Beauvais Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and sampling of a meal test tray, the facility failed to ensure food prepared by the facility was palatable for seven of seven residents (Resident (R) 42, R129, R77, R99, R109, R96, and R132) reviewed for palatability out of a total sample of 48. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. The facility census was 136. Findings include: 1. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/25 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated no cognitive impairment During an interview on 03/17/25 at 11:48 AM, R42 stated the food did not taste good, and trying to get an alternative was almost impossible. 2. Review of R129's admission MDS, with an ARD of 02/14/25 and located under the MDS tab of the EMR, revealed R129 had a BIMS score of 14 out of 15 which indicated no cognitive…

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, record review, and review of facility policies, the facility failed to deliver meal trays in a manner to prevent cross-contamination for seven of 48 sampled residents (Resident (R) 5, R8, R80, R117, R76, R93, and R91) reviewed for infection control, and administer medications in a manner to prevent cross-contamination for four of four residents (R41, R24, R92, and R106) observed during the medication pass observation. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. The facility census was 136. Findings include: Review of the facility's policy titled, Hand Hygiene, dated 10/24/22, revealed . Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure the fifth-floor shower room was cleaned as required for one of one resident (Resident (R) 109) reviewed for the environment out of a total sample of 48. This failure had the potential to affect the resident's health and ability to utilize the shower area. The facility census was 136. Findings include: Review of the facility's policy titled, Housekeeping- Restroom and Showers, revised 10/24/22, revealed . Showers . Scrub bathtubs and showers . Review of R109's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. Diagnoses included displaced fracture, chronic obstructive pulmonary disease, chronic respiratory failure, and emphysema. Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/25 and located under the MDS tab of the EMR, revealed R109 had a Brief Interview for Mental Status…

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, staff interview, and facility policy, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of change for one of 10 residents (Resident (R) 23) reviewed for significant change assessments out of a total sample of 48. R10 showed a severe weight loss of 11.28% in six months and declined in mobility status that impacted more than one area of the resident's health status. This failure had the potential to cause further decline in the resident's status without further intervention by staff, interdisciplinary review, or revision of the care plan. The facility census was 136. Findings include: Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of 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 record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two of 48 residents (Resident (R) R23 and R136) whose records were reviewed. This had the potential to cause unmet care needs for the residents. The facility census was 136. Findings include: Review of the facility's policy titled, Assessment and Management of Resident Weights, revised 10/24/22, indicated, . V. Significant Weight Change Management: A. Significant weight changes will be reviewed by the Director of Nursing Services or designated licensed nurse. Significant weight changes are: i. 5% in one (1) month, ii. 7.5% in three (3) months, iii. 10% in six (6) months . Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which 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 record review, interviews, and facility policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) level one was updated with a new diagnosis after admission for one of two residents (Resident (R) 91) reviewed for PASARR out of a total sample of 48. This failure had the potential to affect the resident's need for any potential additional services. The facility census was 136. Findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revised 07/27/23, revealed, . The facility also conducts Level 1 screen for current residents who have a mental illness or intellectual disability and experience a significant change in their condition based on MDS [Minimum Data Set] 3.0 guidelines . A negative PASRR Level 1 screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual ability arises later . Review of R91's admission Record, located under the Profile tab 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 record review and interview, the facility failed to develop and implement a care plan for a resident's hospice services for one of one resident (Resident (R) 57) reviewed for hospice out of a total sample of 48. This had the potential to cause unmet care needs. The facility census was 136. Findings include: Review of R57's Face Sheet, located in the Profile tab of the EMR, revealed R57 was admitted to the facility on [DATE]. Review of R57's Physician Orders, located under the Orders tab in the EMR and dated 02/07/25, revealed an order for hospice services. Review of R57's Care Plan, located under the Care Plan tab of the EMR and dated 02/07/25, revealed there was no evidence R57 had a care plan developed for hospice services. During an interview on 03/19/25 at 5:29 PM, the MDS Coordinator (MDSC) stated the facility missed developing a care plan for hospice services for R57. She stated updating the care plan to include hospice was missed since the payor type was not updated. During an interview 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 observation, interview, and record review, the facility failed to ensure staff followed physician orders for the use of a helmet related to fall safety for one of one resident (Resident (R) 2) reviewed for Helmet use out of a total sample of 48. This had the potential to increase R2's risk of injury with any fall. The facility census was 136. Findings include: Review of R2's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's with dyskinesia, functional quadriplegia, mood disorder, schizoaffective, paranoid schizophrenia, vascular dementia, intellectual disabilities, and other seizures. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/25 and located under the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15,…

