Advanced Care Of St Joseph

Based on observations, interviews, and record review, the facility failed to ensure there were no loose pills in the medication carts and failed to date opened vials of Lorazepam (used to treat anxiety) for four of the 29 sampled residents, (Resident #25, #76, #52 and #9). Additionally, staff failed to ensure medication was not left at the bedside for Resident #11. The facility census was 144.Review of facility policy Medication Storage, revised 9/1/22, 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 the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdate, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed.- All drugs and biologicals will be stored in locked compartments…

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, observation, and record review, the facility failed to ensure that the food served to the residents was appealing and appetizing when residents at a group meeting and one Resident (#32) out of 18 sampled residents verbalized concerns over the quality of the food. The facility census was 144.Review of the facility's Food Preparation Guidelines, undated, showed:- It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition or hydration status;- Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature;- Strategies to ensure resident satisfaction include:* providing meals that are varied in color and texture;* serving hot foods/drinks hot and cold foods/drinks cold;* addressing resident complaints about foods/drinks;- Staff shall accommodate resident allergies, intolerance's, and preferences, providing appropriate alternatives when needed;- Staff shall offer residents appropriate alternatives when they choose not 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, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to wear beard nets while working in the kitchen, and failed to maintain proper standards of cleanliness in the walk-in refrigerator. This had the potential to impact all residents by placing them at risk for a food borne illness. The facility census was 144.Review of facility policy Dietary Employee Personal Hygiene, revised 9/1/22, showed all dietary staff must wear hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting food;Review of facility policy Ready to Eat, Time/Temperature, dated 5/30/19, showed leftovers have seven days before they must be discarded and not used for human consumption;A request was made for the facility policy on Kitchen Cleanliness and no policy was provided;During an observation in the Kitchen on 6/30/25 at 8:56 A.M., showed:- Dietary Aide (A) working at the dishwashing station…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate when staff failed to document and screen a one resident (Resident #20) accurately during pain assessments and failed to properly document showers for two residents (Resident #12 and #121). This affected three out of 29 residents sampled. The census was 144. Review of facility policy Maintenance of Clinical Records, revised 6/2/22, showed:- The facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided as well as in a manageable size for use by the care providers;- The facility must maintain medical records on each resident that are: complete, accurately documented, and systematically organized;- The clinical record will contain: a record of the resident's assessments 1. Review of Resident #20's admission minimum data set (MDS), a federally mandated assessment tool completed by…

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

Based on observations, interviews, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when obtaining blood sugars and the administration of insulin, failed to clean the port of the insulin pen prior to attaching the needle and failed to clean the glucometer between three of the 29 sampled residents, (Resident #64, #21, and #100) . The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed:- Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection;- Wash hands prior to administering medication per facility protocol and product;- Review Medication Administration Record (MAR) to identify medication to be administered;- Administer medication as ordered in accordance with manufacturer specifications;- Wash hands using…

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

Based on observation, interview, and record review, the facility failed to provide quality of care when, facility staff documented they had administered prescription eye drops to one resident (Resident #95) and showed the prescription eye drops were opened and dated on 05/02/25, the bottle was still full on 07/02/25 at 04:35 A.M. indicating several doses of the eye medication were missed, but documented. This affected one resident out of the sampled 18 residents. The facility census was 144.Review of facility administration of eye drops policy, revised on 09/24/24., showed: Label new bottle with date opened and follow facility policy or manufacturers instruction for when to discard and replace.Record administration of medication as ordered by the physician.1.Review of resident #95's Quarterly MDS(Minimum Data Set) (A federally mandated assessment completed by facility staff), dated 05/04/25., showed:- Cognition intact, resident is able to make all needs known and understand others.- Diagnoses includes: Insulin dependent diabetic , glaucoma with blindness- Needing assistance of one…

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

Based on observations, interviews, and record review, the facility failed to ensure staff provided catheter (a sterile tube inserted into the urinary bladder to drain urine) care in a manner to prevent urinary tract infection (UTI) or the possibility of a UTI, which affected one of the 29 sampled residents, (Resident #9). The facility census was 144. Review of the facility's policy for Catheter Care, revised 5/24/24 showed: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;- Catheter care will be performed every shift and as needed by nursing personnel;- Gently separate the skin folds to expose the urinary meatus. Wipe from front to back with a clean cloth. Use a new part of the cloth or different cloth for each side. With a new cloth, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. 1. Review of the resident's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment…

