Cedar Pointe

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 70. 1. Review of the facility's Resident Services Policy, dated March 27, 2017, showed the facility provides sufficiant licensed nursing and ancillary services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/01/24; -06/02/34; -06/08/24; -06/09/24; -06/15/24; -06/16/24; -06/22/24; -06/23/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on 07/06/24 and 07/07/24. 4. During an interview on 07/16/24 at 6:50 A.M., RN F said he/she is the certified nurse aide (CNA) instructor for the facility. RN F said, I am here every day, because I am the only RN on staff right now other then the DON, and I work Monday thru Friday. During an interview…

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 develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failured to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use a barrier when performing blood sugars for three (Resident #42, #51, and #53) of four sampled…

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 designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility census was 70. 1. Review of the facility policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 07/18/24 at 3:50 P.M., the administrator said the Assistant Director of Nursing (ADON) is the facility's Infection Preventionist. He said the ADON started the required classes sometime last month, but he is not sure how much longer she/he has. The administrator said he was aware the training and certification needed to be completed before given the position or title of Infection Preventionist. During an interview on 07/23/24 at 10:15 A.M., the ADON said he/she was not aware he/she was the actual Infection Preventionist (IP) yet, due to he/she is enrolled in the Centers for Disease Control and Prevention Infection Preventionist training but is not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to review and revise the care plan after a fall for five (Resident #13, #21, #36, #44, and #52) out of eighteen sampled residents. Facility staff failed to document and update care plans in regard to pressure ulcers for two (Resident #5 and #44) out of seven sampled residents. Staff failed to address and update behaviors for one (Resident #4) of one sampled resident. The facility census was 70. 1. Review of the facility's Miniumin Date Set (MDS) Policy, undated, showed the care plans will be updated quarterly and with changes to the resident plan of care. Changes made to the care will be communicated to the interdisciplinary team. The staff member completing the care are assessment for the specified section will also compete the comprehensive care plan on the resident. 2. Review of the Resident #13's Quarterly MDS, a federally mandated assessment tool, dated 05/02/24, showed staff assessed the resident as: -Moderate cognitive impairment; -One fall…

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 implement their Grievance Policy for two residents (Resident #7 and #25) out of 18 residents when reported missing items and failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 70. 1. Review of the facility's Grievance policy, dated 09/13/19, showed: -A grievance will be translated into writing, containing the name and address of the person filing it if permitted; -The administrator or his/her designee shall conduct an investigation of the complaint; -The Grievance official will complete a review of the grievance no later than 30 days after its filing. The Resident has the right to obtain a written decision regarding his/her grievance; -All written grievance decisions will include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding…

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 thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 70. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated December 14, 2018, showed an injury of unknown source defined as not witnessed by any person and the source of the injury could not be explained by the resident, and the injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Review showed the charge nurse to complete the documentation, neurological flow sheet (if appropriate), notify the responsible party, medical directorm and clinical manager. Review showed staff are directed to: -Complete a Situation, Background, Assessment, Recommendation (SBAR) -Head to toe assessment; -Secure treatment orders if…

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 maintain professional standards of practice when staff did not complete neurological assessments for for three residents (Resident #7, #21, and #36) out of 18 sampled residents after unwitnessed falls. The facility census was 70. 1. Review of the facility's policy titled, Neurological Assessments, undated, showed when resident has an incident with a head injury/trauma, or an unwitnessed fall, the nurse is the perform neurological assessment. Review showed the nurse is required to: -Document the results on the neurological assessment flow sheet in the resident's chart; -Complete checks-Every 15 minutes for one hour, every 30 minutes for the next two hours, and every shift until the 72 hours are completed; -Neurological checks consist of level of consciousness, pupil size, hand grasps, extremities, pain response, and vital signs; -All items above must be completed on each neurological check. 2. Review of Resident #7's Quarterly Minimum…

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 store and label medications in a safe and effective manner when staff failed to date the open multi-dose medication bottles, and placed non-medication in medication storage room refrigerator. The facility census was 70. 1. Review of the facility's Storage of Medication policy, undated, showed facility staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Medications require refrigeration must be store in a refrigerator located in the drug room at the nurses' station or other secured location. -Medications must be stored separately from food and must be labeled accordingly. Review of the facility's Administering Medications policy, dated 03/07/22, showed the facility staff are directed to record the open date on the container when opening a multi-dose medication container. 2. Observation on 07/15/24 at 9:30 A.M., showed the west wing medication cart contained: -One opened bottle of vegetable…