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, staff interview, and facility policy review, the facility failed to ensure vision services related to cataract surgery provided for one of two residents (Resident (R) R16) reviewed for vision and hearing services out of a total sample of 48. R16 had a failed appointment for cataract surgery in May of 2024 and the facility failed to reschedule the appointment. This failure had the potential to prevent R16 from living in the highest practicable physical well-being. The facility census was 136. Findings include: Review of the facility's undated policy titled, Care and Services, revealed, Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of R16's admission Record, located under the Profile tab 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 observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) R2) reviewed for smoking out of a total sample of 48 did not smoke inside the facility. R2, who was assessed to need supervision while smoking locked himself in his bathroom and smoked. The facility census was 136. Findings include: Review of a facility policy titled, Smoking by Residents, revised April 2024, indicated, . Smoking is not allowed anywhere inside the facility . Residents will be allowed to smoke in designated smoking area(s) only . It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that can occur. For this reason, any violations will result in the following actions: 1. First Offense - Written warning and counseling session with the understanding that continued violation will result in further action.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure one of one resident (Resident (R)51), reviewed for oxygen administration out of a total sample of 48, received oxygen per nasal cannula according to the physician's order. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.) The facility census was 136. Findings include: Review of R51's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R51 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia. Review of R51's Physician Orders, dated 01/29/21 and located under the Orders, tab in the EMR, revealed R51 was to receive oxygen at two Liters per Minute (LPM) via nasal cannula as needed for shortness of breath. Review of R51's Care Plan, dated 01/10/23 and located under the Care Plan tab of the EMR,, revealed a focus of Pulmonary…

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 monitor target behaviors for the use of psychotropic medications for one of five residents (Resident (R) 42) reviewed for unnecessary medications out of a total sample of 48. This had the potential to cause R42 to receive unnecessary medications. The facility census was 136. Findings include: Review of R42's Resident Face Sheet, located under the Continuity of Care (CCD) tab of the electronic medical record (EMR), indicated the resident was re-admitted to the facility on [DATE] with diagnoses including mood disorder, anxiety disorder, schizophrenia, and major depression. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/25 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated no cognitive impairment. The resident was coded as receiving antipsychotic, antidepressant, and antianxiety medications. Review of R42's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to offer pneumococcal vaccines for two of seven residents (Resident (R) 92 and R95) reviewed for pneumonia vaccinations out of a total sample of 48. This practice had the potential to increase the risk for these residents to contract pneumonia. The facility census was 136. Findings include: Review of the policy titled, Pneumococcal Disease Prevention, implemented 09/01/23 revealed, . Pneumococcal vaccines are recommended for the following classifications of residents: A. All adults [AGE] years of age and older . Anyone 2 through [AGE] years of age who has a long-term health problem such as: heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid or cochlear implant . Anyone 2 through [AGE] years of age who has a disease or condition that lowers the body's resistance to infection, such as: Hodgkin's disease; lymphoma or leukemia; kidney failure; multiple myeloma; nephrotic…

