Hidden Lake Health Care Center

Based on interview and record review, the facility failed to develop and implement the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all residents in the facility. The census was 53. Review of QAPI at a glance: A step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home, created by the Centers for Medicare and Medicaid Services (CMS), showed: -The Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan within a year of the promulgation (declaration of new law) of a QAPI regulation. However, a more basic reason to build care systems based on a QAPI philosophy is to ensure a systematic, comprehensive, data-driven approach to care. During an interview on 8/16/24 at 8:35 AM, the Administrator said the facility has the CMS QAPI at a glance step by step guide to implementing a QAPI plan but has not added any addendums nor has she initiated a facility specific QAPI plan. She started as administrator March 2024 and is unaware of a plan prior to her start date. 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 provide a safe, clean, comfortable, and homelike environment. The facility had two floors in which residents resided. Lighting issues were identified in the first-floor spa room and men's restroom. The dining room on the first floor had chipped paint and duck-tape on the floor. One resident (Resident #23) had torn drywall and an unfinished ceiling in the bathroom. In addition, 12 additional resident rooms had a variety of environmental concerns. The sample was 14. The census was 53. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission to the facility, showed: -No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the United States solely on account of his or her status as a resident of the Community; -The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy,…

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 encode and transmit resident assessment data within 7 days after a facility completes a resident's assessment for seven of seven residents investigated for Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessments for encoding and transmission, as indicated by the MDS showing in progress or ready to export (Residents #10, #28, #16, #23, #30, #45 and #12). The census was 53. Review of the MDS, version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software); -Transmitting…

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 who required dialysis (the process of filtering toxins from the blood in individuals with kidney failure), received services consistent with professional standards of practice for two of two residents investigated for dialysis services (Residents #107 and #106). In addition, the facility failed to have a policy to address the assessments, monitoring, and communication with dialysis centers for their dialysis residents. The facility identified two residents as receiving dialysis and concerns were identified for both residents. The census was 53. 1. Review of Resident #107's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/24, showed: -No cognitive impairment; -Diagnoses included stroke, end stage renal disease and diabetes; -Special treatments: dialysis. Review of the resident's care plan, in use during the survey, showed: Resident needs dialysis secondary…

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 that seven out of seven residents (Residents #43, #20, #22, #5, #254, #10, and #106) reviewed for siderail use, had a comprehensive risk-benefit assessment completed. This failure had the potential for residents at risk for entrapment to become entrapped in the siderail with a risk of severe injury and/or death with bedrail use. The census was 53. Review of the facility's Side Rail Policy, undated, showed: -Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment; -Use of bed rails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team; -The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted 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.

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the most recent available quarterly payroll-based journal (PBJ) staffing report. The sample was 14. The census was 53. Review of the facility's PBJ Staffing Data Report, dated for Quarter 2 2024 (January 1- March 31), showed: -This staffing data report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey); -One star staffing rating: Triggered; -No RN hours: Triggered; -Infraction dates: Tuesday 1/9, Wednesday 1/10, Thursday 1/11, Friday 1/12, Sunday 2/4, Saturday 2/17, Sunday 2/18, Saturday 3/2, Sunday 3/3, Saturday 3/16, Sunday 3/17, Friday 3/29, Saturday 3/30, and Sunday 3/31. During an interview on 8/16/24 at 1:01 P.M., the administrator said the previous Director of Nursing (DON) may not have changed from DON to RN if he/she came in. He/She may have worked 40 hours and came in on the weekend as an RN and did not change it or knew how to change it. Another RN was picking 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 and interview, the facility failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure the main kitchen and skilled nursing facility (SNF) dish room trashcans were covered when not in use. The facility census was 53. 1. Observations on 8/12/24 at 10:48 A.M. and 2:58 P.M., 8/13/24 at 9:56 A.M., and 8/15/24 at 10:57 A.M., showed: -The trash cans by the hand sink and by the work table were not in use, uncovered and overflowing with cans and trash; -Flies were observed to be in the kitchen in and around areas where food was prepared; -An insect light was turned off. 2. Observations of the SNF dish room on 8/13/24 at 2:01 P.M., showed the trash can was uncovered and contained trash. There were no staff in the dish room. 3. During an interview on 8/15/24 at 2:25 P.M., the Administrator and Assistant Dietary Manager (ADM) said trash cans should be covered when not in use. The ADM said the insect light had the wrong bulbs, which was why it was not on. She called a pest control company and they…

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 document hospice orders and to develop a written plan of care including 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 of three residents receiving hospice services at the facility (Resident #9). The sample was 14. The census was 53. Review of the facility's undated Hospice Service policy, showed: -Policy: To honor the advance directive and care alternative the resident may desire when terminally ill and to afford the resident with care that allows for dignity and comfort during the end stage of their lives; -Specifications: To ensure that appropriate hospice services are available to the residents and families, and to outline the responsibilities of the hospice service provider as well as for facility staff; -Standards: -The resident will be provided hospice care upon 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 offer and/or provide the influenza vaccine (a vaccine that can protect against the flu) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for two of five residents sampled for vaccinations (Residents #44 and #1). The facility census was 82. Review of the facility's undated influenza vaccine program policy, showed: -Policy: it is the policy of the facility that annually residents are offered immunizations against influenza. The facility follows the recommendation of the CDC and the state for influenza vaccinations. Each resident is offered an influenza vaccine from October 1st through March 31 annually unless the influenza vaccination is contraindicated; -Purpose: to reduce the incidence of influenza and the morbidity and mortality attributed to the infection; -The vaccine program begin approximately October 1st and extends through March 31st; -Obtain influenza vaccine information before the beginning of each flu…

