Aurora Health And Rehabilitation

Based on interviews and record review, facility staff failed to notify the physician and family/resident representative in a timely manner of a change in condition for one resident (Resident #1) who had a medical emergency, and failed to notify the family/resident representative for one resident (Resident #1) who sustained a fall. The facility census was 71. 1. Review of the facility's Notification of Changes policy, revised 9/1/21, shows the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his/her authority, resident representative when there is a change requiring notification. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/16/25, showed staff assessed the resident as follows: -Cognitive impairment; -Diagnosis of a Stroke, (when blood flow to the brain is interrupted, causing brain cells to die), high blood pressure, and Dementia. Review of the resident's nurses notes, dates 2/22/25, showed staff documented 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 and interview, facility staff failed to maintain wheelchairs for three residents (Resident #5, #7 and #8) of nine sampled residents. The facility census was 76. 1. Review of the facility's policy, Physical Environment: Space and Equipment, dated 02/03/25, showed staff were directed inspection of resident care equipment will be completed routinely and as needed to maintain and ensure safe operating conditions according to manufacturer's recommendations. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Uses a wheelchair. Observation on 03/20/25 at 12:11 P.M., showed Resident #5 in his/her wheelchair with both arm rest torn. 3. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 12/30/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Uses a wheelchair. Observation on 03/20/25 at 12:46 P.M., showed Resident #7's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide care to meet the hygiene needs for four residents (Resident #3, #5 and #6) out of seven sampled residents when staff did not provide nail care and assist with facial hair. The facility census was 76. 1. Review of the facilities policy, Activities of Daily Living, dated 01/01/25, showed staff are directed to assist a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The policy did not provide direction for staff in regard to when and how to provide personal hygiene. 2. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not exhibit behavior of rejecting care; -Required partial to moderate assistance from staff for personal hygiene. Review of the resident's care plan, dated 01/27/25, showed staff assesed the resident required…

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, facility staff failed to prevent the misappropriation of seven resident's (Resident #2, #3, #4, #5, #6, #7, and #8) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/22/22, showed misappropriation defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's permission. 2. Review of the facility's investigation, dated 9/12/24, showed staff had suspicions the narcotics count were off when they identified LPN A had subtracted various pills inaccurately for multiple residents. Upon their investigation it was identified five residents had counts off or were given a narcotic outside of their normal scheduled timeframe. When LPN A was notified he/she did not cooperate and did not…

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

Based on interview and record review, facility staff failed to report an allegation of misappropriation of narcotics to the State Survey Agency within the 24 hour time frame, in accordance with their policy, and state law for seven residents (Resident #2, #3, #4, #5, #6, #7, and #8) out of 10 sampled residents. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/2022, showed reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframe's. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Review of the facility's investigation, dated 9/12/24, showed the Assistant Director of Nursing (ADON) documented their narcotic count had discrepancies and/or medications being given outside of scheduled timeframe by Licensed Practical Nurse (LPN) A. The ADON attempted to speak with LPN A but he/she never returned to the facility. Review showed the Director of Nursing…

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 staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 83. 1. Review of the facility's Dishwasher Temperature policy, reviewed January 2024, showed manufacturer's instructions shall be followed for machine washing and sanitizing. For low temperature dishwashers with chemical sanitation the washer temperature shall be 120 degrees Fahrenheit (F). Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes. Review showed facility records did not contain a dishwasher temperature log for the month of June 2024. Observation showed a poster labeled General Operating Instructions, hung on the clean side of the dishwasher. The poster instructed users to report to supervisor if water temperature was less than 120 degrees F. Observation on 06/25/24 at 10:04 A.M., showed Dietary Aide…

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 ensure resident's personal medical information was protected for two residents (Resident #9 and #281) of 11 sampled residents when staff left the Electronic Medical Information (EMR) open and unattended in a public area, posted care instructions for residents in a public hallway and failed to provide personal privacy for . The facility census was 83. 1. Review of the facility's Resident Rights policy, dated 09/01/22, showed the resident has a right to personal privacy and confidentiality of his or her personal and medical records. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. 2. Observation on 06/27/24 at 9:36 A.M., showed a tablet opened and unattended on the nurses' desk with resident personal information visible to visitors, residents and staff. During an interview on 06/28/24 at 9:33 A.M., Certified Nursing Assistant (CNA) D said if staff steps away from a screen, the screen should…