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 services to promote the highest practicable physical well-being for two of seven sampled residents (Residents #2 and #1). One resident's resistance to repositioning and transfers due to a stiff painful knee from osteoarthritis (a degenerative joint disease which causes tissues in the joint to break down over time) experienced recurring issues with moisture associated skin damage (MASD, inflammation and erosion of the skin). Nursing staff also failed to consistently carry out physician's orders to get the resident out of bed for meals to improve intake as well as a need for pressure relief (Resident #2). Another resident resisting staff attempts to open and clean his/her contracted (a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints) hand resulted in hand hygiene deficits (Resident #1). The census was 137. Review of the facility policy titled, Pain Management, revised…

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 adequately address the pain of one of seven sampled residents (Resident #3). The facility failed to assess, monitor and implement interventions to adequately address breakthrough pain (a sudden and brief flare-up of pain from a chronic condition like arthritis which breaks through doses of administered pain medication) which impacted the provision of rehabilitation services and assistance with activities of daily living (ADLs). Nursing staff also failed to consistently carry out physician's orders for a neurological assessment to secure Botox treatments to relax the resident's tightly contracted joints. The census was 137. Review of the facility policy titled, Pain Management, revised 10/24/22, showed the purpose of the policy was to ensure accurate assessment and management of a resident's pain. A licensed nurse was to assess residents for pain on admission and routinely as indicated by the resident's health and functional status.…

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 facility policy review, the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for 123 of 125 residents who received nourishment from the kitchen. Findings included: A review of a facility policy titled Equipment Operation and Sanitation, revised in December 2020, revealed, A. All equipment must be thoroughly washed and sanitized between uses in different food preparation tasks. The policy further revealed e. All items washed and sanitized will be air-dried. An observation of the kitchen conducted on 11/06/2023 at 10:24 AM revealed four coffee carafes, eight half-size pans, seven moon-size pans, and three quarter-size pans stacked together on a shelf with leftover moisture present (referred to as wet nesting). A second observation of the kitchen conducted on 11/07/2023 at 11:22 AM revealed nine quarter-size pans and 11 half-size pans stacked together on a shelf with leftover moisture present. During an interview on 11/06/2023 at 10:37 AM, the Dietary Manager (DM)…

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

Based on observation, interviews, and facility policy review, the facility failed to keep the area surrounding the dumpsters free of debris for 2 (dumpsters) of 2 dumpsters observed. Findings included: A review of a facility policy titled Food-Related Garbage and Rubbish Disposal, revised in December 2008, revealed, 7. Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. During an observation of the dumpster area with the Dietary Manager (DM) on 11/06/2023 at 11:11 AM, one bag of trash was found on the left side of the back dumpster. Multiple bags of trash were found under the back dumpster, and debris was found on either side of both dumpsters. Debris items included pieces of paper, cardboard boxes, face masks, a wicker basket, and plastic gloves. Both top doors to the back dumpster were open. The DM stated the housekeeping department was responsible for maintaining the area and that trash was picked up every other day. She stated the trash should have been picked up over the weekend, but it appeared that it had not been. The DM…

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, facility document and policy review, the facility failed to maintain an effective pest control program, as evidenced by mice sightings on 3 (Unit 100, 200, and 500) of 5 units. Findings included: A review of a facility policy titled Pest Control, revised in August 2020, revealed, The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. The policy further revealed, As authorized by the Administrator, the Company will carry out any pest control actions needed to rid the Facility and its grounds of any environmental pests. During an observation on 11/09/2023 at 7:04 AM in room [ROOM NUMBER], a mouse was observed running from under the bed to under the air conditioner unit. During an observation and interview on 11/06/2023 at 11:59 AM, a mouse was observed in room [ROOM NUMBER] under Resident #21's bed behind their headboard. Resident #21 stated they heard mice and only saw them after they were…

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, record review, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter to maintain dignity for 1 (Resident #90) of 3 sampled residents reviewed for urinary catheter management. Findings included: Review of a facility policy titled, Privacy and Dignity, revised 06/2020, revealed, Purpose: To ensure that care and services provided by the facility promote and/or enhance privacy, dignity, and overall quality of life. Policy: The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. Review of a facility policy titled, Catheter - Care of, revised 06/2020, revealed, III. Proper Techniques for Urinary Catheter Maintenance. Further review of the policy revealed F. Collection bags and IV. The resident's privacy and dignity will be protected by placing a cover over drainage bag when the resident is out of bed. Review of an admission Record revealed the facility admitted Resident…

