Fountain Care At Sunset Hills

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 27 opportunities observed, four errors occurred, resulting in a 14.81% error rate (Resident #44 and Resident #58). The census was 89. Review of the facility's Medication Administration policy, reviewed January 2024, showed: -Purpose: -To administer the following: -Right medication; -Right dose; -Right dosage form; -Right route; -Right resident; -Right time; -Procedure: -Read the Medication Administration Record (MAR) for the ordered medication, dose, dosage form, route, and time; -Review the resident's allergies; -Verify the pharmacy prescription on the drug and the manufacturer's identification system matches the MAR; -Verify that any further medication identifiers match the label and the medication; Identifiers may include, but are not limited to -Drug size; -Shape; -Color. -Verify the correction medications , expiration date, dose, dosage form, route and time again by comparing to MAR before administering; -Administer oral medications with a full glass 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 food was served at a palatable, safe, and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F). This affected 2 of 20 sampled residents (Residents #15 and #34). The census was 89. Review of the facility's meal service temperature policy, dated 1/2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: foods shall be provided at point of service to support resident/patient satisfaction. Temperatures of hot food shall be supported to promote service temperatures of hot foods to about 120 degrees F and cold foods to below 50 degrees F. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents receiving dialysis (medical procedure that filters blood when the kidneys are unable to) received breakfast before dialysis. The facility identified 11 residents as receiving dialysis. Of the 11, four were included in the sample of 20 and issues were identified with two residents (Residents #15 and #80). The census was 89. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Receives dialysis while a resident; -Diagnoses included type 2 diabetes and kidney failure. Review of the resident's Physician Order Sheet (POS), dated 4/21/25, showed an order, dated 2/13/25, in house dialysis Tuesday, Thursday and Saturday. During an interview on 4/22/25 at 12:23 P.M., the resident said he/she never gets breakfast before he/she goes to in-house dialysis and has to wait until dialysis is over to eat. He/She…

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 call lights were accessible for two residents (Residents #15 and #58). The sample was 20. The census was 89. Review of the facility's call light protocol policy, dated 1/2022, showed: -Purpose: to respond to resident/patient's request and needs; -Procedure: answer call light in a reasonable amount of time. Respond to request. When unable to meet request, obtain assistance from caregiver that can meet request. Assist resident/patient as needed to a comfortable position with call light within reach. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Diagnoses included type 2 diabetes, kidney failure, and hemiplegia (muscle weakness) and hemiparesis(partial paralysis) following cerebral infarction(stroke) affecting left non-dominant side. Review of the resident's care plan, in use at the time of the survey,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See Event 172412 Based on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect 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 See Event 172412 Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required time after residents were involved in resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11) The sample size was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility shall report immediately, but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation 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 ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required time after residents were involved in resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11) The sample size was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility shall report immediately, but not later than two…

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 address a recommendation from the Registered Dietitian (RD) for a resident with a significant weight loss, to prevent further weight loss (Resident #2). The sample was six. The census was 101. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed the following: -Severe cognitive impairment; -Dependent with activities of daily living (ADLs); -Diagnoses of a stroke; -Weight 157 pounds (lbs); -Gastronomy tube (g-tube, flexible, hollow tube that is inserted through the stomach wall and skin to deliver food and medicine directly to the stomach); -Risk for pressure ulcers(a localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time). Review of the resident's care plan, dated 7/5/24, showed the following: -Focus: G-tube: Alteration in nutritional status related to g-tube placement; -Intervention: Check g-tube for placement prior to administering medication or anything via…

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 prevent the diversion (the unauthorized removal) of Schedule II controlled medications (medication with higher potential of dependency and abuse) for two residents (Resident #1 and Resident #2) of 4 sampled residents. This had the potential to affect all residents in the facility. The census was 92. The Administrator was notified on 7/23/24, of the past non-compliance which began on 7/4/24. The facility began an investigation, counted the medication carts, added a corrected count to all controlled substance logs, interviewed staff and residents, notified the police, the residents affected and their physician, in-serviced staff on abuse and misappropriation of resident property (including drug diversion) and terminated Licensed Practical Nurse (LPN) A. The deficiency was corrected on 7/10/24. Review of the facility's Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised 8/1/22, included: Prevention and Reporting: -The Administrator has primary responsibility in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an appropriate immediate discharge letter to one of three sampled residents (Resident #2). The letter failed to contain the location to where the resident was being transferred and discharged , failed to disclose the appeal rights and the correspondence information and the name, address and telephone number of the designated regional long-term care ombudsman office. In addition, the facility failed to readmit the resident when the discharge was dismissed. The census was 93. Review of the facility's Room Changes, Transfers, and Discharges policy, dated 7/2022, showed: -The resident/patient's physician must document evidence in the resident/ patient's clinical record that a discharge is necessary for the following: -The facility determines that the discharge is necessary for the resident/patient's welfare and the resident/patient's needs cannot be met in the facility; -The safety of individuals in the facility is endangered. -The facility 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.