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, staff failed to maintain professional standards of care when staff failed to document follow-up neurological assessments after a fall for four (Resident #47, #60, #73, and #258) of four sampled residents. Facility staff failed to follow physician orders for two (Resident #21and #73) out of nine residents who required tube feedings and/or skin assessments, failed to complete weekly weights for one (Resident #21) of four newly admitted residents. Staff failed to clarify a medication order and obtain lab values for one (Resident #5) of one resident who received Lithium (mood stablizer). The facility census was 83. 1. Review of the facility's Incidents and Accidents Policy, reviewed/revised 09/01/22, showed it is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or alleged involve a resident: -Falls required an incident/accident report; -In the event of an…

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 bathing and personal hygiene for six (Resident #9, #17, #21, #32, #46, and #47) out of twelve sampled dependent residents . The facility census was 83. 1. Review of the facility's Resident Showers policy, dated 2021, showed it is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. The Certified Nurse Aid (CNA) will assess the skin for any changes while performing bathing and inform the nurse of any changes. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/15/24, showed staff assessed the resident as: -Moderate cognitive impairment; -Total dependence of staff with bathing; -Moderate assistance of staff with personal hygiene…

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 ensure residents' environment remained free of accident hazards when staff did not remove chemicals in the dining room during a meal service, and failed to assess self-administration of medication safety for two (Resident #45 and #283) out of two sampled residents who had medication in his/her room in reach. The facility census was 83. 1. Review of the facility's policies showed staff did not provide a policy for chemical storage or chemical safety. 2. Observation on 06/25/24 at 11:52 A.M. through 1:18 P.M., showed a container of sanitizing wipes on dining room table. Five residents sat at the table with the sanitizing wipes. During an interview on 06/28/24 at 8:42 A.M., Certified Nurse Aide (CNA) D said chemicals should not be stored in the dining room or any resident could get hurt with them. During an interview on 06/28/24 at 8:55 A.M., Registered Nurse (RN) I said all chemicals should not be stored in resident reach at any time 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 record review and interview, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications for three (Resident #20, #32, and #45) of seven residents, and failed to ensure as needed psychotropic medication orders were limited to 14 days for one (Resident #60) of seven residents. The facility census was 83. 1. Review of the facility policies provided showed the policies did not contain instructions to obtain an appropriate diagnosis for the use of psychotropic medications. 2. Review of Resident #20's Physician Order Sheet (POS), dated 05/22/24, showed an order for Clonazepam (an anti-anxiety medication). Review of the resident's medical record showed the record did not contain a diagnosis for the medication Clonazepam. 3. Review of Resident #32's POS, dated 05/22/24, showed an order for Buspirone (an anti-anxiety medication). Review of the resident's medical record showed the record did not contain a diagnosis of anxiety. 4. Review of Resident #45's POS…

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 obtain an reason for use of a urinary catheter (tube inserted into the bladder to drain urine) for two (Resident #46 and #281) of three residents who had a urinary catheter, failed to obtain orders for the catheter size and update a care plan for one (Resident #46) of three residents, and failed to appropriately document catheter care for one of three residents (#281). The facility census was 83. 1. Review of the facility's Catheter Care policy dated September 2021, showed the policy did not contain direction for catheter orders, care planning, documentation or indication for use. 2. Review of Resident #46's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/14/24 showed staff assessed the resident as cognitively intact and intermittently catheterized. Review of the resident's care plan, dated 05/22/24, showed: -Had an indwelling catheter; -Cleanse catheter with soap and water, rinse, pat dry every shift…