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 facility policy review, the facility failed to invite the resident or resident RP to participate in the care planning process for 1 (Resident #79) of 25 residents whose care plans were reviewed. Findings included: A review of a facility policy titled Care Planning, revised in June 2020, revealed, The facility will invite the resident, if capable, and their family to care planning meetings and use its best efforts to schedule care planning meetings at times convenient for the resident and family. A review of Resident #79's admission Record revealed the facility admitted the resident on 11/19/2020 with diagnoses that included dementia, diabetes, and chronic diastolic heart failure. A review of Resident #79's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/14/2023, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #79's care plan revealed there had been revisions made on 06/15/2023, but there was no…

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, record review, and facility policy review, the facility failed to notify the physician when there was a need to alter treatment for 1 (Resident #100) of 3 residents reviewed for skin concerns. Findings included: A review of a facility policy titled Change in a Resident's Condition or Status, revised in February 2021, revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. The policy further revealed, 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or 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 interviews, record reviews, and facility policy review, the facility failed to ensure resident care plans were comprehensive for 1 (Resident #128) of 3 residents reviewed for care plans. Findings included: A review of a facility policy titled Care Planning, last revised in June 2020, revealed, A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. The policy further revealed, Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. A review of Resident #128's admission Record revealed the facility admitted the resident on 08/28/2023 with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #128's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/2023…

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, record review, and facility policy review, the facility failed to provide services necessary to maintain good grooming and personal hygiene for 1 (Resident #111) of 9 sampled residents reviewed for activities of daily living (ADL) care. Findings included: Review of a facility policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance to the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care. Review of Resident #111's admission Record, revealed the facility admitted the resident on 06/12/2023 with diagnoses that included diabetes mellitus, cervical disc degeneration, sciatica, and other chronic pain. Review of Resident…

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, record review, and facility policy review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's needs, interests, and preferences as identified in the resident's assessment to enhance quality of life for 1 (Resident #43) of 3 residents reviewed for activities. Findings included: A review of a facility policy titled Activities Program, revised June 2020, revealed, Purpose: to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical, and emotional functioning. The policy revealed II. A variety of activities should be offered on a daily basis, which includes weekends and evenings. III. Activities are developed for individual, small group, and large group participation. The procedure revealed C. The facility will provide equipment and supplies for independent and group activities, and for residents who have special…

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, record review, and facility policy review, the facility failed to ensure a rash for 1 (Resident #100) of 3 residents reviewed for skin concerns were assessed and received treatment. Findings included: A review of a facility policy titled Care and Services, revised in June 2020, revealed, Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Further review revealed, Policy: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. A review of Resident #100's admission Record revealed the facility admitted Resident #100 on 03/23/2023 with diagnoses that included chronic heart disease, type 2 diabetes mellitus (DM II), need for assistance with…

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, record reviews, and facility document and policy review, the facility failed to ensure 1 (Resident #538) of 3 residents reviewed for pain management received pain medication as ordered by the physician. Findings included: A review of a facility policy titled Pain Management, revised in June 2020, revealed, A. A licensed Nurse will assess for pain upon admission. The Licensed Nurse will complete a Pain Assessment located in Point Click Care (PCC) [electronic health record] for residents identified as having pain within 8 hours of admission. The policy revealed for pain management, A. The Licensed Nurse will administer pain medication as ordered and document medication on the Medication Administration Record (MAR) and D. Nurse staff will implement timely interventions to reduce the increase in severity of pain. A review of Resident #538's admission Record revealed the facility admitted the resident on 10/02/2023 and discharged the resident on 10/03/2023. Resident #538's diagnoses included a…