Based on observation, interview and record review, the facility failed to follow its policy when an injury of unknown origin was discovered and not reported, assessed, or investigated for one resident (Resident #1). The census was 92. Review of the facility's Accident and Incident Protocol, reviewed 7/2022, included: -The facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident); -The facility defines an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome; -The event may be an accident or a situation that could result in an accident. Accidents/incidents may include, but are not limited to the following: 1. Unexplained bruises/skin tears; 2. Injuries of unknown origin; 3. Injury to resident/patient during handling; -Should an accident/incident occur, the facility strives to prevent such an occurrence from happening again; -A thorough investigation and follow-up…

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 follow its policy by not obtaining a physician's order for a skin tear of unknown origin for one resident (Resident #1), thereby potentially increasing the risk of a negative outcome related to the healing process due to a diagnoses of Type 2 diabetes mellitus with diabetic chronic kidney disease. The census was 92. Review of the facility's Physician Orders policy, last revised 5/1/11, showed: -Protocol: At the time each resident/patient is admitted , the facility will have physician orders for their immediate care. Physician's orders will be verified by the attending physician at the facility. All physician orders will be dated and signed according to State and Federal regulations; -All clinicians may take verbal and/or telephone orders as permitted by their state licensure board; Procedures included: -Obtain one on the following types of physician orders: -Verbal; -Telephone order; -Transmitted by facsimile machine (fax); -Written by the physician; -Assure physician's orders include the drug or treatment 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 See the deficiency cited at Event J2L412. Based on observation, interview and record review, the facility failed to protect one resident (Resident #400) from misappropriation of property when a staff member took a resident's baseball cap, which he/she received during a trip to the baseball game. The resident said he/she wanted his/her baseball cap back, and not having it made him/her feel bad and sad. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc; -Definitions: -Misappropriation of Resident Property (Includes but is not limited to): Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.…

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 the deficiency cited at Event J2L412. Based on observation, interview and record review, the facility failed to ensure an allegation of misappropriation was reported to the facility Administrator and the state agency in a timely manner, when a staff member, Housekeeper B, removed a resident's baseball cap from the resident's room without his/her knowledge or consent (Resident #400). Another staff member, Housekeeper D, saw Housekeeper B with the resident's baseball cap but did not report the allegation to management until a week later when management asked him/her about the incident. The incident of misappropriation occurred on 11/8/23. The incident was reported to the Administrator on 11/14/23 and to the state agency on 11/15/23. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility encourages and supports all residents, staff and families in feeling free to report any suspected acts of 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.

Based on observation, staff interview, and facility documentation review, the facility failed to staff a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week and failed to ensure the Director of Nursing (DON) worked as a charge nurse only when the facility had a census of 60 or less. The census upon the entrance of the survey team was 102. The findings include: At approximately 12:40 p.m. on 10/11/23, the surveyor asked Receptionist RR for the location of the facility's posting of daily nurse staffing information. Receptionist RR pointed to a plastic sign holder located on the reception desk. In the plastic holder was a sheet of paper titled CHESTNUT REHAB. The date on the top of the form was 10/10/23, and the census was 103. The form included hours worked by Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs) on the day shift and the evening shift, as well as hours worked by LPNs and CNAs on the night shift. Documentation on the form indicated there were no hours worked on any shift 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication carts were securely locked, failed to ensure medication rooms were securely locked, failed to ensure medications contained opened and expiration dates, failed to ensure medication refrigerators were free from spills, and failed to ensure temperature monitoring was documented. The findings include: Review of the facility's policy and procedures titled Medication Storage in The Facility, dated November 2021, indicated: . ID1: Storage of Medications . Policy - Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedures . B. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) permitted to access medications.…