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

Based on observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one of 29 sampled residents (Resident #20). The facility census was 144. Review of facility policy Pain Management, revised 4/23/25, showed:- The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences;- The facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated;- Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;- Facility staff will observe for nonverbal indicators which may indicate the presence of pain;- Observe for difficulty in sleeping;- Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain;- The facility will use a pain assessment tool which is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to complete neurological assessment's for one resident (Resident #1), after the resident reported to Registered Nurse (RN) A on he/she had fallen the night prior and someone picked him/her off the floor. The resident was noted to have bruise to his/her torso and increased confusion. RN A did not initiate neurological assessment's. Additionally, the facility Certified Nurses Aide (CNA) A failed to notify the nurse immediately when he/she found the resident on the floor during the night of 12/4/24. CNA A and CNA B assisted the resident off the floor and back to bed. The facility census was 139. Review of the fall policy dated 2020 showed: - The staff were supposed to assess the resident after a fall; - The staff were supposed to complete a post-fall assessment. Review of the head injury policy dated 9/1/21 showed: - The staff were expected to assess if there is a known, suspected or verbalized head injury; - Perform neurological assessments as indicated. 1.…

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 care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for three of five sampled residents sampled when medications were not administered timely (Resident #1, #4, and #5) and when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) for two residents, (Resident #4 and #5). The facility census was 128. Review of facility policy, Medical provider orders, revised 4/7/22, showed: -Following of Medication and/or Treatment Orders: -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of the facility policy, Medication Administration, revised 9/1/22, showed: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the…

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

Based on observation, interview, and facility policy review, the facility failed to ensure dry foods were stored in sealed containers for food freshness and protection from pest for all 128 residents who received food prepared in the kitchen. Findings include: Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. During the initial tour of the kitchen, on 06/17/24 at 9:01 AM, with the Dietary Manager (DM), the following was observed: a. Two 25 pound bags of breadcrumbs were observed in a small storage room adjacent to the larger dry storage room. One of the two bags was open to air, undated, and unsealed. The second 25 pound bag was unopened. Both bags were made of paper. Neither was in a sealed container, subject to insects, pests, or rodents. b. Three 18 gallon plastic containers were placed next to each other between the ends of a metal shelf. The containers were wider at the top than the bottom and did not fit flush against each other, which…

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, document review, and facility policy review, the facility failed to maintain an effective pest control program for five of six halls (100, 200, 300, 400, and 600), two nurses' stations, shower rooms, therapy room and the kitchen which includes the dish room area. Findings include: Review of the facility's policy titled Pest Control Program, dated 09/01/21, noted It is the policy of this facility to maintain an effectiye (sic) pest control program that eradicates and contains common household pests and rodents .Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). During the initial tour of the kitchen, on 06/17/24 at 9:01 AM, with the Dietary Manager (DM), a hole, approximately two inches in circumference, was observed behind the cove base in the small storage room, creating the potential for insects, pests, or rodents to access. During the second tour of the kitchen, on 06/20/24 at 1:57 PM, a clear plastic container…

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, record review, facility policy review and review of manufacturer's instructions, the facility failed to provide respiratory care in accordance with professional standards for four (Residents (R) 62, R24, R45, and R53) of four residents reviewed for respiratory care out of a total sample of 33 residents. Respiratory equipment, such as bipap (bilevel positive airway pressure), cipap (continuous positive airway pressure), and nebulizer masks and chambers, were not stored in a sanitary manner; oxygen, cipap, bipap, and nebulizer units were dusty with grim; and there was no process for cleaning and maintaining cipap/bipap units. R62 did not have a physician order for cipap, R24's oxygen rate was not per the physician's order, and R45 and R53 had liquid in their nebulizer chambers. This failure had the potential for residents to develop respiratory issues, infections, or other medical issues. Findings include: Review of the facility's policy titled, Oxygen Administration, 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 observations, interviews, record review, and facility policy review, the facility failed to implement an appropriate infection control program for eight of 33 residents (Resident) R)6, R24, R34, R47, R61, R79, R94, and R115 resulting in psychosocial harm to R61. Specifically, the facility failed to 1. follow their policy for isolation during treatment for scabies for R61; 2. follow enhanced barrier precautions for six residents R6, R24, R94, R115, R34 and R47; and 3. follow appropriate hand hygiene during meal service for R79. Findings include: Review of the facility's policy titled, Transmission -Based Precautions, dated 2021, provided by the Infection Control Preventionist (ICP) indicated, It is our policy to take appropriate precautions to prevent transmission of infectious agents, based on the agents' modes of transmission. For the Infection/Condition of scabies, the Precaution indicated listed as contact; with the Duration identified as until 24 hours after initiation of treatment. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one of three residents (Resident (R) 37) and their resident representatives (RR) in the sample of thirty-three reviewed for facility initiated emergent hospital transfer, was provided with a written transfer notice that contained all the required information. This failure has the potential to affect the resident and their RRs by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of R37's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 07/21/17. Review of R37's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/24 and located in the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. Review of R37's Nursing Note, dated 06/10/24 located in the Progress Notes tab of the EMR,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide one of three residents, or their resident representative (RR) reviewed for hospitalization (Resident (R) 37) with written notification of the bed hold policy prior to transfer to the hospital. This created a potential for the resident to experience distress or confusion related to readmission to the facility due to the facility-initiated discharge. Findings include: Review of R37's admission Record found in the Profile tab of the electronic medical record (EMR) revealed an admission date of 07/21/17. Review of R37's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/24 and located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. Review of R37's Nursing Note, dated 06/10/24 located in the Progress Notes tab of the EMR, revealed, Hospice medical director ordered resident to be sent to ER [Emergency Room] for…

