Grand Manor Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of transfer and discharge and failed to provide a written notice of transfer/discharge for one resident (Resident #4) when the resident was transferred to another facility. The sample was four. The census was 114. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 5/14/24, showed the following: -Purpose: -Establish policy and procedure regarding the transfer/discharge of residents; -Definitions: -Facility-initiated transfer or discharge: A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; a. Consent to or Agreement with the discharge or transfer means that the resident or their legally authorized representative has consented to or agreed with the transfer or discharge;…

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 the safety of one resident with a diagnoses of diabetes and substance abuse, who left the building unnoticed for leave of absence (LOA). Staff last saw the resident on 3/31/25 at approximately 1:00 P.M. to 2:00 P.M. It was approximately seven hours until staff realized the resident was gone. Staff did not administer ordered afternoon and evening insulin (a hormone that helps your body use blood sugar for energy) injections (Resident #2). The sample was four. The census was 114. The Administrator was notified on 4/17/25 at 9:00 A.M., of the past non-compliance, which occurred on 3/31/25. The facility provided in-servicing for all staff regarding the facility's Resident's Outside Pass Policy and Elopement and Wandering Policy. The facility also updated Resident #2's care plan. The deficiency was corrected on 4/2/25. Review of the facility's Resident Outside Pass Policy (OSP), date 6/29/23, showed the following: -Purpose: -To ensure that the facility provides education and treatment/medications to 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 interview and record review, the facility failed to have a system in place to ensure residents' individual trust fund accounts were not allowed to go into a negative balance. The facility managed funds for 61 residents. A sample of eight residents were chosen and the deficient practice affected six residents (Residents #8, #30, #37, #64, #66 and #78). The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Negative Balances in Resident Accounts; -On the last day of every month the Resident Trust Clerk must confirm that all transactions for the month have been posted and then should run a Current Account Balance report from the banking system on the last day of the month to verify resident balances. If any resident has a negative balance on the last day of the month a positive adjustment must be posted in the banking system to make their balance zero. The banking system batch should be labeled Negatives to Fund in the batch description. The state agency 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 interview and record review, the facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for two months. The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Resident Trust Bank Reconciliation: A reconciliation of the bank statement module must be completed monthly. This will be completed by the facility's staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk. Review of the facility's resident trust accounts, showed no documentation of bank statement reconciliation's from January 2024 and April 2024. During an interview on 9/13/24 at 12:05 P.M., the Business Office Manager (BOM) and the Administrator said the previous owners of the facility no longer allowed access to the bank statements. The BOM said she thought she had copies of the bank statements. The new owners took over in May 2024.

Based on record review, interview, and policy review, the facility to provide one of one residents (Residents (R) 81) a Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when he completed his Medicare A therapy services. This failure to provide the CMS for SNF ABN prevented the resident from knowing he had days remaining under Medicare A. Findings include: Review of the facility's policy titled, Advanced Beneficiary Notice implemented 01/01/24 stated, .The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). [sic] Contents of the form shall comply with related instructions and regulations regarding the use of the form. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary (SNF ABN), Form CMS-10055. Record review of R81's Face Sheet, located in the Profile tab of the electronic medical record (EMR) was admitted to the facility for long-term care and was being skilled in therapy after 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to notify the Ombudsman of a transfer for one of three residents (Resident (R) 84) out of a total sample of 26 residents. Findings include: Review of the facility's policy titled, Resident Transfer/ Discharge, Immediate Discharge, and Therapeutic Leave Policy last revised 05/14/24, indicated, . Who Must Receive Notice. In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman. In Section III. r their legal representative, a copy of the Bed Hold Policy. Review of R84's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of R84s's most recent Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) on 06/23/24 revealed his Brief Interview of Mental Status (BIMS) was an 11, indicating he was moderately cognitively impaired.…

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 policy review, the facility failed to issue one of three residents (Resident (R) 84) or their responsible party out of a total sample of 26 residents a bed hold notice when R84 was sent to the emergency room. This failure could leave a resident to believe they would not be allowed to return when hospital ready from Findings include: Review of the facility policy titled, Bed Hold Policy, last revised 11/06/23 stated, .When a resident is discharged to the hospital . the Facility will provide to the resident or their legal representative, a copy of the Bed Hold Policy. Review of R84's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of R84s's most recent Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) on 06/23/24 revealed his Brief Interview of Mental Status (BIMS) was an 11,…