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 maintain personal medical information in a manner to protect three residents' privacy (Residents #1, Resident #2, Resident #3). The facility census was 77. 1. Review of the facility's Resident Confidentiality/Health Insurance Portability and Accountability Act (HIPPA), undated, showed the care of the patient is always personal in nature, and therefore any protected health information about his/her condition, treatment or personal data is absolutely confidential and must not be discussed with anyone other than those who are directly responsible for his/her care and treatment. Information generated through contact between patient and health care provides at the facility is privileged and confidential. This privilege extends to all form and formats in which the information is maintained and stored, including, but not limited to verbal, written and/or electronic forms; Review of the facility's Administering Medications Policy, revised December 2012, showed the medication cart and/or Medication Administration…

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 follow professional standards when they failed to destroy narcotics with two staff present according to policy for one resident (Resident #4), failed to maintain documentation of a controlled substance destruction sheet for one resident (Resident #5), and failed to remove medications as directed from the ISTAT. The facility census was 77. 1. Review of the facility's Controlled Substances policy, revised October 2014, showed staff are to document the disposal on the medication disposition record, (the medication disposition record will contain the following information: method of disposition, reason for disposition and signature of witnesses). Review showed the documentation should include the signature(s) of at least two witnesses. Review showed disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident and completed medication disposition records shall be kept on file in the facility for at least two years or as mandated by state law governing…

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 the residents' environment remained free of accident hazards when to staff failed to properly store medications. The facility census was 77. 1. Review of the facility's Administering Medications Policy, revised December 2012, showed staff are directed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. 2. Observation on 2/28/24 at 9:57 A.M., showed Certified Medication Technician (CMT) A left the medication cart unlocked and unattended in the hall, with his/her keys in the lock. Observation showed CMT A returned to the medication cart and retrieved the keys but did not lock the cart. Observation on 2/28/24 at 10:04 A.M., 12:49 P.M., and 12:53 P.M., showed CMT A left the medication cart unlocked and unattended in the hall, with his/her keys in the lock. Observation on 2/28/29 at 3:33 P.M., showed the treatment cart unlocked and unattended. Observation showed 15 insulin pens in the top drawer. Observation showed 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 an ongoing program of activities designed to meet residents' interests, for four (Resident #1, #2, #3, and #4) and on the weekend. The facility census was 75. 1. Review of the facility's Activity Department Policy, dated 8/17/21, showed: -The facility will provide, based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; -Activities refers to any endeavor, other than routine Activities of Daily Living (ADL's), in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical , cognitive, and emotional health.…

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 maintain thermometers in the resident room refrigerators, clean vents over resident tables in the dining room, and ensure the ice machine drained through an air gap. This failure had the potential to affect all residents. The census was 69. 1. Review of the facility's Food Storage: Refrigeration in Resident Rooms policy, undated, showed: - Internal thermometers shall be placed in the front section of each unit and shall be large enough for easy visibility; - Refrigeration temperatures shall be maintained below 40 degrees, with a preferred temperature of 36-38 degrees for maximum chilling; - Refrigerator temperatures in residents' rooms shall be monitored daily to ensure the temperature is within the specified range; - The policy did not address documenting refrigerator temperatures; - The policy did not address which staff was responsible to maintain and monitor the refrigerator thermometers. Observation on 4/5/23 at 11:25 A.M.,…

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 follow-up with a written response to grievances. The facility census was 69. 1. Review of the facility's Resident Rights policy, dated January 5, 2017, showed: - Residents have the right to organize and participate in resident groups in the facility; - The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings; - The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendations of such groups concerning issues of resident care and life in the facility. Review of the Resident Council minutes, dated January 18, 2023, showed the council had the following concerns: - Television channels do not work. Housekeeping is throwing away personal items, and some residents are missing clothing; - Medication is not correctly passed at night; - When residents turn on their call lights on the night shift it…

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 a comfortable and homelike environment, when staff failed to ensure resident rooms were clean and free of needed repairs and the dining experience was free from odors. The facility census was 69. 1. Review of the facility's Homelike Environment policy, dated May 2017 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 which include a clean, sanitary and orderly environment, and pleasant, neutral scents. Review of the policies provided by the facility showed they did not provide a policy or procedure to manage or report environmental repairs. 2. Observations on 4/4/23 between 10:23 A.M. and 4:47 P.M., during facility tours, showed: -Resident occupied room [ROOM NUMBER]…

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 provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Residents #13, #26, and #64). The facility census was 69. 1. Review of the facility's Hospital Transfer and Bed Hold Policy, undated, showed a copy of the policy will be sent with other papers accompanying the resident to the hospital. The bed hold policy represents the bed hold letter. 2. Review of Resident #13's medical record showed the cognitively impaired resident was transferred to the hospital on 1/27/23 and 2/02/23. Staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. During an interview on 4/05/23 at 10:48 A.M., Resident #13's spouse said the resident had been sent to the hospital two or three times since admission and staff never talked to him/her about a bed hold. 3. Review of Resident #26's medical record showed the resident was transferred to the hospital on 4/01/23. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for five sampled residents (Residents #53, #58, #219, #221, and #225). The facility census was 69. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Discharge Assessment for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. Review of the facility's MDS policy, dated February…