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 review of the facility policy, the facility failed to store and prepare food in accordance with professional standards for food service safety for one of one main kitchen. The findings include: 1. Review of the facility policy titled, Food Storage - Refrigeration last revised 1/2016, revealed: 4 - All refrigeration units shall have temperatures monitored on a daily basis by the Manager and/or his/her designee. Temperatures shall be recorded daily and the monthly record shall be maintained in the Managers office for a period of two (2) years. Internal thermometers shall be placed in the front section of each unit and shall be large enough for easy visibility visibility. Refrigeration temperatures shall be maintained below 40 degrees but with a preferred temperature of 36-38 degrees for maximum chilling. [sic] On 10/10/23 at 9:45 a.m., the reach-in refrigerator (near the handwashing sink) did not have a thermometer inside of the unit. The Certified Dietary Manager (CDM) stated that when she last checked, there was a thermometer in 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 observations and interviews, the facility failed to maintain the dumpster area in a manner to keep the area clean and free of waste. This affected two of two dumpsters used to serve the facility. The findings include: On 10/10/23 at 9:57 a.m., 10/10/23 at 2:50 p.m., 10/11/23 at 7:48 a.m., and 10/11/23 at 11:49 a.m., the ground surrounding the dumpsters had a heavy accumulation of trash, cigarette butts, and debris. There were two trash compactors, and the lid of one of the trash compactors was open. Staff were not observed taking out any trash. During an interview with the Certified Dietary Manager (CDM) on 10/10/23 at 10:00 a.m., the CDM stated the dumpsters are used by all departments of the facility, including nursing. The CDM stated she expected all departments that utilized the dumpsters to keep the area clean. The CDM stated everyone should be pitching in to keep it clean, not just dietary. The CDM revealed she and other dietary staff had seen wildlife (racoons, possums, deer, and rodents) near the dumpster area because of the heavy accumulation of waste and trash 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 observations, record review, interviews, and review of the facility policy, the facility failed to protect the dignity of three of six residents reviewed for urinary catheters [Resident (R) #9, R #18, and R #24]. The findings include: Review of the facility policy titled Resident Rights revealed: The facility will address ethical issues and respect resident rights in providing care. The facility recognizes the resident right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making, consistent with State law and Federal regulation. [sic] 1. On 10/10/23 at 11:00 a.m., 11:53 a.m., and 1:00 p.m., observations of R #9's foley catheter bag was visible to staff and visitors. The catheter bag was observed to contain a yellow substance and was not covered to protect the resident's dignity. Staff were not observed to ask the resident if they could empty the catheter bag, nor were staff observed to provide the resident with a privacy cover. R #9 was admitted…

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 review of the facility policy, the facility failed to provide the residents with a safe, sanitary, and comfortable homelike environment for two of three units observed during the survey. The findings include: Review of the facility policy titled Cleaning and Disinfecting, last updated 7/2022, revealed: Purpose - The purpose of this procedure is to provide guidelines for cleaning and disinfecting. General Guidelines 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three [3] times per week) and when surfaces are visibly soiled. Further review of the policy revealed an adendum [sic], dated 10/11/23, stating: All common areas (lobbies, hallways, day room etc.) will be cleaned daily and as needed including sweeping, mopping, dusting, vacuuming, etc. Dining rooms will be swept and mopped after every meal and as needed. [sic] 1. On 10/10/23 at 10:42 a.m., 12:50…

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 policy review, the facility failed to establish and maintain an effective infection control program by: 1. Failing to ensure one Certified Medication Technician (CMT) performed hand hygiene during administration of medications; and one CMT and one Licensed Practical Nurse (LPN) cleaned a portable blood pressure cuff before or after using it on different residents; and 2. Failing to develop and implement written policies and procedures in accordance with accepted national standards and guidelines for the use of personal protective equipment (PPE) when suctioning during tracheostomy care. The findings include:1. During medication administration observations on 10/11/23 at 7:52 a.m., CMT BB removed a portable blood pressure cuff from the top of the medication cart and entered the room of Resident (R) #12. CMT BB attached the blood pressure monitor cuff to R #12's upper arm and measured his blood pressure. CMT BB then placed the blood pressure monitor to the top 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 protect one resident (Resident #400) from misappropriation of property when a staff member took a resident's baseball cap, which he/she received during a trip to the baseball game. The resident said he/she wanted his/her baseball cap back, and not having it made him/her feel bad and sad. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc; -Definitions: -Misappropriation of Resident Property (Includes but is not limited to): Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #400's annual Minimum Data…

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 ensure an allegation of misappropriation was reported to the facility Administrator and the state agency in a timely manner, when a staff member, Housekeeper B, removed a resident's baseball cap from the resident's room without his/her knowledge or consent (Resident #400). Another staff member, Housekeeper D, saw Housekeeper B with the resident's baseball cap but did not report the allegation to management until a week later when management asked him/her about the incident. The incident of misappropriation occurred on 11/8/23. The incident was reported to the Administrator on 11/14/23 and to the state agency on 11/15/23. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility encourages and supports all residents, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury of unknown…

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 review, and review of the facility policy, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed in a timely manner after a significant change in status was identified for one of 20 residents [Resident (R) #64] reviewed. The findings include: Review of the facility's policy title, MDS Process, dated 1/2022, revealed: Policy: The facility will complete the MDS/RAI [Resident Assessment Instrument] process according to and in compliance with Federal and State Mandates. Procedure: The MDS Nurse/Coordinator and team members contributing to the MDS process will complete the MDS/RAI process and all related functions in compliance with Federal and State mandates, utilizing guidelines established in the Federal RAI manual. R #64 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, degenerative disease of nervous systems (neurodegenerative diseases affects the body's activities such as balance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility policy, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one of 20 residents [Resident (R) #64] reviewed. The findings include: Review of the facility's policy titled MDS Process, dated 1/2022, revealed: Policy: The facility will complete the MDS/RAI [Resident Assessment Instrument] process according to and in compliance with Federal and State Mandates. Procedure: The MDS Nurse/Coordinator and team members contributing to the MDS process will complete the MDS/RAI process and all related functions in compliance with Federal and State mandates, utilizing guidelines established in the Federal RAI manual. R #64 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, degenerative disease of nervous systems (neurodegenerative diseases affects the body's activities such as balance, movement, talking, breathing, and heart function), heart failure, and acute kidney failure.…