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 provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two out of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #2 and #25). The facility census was 53. 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…

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 their grievance policy for one sampled resident (Resident #43). The facility failed to provide prompt resolution of Resident #43's grievance regarding the family member's concern of how the resident was transferred. The facility did not follow up on the grievance recommendation to resolve the issue by therapy evaluating the resident to determine the correct device for transferring. The sample was 22. The census was 51. Review of the facility's grievance policy, undated, showed: -Policy: The facility will assist residents, their representatives such as, other interested family members or other resident advocates in filing grievances or complaints when such requests are made; -Policy Specifications: -1. Any resident, their representative, family member, or other advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. -2. Upon admission, residents are provided with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment accurately reflected the resident's status, in all required sections for two of 14 sampled residents (Residents #28 and #106). The census was 53. Review of the facility's Resident Assessment Instrument (MDS 3.0) policy, effective 10/2016, showed: -Policy: The facility follows the Resident Assessment Instrument (RAI) process, which includes the MDS version 3.0, Care Area Assessments (CAA), and RAI Utilization Guidelines. This will provide information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified. This process will include coordinating, scheduling, assessing, decision-making, care planning as needed, completing, submitting, correcting, evaluating and maintaining the data for each resident; -Policy Specifications included:…

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 implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #305) of one resident sampled who was a new admission. The facility census was 53. Review of the facility's policy titled, Care Plan - Preliminary, revised August 2006, showed: -To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission; -The Admitting Nurse will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatments, etc.), and implement a care plan to meet the resident's immediate care needs; -The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. Review of Resident #305's medical record, showed: -An admission date of 8/6/24; -No documentation of a baseline care plan. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for three of 14 sampled residents (Residents #28, #44 and #106). The census was 53. Review of the facility's Care Planning-Interdisciplinary Team (ITD) policy, revised 8/2006, included: -Our facility's Care Planning/ITD is responsible for the development of an individualized comprehensive care plan for each resident; -The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/ITD which may include, but is not necessarily limited to the following personnel: -The resident's Attending Physician; -The Dietary Manager/Dietician; -The Director of Nursing (DON); -The nurse responsible for the care of the resident; -Nursing Assistants responsible for the resident's care; -Others appropriate or necessary to meet the needs of the resident. 1. Review of Resident #28's quarterly Minimum Data Set…

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 supervision and assistance to prevent accidents for one resident. Staff allowed the resident to smoke during an outside activity (Resident #14). The facility is a nonsmoking facility that does not have smoking safeguards in place. The census was 53. During entrance conference on 8/12/24, the Administrator said the facility is a nonsmoking facility and they do not have current resident smokers. Review of the facility's contract between residents and the facility, showed the resident will be responsible to comply with the facility's smoking policies. Review of Resident #14 medical record, showed: Diagnoses included dementia, anxiety, impaired balance, and major depressive disorder. Review of the resident's smoking safety screen, dated 10/11/22, showed the resident is safe to smoke with supervision. Review of the resident's physician orders dated 11/1/22, showed: The resident can smoke with supervision only and nursing staff will keep cigarettes in medication room. 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 observations, interview and record review, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for one resident (Resident #8). The resident was administered the wrong enteral nutritional supplement via enteral tube (feeding tube) for one of one resident investigated for feeding tubes. The census was 53. Review of the facility's undated General Guidelines for Administering Medication Via Enteral Tube, showed: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist. During an interview on 8/14/24, the Administrator said the facility does not have a policy and procedure for physician orders. Review of Resident #8's medical record, showed: -Diagnoses included stroke, dysphagia…

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 in accordance with acceptable standards of practice. The facility identified four medication carts and two medication rooms. Of those medication storage areas one medication room and two carts were reviewed and issues were found in one medication room when two separate gallon Ziplock bags contained resident home medications, not in use at the facility. The census was 53. Review of the undated, pharmaceutical storage policy, showed: -Policy: drugs and biologicals shall be stored in a safe, sanitary and orderly manner; -Specifications: to establish guidelines for the control and storage of drugs; -Standards: -The facility shall not store anywhere on the premises any drug for a resident except those prescribed or ordered for the individual resident; -Drugs prescribed shall be locked in the medication room or locked in the medication cart; -Medications are stored under proper conditions of security; -Medication cabinets shall be locked at all times; -Only…