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

Based on interviews, record reviews, facility document and policy review, the facility failed to ensure a resident receiving antipsychotic medication had an appropriate diagnosis for continued use for 1 (Resident #128) of 6 residents reviewed for antipsychotic medications: Findings included: A review of a facility policy titled Psychotherapeutic Drug Management, revised in June 2020, revealed, The psychotherapeutic medication order will include the following information: i. Informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage as per state guidelines. ii. Diagnosis for the medication. Further review of the policy revealed, H. The Attending physician will respond to any irregularities reported by the pharmacist as described in section VI (D) by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it. i. If no action has been taken, the attending physician must document his/her rationale. ii. Documentation 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 interviews and record review, the facility failed to maintain medical records that were complete and readily accessible for 1 (Resident #70) of 2 residents reviewed for hospitalizations. Findings included: During an interview on 11/09/2023 at 3:15 PM, the Regional Nurse Consultant stated the facility did not have a specific policy related to obtaining hospital discharge paperwork for residents who returned from the hospital. A review of Resident #70's admission Record revealed the facility admitted the resident on 09/25/2023 with a diagnosis that included type 2 diabetes mellitus without complications. A review of Resident #70's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2023, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of diabetes mellitus and received insulin daily during the seven-day lookback period. A review of a care plan focus area for Resident #70, revised on 09/29/2023, revealed 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 observations, interviews, record review, and facility policy review, the facility failed to ensure two staff members wore appropriate personal protective equipment (PPE) to prevent the spread of infection when caring for 1 resident who was COVID-19 positive (Resident #187) of 4 residents sampled for infection control. Findings included: A review of a facility policy titled Resident Isolation - Categories of Transmission-Based Precautions, revised 10/24/2022, revealed, I. Transmission-based precautions are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. A. The facility will initiate transmission-based precautions for a constellation of new symptoms consistent with a communicable disease. These transmission-based precautions may be adjusted or discontinued when additional clinical information becomes available (e.g., confirmatory laboratory results. The policy revealed IIII. Contact Precautions. A. Contact precautions are…

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.

See Event ID LTWZ12 Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The residents' feet were extremely dry with large areas of skin that flaked and peeled (Residents #21 and #22). The census was 133. 1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/23, showed the following: -Short/Long term memory loss; -Required extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene; -Required total staff assistance for toilet use and bathing; -Diagnoses of malnutrition, arthritis and anemia; -No foot problems documented. Review of the resident's care plan, dated 8/10/23, showed the following: -Problem: Resident has activities of daily living (ADL) self-care performance deficit due to weakness, decreased cognition and disease process; -Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe…

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 the resident Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment accurately reflected the resident's status, for five of 29 sampled residents (Resident #141, #143, #56, #38 and #60). The census was 143. 1. Review of Resident #141's medical record, showed: -An incident note, dated 11/9/19, resident stated he/she had an area on his/her bottom that he/she wanted evaluated. Upon assessment, Non blanchable, red excoriation noted to left buttocks. Area approximately 3.3 x 1.0 centimeter (cm). Physician notified and new orders obtained; -An order dated 11/10/19, for skin prep wipes to left gluteal (buttocks) two times day; -An annual MDS, dated [DATE], showed: -Other ulcer, wounds and skin problems: No; -Moisture associated skin damage (MASD): Not marked; -A weekly wound observation tool, dated 12/10/19: Left buttocks MASD measured 1.8 x 2 x 0.1; -A weekly skin observation, dated 2/11/20: Left…