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 plan of care was reviewed and revised after a fall for one of 20 residents whose care plans were reviewed (Resident (R) #7). The findings include: Review of facility policy titled Falls Programs Policy and Procedure, with a review date of 1/2023, revealed the purpose of the policy was to identify all residents who have a high risk for falls and to ensure adequate interventions are in place to prevent a major injury. The procedure section noted, 3. The MDS (Minimum Data Set) nurse will be responsible for completing the Comprehensive Plan of Care for falls. The policy does not identify to review and revise the plan of care after each fall to ensure interventions identified were effective or needed revision. Review of facility policy titled Policy for Comprehensive Care Planning, with a review date of January 2022, revealed, the purpose was to develop and maintain an individualized care plan for residents residing in the facility. The procedure…

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 review, and review of the facility policy, the facility failed to ensure one of three residents reviewed received a final summary of the resident's status prior to being discharged from the facility [Resident (R) #99]. The findings include: Review of the facility policy titled, Room Changes, Transfers, and Discharges, last reviewed 4/2022, revealed: Protocol . Transfers and discharges will be conducted according to State and Federal regulations. Review of R #99's face sheet revealed the resident was admitted to the facility on [DATE] and discharged on 8/27/23 with diagnoses including, but not limited to, osteoarthritis of knee, pain, and presence of right artificial knee joint. Further review of R #99's Electronic Health Record (EHR) revealed the resident discharged herself from the facility Against Medical Advice (AMA). Review of R #99's Voluntary Discharge Against Medical Advice and Release of Liability form, dated 8/27/23, revealed the resident was discharged and taken home by her…

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 emergency equipment was available at the bedside for immediate access in the event of an unplanned decannulation for one of three residents reviewed for tracheostomy care [Resident (R) #90]. The findings include: Review of the facility's policy titled Tracheostomy and Tracheostomy Tube Care (undated) found no mention of the need to maintain sterile emergency equipment at the bedside for immediate access in the event of unplanned extubation or decannulation. The Centers for Medicare and Medicaid Services identified the following: . the facility must determine whether it has the capability and capacity to provide the needed respiratory care/services for a resident with a respiratory diagnosis or syndrome that requires specialized respiratory care and/or services. This includes, at a minimum, sufficient numbers of qualified professional staff, established resident care policies and staff trained 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 interview and record review, the facility failed to document in the medical record the circumstances leading up to a resident's transfer to the hospital and details of the resident's return to the facility, for one of four residents reviewed for rehospitalizations [Resident (R) #18]. The findings include: Record review revealed R #18 was readmitted to the facility on [DATE], and diagnoses included: acute and chronic respiratory failure with hypoxia, heart failure, and encounter for attention to tracheostomy. Review of R #18's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive to total assistance from one or more persons for most activities of daily living, including bed mobility, transfers, dressing, bathing, and personal hygiene. Review of R #18's care plan revealed the following Focus Area (last revised on 3/16/23): - BREATHING DIFFICULTY: [R #18] has potential 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 interview and record review, the facility failed to follow their abuse policy when staff failed to report an allegation of abuse to the state agency. On the evening of 8/2/23, the facility was made aware Resident #3 said Certified Medication Technician (CMT) D made disrespectful remarks which included CMT told the resident he/she would give the resident something to take (him/her) out of here. This caused the resident to refuse his/her medications that evening. The facility failed to make an initial report and failed to submit a completed investigation of the resident's allegations to the Department of Health and Senior Services within the required time-frames. Fourteen residents were sampled and problems were found with one. The census was 90. Review of the facility Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin policy, dated 8/17/16 and last revised on 8/1/22, included the following: Prevention and Reporting: 1. The Administrator has primary responsibility in the facility for implementation of the abuse/neglect program; a. 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 interview and record review, the facility failed to follow their abuse policy by failing to complete a thorough investigation for an allegation of abuse. On the evening of 8/3/23, Resident #3 said Certified Medication Technician (CMT) D made disrespectful remarks, and told the resident he/she would give the resident something to take (him/her) out of here. This caused the resident to refuse his/her medications that evening. The facility failed to interview three staff who worked on the unit with CMT D and the resident. Two of the three staff were interviewed by the surveyor. Both said the resident was upset and emotional on the evening of 8/2/23. Certified Nursing Assistant (CNA) H confirmed the resident cried and CNA I overheard CMT say a disrespectful remark to the resident. This had the potential to affect all residents. The census was 90. Review of the facility Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin policy, dated 8/17/16 and last revised on 8/1/22,…