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 critical lab results were received and reported to the physician timely. The facility also failed to obtain a urine sample in a timely manner and did not document a reason for the delay in obtaining the sample for one resident (Resident #306). The sample was 14. The census was 53. Review of the facility's undated Lab, Diagnostic Test Results and Change in Resident's Condition policy, showed: -A licensed nurse will review all diagnostic tests results: -If a critical lab result is verbally reported by the lab provider to the nurse, the nurse will record and read back the report result to verify the information; -If the staff member who first receives or reviews lab and diagnostic test results is unable to follow the remainder of this procedure (i.e. reporting and documenting the results and their implications), another nurse in the facility should follow and coordinate procedural compliance; -The person who is to communicate results to a physician…

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 residents with a nourishing, well-balanced diet, taking into consideration each resident's preferences. The facility failed to respect each resident's right to make choices about his/her diet and be provided with acceptable alternative choices or substitutions for one sampled resident (Resident #44). The sample was 14. The facility census was 53. Review of Resident #44's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Required set-up for eating and oral hygiene; -Required supervision for showering and personal hygiene; -Mobility: independent; -Diagnoses included heart failure, high blood pressure, dementia and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lung). Review of the resident's care plan, last revised on 6/28/24 and in use during the survey, showed staff did not address the resident's dietary preferences. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for two of two residents (Residents #8 and #3) who the facility identified needed specialized equipment to assist with eating and drinking. The facility census was 51. Review of the facility's undated Adaptive Eating Devices policy, showed: -Policy: Adaptive eating devices are available during meal service for resident use; -Policy Specifications: Residents are reviewed upon admission, and at meals, to determine the need for adaptive eating devices. Referrals may be made by a variety of staff including the physician, occupational therapy, nursing, or food service; -A written order will be provided to food service and specific device and/or devices to be used; -Adaptive eating devices will be noted on the meal ticket; -Adaptive eating devices will be cleaned and sanitized after each meal by food service; -Adaptive eating devices available may include: Plate guard, built-up handles or weighted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to follow the facility's policy to immediately notify the Administrator of a physical altercation involving two residents (Residents #1 and #4) after Resident #1 demonstrated physical aggression toward Resident #4, and facility staff failed to report the incident to the residents' physicians and responsible parties. The failure to notify the Administrator resulted in a delayed investigation and delayed implementation of interventions to prevent further incident. The following day, Resident #1 went back to the room of Resident #4 and exhibited physical aggression requiring staff intervention. The sample was four. The census was 51. Review of the facility's Abuse Prevention policy, undated, showed: -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation,…

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 in interview and record review, the facility failed to ensure staff consistently documented and detailed specific behaviors exhibited by one resident with dementia who displayed psychosocial adjustment difficulty (Resident #1). This failure resulted in insufficient information available for consideration by the interdisciplinary team (IDT) when determining resident-specific non-pharmacological interventions to address the resident's behaviors and to assist the resident in attaining his/her highest practicable mental and psychosocial well-being. The facility failed to ensure psychosocial follow-up was provided to one resident (Resident #3) who expressed feelings of fearfulness following an incident in which his/her femur was fractured when another resident (Resident #1) pushed him/her down. The sample was 4. The census was 51. Review of the facility's Problematic Behavior Management policy, revised August 2008, showed: -Identify individuals with a history of impaired cognition (for example, dementia),…

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 three of three sampled residents had complete, accurate and individualized care plans completed timely and to include post fall interventions after experiencing falls (Residents #1, #2 and #3). The census was 44. Review of the care plan policy, updated 10/2022, showed: -Policy: an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident; -Specifications: each resident's care plan is designed to: -Incorporate identified problem areas; -Incorporate risk factors associated with identified problems; -Build on resident strengths; -Reflect treatment goals and objectives in measurable outcomes; -Identify professional services that are responsible for each element of care; -Aid in preventing or reducing declines in the resident's functional status and/or functional levels; -Enhance optimal functioning 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 the facility's policy after an unwitnessed fall when staff did not document the fall and assessment when it occurred. On 6/23/23, staff discovered the resident with facial bruising. The resident said he/she fell the night before and staff picked him/her up off the floor and put him/her into bed. Staff failed to ensure neurological assessments were completed. Staff also failed to develop the baseline care plan and fall interventions (Resident #1). Additionally, staff failed to ensure neurological assessments were completed for an unwitnessed fall (Resident #2). This affected 2 of 3 residents sampled for falls. The census was 44. Review of the facility fall clinical protocol, revised 8/2008, showed: -Assessment and recognition: the staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events; -Monitoring and follow-up: the staff with 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 provide a restorative nursing program that would assist residents in attaining or maintaining their highest most functional level. The facility identified eight residents that could benefit from a restorative nursing program that provided ambulation and/or transfer training, 16 residents with contractures that may benefit from range of motion (joint exercises) and/or splints/braces, and 11 residents that may benefit from a restorative dining program. Three sampled residents were among those identified that could benefit from a restorative nursing program. One for ambulation (Resident #13), one for contracture management (Resident #25), and one for dining assistance and transfer training (Resident #8). The census was 51. Review of the facility's Restorative Nursing Program policy, undated, showed: Intent: -It is the policy of the facility to assist each resident to attain and/or maintain their individual highest most practicable functional…

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 residents for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative prior to installation, for 11 of 14 sampled residents and two expanded sampled residents (Residents #8, #15, #18, #22, #25, #29, #32, #33, #35, #37, #38, #41, and #43). The census was 51. Review of the facility Bed Safety policy, dated 2001 and revised on 8/2009, showed: -Policy Statement: Our facility shall strive to provide the safest possible sleeping environment for the resident that prevents/reduces hazards such as resident entrapment with hospital beds; -Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be designed based on an interdisciplinary assessment of the resident's safety, medical, comfort, and freedom of movement needs, as well as input from the resident and family regarding previous sleeping and bed environment; 2. In 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.

