St Elizabeth Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails for two residents (Resident #31 and #48) of two sampled residents. The facility census was 52. 1. Review of the facility's policy titled Proper Use of Bed Rails, dated February 2025, showed informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: the resident's risk from the use of bed rails and likelihood of the benefits, and the risks from the use of bed rails an how these risk will be mitigated. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/24, showed staff assessed 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 observation, interview, and record review, facility staff failed to follow infection control practices when staff did not properly sanitize the blood glucose monitor for four residents (Resident #53, #7, #6 and #20) out of four sampled residents. The facility census was 52. 1. Review of the facility's policy titled Glucometer Disinfection, dated February 2025 showed the facility will ensure glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA), an independent agency of the United States government tasked with environmental protection matters, registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C and Hepatitis B virus. -Procedural steps include: -retrieve two disinfectant wipes from container; -Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; -After cleaning, use 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, facility staff failed to educate and offer the Coronavirus disease (COVID-19) vaccination for five residents (#14, #31, #34, 40 and #51) out of five sampled residents. The facility census was 52. 1. The Center's for Disease Control COVID-19 Vaccination Long Term Care guidelines, dated August 2024, recommends everyone ages 5-64 years, including people who live and work in long-term care (LTC) settings, get one dose of a 2024-2025 COVID-19 vaccine; and everyone ages 65 years and older, including people who live and work in LTC settings, get two doses of a 2024-2025 COVID-19 vaccine 6 months apart. 2. Review of Resident #14's medical record showed: -The resident is under age [AGE]; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 3. Review of Resident #31's medical record showed: -The resident is under age [AGE]; -admitted on…

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

Based on interview and record review, facility staff failed to ensure one resident (Resident #2) remained free from verbal and emotional abuse, when Certified Nurse Aid (CNA) E threatened to take the resident to the floor, blocked and refused to leave the resident's room after repeated requests made by the resident. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed abuse is the willful infliction, injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Verbal abuse includes speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Mental abuse includes humiliation, harassment, threats of punishment or deprivation, or abuse that is facilitated or caused by nursing home staff. Verbal abuse includes the use of verbal conduct by staff 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 interviews and record review, facility staff failed to report an allegation of employee to resident emotional abuse to the Department of Health and Senior Services (DHSS) within the two hour timeframe for one resident (Resident ##2) who reported an allegation of abuse. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed the licensed nurse will protect the resident from further incident and remove the accused employee from resident care areas. The nurse will then notify the administrator or designee. Should the incident be a reportable event, the administrator should notify appropriate agencies immediately, as soon as possible, but no later that 24 hours after the discovery of the incident. In case of serious bodily injury, no later than two hours after discovery or forming the suspicion. 2. Review of the facility's investigation, dated 11/02/24, showed the resident notified staff on 11/1/24 that Certified Nurse Aide (CNA) E abused him/her when CNA E would not leave the resident's room after being asked to leave…

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 develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 49. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative…

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, the facility staff failed to maintain an accurate accounting system that assured the resident fund bank statement matched the reconciliation for the same month from 09/01/22 through 03/31/23. This had the potential to affect all residents that had funds entrusted to the facility on the residents' behalf. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated 9/17/21, showed: -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed; -A reconciliation of the bank statements, checkbook and trust funds must be completed monthly. 2. Review of the facility's Bank Statement dated 09/30/22 showed: -A beginning balance of $6,699.59; -An ending balance of $5,138.51. Review of the facility's Reconciliation dated 09/01/22 through 09/30/22, showed the bank with: -A beginning balance of $15,003.88; -An ending balance of $14,631.56. 3. Review of the facility's Bank Statement dated 10/31/22 showed: -A beginning balance of $5,661.87; -An ending balance…

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 refunds of personal funds to residents from the facility operating account in a timely manner for four residents (Resident #1, #2, #3, #4, and #8) discharged from the facility. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated [DATE], showed: -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident trust account balance; -The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge along with a complete accounting record of the funds; -Checks received after a resident is discharged should be either forwarded to the resident or returned to the sender; -If the facility is Representative Payee, any unspent Social Security or Social Security Income (SSI) funds that are held on behalf of a beneficiary belong to that beneficiary; -Upon the death of a resident who had received aid or assistance from 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 observation and interview, the facility staff failed to ensure complete privacy for residents by failing to close an exterior curtain for one resident whose abdomen was exposed during an insulin injection (Resident #27), close an exterior curtain for one resident who was being assisted to bed (Resident #30), and to close a privacy curtain between two residents who shared a room during assistance to bed (Resident #30 and #34) and failed to ensure resident's personal information was protected when they left the Medication Administration Records (MARs) open and unattended in public hallways. The facility census was 49. 1. Review of the facility's Resident Rights Policy, dated 7/5/23, showed: -The resident has the right to personal privacy and confidentiality of his or her personal and clinical records; -Personal privacy includes personal care and accommodations. Review of the facility's Medication Administration and Monitoring policy, dated 09/2023 showed it did not contain direction on privacy during medication administration. 2. Observation on 10/17/23 at 01:44 P.M., showed…