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 ensure all staff, including agency staff, were adequately trained and informed of facility policies and expectations per acceptable nursing standards. In addition, key management staff in the facility failed to be knowledgeable about the location of and process for medical record documentation. This failure has the potential to affect all resident in the facility. The census was 85. 1. Review of the State Operations Manual appendix PP, section 483.70(e) revised 11/22/17, Facility Assessment showed: -An assessment of the resident population is the foundation of the facility assessment and determination of the level of sufficient staff needed; -The assessment of the resident population should drive staffing decisions; -Inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served; -The facility's assessment must address/include: -An evaluation of staff competencies that are necessary to provide the level and types 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.

Based on interview and record review, the facility failed to ensure certified nurse aides received the required 12 hours of training per year and have a system to track the hours for eight of nine employees reviewed who worked at the facility for over a year. The census was 85. Review of the training records provided by the facility, showed: -Nine certified nurse aides (CNAs) worked at the facility for over a year; -CNA D hired 4/19/11, with 1 hour and 30 minutes of in-service education in the past year; -CNA I hired 9/26/12, with 1 hour of in-service education in the past year; -CNA G hired 9/4/15, with 8 hours and 30 minutes of in-service education in the past year; -CNA F hired 9/5/15, with 8 hours and 15 minutes of in-service education in the past year; -CNA H hired 5/31/17, with 4 hours and 45 minutes of in-service education in the past year; -CNA E hired 6/4/18, with 2 hours and 30 minutes of in-service education in the past year; -CNA K hired 5/1/19, with 5 hours and 15 minutes of in-service education in the past year; -CNA J hired 7/2/19, with 30 minutes of in-service…

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 store and prepare food in accordance with professional standards for food service safety by failing to label and date food. The facility failed to check and record refrigerator temperatures and dishwasher chemical levels. In addition, the facility failed to ensure the ice machine had an air gap, to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. These deficient practices had the potential to affect all residents. The census was 85. Observations of the kitchen, showed: -On 9/14/20 at 10:31 A.M.: -Fifteen health shakes in the refrigerator, undated. Dietary Aide Z, said the heath shakes come in frozen and were thawed in the fridge, they should be dated; -A package of hamburger patties, opened and undated; -Two pitchers of tea uncovered; -Three sandwiches with Cheetos, wrapped in plastic wrap, undated, sitting on a tray marked 12/13; -The refrigerator temperature log located on front of the refrigerator, showed dates of 4/2020, the 1st through the 8th, 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 have a Facility Assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and in emergencies, as required. The lack of a Facility Assessment has the potential to affect the entire resident population. The facility census was 85. Review of the State Operations Manual appendix PP, section 483.70(e) revised 11/22/17, Facility Assessment, showed: -An assessment of the resident population is the foundation of the facility assessment and determination of the level of sufficient staff needed; -It must include the number of residents and the facility's resident capacity; -It must include an evaluation of: -Diseases; -Conditions; -Physical, functional or cognitive limitations of the resident population's; -Acuity (the level of severity of residents' illnesses, physical, mental and cognitive limitations and conditions); -And any other pertinent information about the residents that may affect the services the facility must provide; -The assessment of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow general acceptable accounting principles by not knowing where the money for closed resident accounts were dispersed to (Residents #301 and #302) and by having negative balances in resident's accounts (Residents #108, #303 and #304). In addition, the facility did not provide quarterly statements to residents (Residents #107, #153, #152, #106 and #207). The facility held funds for at least 44 residents. The census was 85. 1. Record review of Resident #301's trust account, showed he/she expired on [DATE]. The balance in his/her account at that time was $2685.41. During an interview on [DATE] at 1:32 P.M., the business office manager (BOM) said he was not sure where the resident's money went. The balance showed zero. There was no record to show where it went. He was newer in the position and recently started overseeing the resident trust account. When he took over, he noticed there were frozen accounts for residents who had expired, so he closed…

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 notify the resident and/or their parties when a resident's fund reached within $200 of the SSI limit ($4,800), for one resident (Resident #308) and failed to ensure a third party liability (TPL), forms were completed for the final accounting for residents who expired. This affected five residents who expired and had money in their account (Resident's #301, #302, #305, #306 and #307). The census was 85. 1. Review of Resident #308's trust account, showed the following: -[DATE], a balance of $7105.24; -[DATE], a balance of $7105.71. During an interview on [DATE] at 10:54 A.M., the Business Office Manager (BOM) said he knew the resident was over the limit. He gave the resident a letter but did not keep a copy. He did this the first week he was given the responsibility of overseeing the resident funds in [DATE]. The letter said the resident was over the limit. During an interview on [DATE] at 11:25 A.M., the resident said he/she was not aware of how much…