Based on observation, interview, and record review, the facility failed to ensure no more than 14 hours separated supper/dinner from the next morning's breakfast time, without providing a substantial, nourishing snack at bedtime. The facility served supper/dinner at 5:00 P.M., and breakfast 15 hours later at 8:00 A.M. Although snacks were served at bedtime, they were not substantial and/or nourishing. The census was 51. Review of the facility meal time list, presented to the survey team on 10/25/22, showed: Breakfast 8:00 A.M., lunch 12:00 P.M., and supper/dinner 6:00 P.M. Observation on 10/25/22 at 5:34 P.M., of the first floor dining room, showed the dinner service had been completed. No dietary staff were in the kitchenette. Only two residents continued to eat their meal as staff were observed cleaning the tables were other residents had eaten. During an interview on 10/25/22 at 5:38 P.M., Certified Nursing Assistant (CNA) I, working on the first floor, said dinner was served at 5:00 P.M. During an interview on 10/25/22 at 5:47 P.M., Dietary Aide H said dinner is served at 5:00…

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

Based on observation, interview and record review, the facility failed to store food brought in by residents and visitors, which was stored in the facility's refrigerators on the first and second floor, stored per acceptable standards of practice, failed to ensure dietary staff dated food items in the walk in cooler and freezer after opening the items, including a one gallon jar of mustard past the manufacturer's use by date, and failed to obtain food temperatures on steam tables on the first and second floor. In addition, the facility failed to ensure staff used proper handling techniques to prevent contamination during meal service. The census was 51. Review of the facility's undated Use and Storage of Outside Foods in Resident's Room policy, showed: -Attention residents, resident representatives and visitors: To ensure that food brought in to the facility is stored, handled and consumed safely, these instructions must be followed: -Refrigerator in Resident's room: Resident responsibilities: -The resident is permitted to have a small refrigerator in the room; -The maintenance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their Quality Assurance Performance Improvement plan (QAPI), which describes the process for identifying and correcting quality deficiencies as well as opportunities for improvement, by failing to implement their water management program to prevent the spread of waterborne pathogens, such as Legionella; providing a restorative nursing program to assist residents in attaining or maintaining their highest most functional level, offering alternative menu items to residents who preferred not to eat the meal served, and assessing the residents for risks of entrapment and/or harm before installing and/or utilizing the bedrails. This deficient practice has the potential to affect all residents who reside in the facility. The census was 51. Review of the facility's QAPI policy, undated, showed: -Our organization provides services across the continuum of care. These services have an impact on the clinical care and quality of life 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 ensure their infection preventionist was trained and had completed specialized training in infection prevention and control. The census was 51. Review of the facility's Job Description Job Title: Long Term Care Infection Preventionist job summary, showed: -The infection preventionist (IP) is responsible for the development, direction, implementation, management and operation of the infection prevention in the long-term care facility; -Qualified candidate: Candidate must have the following minimum qualifications: Has completed specialized training in infection prevention. During an interview on 10/25/22 at 8:58 A.M., the administrator said the Director of Nursing (DON) is the infection preventionist. She has been in the IP role for about a year and nine months, with an approximate two to three month break in the middle. She has started the specialized IP training but has not completed it During an interview on 10/26/22 at 2:10 P.M., the DON said she knows she is behind on getting her infection preventionist training done.…

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 vaccinate eligible residents with the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for six of 10 residents sampled for vaccination requirements (Residents #26, #37, #38, #41, #43, and #204). This had the potential to affect all residents admitted who would qualify for the pneumonia vaccination. The census was 51. Review of the facility's pneumonia, bronchitis and lower respiratory infections clinical protocol, provided by the facility as their pneumonia vaccination policy, showed: -Treatment/management: The staff and physician will identify measures to try to prevent recurrent lower respiratory infections (for example, provide pneumococcal pneumonia vaccination); -The policy failed to identify the process to offer or administer the pneumonia vaccination to residents upon admission…

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 completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for 13 of 14 sampled residents, (Residents #8, #15, #18, #22, #25, #29, #32, #33, #35, #37, #38, #41, and #43). The census was 51. Review of the facility Bed Safety policy, dated 2001 and revised on 8/2009, showed: -Policy Statement: Our facility shall strive to provide the safest possible sleeping environment for the resident that prevents/reduces hazards such as resident entrapment with hospital beds; -Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be designed based on an interdisciplinary assessment of the resident's safety, medical, comfort, and freedom of movement needs, as well as input from the resident and family regarding previous sleeping and bed environment; 2. In an effort to reduce/prevent deaths/injuries from entrapment…