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 develop and implement a comprehensive person-centered care plan regarding infections, nutrition/weight loss, and pain management for eight of 29 sampled residents (Residents #138, #56, #38, #60, #85, #123, #62 and #127). The census was 143. 1. Review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: -admitted [DATE] from an acute hospital; -Diagnoses included septicemia (sepsis, systemic infection of the blood); -Infection of the foot; -Application of nonsurgical dressings other than to feet; -Applications of dressings to feet. Review of the resident's care plan, in use while a resident at the facility, showed: -Focus: The resident has infection of the (specify): -Goal: Be free from complications related to infection; -Interventions: (blank). Review of the resident's diagnoses list, showed: -Cellulitis (infection of the skin), acute infection, diagnosis 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 observation, interview and record review, the facility failed to ensure a discharge planning process was in place which addressed discharge goals and needs, including an updated care plan, caregiver support and referrals to local contact agencies as appropriate, that involved the resident and interdisciplinary team in developing a discharge plan for four of 29 sampled residents (Residents #139, #398, #2, and #1). The census was 143. 1. Review of Resident #139's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/20, showed the following: -admitted to the facility on [DATE]; -Ability to understand others and to make him/herself understood; -Always continent of bowel and bladder; -Adequate speech, hearing and vision; -A Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment) score of 15 out of 15 (cognitively intact); -No behaviors; -Independent with all activities of daily living (ADLs); -Diagnosis that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly monitor residents nutritional status to ensure early identification of residents with, or at risk for, impaired nutrition or hydration status. This would allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise. The facility failed to obtain weights as directed by the resident's care plan for one resident (Resident #56) and failed to ensure the dietician monitored residents nutritional status quarterly for four of eight residents reviewed for nutritional needs (Resident #56, #85, #123, and #144). The sample was 29. The census was 143. Review of the facility's Nutrition and Unplanned Weight Loss/Gain policy, dated 6/28/19, showed: -The facility will assess and monitor the nutritional status of residents to assist the resident in maintaining adequate nutritional status, to the extent possible, giving careful consideration to the following: The residents choice…

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 assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services. The facility relied on staffing agencies to provide nursing services for the residents. The facility did not train the agency staff on facility policies and procedures. In addition, the facility staff failed to demonstrate competency in care provided to treat wounds. The census was 143. Review of the facility assessment, revised 12/9/19, showed: -Staff: -Registered Nurses (RN); -Licensed Practical Nurses (LPN); -Direct care staff; -Nurse educator; -(Agency staff not indicated as staff utilized) -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes; -Certified Nursing Assistants (CNAs) are given core in-service to ensure completion of mandatory 12 hours of training in conjunction with…

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

Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified 68 certified nursing assistants (CNAs) employed at the facility for more than a year. Seven CNAs were sampled and five of the seven did not have the required 12 hours of in-service training. The census was 143. Review of the facility assessment, revised 12/9/19, showed: -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes; -CNAs are given core in-service to ensure completion of mandatory 12 hours of training in conjunction with facility identified training needs. 1. Review of CNA S's employee file and training log, showed: -Date of hire (DOH) 8/27/17; -Training hours reviewed from 8/2018 through 7/2019 = 0. 2. Review of CNA V's employee file and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are stored and labeled in accordance to current acceptable professional standards for two of three observed medication carts and two of three observed nurse treatment carts. The census was 143. 1. Observation on [DATE] at 6:36 A.M., of the second floor treatment cart, showed the following: -A tube of protective ointment cream labeled with a resident's name, the lid opened, and the tube lay directly in the drawer of the cart; -A tube of hydrogel wound cream (ointment used to keep wounds moist and promote healing) with vitamin E, the lid opened and the tube lay directly in the drawer of the cart. No resident name labeled on the tube; -A tube of itch relief cream, opened and lay directly in the drawer of the cart. No resident name labeled on the tube; -A 30 gram tube of Santyl cream (used to treat wounds), opened and lay directly in the drawer of the cart. No resident name labeled on the tube;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to keep items labeled and dated in the kitchen storage rooms, to ensure the deep fryer was free of debris, microwaves and cabinets were free of dirt and debris and the vents above the preparation areas were free of dust buildup. This had the potential to affect residents who received food from the facility kitchen. The census was 143. Observation of the kitchen on 3/11/20, showed the following: -At 6:45 A.M., three large containers of dry cereal in the storage room did not have a label or date; -At 6:46 A.M., grease and debris on the top and sides of the deep fryer. The vents above the food preparation area covered with dust; -At 6:50 A.M., the microwave in the kitchenette of the main dining room had dried food and debris on the inside. Three dead bugs in the cabinets next to the microwave in the kitchenette of the main dining room; -At 7:15 A.M., the microwave in the [NAME] kitchenette had dried food and debris on the inside. Observation of the kitchen 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 observation, interview and record review, the facility failed to ensure the quality assessment and assurance committee develop and implement appropriate plans of action to correct identified quality deficiencies. The facility received repeated deficiencies for the prior year's annual survey to the current year's annual survey. In addition, the facility failed to implement a performance improvement plan for an identified concern with pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) care that resulted in a citation at the isolated actual harm level, which is a higher grid level than the citation received the prior year for the same concern. The census was 143. Review of the facility's Quality Assurance Process Improvement and Compliance policy, last revised 4/30/18, showed: -This organization will implement and maintain an active quality assurance process improvement and compliance (QAPIC) program; -QAPIC efforts will be ongoing, comprehensive and will…

