Magnolia Wellness Center

Deficiency Text Not Available

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 34 opportunities observed, nine errors occurred resulting in a 26.47% error rate (Residents #11, #7, #12 and #4). In addition, Resident #1, Resident #4, and residents attending the 3/3/25 Resident Council meeting complained about receiving medications late. The census was 86. Review of the facility Medication-Administration policy, dated 5/2017, showed: -Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations; -Procedure: -Medications are prepared, administered, and recorded only by licensed nursing, Certified Medications Technicians (CMTs), medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications; -Current medications and dosage schedules are listed on the resident's Medication Administration Record (MAR); -Medications are administered within 60 minutes of scheduled time (60 minutes before or after 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 residents who required enhanced barrier precautions (EBP) for infection control interventions had a sign on their door or wall next to the room entrance instructing staff to use EBPs while providing personal care. In addition, the facility failed to ensure personal protective equipment (PPE, gloves, gowns, masks and goggles/face shields) were readily accessible for residents requiring EBP, and staff were inserviced on EBP and which residents required EBPs. The facility identified 18 residents who required EBPs, and this had the potential to affect all residents (Residents #5, #6 and #3). The census was 86. Review of the facility's Standard and Enhanced Precautions policy, dated 4/1/24, showed: -Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents; -Policy: The facility will utilize current guidelines from the Centers for Disease Control (CDC) 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 consistently notified physicians when residents' high blood glucose levels exceeded the ordered parameters. The facility identified 10 residents with orders for routine blood glucose level checks, four were sampled and problems were found with two (Residents #13 and #3). The census was 86. Review of the facility Change of Condition - Observing, Reporting and Recording policy, dated 5/17, showed: -Policy: It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following: -A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications; -A need to alter treatment significantly; -The attending physician should be notified as soon as possible when immediate attention is required; -Documentation: -Date, time…

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 Resident #3's physician was notified and monitoring was started after staff documented on shower review forms the resident had blisters on his/her bilateral feet. In addition, the facility failed to ensure staff initialed treatments had been completed and failed to ensure the resident wore his/her protective boots. Three residents were sampled and problems were found with one. The census was 86. Review of the facility Wound Management policy, dated 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents wit wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus (DM, high/low blood sugar) and peripheral neuropathy (damage or disease affecting the nerves). The diabetic ulcer characteristically occurs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to maintain a measurable, goal oriented restorative nursing program, and/or exercise program, to ensure residents requiring physical assistance were assisted by staff to maintain or improve their physical abilities, per facility policy. The facility provided a list of 11 current residents who had been discharged from skilled therapy services. Of those 11, two were identified with concerns of not getting recommended restorative therapy (Residents #21 and #19). The census was 87. Review of the facility Restorative Nursing Program Guidelines, dated 6/20, showed the following: -Purpose: The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary behavioral health care services when staff did not intervene during a resident's agitated and heightened state (Resident #6) who then kicked another resident (Resident #8). The facility also failed to intervene when Residents #6 and #5 were involved in a verbal altercation that led to Resident #5 reaching out and wrapping his/her hands around Resident #6's neck. Resident #6 complained of bruising to his/her neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Behavior Management policy, revised 06/2020, showed: -Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the resident's quality of life; -The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial…

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 resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercation, in which one resident placed their hands around another resident's neck (Residents #1 and #2). The sample was 32. The facility census was 74. The facility was notified of past non-compliance on 7/2/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 6/29/24. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification,…

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, record review, and interviews, the facility failed to ensure food was not expired, skim milk was available according to physician orders, dented cans were not stored in areas of usage, dish machine concentration levels were monitored, the hood was cleaned, and food temperatures were within proper parameters and properly monitored in accordance with professional standards for food service safety for one of one kitchen for 76 census residents. Findings include: Review of the job description for the Dietary Manager (DM), revised 04/20, revealed The dietary manager is responsible for assisting and supporting dietary staff within established state and federal regulations .The dietary manager is also responsible for assuring that meals are healthy, nutritious and look appealing and monitoring safety in the kitchen. Review of the facility's policy titled, Purchasing and Storage: Facility and Resident Food Supplies, revised 01/24, revealed Purchases shall be inspected upon delivery by the manager or his/her designee. Supplies which do not meet appropriate standards 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 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 46 residents. A sample of eight residents were chosen and the practice affected four residents (Residents #101, #104, #56 and #105). The census was 74. Review of the facility's Trust Policies and Management Policy, undated, showed the following: -admission Requirement Regarding Resident Trust: Upon admission the resident or resident's representative may request the facility to hold the resident's funds in the resident trust account; -General Information Regarding Responsibilities of Holding Resident Funds: -The Business Office Manager (BOM) shall keep an accurate record and maintain the accounting system for the residents who choose to have their personal financial affairs managed; -These funds shall be safeguarded by the facility, including complete and separate accounting principles, which preclude any commingling of resident funds with facility funds; -There was no…