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

Based on observation, interview, and record review, facility staffed failed to post required nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 83. 1. Review of the facility's Nurse Staffing Posting Information policy, dated 09/01/21, showed staff are instructed to make staffing readily available in a readable format to residents and visitors at any given time: -The daily staffing sheet will be posted on a daily basis and will contain the following information: facility name, the current date, facility current resident census, and the total and actual hours worked by the following categories of licensed and unlicensed staff direction responsible for resident care per shift; Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, and Certified Nurse Aides; -The facility will post the daily staffing sheet at the beginning of each shift; -The information posted will be presented in 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 record review and interviews, the facility staff failed to ensure residents were allowed to make choices about aspects of their lives in the facility when facility staff failed to allow four residents (Resident #1, #2, #3, and #4), who was his/her own responsible person to smoke. The facility census was 73. 1. Review of the Facility's Resident Rights Policy, not dated, showed staff are directed as follows: -The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 2. Review of the resident #1's annual Minimum Data Set (MDS), a federally mandated assessment, dated 02/12/24, showed the staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors exhibited by the resident. During an interview on 02/22/24 at 12:15 P.M., the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical and nursing needs for four residents (Residents #1, #2, #3 and #4) who smoke cigarettes. The facility census was 73. 1. Review of the facility's Resident smoking policy, revised 9/22/22, showed staff were directed to the following all residents shall be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS) assessment process. 2. Review of the facility's policies showed the facility did not provide a policy for the development of comprehensive care plans. 3. Review of the Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment, dated 02/12/24, showed the staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors exhibited by the resident. Review of Resident's Care Plan, dated 11/20/23, showed the care plan did not contain interventions for the…

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

Based on interviews and record review, facility staff failed to notify the resident's guardian in a timely manner of an allegation of abuse and an injury of unknown source for one resident (Resident #1). The facility census was 68. 1. Review of the facility's Notification of Changes policy, revised March 2022, showed a facility representative will notify the resident, his/her family, or representative when there is a change in condition to include deterioration in health, mental, or psychosocial status. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 12/16/23, showed staff assessed the resident as severely cognitively impaired. Review of the facility's investigation, dated 1/13/24, showed staff documented Certified Nursing Assistant A reported to Registered Nurse (RN) B, Resident #1 had a large bruise on his/her chest. Review showed staff interviewed did not have knowledge of how the resident received the bruise. Review showed the investigation did not contain documentation staff notified the resident's…

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

Based on interview and record review, facility staff failed to complete a thourough investigation when one resident (Resident #1) reported a staff member held him/her down. Staff did not interview additional residents, witnesses and other who might have knowledge of the allegation. The facility census was 68. 1. Review of the facility's Abuse and Neglect policy, revised 8/22/22, showed the policy is designed to provide protections for the health, welfare and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property: -Investigation of alleged abuse: an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur; -Identify and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 2. Review of Resident #1's Quarterly Minimum Data Set, a federally mandated assessment tool, dated 12/16/23,…