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

Based on record review, interviews, policy review and review of the Resident Assessment instrument (RAI) manual, the facility failed to accurately code the Minimum Data Set (MDS) for one of 33 residents (Resident (R) 37) reviewed for MDS accuracy. Failure to accurately code the MDS could result in the resident not receiving care and services. Findings include: Review of Centers for Medicare and Medicaid Services (CMS)'s RAI Version 3.0 Manual CH 3: Section O indicated, .Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . Review of R37's admission Record under the Profile tab of the electronic medical record (EMR) revealed and admission dated of 07/21/17. Review of R37's annual Minimum Data Set (MDS) assessment, with a reference date (ARD) of 05/21/24 and located in the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated resident was severely cognitively impaired. Review of the MDS Section…

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 staff interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed for two of three residents (Resident (R) 22 and R60) reviewed for PASARR. Findings include: R22's undated Face Sheet, found in the electronic medical record (EMR) under the admission Record tab, indicated the resident was most recently admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, and anxiety. R60's undated Face Sheet, found in the EMR under the admission Record tab, indicated the resident was most recently admitted to the facility on [DATE] with diagnoses including bipolar disorder and schizoaffective disorder. Review of R22 and R60's EMRs indicated no documentation that a Level 1 PASARR had ever been completed. During an interview with the Business Office Manager (BOM) on 6/19/24 at 5:23 PM, the BOM confirmed a Level 1 PASARR could not be found in R22 and R60's EMRs. She stated, (R22) and (R60)…

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, record review, and facility policy review, the facility failed to develop a comprehensive care plan for one of 33 residents (Resident) R) 61) in the sample creating the potential for R61 to be at risk for unmet needs due to a skin condition. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], indicated It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of R61's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R61 was admitted on [DATE]. Review of R61's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] indicated R61 had a Brief Interview for Mental Status (BIMS)…

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, interviews, and policy review, the facility failed to provide documentation of behavior monitoring for the continued use of an antipsychotic medication for one of five residents (Resident (R)121) reviewed for unnecessary medications. Failure to provide quantitative data regarding target behavior reduction/management has the potential to affect the resident receiving the lowest dose possible of a psychoactive medication. Findings include: Record review of the facility's policy titled, Use of Psychotropic Drugs revised on 09/01/21, indicated Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives,…

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

Based on observations, interviews, and policy review, the facility failed to ensure for one Resident (R)26) of one resident in the sample of 33 residents. The nursing staff failed to follow the facility's policy to secure 17 insulin pens in the medication cart or medication room. This practice could potentially affect the safe administration of residents' medications. Findings include: Review of the facility's policy titled Medication Storage dated 09/01/21 revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the .or medication rooms according to the manufacturer's recommendations .all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During observations of R26's room on 06/17/24 at 11:15AM, there were two full vials of the medication albuterol sulfate next to the nebulizer machine. Review of R26's Physician Orders dated 06/14/24 in the Orders tab of the EMR revealed Ipratropium-Albuterol Solution 3mg…

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 operationalize the Illegal Drug Use policy to ensure the environment for two sampled residents (Resident #1 and Resident #2) were free from hazards when staff repeatedly found illegal drugs and/or drug paraphernalia in a shared room occupied by two residents, Resident #1 and Resident #2. The facility census was 106. Review of the facility's policy Resident Rights revised, [DATE], included the resident has the right to safe environment including receiving supports for daily living safely. Review of the facility's policy Illegal Drug Use dated, [DATE], included: -The facility is an illegal drug-free facility; -The purpose of this policy is to ensure the safety of all employees, residents, family members, visitors and any others that enter the facility. -No one is allowed to possess, be under the influence of or use any illegal drugs on the premises of this facility; -The facility reserves the right to inspect our premises, conduct alcohol and drug…