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 they maintained a surety bond for the resident trust fund accounting in the amount of one and one-half times the average monthly balance for the last 12 months. The census was 51. Record review of the resident trust account for the past 12 months, showed an average monthly balance of 14,000. This would yield a required bond of 21,000. Review of the Department of Health and Senior Services (DHSS) approved bond records, showed an approved bond of 15,000. Review of the resident trust, showed 6 months (October 2021 to September 2022) where their balance was over 15,000. During an interview on 10/26/22 at 12:37 P.M., the business office manager said there is a consultant company who oversees the bond. During an interview on 10/28/22 at 11:46 A.M., the administrator said ultimately it is the responsibility of the administrator and corporate office for making sure the bond is adequate and increasing if not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide residents a transfer notice upon transfer to the hospital, for two of two residents investigated for hospital transfers (Residents #18 and #43). In addition, the facility failed to submit a monthly list of transferred residents to the office to the Long-Term Care Ombudsman office. The census was 51. Review of the facility's Transfer and Discharge policy, undated, showed: -To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident; -When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waves the notification period or in an emergency situation; -The policy failed to identify the requirement to notify the Ombudsman monthly of all emergency…

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 residents a bed hold notice upon transfer to the hospital, for two of two residents investigated for hospital transfer (Residents #18 and #43). The census was 51. Review of the facility's bed hold and readmission policy, dated November 2016, showed: -It is the policy of this facility to readmit residents after hospitalization or temporary therapeutic leave when the resident requires services which can be provided by the facility. This may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a resident does not desire to hold the specific bed; -Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated state form. The notice to the resident 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 residents with a mental disorder and individuals with intellectual disability had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) level II screen is required) as required, for three of three residents investigated for the PASARR requirement (Residents #33, #34, #38). The census was 51. 1. Review of the Resident #33's level one nursing facility pre admission screening for mental illness/mental retardation or related condition(DA-124C) dated 4/12/19, showed: -The resident was not diagnosed as having a major mental disorder; -The resident was not known or suspected to have a related condition. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/19/19, showed: -Date of admission on [DATE]; -The resident was not determined to have a serious mental illness 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 to develop person centered care plans based on resident's current needs and/or follow residents' existing care plans. The care plans of three of four residents, observed during transfers, did not identify the type of assistance the residents required, or identify gait belts (a belt applied snuggly around the resident's waist to provide stability during a transfer) as interventions. One showed a sit to stand lift should be used to transfer the resident, and staff failed to use the lift during the observation (Residents #8, #35, #37 and #45). One resident's care plan showed a call light should be left within the resident's reach, but did not address an order for the resident's pressure relieving boots, which were not observed on during observations (Resident #8). In addition, one resident's care plan did not address an order for built-up utensils and an adaptive sippy cup (a cup with a lid) and another resident's orders for a hand…

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 padding was added to side rails as ordered for one resident who had experienced an injury from the side rails (Resident #22). The facility failed to ensure staff used gait belts (a belt applied around a resident's waist to provide stability during a transfer or while ambulating (walking)) during observations of residents assessed to need a sit to stand lift (a machine used to transfer a resident that is capable of bearing weight) and/or one person physical assistance during transfers for four of four residents observed during transfers. In addition, call lights were observed being left out of two resident's reach while staff were not present. (Residents #35, #37, #8 and #45). The census was 51 Review of the facility Bed Safety policy, dated 2001 and revised on 8/2009, showed: -Policy Statement: Our facility shall strive to provide the safest possible sleeping environment for the resident that prevents/reduces hazards such 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 ensure staff had appropriate competencies and skill sets to provide nursing and related services to attain or maintain the highest practicable well-being of each resident. Staff failed to competently provide AM care, cleanse shared medical equipment between resident use, and transfer residents using acceptable standards of practice. Staff voiced not receiving the required training and/or could not demonstrate competency during observed care. The facility could not produce documentation of in-service training provided that addressed identified concerns. The census was 51. 1. During an interview on 10/28/22 at 9:02 A.M., the Human Resource (HR) Director said the Director of Nursing (DON) is responsible for in person training. HR is only responsible for tracking training hours and the online training. 2. Review of Resident #8's care plan, dated 8/19/22, showed the care plan did not identify the resident's personal hygiene needs. Observation…

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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week over the three most recent quarters, to include weekends and week days. The census was 51. Review of the facility's list of current employees, provided on 10/24/22, showed a director of nursing (DON). No other registered nurse (RN) employed. Review of the facility's payroll based journal (PBJ) report for quarter 2 and resident census, showed: -No RN hours in the month of January 2022, on: -Saturday 1/1/22 with a census of 45; -Sunday 1/2/22 with a census of 44; -Saturday 1/8/22 with a census of 46; -Sunday 1/9/22 with a census of 46; -Saturday 1/22/22 with a census of 48; -Sunday 1/23/22 with a census of 47; -Saturday 1/29/22 with a census of 46; -No RN hours in the month of February 2022, on: -Saturday 2/5/22 with a census of 48; -Sunday 2/6/22 with a census of 48; -Saturday 2/12/22 with a census of 52; -Sunday 2/13/22 with a census of 52; -Saturday 2/19/22 with a census of 53; -Sunday 2/20/22 with a census of 53; -Saturday…