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 ensure the resident's code status listed on the current physician order sheet (POS) matched the advance directive wishes for 12 of 31 residents sampled (Residents #113, #155, #203, #204, #207, #104, #107, #108, #109, #110, #253, and #151). The census was 85. 1. Review of the facilities Advanced Directives policy, revised [DATE], showed: -Advanced Care Directive Policy Statement: Subject to our overall philosophy, the facility will comply with a resident's advanced care directives in pre-determining their health care future, whenever possible, should they become terminally ill and unable to communicate, be in a permanently unconscious state and/or in an emergency situation. The facility will actively seek to obtain information regarding Advanced Directive wishes from each resident. Any existing directive will be reviewed and copied at the time of admission. If none exists, the facility will attempt to determine the wishes of the resident, 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 issue a Notice of Medicare Non-Coverage (NOMNC) for two of three sampled residents, one who remained in the facility (Resident #118) and one who went home (Resident #117) after discharge from Medicare Part A rehabilitation services. The facility census was 85. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered…

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 maintain resident rooms, walls, floors, and shower rooms in good repair to ensure a safe, clean, comfortable and homelike environment. In addition, the facility failed to provide effective pest control and eliminate offensive odors in a resident use elevator. The census was 85. 1. Observation on all days of survey, from 9/14/20 through 9/18/20, 9/21/20 and 9/22/20, of the resident use elevator located closest to the facility entrance, showed it smelled strongly of mold and gnats were observed on the ceiling. During an interview on 9/16/20 at 8:20 A.M., Resident #151 said the elevator smelled so bad, like you could die taking it. He/she believed the smell was sewage. He/she said the smell is really bad and the elevator shouldn't be used, especially by people with breathing problems. Sometimes, the smell would linger all the way down the hall. During an interview on 9/17/20 at 10:15 A.M., the housekeeping supervisor said she was not aware 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 develop an admission policy or implement an admission protocol to ensure accurate accounting of resident's personal belongings to prevent resident liability for possessions if items were missing or stolen, when the facility failed complete and update an inventory list for eight of 31 sampled residents (Residents #104, #110, #201, #204, #251, #256, #253, and #254). The census was 85. 1. Review of the facility's undated admission contract, showed: -The responsible party and/or resident agree as follows: -To be fully responsible for all financial obligations incurred by the Resident, including not limited to, all medical, dental, hospital, and ambulance charges, and any other miscellaneous charges incurred by the Resident; -To provide all necessary personal clothing and effects necessary for good grooming and well-being of the resident; -To provide all spending money for the resident; -To pay such additional monthly charge of the following…

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 within 48 hours of admission for three of four sampled newly admitted residents (Residents #251, #204, and #206). The sample was 31. The census was 85. 1. Review of Resident #251's medical record, showed: -A face sheet, with an admission date of 8/13/20; -Physician progress notes, dated 9/1/20 with diagnoses that included: seizures, osteomyelitis (inflammation of bone and bone marrow) to coccyx (tail bone area) wound, multiple strokes with left hemiparesis (weakness or inability to move one side of the body), high blood pressure and urinary catheter; -No baseline care plan. During an interview on 9/15/20 at 10:40 A.M., the resident said that he/she required assistance going to bathroom and moving around in bed. He/she uses the call light for when he/she needs help because he/she cannot move the left side very good. Observation on 9/15/20 at 9:35 A.M., showed the resident required two staff members…

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/or implement, accurate and individualized care plans completed within 21 days of admission, to address the specific needs of the residents, for seven of 31 sampled residents (Residents #108, #153, #155, #154, #202, #251 and #254). The census was 85. 1. Review of Resident #108's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Cognitively intact; -Diagnoses included atrial fibrillation (irregular heart rate), high blood pressure, Alzheimer's disease, dementia, and anxiety; -No behaviors; -Independent with bed mobility; -Required supervision with transfers, dressing, eating, toileting, and hygiene; -Continent of bowel and bladder; -Anti-psychotic, anti-depressant, anti-coagulant, and antibiotics administered in the last seven days. Review of the resident's care plan, dated [DATE], showed: -Focus: Chose to be a Do Not Resuscitate (DNR, no life saving…

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 services provided met professional standards of practice by failing to obtain physician orders for a catheter and a colostomy. In addition, the facility failed to ensure all physician orders were followed by not obtaining weights as indicated and ensuring treatment and therapy orders were followed. For six of 31 sampled residents (Residents #202, #203, #106, #251, #253, and #254). The census was 85. 1. Review of Resident #202's medical record, showed: -admitted [DATE]; -Diagnoses included: Quadriplegia (paralysis of all four limbs), anxiety, high blood pressure, tracheostomy (tube surgically inserted into the trachea for the purpose of breathing) and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall). Review of the resident's physician order sheet (POS), dated 9/1/20 through 9/30/20, showed: -No order for an indwelling urinary catheter (a tube inserted into the bladder) or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure each resident receives adequate supervision and assistance devices to prevent accidents by failing to ensure wanderguards (an electronic device used to manage residents who wander by either setting off an alarm when the person wearing the device gets too close to an exit, or locking the exit door) were functioning properly for two of four sampled residents with a wanderguard. In addition, the facility failed to ensure one resident who wandered was assessed for elopement/wandering risk (Residents #115, #108, and #155). The sample was 31. The census was 85. During an interview on 9/22/20 at 10:20 A.M., the administrator and Director of Nursing (DON) said the facility did not have a policy that addressed residents that are elopement risks and the use of the WanderGuard. 1. Review of Resident #115's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/9/20, showed: -Severe…