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 implement procedures for the provision of infection prevention and control utilizing current standards of practice for three of four residents observed during wound care (Resident #135, #60 and #38). In addition, the facility failed to ensure employee purified protein derivative (PPD) test (a test that helps diagnose (TB) tuberculosis) results were documented completely for seven of 10 sampled employees. The sample was 29. The census was 143. Review of the facility's Skin Ulcer-Wound policy, dated 8/15/18, showed: -All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations; -Purpose: To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Skin ulceration prevention: Promotion of clean, dry and well moisturized skin; -Treatment protocols: Follow standard precautions and good hand hygiene techniques. Review of the facility's Infection Control Program,…

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

Based on interview and record review, the facility failed to implement a training program to provide training to agency staff tasked with the responsibility to care for residents to include abuse, neglect, exploitation, misappropriation of resident property, dementia management and resident abuse prevention. The census was 143. Review of the State Operations Manual, showed staff includes for the purposes of the training guidance, all facility staff, (direct and indirect care and auxiliary functions) contractors, and volunteers. Review of the facility assessment, revised 12/9/19, showed: -Staff: -Registered Nurses (RN); -Licensed Practical Nurses (LPN); -Direct care staff; -Nurse educator; -(Agency staff not indicated as staff utilized); -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes; -Abuse, neglect and exploitation: Training that at a minimum educates staff on 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.

Based on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to assess if a resident's bed/side rails posed a safety risk or if they could be used by the resident safely, providing independence with bed mobility and/or transfers in and out of the bed. The facility removed Resident #38's bed with bed/side rails and replaced it with a regular bed without bed/side rails, without assessing and providing the resident an alternate accommodation to allow the resident to maintain independence with bed mobility, for one of 29 residents sampled (Resident #38). The census was 143. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/19, showed: -Moderate cognitive impairment; -No behaviors; -Extensive assistance for bed mobility, dressing, personal hygiene, toilet use and with locomotion on and off unit; -Total dependence for transfers; -No bed/side rails used. Review of the resident's care plan, dated 12/22/19,…

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

Based on interview and record review, the facility failed to develop and implement written policies and procedures that include screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property by failing to complete required background checks timely for three of 10 employees sampled. In addition, the facility policy failed to require the nurse aide registry check on employees. The census was 143. Review of the facility's Employment Screening policy, revised 12/2016, showed: -In accordance with state and federal regulations, this facility will not knowingly hire, contract or retain any individual that is ineligible to work in healthcare facility, that has been excluded from participation in the Medicare or Medicaid programs, or that has not met required licensure or certification requirements for the position being considered; -Unless otherwise stipulated by this policy a new employee may not start working until all the following is completed or initiated: -At least two days prior to scheduled resident contact check the employment…