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 See 0Q2H12. F622. Based on interview and record review, the facility failed to allow two residents (Resident #39 and #401) to return to the facility after a hospital stay and failed to provide a discharge location for the residents in their emergency discharge notices. The facility census was 76. 1. Review of the facility's Resident Transfer and Discharge Policy -Emergency policy, revised August 2018, showed staff are directed that residents will not be transferred unless: -The transfer or discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility; -The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; -The health of individuals in the facility would otherwise be endangered. If a resident exercises his/her right to appeal a transfer or discharge notice he/she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety 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 staff failed to properly clean and sanitize mechanically washed dishes to prevent cross-contamination. Facility staff failed to allow mechanically washed dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to store food in manner to prevent contamination and out-dated use. The facility census was 73. 1. Review of the facility's Food Safety Requirements policy, date 04/07/22, showed: -Food will be stored, prepared and served in accordance with professional standards for food service safety; -Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of this process includes the equipment used in the handling of food, including dishes, utensils, mixers, grinders, 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 observation, interview, and record review, the facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff failed to knock, announce themselves and wait for permission before entering resident rooms for four residents (Resident #9, #48, #55, #368), hung signs that instruct staff how to care for residents for two residents (Resident's #12 and #38), failed to provide privacy or fully cover the residents with a bath blankets while moving the residents from the spa for two residents (Resident #30 and #368), maintain a dignified dining room experience for one resident (Resident #11), and failed to care for the resident in a manner to promote his/her quality of life when they failed to recognize the resident was exposed, and failed to intervene in a timely manner for one resident (Resident #381). The facility census was 73. 1. Review of the facility's policy titled, Dignity, revised 2/2021, showed staff were directed to do the following: -Each resident shall be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow two residents (Resident #39 and #401) to return to the facility after a hospital stay and failed to provide a discharge location for the residents in their emergency discharge notices. The facility census was 76. 1. Review of the facility's Resident Transfer and Discharge Policy -Emergency policy, revised August 2018, showed staff are directed that residents will not be transferred unless: -The transfer or discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility; -The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; -The health of individuals in the facility would otherwise be endangered. If a resident exercises his/her right to appeal a transfer or discharge notice he/she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, staff failed to maintain professional standards of care by not following physicians order for two residents (Resident #25 and #378) and staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) following unwitnessed falls, and falls with a known head injury, for four residents (Resident #25, #35, #36, and #56). Additionally, staff failed to appropriately label a multi-use vial of Humulin (a type of insulin given to control the amount of glucose in your bloodstream) with the open and expiration date. The facility census was 73. 1. Review of the facility's Medical Provider Orders Policy, revised 04/7/22, showed staff are directed as follows: -Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Staff should follow all valid medical provider orders timely unless there is an emergency which 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 observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekend. The facility census was 73. 1. Review of the facility's Activities Program policy, revised 04/07/2022, showed the following: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident.; -Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. 2. Review of the facility's Activity Calendar, dated August 2023, showed the following: -Sunday, 8/6/23: Cards & Family Visits; -Saturday, 8/12/23: Cards & Coffee; -Sunday, 8/13/23: Cards & Family Visits; -Saturday, 8/19/23: Cards & Coffee;…

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 properly propel two residents (Resident #37, and one unknown resident) in wheelchairs in a manner to prevent accidents, failed to provide safe propulsion of one resident (Resident #30) down the hall in a shower chair, and failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store razors/sharps, and medications. Staff failed to ensure hallway and emergency exits were kept clear of obstacles. The facility census was 73. 1. Review of the facility's policy titled, Wheelchair, Safe use, dated 05/04/2022, showed staff were directed to do the following: -Leg rests should be used when transporting a resident in a wheelchair; -Check the residents' legs and feet for proper placement on the leg rests prior to transport. 2. Review of Resident #37's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/03/23, showed staff assessed the resident as: -Moderate…

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 obtain orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), and failed to have a system in place for ongoing communication with the dialysis clinic for three residents (Resident #49, #372, and #377 ) who receive dialysis. The facility census was 73. 1. Review of the facility's policy titled, Hemodialysis, dated March 2022, showed staff were directed to do the following: -The facility will assure that that each resident receives care and services for the prevision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice; -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments,…

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 communicate pharmacy recommendations to the physicians for four residents (Resident #11, #34, #49, and #55) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census was 73. 1. Review of the facility's Pharmacy Services - Role of the consultant pharmacist Policy, revised April 2019, showed: -The facility shall obtain and retain the services of a consultant pharmacist. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to: -develop, implement, evaluate and revise (as necessary) the procedures for the provision of all aspects of pharmacy services, including procedures to support residents quality of life such as safe, individualized medication administration programs; -coordinate pharmacy services when multiple pharmacy service providers (infusion, hospice, etc.) are utilized;…

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 ensure medication were stored in a safe and effective manner for two of two medication carts, and medications left in two residents' rooms (Resident #8 and #26). Additionally facility staff failed to keep medication and treatment carts securely locked when not in use. The facility census was 73. 1. Review of the facility's medication storage policy, revised 04/07/22, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitization, temperature, light, ventilation, moisture control, segregation and security; -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for three residents (Resident #12, #22, and #40), failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after use for three residents (Resident #14, #20, and #23), failed to maintain transmission based precautions for two residents (Resident #6 and #373) in order to prevent the transmission of shingles (a viral infection that causes a painful rash) and clostridium difficile [C-diff- a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)] infection and failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis TB) was completed and on file in accordance with their policy for nine employees (Transport driver,…

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.