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 provide a clean, homelike and comfortable environment when staff failed to clean and maintain resident rooms. The facility census was 49. 1. Review of the facility's policy Environmental Rounds, dated 6/09/23, showed staff were directed as follows: -Environmental rounds are to be done daily by department heads using the environmental rounds form; -The department head should be inspecting the rooms for potentially hazardous items and any areas that may not be in compliance of state and federal regulations. Review of the facility's policy Work Order Policy, dated 12/21/22, showed staff were directed as follows: -The facility maintenance department's function is to provide material and labor to maintain the buildings, equipment and grounds; -Work order forms should be submitted for any issues that an employee observes which need the attention of facility maintenance. 2. Observation on 10/17/23 at 10:05 A.M., showed the floors of 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, facility staff failed to provide written notice to the resident or the resident's representatives regarding resident transfers to the hospital for two of two sampled residents (Resident #26 and #42). The facility census was 49. 1. Review of the facility's policy titled, Resident Transfer / Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/23, showed before any resident is transferred or discharged , staff are directed to notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand. 2. Review of Resident #26's medical record showed the following: -Transferred to the hospital on [DATE] and returned on 09/27/23; -Did not contain documentation staff provided written notification to the resident or resident's representative of the resident's transfer to the hospital. 3. Review of Resident #42's medical record showed the following: -Transferred to the hospital on [DATE] and returned on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two sampled residents (Resident #26 and #42). The facility census was 49. 1. Review of the facility's policy titled, Resident Transfer / Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/23, showed: Notice of Bed Hold Policy; -When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy; -This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of transfer; -If the emergency transfer was to a hospital, the facility may send copy of the bed hold policy to the resident in the hospital if a hospital representative such as a social worker,…

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 document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) by not accurately coding use of a blood thinner and gastrostomy tube (g-tube, tube inserted into the stomach used for nutrition and medication administration) for one resident (Resident #34), failed to record signs and symptoms of possible swallow disorders for two resident's (Resident #19 and #38). The facility census was 49. 1. Review of the facility's MDS Care Assessment Summary and Individualized Care Plans policy, dated 02/26/21 showed: -Section K to be completed by Dietary Manager. This section addresses nutritional and swallowing status; -Section N is to be completed by Nursing Staff. This section focuses on the medications the resident has received in the last 7 days or since admission or re-entry if less than 7 days; -MDS assessments must be kept current and up to date. 2. Review of Resident #34's admission MDS, dated…

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 and/or revise the comprehensive person-centered care plan for four residents (Resident #19, #38, #42, and #46) to meet their medical and nursing needs. The facility census was 49. 1. Review of the facility's policy titled, Comprehensive Care plans and Baseline Care Plans, revised 01/19/22, showed staff were directed to do the following: -The facility must develop a comprehensive care plan for each resident that includes measureable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment; -A Licensed Nurse, that has been designated by the facility administration, will coordinate each assessment with the appropriate participation of health professionals known as the Interdisciplinary Team (IDT); -Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional, and psychosocial problems; -From the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to maintain professional standards of documentation for falls and neurological checks of one resident (Resident #19), failed to appropriately sign out administration of Schedule narcotics (drugs based on medical value and potential for abuse as classified by the Drug Enforcement Agency (DEA)) for three residents (Resident #5, #22, and #27), failed to obtain a hold order for an antipsychotic for one resident (Resident #22), failed to clarify medication orders for one resident (Resident #34) who was to receive nothing by mouth, and failed to update the advanced directives listed in a folder on a crash cart (cart used in emergency situations) in the main dining area per facility policy. The facility census was 49. 1. Review of the facility's policy titled, Post Fall Protocol, revised 06/30/23, showed staff were directed to do the following: -The Licensed Practical Nurse/Registered Nurse (LPN/RN) on duty will perform a head to toe…