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 Please refer to Event ID MW6512 for this deficiency content. Based on record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse when one resident (Resident #3) reported he/she was sexually abused by his/her roommate (Resident #4). The facility failed to provide evidence the alleged violations were thoroughly investigated and to follow facility policy when failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. The facility census was 123. Review of facility policy, Abuse, Neglect, and Exploitation, revised 8/22/22, showed: -It was policy of facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Sexual abuse is non-consensual sexual contact 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Please refer to Event ID MW6512 for this deficiency content. Based on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for two of four residents (Resident #1 and #2) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) and when staff left medication at Resident #1's bedside to self administer. This affected two of four sampled residents. The facility census was 123. Review of the facility policy, Medication Administration, revised 9/1/22, showed: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review MAR and identify medication to be administered; -Administer medication as ordered in…

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

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen and dining room, failed to label and date food when it was opened, failed to completed temperature checks on fridge/freezers, failed to store food off the floor, failed to ensure proper sanitation of food preparation services, failed to use clean serving bowls, failed to keep trash cans covered, failed to use proper hand washing techniques during food preparation and meal service, and failed to have cleaning routines in kitchen. This had the potential to impact all residents in the facility. The facility census was 119. 1. Review of facility policy, food safety requirements, dated 11/2017, 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. -Storage of food in a manner that helps prevent deterioration or contamination 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided showers to dependent residents when staff did not provide at least two showers a week to five residents (Resident #1, #2, #3, #4, #5) of five residents sampled. The facility census was 119. Review of facility's resident shower policy, dated 9/1/21, 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. -Partial baths may be given between regular shower schedules as per facility policy. Review of facility policy, bathing a resident, dated 9/1/21, showed: -It is practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Review of the facility policy, activities of daily living (ADL's), dated 9/1/21,…

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

Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. The facility census was 119 Review of policy, medication storage, dated 9/1/21, 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 the manufacturer's recommendations and sufficient to ensure proper sanitation, 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. -Only authorized personnel will have access to the keys to locked compartments. -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Observation on 1/11/24 at 3:23 P.M., showed medication cart 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 record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse when one resident (Resident #3) reported he/she was sexually abused by his/her roommate (Resident #4). The facility failed to provide evidence the alleged violations were thoroughly investigated and to follow facility policy when failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. The facility census was 123. Review of facility policy, Abuse, Neglect, and Exploitation, revised 8/22/22, showed: -It was policy of facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Sexual abuse is non-consensual sexual contact of any type with a resident; -Investigation of Alleged Abuse…

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 care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for two of four residents (Resident #1 and #2) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) and when staff left medication at Resident #1's bedside to self administer. This affected two of four sampled residents. The facility census was 123. Review of the facility policy, Medication Administration, revised 9/1/22, showed: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review MAR and identify medication to be administered; -Administer medication as ordered in accordance with manufacturer specifications; -Sign MAR after…

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 monitor, assess, and implement interventions to prevent an elopement of one resident (Resident #1) when staff allowed the resident to elope from facility on 12/5/23 which resulted in resident becoming intoxicated and taken to emergency room. This affected one of three sampled residents. The facility census was 116. Review of facility policy, elopements and wandering residents, dated 9/1/22, showed: -Facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. -Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement 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 interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected seven additionally sampled residents (Residents #245, #246, #247, #248, #249, #250, and #251) Facility census was 92. 1. Review of the facility Refund Process policy, dated 7/15/21, showed: - Refunds are requested to process money that was overpaid to the facility for resident services provided. Refunds may be made payable to the responsible party, resident, insurance company, State, or medical providers. Potential refund amounts can be identified on the Accounts Receivable (AR) aging report for the facility. - Refunds may be requested by the center or Corporate Business Office (CBO). The Business Office Manager (BOM) will forward completed refund request with all required documentation to AR. Refunds must be requested timely, most States require that a private pay refund be done within 30 days of discharge. 2. Review of the facility's aging report, 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.

Based on observation, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety, and failed to ensure they stored food properly. The facility census was 92. Review of the facility's policy, revised 4/29/18 Food Storage: Cold Food in part said: - All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. 1. All food items will be stored 6 inches above the floor and 18 inches below the sprinkler unit. 2. All perishable foods will be maintained at a temperature of 41 degrees farenheit or below, except during necessary periods of preparation and service. 3. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. 1. Observation on 2/22/22 beginning at 9:05 A.M., showed the following: - Containers of pickles, tomato, lettuce, onion, and cheese in the refrigerator not labeled or dated . - Half of a ham in the walk in freezer,…

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.