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 are labeled in accordance with currently accepted practices. These practices affected two of three medication carts reviewed. The sample was 14. The census was 51. Review of the facility's administration procedures for all medications policy, revised 1/2018, showed: -Policy: To administer medications in a safe and effective manner; -Procedure: Check expiration date on package/container before administering any medication; When opening a multi dose container, place the date on the container. Review of the facility vials and ampules of injectable medications, revised 1/2018, showed: -Policy: ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provided pharmacy directions for storage, use and disposal; -Procedures: -Expiration dates: Unopen vials expire on the manufacturer's expiration date; Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both…

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 offer alternative menu items to residents who preferred not to eat the meal served, for seven residents observed during meal service (Residents #26, #18, #16, #29, #33, #34 and #43). This failure had the potential to affect all residents in the facility who were not being provided a meal they preferred. The census was 51. 1. Review of the Resident Council Meeting minutes, dated 8/18/22, showed: -Dietary: A resident said meal tickets are not being read. I eat in my room and have a mechanical soft diet and they send food I am not supposed to have. Residents asked why an alternate meal was not available and if they did not like the alternate meal, could the ala carte menu be utilized. Residents requested the food services director to come around and get their likes and dislikes for meals and drinks; -No documentation of staff in attendance during meeting. Review of the Resident Council Meeting minutes, dated 9/22/22, showed: -Dietary: Milk…

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 report or investigate an injury of unknown origin, provide a written report of the investigation outcome, including resident response and/or condition, final conclusion and actions taken to prevent reoccurrence, for one resident (Resident #46). In addition, the facility's abuse and neglect policy failed to define an injury of unknown origin or direct staff to report or investigate an injury of unknown origin. The census was 51. Review of the facility's Abuse Prevention Program Facility Procedures, updated 4/7/17, showed: -Facility will provide a comfortable and safe environment; -The policy failed to define an injury of unknown origin or direct staff on the reporting, investigating, training or prevention of injuries of unknown origins. Review of Resident #46's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff), dated 5/2/22, showed: -Resident is unsteady but can stabilize using staff; -Extensive assistance required for bathing, grooming, transfers 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 staff provided and/or assisted three of three residents who were assessed to require assistance with activities of daily living (ADLs) including personal hygiene and bathing (Residents #8, #37 and #35). The census was 51. Review of the facility's undated Activities of Daily Living policy, provided as the A.M. care policy, showed grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure, and/or application of deodorant or powder. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/22, showed: -Adequate hearing; -Highly impaired vision - object identification in question, but eyes appear to follow objects; -Makes self understood: Understood; -Ability to understand others: Understands; -Clear…

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 a medication error rate of less than 5%. Out of 35 opportunities observed, two errors occurred resulting in a 5.71% error rate (Resident #32). The census was 51. Review of the facility's Administration Procedures for all Medications policy, revised 1/2018, showed: -Policy: To administer medication in a safe and effective manner. -Procedures: - Review 5 rights (3) times (a recommendation to reduce medication errors; right resident; right drug; right dose; right route; right time). -Prior to removing the medication package/container from the cart/drawer; - Check the medication administration record (MAR) and treatment administration record (TAR) for order; -Note any allergies or contraindications the resident may have prior to drug administration; -Prepare the resident for medication administration; -Prior to removing the medication from the container; -Check the label against the order on the MAR; -After administration, return to cart, replace medication container and document administration in the MAR…

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 offer special dietary equipment, if ordered by the physician and to assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, for a resident (Resident #32). The sample was 14. The census was 51. Review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/1/22, showed the resident needs extensive assistance, supervision, set-up cue with eating. Review of the resident's physician order sheet, showed an order dated 10/25/21, for the resident to have built-up utensil and sippy cup with each meal in order to promote independence with self-feeding. Review of the resident's lunch mealtime ticket, on 10/27/22 at 12:40 P.M., showed: -Pureed diet; -Physician's order sippy cup, built-up utensil, no fish/shellfish (allergy). Observation on 10/25/22 at 2:25 P.M., showed staff served the resident apple juice and lemonade, both drinks had white flex straws in regular…