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 ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of six residents (Resident (R) 30 and R1) reviewed for unnecessary psychotropic medications. Findings include: Review of the facility's policy titled, Use of Psychotropic Medication Policy last revised 06/26/24 revealed Purpose: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication .13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. Review of R30's undated admission Record,…

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 medical record reviews, staff interviews and facility policy review, the facility failed to maintain complete and accessible medical records for three of 31 sampled residents ((R)6, R9 and R47) whose electronic medical records (EMRs) were reviewed for the recertification and complaint survey. Specifically, the EMRs for R6, R9 and R47 contained no current care plans following the facilities migration from one electronic medical record system to another. This meant the Certified Nurse Aids could not access a current Plan of Care to provide appropriate care and services. As well as failed to ensure the one out of eight residents (R95) medication prescription was accurately documented in the medical record. The findings include: Review of the facility policy titled, Medical Records, dated 02/2024 revealed, .The facility shall maintain medical records on each resident that are complete, accurately documented, accessible and organized. In an interview with the Administrator and Regional Director of Operations…

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 ensure nursing staff properly stored a residents BiPAP mask when not in use for one of one sampled resident (Resident (R) 32). Findings include: A review of the facility's policy titled CPAP/BiPAP Cleaning Policy revised 05/14/24 revealed, BiPAP mask should be cleaned daily after use, dry well and cover with plastic bag or completely enclosed in machine storage when not in use Review of R32's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed readmission to the facility on [DATE] and with diagnosis of respiratory failure, sleep apnea and chronic obstructive pulmonary disease (COPD). Review of R32's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/14/24, revealed the Brief Interview for Mental Status (BIMS), revealed a score of 15 out of 15 which indicated no cognitive impairment. The resident was coded as receiving…

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 one resident's (Resident #6) right to be free from abuse was not violated, when the resident was abused by another resident (Resident #7), of eight sampled residents. Upon discovery of the abuse, a mental health aide walked away, while the victim was still on the floor with the perpetrator at his/her side, to call for a nurse. During this brief period of time, Resident #7 threw an unlit cigarette at Resident #6. The census was 87. Review of the facility's Abuse and Neglect policy, dated 7/2022, showed: -Abuse definition: The willful infliction of injury, unreasonable confinement, intimidation, exploitation, mistreatment, or punishment with resulting physical harm, pain, or mental anguish. Included is verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled with technology. Willful, as used in this definition of abuse, means the individual acted deliberately, not that the individual must have intended to…

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

Based on observation and interview, the facility failed to store food appropriately by failing to label, date, cover and discard outdated items. The facility also failed to ensure kitchen equipment was clean and in working condition. In addition, staff failed to ensure a leaking pipe under the kitchen sink was repaired in a timely manner. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The census was 62. 1. Observations on 7/10/23 at 9:15 A.M., 7/11/23 at 7:30 A.M., 7/12/23 at 9:30 A.M., showed the following: -Storage room: -A bottle of Apple Ready Care drink mix with an expiration date of 4/22/23; -Six (6) packs of V8 original Vegetable Juice with expiration dates of 11/9/19. Five packs contained all 6 cans inside the packages unopened and the one package was opened with three cans remaining; -A package of noodles wrapped in plastic wrap; without a date; -Freezer: -An opened box that contained an opened package of chicken, opened and exposed to air; -A zip lock bag contained bread sticks, without a date; -An opened…

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 quarterly statements to residents and/or their representatives (Residents #24, #44, #37 and #55). This affected 60 residents whose funds were handled by the facility. The census was 62. 1. Review of the facility's Trial Balance report, showed the facility holds funds for 60 residents, including Residents #24, #44, #37 and #55. 2. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/23, showed: -Cognitively intact; -Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 7/11/23 at 10:44 A.M., Resident #24 said the facility holds funds for him/her. Today, he/she received a quarterly statement showing transactions for his/her account. Today is the first time he/she received a quarterly statement. 3. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Cognitively intact;…

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 a clean, comfortable, homelike environment for the residents. This includes the failure to keep resident floors clean and kempt, keeping resident hall bathrooms in clean and working order, and the failure to provide homelike common areas designated on resident halls. The sample was 16. The census was 62. 1. Observation on 7/10/23 at 9:16 A.M., showed white liquid and leftover food from the breakfast meal on the floor of room [ROOM NUMBER]. At 1:21 P.M., the white liquid remained on the floor. Observation of the 300 hall on 7/10/23 at 9:21 A.M. and on 7/11/23 at 7:45 A.M., showed the floor was sticky and appeared to have a gummy film across the floor tiles. While walking across the floor, the surveyor's shoes made a loud sound as the adhesive properties of the uncleaned floor stuck to the bottoms of the surveyor's shoes. Observation of the 300 hall common room on 7/10/23 at 12:39 P.M., showed the floor of the common area was dirty,…