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 develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to address catheter care for one resident (Resident #26), failed to address dressing assistance, toileting assistance, and restorative services for one resident (Resident #35), failed to address smoking, personal hygiene preferences and oxygen for one resident (Resident #220), failed to address falls, personal hygiene preferences, pain and edema (swelling of the limbs) and antidepressant use for one resident (Resident #221), failed to address advanced directives and personal hygiene preferences for one resident (Resident #222) and failed to address the use of an antipsychotic and intravenous antibiotics for one resident (Resident #227). The facility census was 69. 1. Review of the facility's MDS Policy, dated February 2022, showed: -The comprehensive care plan will be developed and entered into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide thorough orders, monitoring, and ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for two out of two residents (Residents #11 and #17) who received services at the dialysis facility. The census was 69. 1. Review of the facility's Dialysis policy, dated 9/2017, showed the following: -The facility will ensure that residents who require dialysis will receive such services, consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents' goal and preferences; -Professional standards of practice include: ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -Ongoing communication,…

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 provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours per day, seven days a week. The facility census was 69. 1. Review of the facility's Nursing Staff schedule, dated 3/27/23 through 4/6/23, showed staff did not document an RN was scheduled to work on 3/27/23 through 4/6/23. Review of the facility's RN staff time sheets, dated 3/1/23 through 4/6/23, showed the hours worked between the three facility RNs as follows: -The Director of Nursing (DON), not responsible for direct resident care, Monday through Friday, 8 hours per day, he/she did not work on Saturday or Sunday; -The RN Educator worked Monday through Wednesday, averaging at least 8 hours per day. He/She worked 7 hours on Saturday 3/4, 1 hour on Saturday 3/11, 5 hours on Saturday 3/18, and 2 hours on Saturday 3/25. He/She did not work on Sundays; -The RN Wound Nurse/Infection Preventionist, worked on Thursday and Friday of each week with an average of 8 hours per day, but did not work any Saturdays or Sunday hours. -There was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, 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 (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #15, #30 and #226). The facility census was 69. 1. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Review of Seroquel (Quetiapine) product monograph (a factual, scientific document on a drug product that, devoid of promotional material, describes the properties, claims, indications and conditions…

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 store and label medication in a safe and effective manner in one of two medication storage carts, and two of two medication storage rooms. The facility census was 69. 1. Review of the facility's policy Medication Storage & Labeling Policy, undated, showed staff are directed as follows: - Medication must be stored in a clean, dry environment behind a single lock; - Expiration dates must be checked prior to administration. Expired medications are removed from the area of care immediately, and disposed of according to the facility medication disposal policy, per state and federal guidelines. 2. Observation on 4/5/23 at 1:11 P.M., showed the north medication storage room contained one package of dicyclomine (used to treat irritable bowel syndrome) 10 milligram (mg) capsules located on the floor of the medication storage room. The information label and resident information was torn from the top of the packaging. The package contained five out of 30 capsules. During an interview on 4/5/23 at 1:15 P.M., Licensed…

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 when staff failed to change their gloves and/or perform hand hygiene during perineal care for one resident (Resident #44), and failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for two residents (Resident #56 and one unknown resident). The facility census was 69. 1. Review of the facility's Infection Control and Prevention Guidelines, undated, showed the following: -Wash hands before and after procedures and before and after resident contact; -Wear sterile or clean gloves when appropriate; -Maintain sterility or cleanliness of the equipment and working field as necessary; -Clean all equipment and return to appropriate storage area; -Wash hands whenever visibly soiled; -Gloves should be used as an addition to not as a substitute for hand 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 interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility also failed to ensure two residents (Resident #63 and #219) of five sampled were offered the flu vaccine. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; -The pneumococcal vaccine will be offered to the residents of the facility; -The policy did not provide a timeline for offering the pneumococcal vaccine. Review of the facility's Prevention and Control of Seasonal Influenza policy, undated, showed: -The Infection Preventionist will promote and…

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

Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against Covid-19 for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; 2. Review of Resident #32's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 3. Review of Resident #47's medical record showed: -Most recent admission date of 11/01/21; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 4. Review of Resident #56's medical record showed: -Most recent admission date of 11/14/22; -The record did not contain documentation the resident received, refused, or was offered…

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.