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 a Registered Nurse (RN) for eight consecutive hours during the day shift on the weekends from 5/1/19 through 8/25/19. This deficient practice had the potential to affect all residents in the facility. The census was 49. Observation on 8/26/19 at 5:30 A.M., of the daily staffing schedule located on the second floor nursing unit, showed no RN scheduled for Saturday 8/24/19 or Sunday 8/25/19. Licensed Practical Nurse's (LPN)s were scheduled for all three shifts on both days. Review of the facility's daily nursing staffing schedule dated 8/24/19 and 8/25/19, provided by the facility on 8/27/19, showed no RN scheduled for Saturday 8/24/19 or Sunday 8/25/19. LPNs were scheduled for all three shifts on both days. During an interview on 8/27/19 at 1:00 P.M., the administrator and Director of Nurses (DON) verified the facility did not have an RN on duty for eight consecutive hours during the day shift on Saturday, 8/24/19 and Sunday, 8/25/19. The DON said since she started work at the facility in May 2019, 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 implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they did not implement appropriate interventions to correct on-going, systemic issues. This deficient practice had the potential to affect all residents. The facility census was 49. Review of the facility's annual statement of deficiencies (SOD), dated 11/20/18 and the current SOD, dated 8/27/19, showed the facility received the following citations consecutively: -F657, failure to develop and revise comprehensive care plans; -F689, failure to provide an environment free of accidents hazards/supervision/devises; -F698, failure to provide dialysis care (process for removing toxins from the blood for individuals with kidney failure) using acceptable nursing practices; -F730, failure to ensure certified nurse aides received the required 12 hours of in-service training based on performance reviews; -F868, failure to have a QA committee in place. The facility received a citation on 5/2/19 and on the current SOD for F686,…

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 provide documentation showing the quality assurance and assessment (QAA) committee met quarterly for a quality assurance performance improvement (QAPI) meeting. This deficient practice had the potential to affect all residents. The census was 49. During the entrance conference on 8/22/19 at 10:30 A.M., the administrator said he had been at the facility for four weeks. There was not a functioning QA/QAPI program or committee. There was a meeting scheduled next week. A request for any documentation regarding the QAA committee and QAPI policy and procedure was requested. As late as 8/27/19 at 4:00 P.M., the facility had not provided any information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment, by not ensuring walls, carpets and floors were clean and in good repair on the first and second floors. The census was 49. 1. Observation of the first floor dining room on 8/22/19 at 12:30 P.M., 8/23/19 at 12:46 P.M., 8/26/19 at 9:05 A.M. and 1:49 P.M. and 8/27/19 at 9:12 A.M. and 11:00 A.M., showed the following: -A chair-height white scrape approximately 3/4 inches wide on the column near the medication cart; -Black scuff marks at chair-height, on the white wood trim approximately 10 inches wide, on the west dining room wall; -Gouges in the walls, approximately 1/8 inch deep, to the left and right of the doorway leading outside; -An approximate 12 inch white gouge in the wall to the right of the doorway at chair-height; -Multiple gouges in the wall to the right of the door, under the window and above the cove base, all along the west wall; -A large amount of tiny black bugs on cobwebs on each…

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 care plans reflected residents' current needs by not updating them to include falls and new/additional fall interventions for two (Residents #2 and #9) of 13 sampled residents, and failed to remove hospice information for one resident (Resident #14) when discharged from hospice. The census was 49. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/25/19, showed the following: -Short and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Extensive assistance of staff required for most activities of daily living (ADLs); -Incontinent of bowel and frequently incontinent of bladder; -Two falls; -Received antipsychotic, antidepressant and opioid medication the last seven days; -Diagnoses included anemia, heart failure, Alzheimer's disease, dementia and depression. Review of the resident's care plan, updated on 12/10/18 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 all physician orders were followed by not notifying the physician regarding a resident's weight gain, not discontinuing hospice care services on the current physician's order sheet, not obtaining laboratory tests and by not obtaining orders for oxygen usage for six of 13 sampled residents (Residents #46, #44, #14, #13, #4 and #9). The census was 49. 1. Review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/19, showed the following: -No cognitive impairment; -Extensive assistance of staff required for transfers, toileting and personal hygiene; -Occasionally incontinent of bowel and bladder; -Not steady when walking, moving from seated to standing, turning, moving on and off the toilet and transferring between bed to chair or wheelchair; -Diagnoses include heart failure, high blood pressure, pneumonia, diabetes and respiratory failure. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to prevent resident access to harmful chemicals and razors in three of four unlocked spa rooms and one unlocked laundry room. This had the potential to affect all residents who could move about freely in the facility. The sample was 13. The census was 49. 1. Observation of the spa room on the first floor near room [ROOM NUMBER], showed the following: -On 8/23/19 at 7:15 A.M. and 8:16 A.M. and on 8/26/19 at 7:44 A.M., one disposable razor lay in the vanity drawer, and a one gallon plastic container of whirlpool disinfectant cleaner, approximately one half full, with no lid, sat in the unlocked vanity cabinet. The label on the container read: DANGER Keep out of the reach of children. Corrosive. Causes irreversible eye damage and skin burns. Do not get in eyes, on skin or on clothing. Wear goggles, face shield, rubber gloves and protective clothing. Harmful if absorbed through skin. Harmful if swallowed. Wash thoroughly with soap and water after handling.…

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 routinely assess, monitor and document on three residents receiving dialysis (process for removing toxins from the blood for individuals with kidney failure) regarding their shunts (artificial link between an artery and a vein) and/or fistulas (a real connection between an artery and a vein). The facility identified four residents as receiving routine dialysis treatments, and problems were found with all four residents (Residents #28, #13, #42 and #15). Furthermore, the facility failed to obtain a contract for one of two dialysis centers utilized by residents. The sample was 13. The census was 49. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/19, showed the following: -admission date of 4/12/19 -No cognitive impairment; -Required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene; -Diagnoses included high blood…