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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident for two of three sampled residents admitted within the past 30 days (Residents #143 and #498). The census was 143. 1. Review of Resident #143's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/20, showed: -admitted [DATE] from an acute care hospital; -Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene; -Diagnoses included high blood pressure and seizure disorder; -At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction); -One stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister) on admission. Review 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 observation, interview and record review, the facility failed to develop the comprehensive care plan within 7 days after completion of the comprehensive assessment, for one of three sampled residents admitted within the past 30 days (Resident #143). The census was 143. Review of Resident #143's admission MDS, dated [DATE], showed: -admitted [DATE] from an acute care hospital; -Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene; -Diagnoses included high blood pressure and seizure disorder; -Care area assessment summary (CAAS), showed the following care areas triggered and the facility indicated the areas were care planned: -Urinary incontinence and indwelling catheter (tube inserted into the bladder to drain urine); -Nutritional status; -Feeding tube; -Dehydration/fluid maintenance; -Pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue). Review of the resident's medical record, reviewed on 3/11/20, showed: -No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene per resident wishes and standards of practice for two residents (Residents #60 and #135). The sample was 29. The census was 143. 1. Review of Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/20, showed: -Cognitively intact; -Rejection of care: Behavior not exhibited; -Total dependence for bed mobility, dressing and personal hygiene; -Bathing: Total dependence; -Diagnoses included cerebral palsy (disorder that affect movement and muscle tone), anxiety and depression. Review of the resident's care plan, dated 7/9/18, showed: -Focus: Activities of daily living (ADL) self-care performance deficit related to limited mobility and quadriplegia. Required total assistance with ADLs. Prefers to have showers done at 10:00 A.M. on Mondays and Wednesdays: -Goal: Would like for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to routinely assess, monitor and document on two residents receiving dialysis (process for removing toxins from the blood for individuals with kidney failure). The facility identified 6 residents as receiving routine dialysis treatments, three were sampled and problems were found with all three. (Residents #123, #62 and #127). The census was 143. Review of the facility's End Stage Renal Disease Dialysis Policy, dated 1/4/20, showed the following: -Purpose: To ensure a resident with End Stage Renal Disease (ESRD), including dialysis care and treatment outside the facility, receive services by facility staff trained in the care and special needs of these residents; -Policy: Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility shall be trained in the care and special needs of these residents; -Education and training of staff in the care of ESRD/dialysis resident may be managed by the contracted…

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 failed to ensure hot foods were at least 120 degrees Fahrenheit (F) when served to residents for one of one test trays sampled on the 100 hall. The census was 143. Observation of the 100 hall meal service on 3/11/20, showed the following: -At 8:30 A.M., during an interview, Nurse A said breakfast trays had not arrived to the hall; -At 8:35 A.M., observation of the main dining room showed five trays covered. During an interview, the Assistant Dietary Supervisor (ADS) said the meal trays were for 101 to 116 hall trays; -At 8:50 A.M., observation showed hall trays delivered to the hall; -At 9:00 A.M., hall trays passed out by staff. A test tray of a hall tray, completed with ADS, showed eggs at 100 degrees F and sausage at 80 degrees F. The sausage was cold to taste. During an interview at that time the ADS said the food should be served at 160 degrees F. During an interview on 3/12/20 at 10:06 A.M., seven of seven residents said there is too much of the same types of food and food can often be cold for most meals. During an interview 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 observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for two resident (Residents #56 and #38). The sample was 29. The census was 143. 1. Review of Resident #56's hospital discharge transfer orders for the receiving facility, showed: -discharged to facility on 2/20/20; -Procedure site: Sacral/coccyx (buttocks/tailbone area): Wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to sacrum. Review of the resident's medical record, showed: -A readmission assessment, dated 2/20/20: admitted from hospital on 2/20/20 at approximately 5:45 P.M. Skin issues present; -An order dated, 2/21/20 for collagenase ointment (an enzyme that helps promote healthy tissue growth), apply to affected area topically daily; -An order dated 3/2/20: Change wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to buttocks on Mondays, Wednesdays and Fridays: -Not documented as applied until 3/4/20;…

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.