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 staff failed to ensure three Nurse Aides (NA) (NA O, NA P, and NA Q) of a sample of seven completed the nurse aid training program within four months of their employment in the facility. The facility census was 49. 1. Review of the facility's policy titled, Facility Assessment Policy and Tool, revised 06/29/23, showed staff were directed to: -Facility must have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety; -Facility must develop, implement, and maintain an effective training program for all new and existing staff. Review of the facility staff list showed seven NAs employed in the facility. Three were found to be employed beyond 120 days without becoming certified. 2. Review of NA O's personnel file showed a hire date of 05/08/23 and did not contain documentation he/she completed the nurse aide training program. 3. Review of NA P's personnel file showed a hire date of 02/06/21 in a non-nursing department. Further review showed he/she was moved 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, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage room, and one of two medication carts sampled. The facility census was 49. 1. Review of the facility's policy Medication Storage and Destruction, dated 01/05/23, showed the policy did not contain direction on expired medications. Observation on 10/19/23 at 10:35 A.M., showed the medication storage room contained: -1 Assure dose bottle with an expiration date of 05/19/23; -6 boxes of Evencare G2 glucose control solution with an expiration date of 07/08/23; -1 bottle of Fiber laxative 90 capsules with an expiration date of 02/23; -1 bottle of Flamontidine 30 tablets with an expiration date of 06/23. -Bottles of Gatorade and a bottle of vodka stored with disinfectant cleaners and a spray bottle of odor eliminator. During an interview on 10/20/23 at 8:47 A.M., Certified Medication Technician F said expired medication is brought to a nurse to be destroyed or the pharmacist checks for out of date medication for destruction.…

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 document the administration or refusal of the pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for four (Resident #22, #32, #33, and #40) of six sampled residents. The facility census was 49 residents. 1. Review of the facility's Pneumococcal Vaccine Policy, dated 6/30/23 showed: -As part of the admission process, the resident or the resident's legal representative will be provided education on both the benefits and potential side effects of the pneumococcal immunization; -All Centers for Disease Control (CDC) recommendations for the pneumococcal immunization will be followed; -The residents clinical record will document the resident or legal representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization and if the resident either received the pneumococcal immunization or did not receive it due to medical contraindications or refusal. Review of the CDC…

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 staff failed to ensure staff received the required trainings upon hire and/or annually. The facility census was 49. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the facility assessment, dated 09/20/23, showed staff were to have the following training: -All New hires receive Preventing, Recognizing, and Report Abuse; -All New Nursing, Social Service, and Activities hires receive additional training of Care of the Cognitively Impaired, and Communicating with Older Adults with Dementia; -All New Administrators, Director of Nursing (DON), Register Nurse (RN), and Licensed Practical Nurse (LPN) hires receive additional training of Documentation that Prevents Fraud and Abuse; -All employed staff receive annual training of Preventing, Recognizing, and Reporting Abuse. Review of the facility's Census and Condition of Residents showed there was seven residents that resided within the facility with a diagnosis of dementia and/or Alzheimer's disease. Review of the facility's Training…

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 perform Gradual Dose Reductions (GDRs) on psychotropic medications for two residents (Resident #19 and #45). The facility census was 49. 1. Review of the facility's policy titled, Antipsychotic and Psychotropic Medications, revised 06/29/23, showed staff were directed to do the following: -Residents who use psychotropic drugs will receive GDR and behavior intervention, unless clinically contraindicated, in effort to discontinue these drugs; i. If GDR is not desired by the physician, they must document reasoning in resident's clinical record; ii. Documentation should include any previous attempts failed, and/or resident is at baseline with current dose, and/or current dose is needed for resident to sustain a quality of life. 2. Review of Resident #19's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/04/23, showed staff assessed the resident as: -Unable to assess cognition level; -No speech; -At risk for falls; -Received…

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 to meet the resident's medical, dietary, and nursing needs for one resident (Resident #1). The facility census was 46. 1. Review of the facility's Comprehensive care plans and baseline care plans, dated 1/19/22, showed the comprehensive care plan must be completed within 14 days of admission. Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional, an psychosocial problems. From the meeting, information will be individualized to the resident's plan of care. On Monday morning, the resident's status will be reviewed from the weekend to ensure all areas that need to be assessed for care plan needs are addressed. The care plan will be oriented toward managing risk factors, using current standards of practice in the care planning process, evaluating treatment objectives and outcomes of care, and assessing and planning for care sufficient to meet the care…

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 meet professional standards when staff did not transcribe orders for one resident (Resident #1) who had a tracheostomy ( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), Pecutaneious Endoscopic Gastrostomy (PEG) tube (provide a means of feeding when oral intake is not adequate), continuous feedings, and utilized oxygen. The facility census was 46. 1. Review of the facility's Transcription of orders/following physician's orders policy, dated 7/9/21, showed staff are directed upon receipt of a physician's order by telephone, fax, written order, verbal order, transcribed order or other, it will be written on the physician order sheet (POS). The order is transcribed on the right side of the POS, the nurse must place their initial and noted and the date to verify the order has been addressed. Any changes in medication are to be addressed on the left side of the POS where 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.