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 certified nurse assistants (CNAs) received the required 12 hours of in-service training based on performance reviews, for four of five CNA employee files reviewed who worked in the facility more than one year. The facility showed they currently had 11 CNAs, who worked in the facility more than one year. The census was 49. 1. Review of CNA G's training record, showed the following: -Date of hire, 5/12/14; -Total hours of training completed for the last full year of employment, 7 hours. 2. Review of CNA H's training record, showed the following: -Date of hire, 4/18/16; -Total hours of training completed for the last full year of employment, 7 hours and 45 minutes. 3. Review of CNA I's training record, showed the following: -Date of hire, 4/18/17; -Total hours of training completed for the last full year of employment, 9 hours and 30 minutes. 4. Review of CNA J's training record, showed the following: -Date of hire, 2/11/18; -Total hours of training completed for the last full year 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.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs, in sufficient detail, to enable an accurate reconciliation for two of two floors. The census was 49. 1. Review of the shift change controlled record, dated August 2019 and provided 8/23/19 for the first floor, showed the following: -Did not specify type of narcotic, who prescribed the narcotic and/or for which resident; -Illegible narcotic count, a total of six days at the beginning and end of each shift; -Number of narcotic packages counted, but not the number of pills; -No on-coming nurse's signature for a total of 13 out of 67 opportunities; -No off-going nurse's signature for a total of 34 out of 67 opportunities. 2. Review of the shift change controlled record, dated August 2019 and provided 8/23/19, for the second floor, showed the following: -No recorded narcotic count a total of 13 shifts; -No on-coming nurse's signature for a total of 18 out of 67 opportunities; -No off-going nurse's signature for a total of 28 out of 67…

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 two residents (Residents #35 and #2), who received antipsychotic medications, had appropriate diagnoses, and as needed (PRN) use of psychotropic drugs were limited to 14 days for one resident (Resident #14) of 13 sampled residents. The census was 49. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/19, showed the following: -Moderate cognitive impairment; -Extensive assistance of staff required for transfers, dressing, toilet use and personal hygiene; -Total dependence on staff for bed mobility and bathing; -Incontinent of bowel and bladder; -Received antipsychotic and hypnotic medications in last seven days; -Diagnoses included orthostatic hypotension (blood pressure drop when standing), dementia and diabetes. Review of the resident's care plan, updated on 12/17/18 and in use at the time of the survey, showed the following: -Focus:…

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 date insulin flex pens (prefilled insulin pens) once opened, and failed to discard an outdated insulin pen on two of two medication carts for three of nine insulin pens observed. The census was 49. 1. Observation on [DATE] at 12:30 P.M., of the medication cart on the second floor, showed the following: -One Lantus (long acting insulin) flex pen, with an opened date of 7/20 /19; -One Levemir (long acting insulin) flex pen with no date opened or date expired. During an interview on [DATE] at approximately 12:40 P.M., Licensed Practical Nurse (LPN) C said after an insulin flex pen was opened, it was good for 15 to 30 days, depending on the brand. He/she said if the flex pen was expired, it should go in the cart in the medication room to be returned to the pharmacy. 2. Observation on [DATE] at 12:45 P.M., of the medication cart on the first floor, showed the following: -One Lantus flex pen with no date opened or date expired. 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.

Based on observation and interview, the facility failed to maintain the cleanliness of the vent in the first floor dish room, which could blow air on all clean utensils, glassware, dishware and cookware in the dish room. This deficient practice affected all residents who ate at the facility. The census was 49. 1. Observations of the dish room on the first floor on 8/22/19 at 10:43 A.M. and on 8/27/19 at 7:51 A.M., showed a ceiling vent perpendicular to the only door of the dish room. The vent had a heavy build up of dark gray dust on the grates of the vent. The dust extended approximately three feet away from the vent on the walls and ceiling. 2. During an interview on 8/27/19 at 10:19 A.M., the dietary manager said the the maintenance department was responsible for cleaning the vent. There had only been one person in the maintenance department for six to seven months, so the vent has not been cleaned. It should be cleaned regularly. 3. During an interview on 8/27/19 at 11:08 A.M., the administrator said the vent should be cleaned routinely. It was the dietary manager's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately assess pain, record the degree and location of pain and notify the physician of ineffective pain control, which allowed severe, unnecessary discomfort. This deficient practice affected two residents (Resident's #42 and #19) out of 13 sampled residents. The census was 49. Review of the facility's Pain Assessment Policy, dated 11/28/19 and last revised on 7/6/18, showed the following; -Purpose: -To establish guidelines for appropriate assessment and intervention to manage pain; -To respect and support the resident's right to optimal pain management; -To measure and document the effectiveness of the plan using objective and subjective assessments; -Responsibility: -Licensed Nurse; -Guidelines: -A pain assessment tool will be used as indicated as a guide in determining a resident's pain in addition to their descriptive words and/or physical behaviors; -A pain assessment will be performed as part of the admission assessment. A pain…

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.