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 electronically transmit residents' Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for 3 of 3 months reviewed. The census was 62. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; -The manual includes a submission timeframe table for MDS record types. Review of the facility's CMS submission, MDS final validation report, submitted 4/5/23, showed: -27 records processed; -8 records submitted late. Review of the facility's CMS submission, MDS final validation report, submitted 4/26/23,…

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 had complete, accurate, and individualized care plans to address the specific needs of four residents (Resident #11, #58, #7 and #23). The sample was 16. The census was 62. Review of the facility's Care Plan Policy, undated, showed: Policy: Care plan coordination to provide the optimum level of functioning of each resident; To assure that all residents have an accurate and updated plan of care that reflect that individual needs and correlates with the submitted Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; Procedure: Each resident's chart will be reviewed quarterly and/or with a change of condition, by a committee consisting of Care Plan Coordinator, Dietary, Wound Care Nurse, Therapy, Nursing, Activities and Social Services; The charge nurse to inform the Care Plan Coordinator with any updated or changed assessments on resident; Care plans to be updated as needed to…

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

Based on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the Medical Director failed to attend the facility's QAPI meetings. The census was 62. Review of the facility's monthly QAPI sign-in sheets for the last 12 months, reviewed 7/11/23, showed the Medical Director or his designee not in attendance. During an interview on 7/13/23 at 1:56 P.M., the Administrator said the facility holds QAPI meetings on a monthly basis. The facility identifies which issues to work on during QAPI meetings. QAPI meetings should be attended by all department heads and the facility's Medical Director. The Medical Director has attended a QAPI meeting in the past 12 months, but the Administrator could not recall the date of the last meeting the Medical Director attended. The Medical Director has not signed in on the QAPI meeting attendance sheets. She expected the Medical Director to attend and QAPI meetings, at least quarterly.

Based on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control (IPC) as the infection preventionist (IP) for the facility's infection prevention control program. The census was 62. Review of the Centers for Disease Control (CDC) and Prevention's interim infection prevention and control recommendations to prevent COVID-19 spread in nursing homes, updated 2/2/22, showed: -Development of an IPC program; -Assign one or more individuals with training in IPC to provide on-site management of the IPC program; -This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment. During an interview on 7/14/23 at 8:51 A.M. the Administrator said one floor nurse is currently certified as an IP, but is not performing those tasks or heading up the…

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

Based on observation, interview and record review, the facility failed to ensure reasonable accommodations of needs were provided for one resident (Resident #58) with diagnoses of aphasia (language impairment) and hemiplegia (paralysis on one side of the body). The sample was 16. The census was 62. Review of Resident #58's medical record, showed: -The resident listed as his/her responsible party; -Diagnoses included stroke, aphasia, hemiplegia affecting left non-dominant side, and depression, recurrent and severe. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/29/23, showed: -Resident rarely/never understood; -Short term memory ok; -Made decisions regarding tasks of daily life independent - decisions consistent/reasonable; -Required extensive assistance of one person physical assist for bed mobility; -Total dependence of two (+) person physical assist for transfers; -Upper and lower extremity impairment to one side. Review of the resident's care plan, in use at the time of survey, 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 interview and record review, the facility failed to verify the accurate code status due to conflicting information in the medical record for one of 16 sampled residents (Resident #7). The census was 62. Review of the facility's Advanced Directives policy, showed: Regarding: Ensure the residents' wishes are communicated; -Procedure: -Upon admission, the resident will give the facility any legal documents such as durable power of attorney, living will and trust, legal guardianship documents, and/or any surrogate delegation of rights with those rights clearly written; -Should a resident change their code status abruptly, you are to go by their wishes and document the change of the code status; -Should the resident not have prior advance directives, the social services department and/or nursing will ask the resident questions to determine what decisions the resident has made regarding emergency end of life care. If there are no advance directives, cardiopulmonary resuscitation (CPR, initiate life sustaining…