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 have a system in place to routinely assess, monitor and document on resident's receiving dialysis (process for removing toxins from the blood for individuals with kidney failure). In addition, the facility failed to have a policy to address the care for residents who require dialysis. The facility identified two residents as receiving routine dialysis treatments, one resident was sampled (Resident #207). The sample was 31. The census was 85. Review of Resident #207's medical record, showed: -admitted : 9/28/17; -Diagnoses included chronic congestive heart failure (CHF, impaired heart function), end stage renal disease (ESRD, chronic irreversible kidney disease), diabetes and high blood pressure. During an interview on 9/14/20 at 11:15 A.M., the resident said he/she goes out for dialysis three times a week. Review of the resident's physician order sheet (POS), dated 9/1/20 through 9/30/20, showed no order for dialysis treatments and no orders for pre and post dialysis assessments. Review of the resident's 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.

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation, for five out of five narcotic books reviewed. The census was 85. Review of the facility's controlled drug administration policy, dated 10/2/08, showed controlled substances shall be counted every shift by two licensed personnel to ensure adequate control. When there is a discrepancy in the records, nursing administration shall be notified as soon as possible. 1. Review of the Spectrum/rehab medication cart on 9/15/20 at 9:00 A.M., showed: -A control substance shift change count sheet dated July 2020, which contained the following information: -27 out of 93 shifts with only one nurse signature of the shift change count; -26 out of 93 shifts with no count of narcotics; -A control substance change count dated August 2020, which contained the following information: -27 out of 93 shifts with only one nurse signature of the shift change count; -41 out of 93 shifts with no count of narcotics; -A control substance…

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 resident medication regimen reviews (MRR) were completed by a licensed pharmacist on a monthly basis, for 4 out of 4 residents reviewed for completed MRR (Resident #104, #203, #253, and #151). In addition, the Director of Nursing (DON), who is required to receive a copy of all pharmacy recommendations, failed to have knowledge of where pharmacy recommendations were documented. The sample was 31. The census was 85. Review of facility's pharmacy review policy, revised November 2002, showed: -Purpose: To ensure that all pharmacy recommendations are forwarded to the physician for a response in a timely manner; -Policy: All pharmacy recommendations will be forwarded to the physician. A response must be documented within 30 days. Copies of the recommendations will be kept in a separate notebook on each nurse's station for reference; -Procedure: Pharmacy recommendations will be forwarded to the nursing supervisor by the DON when they are received from…

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 each resident's drug regimen is free from unnecessary psychotropic drugs by failing to thoroughly assess, monitor and document the use of non-pharmacological approaches prior to administration of a psychotropic drug. In addition, the facility failed to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days for 5 of 5 residents reviewed for unnecessary medications (Residents #104, #108, #206, #204 and #106). The resident sample was 31. The facility census was 85. 1. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/20, showed: -Cognitively intact; -Diagnoses included anemia, high blood pressure, peripheral vascular disease (PVD, circulatory disorder), anxiety, depression, manic depression and asthma; -Resident mood interview: -Trouble falling or staying asleep, or sleeping too much: yes; -Feeling tired or having little…

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 ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility failed to properly label medications and vaccinations once opened, ensure the medication rooms were locked and controlled medications were locked behind two locks, monitor the medication refrigerator temperature to assure it is maintained at a safe temperature and ensure employee food was not stored in a medication refrigerator for two out of three medication storage rooms and two out of five medication carts observed. The census was 85. Review of the facility's medication storage policy, dated 12/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations; -Procedure: -Medication rooms, carts, and medication supplies are locked or attended by person with authorize access: licensed nurses; -External medications including ointments for skin irritations and medication for application to wounds should be kept in treatment…

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 observation, interview and record review, and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for COVID-19, the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. In addition, the facility failed to have a process for monitoring and tracking infections (Residents #114 and #119). The resident sample was 31. The census was 85. 1. Review of the CDC, Preparing for COVID-19 in Nursing Homes, updated June 2, 2020, showed: -Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP); -Regularly review CDC's Infection Control Guidance for Healthcare…

