelines, revised 12/18,…

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 observations, interviews and record review, the facility failed to ensure staff did not make significant medication errors when they failed to follow the guidelines for the use of insulin pens when they did not prime the insulin pens prior to administering insulin to two of 12 sampled residents, (Resident #15, #12). The facility census was 37. Review of the facility's policy administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions. Review of the facility's policy for insulin administration, revised September 2014, showed, in part: - The purpose is to provide guidelines for the safe administration of insulin to residents with diabetes; - Did not address the use of insulin pens. Review of the Novolog flexpen ( a fast acting insulin contained in a pen that should be given five to ten minutes before a meal ) guidelines, revised 12/18, showed, in part: - Pull…

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 kitchen in a sanitary manner when staff failed to ensure the ceiling light fixtures and ceiling air vents were free from dust build up and when staff failed to store dishes inverted to remain free from dust and food particles. Additionally, the facility failed to ensure food items were properly dated and labeled and failed to ensure dented cans were removed from the shelves. These have the potential to affect all residents residing in the facility. The facility census was 37. Review of the facility's sanitation policy, with a revision date of November 2022 showed: - Policy Statement: The food service area is maintained in a clean and sanitary manner. - Policy Interpretation & Implementation: - All kitchen areas are kept clean and free from garbage and debris; - All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Review of the facility's food receiving 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 observations, interviews, and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. Facility census was 37. During the entrance conference on 06/11/2023 at 11:20 A.M. the facility's QAPI plan was requested. The policy provided on 6/13/23. Review of the facility's Quality Assurance and Performance Improvement Program, dated April 2014., showed: - This facility shall develop, implement and maintain an ongoing facility-wide quality assurance program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. -The quality assurance and performance improvement program has been developed with five strategic elements in mind: Design and scope, governance and leadership, feedback with data systems/ monitoring, performance improvement projects, and root cause analysis. - The QUAPI committee will work in tandem with the facility leadership. Review of the facility's minutes from the most current quality assurance…

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

Based on interview and record review, the facility failed to develop a comprehensive, data-driven quality assessment and assurance (QAA) activities and a quality assurance performance improvement (QAPI) program that focused on outcomes of care and quality of life when they failed to provide documentation and evidence of its ongoing QAA/QAPI program. The facility census was 37. Review of the facility's Quality Assurance and Performance Improvement Program, dated April 2014., showed: - This facility shall develop, implement and maintain an ongoing facility-wide quality assurance program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. -The quality assurance and performance improvement program has been developed with five strategic elements in mind: Design and scope, governance and leadership, feedback with data systems/ monitoring, performance improvement projects, and root cause analysis. -The QUAPI committee will work in tandem with the facility leadership. The facility did not provide QAA committee…

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 interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 37. Review of the facility's Quality Assurance and Performance Improvement Program, dated April 2014., showed: - This facility shall develop, implement and maintain an ongoing facility-wide quality assurance program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. -The quality assurance and performance improvement program has been developed with five strategic elements in mind: Design and scope, governance and leadership, feedback with data systems/ monitoring, performance improvement projects, and root cause analysis. - The QUAPI committee will work in tandem with the facility leadership. The facility did not provide a policy regarding their QAA committee. The facility was unable to provide any record or minutes of the QAA program. Review of the facility's minutes from the most…

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 implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) and failed to develop and implement a water management plan. The facility census was 37 Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - The facility should develop and implement a water management program that…

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

Based on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe to meet the residents medical, nursing, mental, and psychosocial needs for one (Resident #12) of twelve residents sampled residents. The facility census was 37. Review of the facility care plan policy, revised October 2010 showed: -Within 48 hours of admission all residents will have a baseline care plan which included the instructions needed to provide effective and person-centered care that meets professional standards of quality of care. - During the care plan process, the facility will include the resident and or resident representative and the assessment will include residents' strengths and needs and residents' personal and cultural preferences will be used in developing care plan goals. - All nursing/dietary staff will be educated regarding the residents' baseline care plans to ensure that all residents' choices will be followed. - Residents or representatives will participate 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.