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 assure each resident received an accurate assessment, reflective of the resident's status for 3 of 16 sampled residents (Residents #7, #11 and #23). The census was 62. 1. Review of Resident #7's progress notes, dated 10/27/2022 at 11:09 A.M., showed the resident was put onto hospice on 10/26/22. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/23 showed: -admission date of 2/27/18; -Moderate cognitive impairment; -Required extensive assistance from staff for activities of daily living (ADLs) such as personal hygiene, eating, dressing, bathing, mobility and dressing. -Diagnoses of anemia (low red blood cell count), wound infection and hip fracture; -Special services received while a resident: Hospice Care; -Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No; -Staff failed to accurately document 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 ensure one resident (Resident #58) received a splint as ordered for contracture management. The facility identified seven residents with splints. The census was 62. Review of Resident #58's medical record, showed: -Diagnoses included stroke, aphasia, (language impairment) and hemiplegia (paralysis on one side of the body; -A physician order, dated 10/5/22, to apply left resting hand splints as tolerated. Review of the resident's occupational therapy Discharge summary, dated [DATE], showed: -Diagnoses included contracture, left hand; -Goal, discontinued 2/1/23: Patient will achieve normal anatomical alignment of left hand and left fingers for 8 hours in order to achieve proper alignment, in order to decrease discomfort, in order to facilitate joint mobility, and in order to maintain joint integrity;. -Comments: The patient needs to continue wearing the splint daily up to 4 hours. Review of the resident's quarterly Minimum Data Set (MDS), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe transfer for one resident (Resident #11) and implement fall prevention interventions for two residents (Residents #58 and #49). In addition, the facility failed to secure soiled utility and janitors' closets on the 200 and 300 halls that contained trash, soiled linen, cleaning equipment and chemicals. The sample was 16. The census was 62. Review of the facility's Transfer policy, undated, showed: Policy: All residents shall be assessed upon admission to determine their method of transfer; Input regarding transfers shall be made by nursing services, restorative and/or the therapy department to ascertain the safest method of transfer for the resident; -Nursing services shall review the resident's current diagnosis, condition, cognitive status, weight bearing status, mobility, and other pertinent physical information to determine the safest method of transferring the resident; -Once the safest method of transfer has been…

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 adequate respiratory services were provided for one resident (Resident #18) when staff failed to ensure the oxygen related orders matched the electronic physician orders sheet (ePOS), physician order sheets (POS) in the resident's medical record and the Treatment Administration Record (TAR). Staff also failed to obtain physician orders related to changing oxygen tubing and the oxygen humidifier bottle. The sample was 16. The census was 62. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/23, showed: -Cognitively intact; -Diagnosis of chronic obstructive pulmonary disease (COPD, lung disease that prevent the lungs from working properly); -Oxygen therapy. Review of the resident's care plan, in use at the time of survey, showed: -Problem: -The resident is at risk for shortness of breath related to COPD; -The resident is non-compliant by continuing to smoke cigarettes despite resident teaching; -Approach:…

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 bed rail (side rail) assessments were completed accurately and routinely in accordance with the facility's policy for three residents (Residents #58, #34 and #14) and to obtain physician orders for the use of the side rails. The facility identified six residents with side rails. The census was 62. Review of the facility's Side Rail and Bed Assessment policy, undated, showed: -Procedure: The resident's sleeping environment shall be assessed by the interdisciplinary team (IDT), considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -After appropriate review and consent, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); -Side rails may be…

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 perform a yearly review of code status, full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed), and failed to verify code status by having conflicting information in the medical record for six of 20 sampled residents (Residents #17, #57, #83, #67, #9 and #93). The census was 96. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/3/19, showed the following: -readmitted to the facility on [DATE]; -Diagnoses included major depression, obesity and heart disease. Review of the medical record on 12/4/19, showed a signed facility code status form in the front of the chart read full code, dated 11/7/18. Further review of the medical record on 12/5/19, showed the signed form, dated 11/7/18, replaced with a blank code status form, dated 12/4/19. 2. Review 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 clarify the diagnosis for administration of antibiotic medication, failed to obtain a neurology consultation in a timely manner and left medication at a resident's bedside without an order. The facility also failed to obtain orders for the use of an indwelling catheter, the use of siderails, the use of a Bi-level Positive Airway Pressure machine and failed to transcribe the size for an indwelling urinary catheter to the physician's orders sheet, for five of 20 sampled residents (Residents #93, #29, #50, #9 and #13. The census was 96. 1. Review of Resident #93's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/19, showed the following: -Cognitively intact; -Required limited assistance with activities of daily living; -Diagnoses included diabetes, chronic obstructive pulmonary disorder (COPD, a group of lung diseases that block airflow and make it difficult to breathe) 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 proper perineal care (peri-care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for two of four observations (Residents #74 and #82) and failed to provide personal grooming to one resident by not shaving him/her (Resident #84). The sample size was 20. The census was 96. 1. Review of Resident #74's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/11/19, showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Dependent on staff for personal hygiene and toileting; -Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) and frequently incontinent of bladder; -Diagnosis of Alzheimer's disease. Observation on 12/3/19 at 10:52 A.M., showed the resident sat on the toilet and, with gloved hands, Certified Nurse Aid (CNA) A removed the colostomy bag 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 obtain physician's orders for dialysis (process for removal of waste and excess water from the blood due to kidney failure) care and monitoring of dialysis access sites, administer medications as ordered on dialysis days and ensure a resident's dialysis center information on the care plan and physician's order sheet (POS) were congruent, for four residents (Residents #88, #5, #68 and #32) who received dialysis. The facility identified seven residents on dialysis, four were chosen for the sample of 20 and problems were found with all four of them. The census was 96. 1. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/13/19, showed the following: -Cognitively intact; -Independent with activities of daily living (ADLs); -Received dialysis; -Diagnoses included high blood pressure and diabetes. Review of the resident's care plan, updated on 11/27/19,…