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 treat each resident with respect and dignity and care for each resident in a manner to protect and promote the rights of the resident when staff failed to provide assistance with a transfer to bed per the resident's request (Resident #114). The sample size was 31. The census was 85. Review of Resident #114's medical record, showed: -Newly admitted to the facility on [DATE]; -Diagnoses included stroke, high blood pressure, depression, and dysphagia (difficulty swallowing). Observation and interview on 9/21/20 at 2:00 P.M., showed the resident lay in bed. The resident said a Certified Nursing Assistant (CNA) had refused to help him/her. He/she forgot the CNA's name. That day started out well. The CNA assisted him/her with getting cleaned up and dressed. He/she did not have any issues. He/she was transferred from the bed to the wheelchair around 9:00 A.M. He/she was given orders from therapy that he/she could sit in the wheelchair as long as…

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 assess a resident's ability to safely self-administer their own medications for two residents when staff left medications at the bedside (Residents #111 and #152). The sample was 31. The census was 85. 1. Review of Resident #111's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/20, showed: -Cognitively intact; -Diagnoses included anemia, high blood pressure, renal (kidney) failure, stroke, dementia, malnutrition, anxiety, and asthma; -Required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene. Review of the resident's care plan, dated 4/15/20, showed: -Focus: Dependent on staff for meeting emotional, intellectual, physical, and social needs related to impaired mobility; -Focus: Impaired cognitive function/dementia or impaired thought processes related to impaired decision making; -Interventions: Administer medications as ordered.…

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 maintain acceptable parameters of nutritional status to prevent weight loss for one resident (Resident #154) when staff failed to follow the facility's weight protocol, dietician recommendations and physician orders for weight monitoring and administration of tube feeding. The resident was dependent on staff to be fed via gastrostomy tube. The sample was 31. The census was 85. Review of the facility's Weight Protocol, undated, last reviewed on 5/28/19, showed: -Purpose: To provide a permanent, accessible record of resident weights; -Procedure: Residents will be weighted within 24 hours upon admission/re-admission by the certified nurse assistant (CNA). Residents will be weighed weekly for four weeks and then monthly ongoing by designated staff; -Monthly weights will be completed by the 5th of the month. Weights will be given to the Director of Nursing (DON) or assistant DON (ADON) to input into the electronic medical record (EMR) within 48…

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 respiratory services provided were consistent with professional standards of practice when staff failed to obtain a physician order for oxygen and medication used for breathing and failed to ensure physician orders matched the medication and treatment administration records and failed to care for oxygen concentrators and supplies consistent with professional standards of practice for two residents (Residents #104 and #152). The sample was 31. The census was 85. 1. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/20, showed: -Cognitively intact; -Diagnoses include high blood pressure, peripheral vascular disease (PVD, circulatory disorder), anxiety, depression and asthma. Review of the resident's care plan, dated 4/14/20, showed: -Focus: Resident has emphysema (lung disease)/chronic obstructive pulmonary disease (COPD, lung disease) related…

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 alternate meals for residents which accommodated resident preference and religious restrictions (Residents #151 and #153). In addition, residents were not offered or served an alternate for breakfast. This had the potential to affect all residents who had alternate preferences for the breakfast meal. The sample was 31. The census was 85. Observations of meal service during the survey, showed: -On 9/14/20 at 10:10 A.M., Dietary Aide Z said there are no breakfast alternates; -On 9/15/20 at 9:00 A.M., the breakfast main entree was biscuits and gravy: -Resident #151 was given only a biscuit, he/she said he/she had no gravy because he/she could not eat pork as part of his/her religious beliefs, no substitute was given or offered; -Resident #153, unable to eat pork as part of his/her religious beliefs, was provided oatmeal. No meat alternate given or offered; -On 9/22/20 at 9:08 A.M., the breakfast meal had a main entree of biscuits and gravy. Resident #151 was given a biscuit only with no gravy. 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 interview and record review, the facility failed to keep resident records that were complete, readily accessible and systematically organized when the facility administration failed to be aware that weights, medication regimen reviews, dietary recommendations, and assessments were included in the resident's electronic medical record (EMR). This resulted in a failure to follow-up on recommendations, failure to properly monitor weights for one resident (Resident #154) and failure to ensure assessments and pharmacy reviews were completed as indicated for all residents sampled. The sample was 31. The census was 85. 1. During an interview on 9/14/20 at 9:48 A.M., the Director of Nursing (DON) and administrator said the only information that is in the EMR were the census and resident demographics. They had not had the chance to document any resident information in the electronic medical record. All resident information is found in the hard chart at the nurse's station. 2. Review of Resident #154's hard chart, showed no registered dietician notes or recommendations. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care. In addition, the facility failed to maintain the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, the names and contact information for hospice personnel involved in hospice care of each resident and failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for one resident not identified by the facility as receiving hospice services (Resident #155). The sample was 31. The census was 85. Review of Resident #155's face sheet, showed admitted on [DATE]; Review of the resident's physician order sheet (POS), showed: -Dated 7/1/20…

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.