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 observation and interview, the facility failed to ensure food items were dated when placed in the walk-in refrigerator and failed to cover the stand up mixer and slicer when not in use. The census was 96. 1. Observation of the kitchen, showed the following: -On 12/3/19 at 10:10 A.M. and 4:45 P.M. and 12/4/19 at 11:23 A.M., two thawed and undated five pound rolls of ground beef, two undated, large, thawing turkey roasts and one undated, large, thawing smoked turkey roast, sat on trays on the bottom shelf of the walk-in refrigerator; -On 12/5/19 at 9:39 A.M. and 12/6/19 at 6:45 A.M., one five pound roll of thawed ground beef and one smoked turkey, dated 12/4/19, sat on trays on the bottom shelf of the walk-in refrigerator. During an interview on 12/5/19 at 11:23 A.M., [NAME] H said the turkey and ground beef should be dated when placed in the refrigerator, but sometimes if the packaging was wet, the date, written in marker, came off. 2. Observation of the kitchen, showed the following: -On 12/3/19 at 10:10 A.M. and 4:45 P.M., 12/4/19 at 11:23 A.M. and on 12/5/19 at 9:39 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff utilized acceptable infection control measures during perineal care (peri-care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for one of four residents observed (Resident #74), by allowing urinary catheter (small rubber tube inserted in to the bladder to drain urine) tubing and the privacy bag (rubber bag that holds the catheter bag to provide dignity) to lie on the floor, by feeding two residents at the same time even though one of those residents had an infectious disease (Resident #9), and by not cleansing hands between residents when passing medications. The sample size was 20. The census was 96. 1. Review of Resident #74's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/11/19, showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Dependent on staff for personal hygiene and toileting;…

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 residents' privacy and confidentiality of medical information by leaving identifying information, a physician's order sheet and a laboratory result, in the survey binder, which is accessible to all residents and the public. The census was 96. 1. Observation of the front desk on all days of the survey, from 12/3/19 through 12/6/19, showed a sign which indicated the survey results binder was located at the front desk. Further observation of the front desk, showed a binder labeled Survey Results. 2. Review of the survey results binder, showed the following: -A March 2019 physician order sheet for one resident; -A urinalysis (urine test) result, dated 2/22/18, for one resident; -An audit sheet, dated 11/4/19, identified a resident by name and his/her location; -An audit sheet, dated 10/5/19, identified a resident by name and his/her location. 3. During an interview on 12/6/19 at 10:00 A.M., the administrator said she and the business office manager maintain the survey results binder. She agreed there…

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 contact the physician and dietician when a resident experienced a significant weight loss for one of 20 sampled residents (Resident #50). The census was 96. Review of Resident #50's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal care; -Diagnoses included altered mental status and osteoporosis (brittle bones). Review of the facility face sheet, showed an additional diagnosis of dementia. Review of the care plan, dated 11/27/19 and in use during the survey, showed the following: -Problem: Nutritional status; -Goal: Regular diet. Resident requires assistance with feeding due to low vision and resident will verbalize understanding of dietary regimen; -Interventions: Assist with meals, obtain dietary consult and follow recommendations, provide Boost (nutritional supplement), one can by mouth four times a day Review of the dietician's note,…

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.