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

Based on observations, interviews, recipe review, and pureed food guideline review, the facility failed to ensure proper pureed consistency for residents receiving pureed texture of 76 census residents. Findings include: Review of the undated pureed meat recipe, provided by the facility, revealed Place entrée in blender. Grind. Add bread. Grind. Add 4[sic] oz [ounce] or ½ [half]cup liquid until consistency is smooth and between pudding and mashed potato consistency. Review of the undated Pureed Food Guideline, provided by the facility, revealed The consistency of the pureed food should not be thinner than pudding or thicker than mashed potatoes. During an observation on first floor meal service on 02/07/24 at 11:54 AM, the pureed texture had the appearance of moist mechanical soft texture. The staff serving the food confirmed it was supposed to be pureed meat. During an interview on 02/07/24 at 1:03 PM, the Dietary Manager (DM) stated Dietary Staff (DS) 2 was educated on the proper pureed texture. She stated pureed texture should have been more like mashed potato, pudding like…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure safe, functional, sanitary, and comfortable resident equipment for three of four residents (Residents (R) 44, R272, and R12) reviewed for wheelchair and recliner chair maintenance. The facility failed to ensure accessible Emergency Medical Services (EMS) access for 76 census residents. Findings include: Review of the facility's undated policy titled, Maintenance Service revealed Maintenance shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Review of the facility policy Resident Environmental Quality, dated 08/13/04; and Safety and Supervision of Residents, revised July 2017 did not reveal information on maintaining a after hours emergency services access. No policy was provided that addressed functional door call systems for after hours emergency services…

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 complete Minimum Data Set (MDS) assessments in the allotted time frame as stated in the Resident Assessment Instrument [RAI] manual for two of two residents (Resident (R) 171 and R173) reviewed. Findings include: Review of the facility policy titled MDS Submission and Transmission Timeframes, revised July 2017, showed: Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the he Resident Assessment Instrument Manual. Review of the October 2019 Resident Assessment Instrument (RAI) Manual…

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

Based on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) level one screen was completed prior to admission for one (Resident (R) 38) of three residents reviewed for PASARR. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of the facility's policy titled, admission Criteria revised 12/2016, indicated, .9. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. Review of R38's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed an admission date of 11/22/17 with diagnoses that included schizophrenia and major depression. Review of R38's annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure care conferences were conducted for one of three residents (Resident (R) 16) reviewed for care conferences of 76 census residents. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/16, revealed The care planning process will: facilitate resident and/or representative involvement . Review of R16's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), muscle weakness, other abnormalities of gait and mobility, and weakness. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. During an interview on 02/05/24 at 10:13 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one of two residents (Resident (R) 171) reviewed for bed rail use had a bed rail that was considered a safe design for use. This failure had the potential for the resident to become entrapped in the bed rail with a risk of severe injury and/or death with bed rail use. Findings include: Review of the facility's policy titled, Resident Beds and Bed Safety Rails Program, effective 10/28/19, stated Purpose: 1. To establish and verify that NHS Facilities meet the requirements of the FDA and other regulatory agencies; And [sic] to establish mitigation and preventative requirements and activities that maintain a constant state of safety related to Resident Care Beds and Bed Safety Rails. Review of the facility's policy titled, Proper Use of Side Rails, revised December 2016, showed, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure timeliness of medication administration was provided for one of one resident (Resident (R38) reviewed for late medications of 76 census residents. Findings include: Review of the facility's policy titled, Administering Medications, revised 12/12, revealed Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. Review of R38's undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnosis which included type two diabetes, cerebrovascular disease, major depressive disorder, schizophrenia, and essential hypertension. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated the resident had intact cognition. Review of the Medication Admin…

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 review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction and/or resident injury. This failure had the potential to affect any of the 76 residents who reside at the facility and use a bed. Findings include: Review of the facility policy Bed Safety, revised December 2007, showed: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation l. The resident's sleeping environment shall be assessed by the interdisciplinary team, 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. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, 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 record review, interview, and review of the facility policy, the facility failed to implement and maintain a training program for lift equipment training for one Certified Nurse Aides (CNA1). This failure to train CNA1 had the potential to affect the care and services provided to any of 76 residents that might require lift transfers by CNA4. Findings include: Review of the facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, dated January 2008, did not address contract staff or training on facility equipment specifically, stating: 2. Our orientation program includes, but is not limited to: a. A tour of the facility, which includes: (1) A description of the resident population; (2) An overview of the resident's daily routine; and (3) A demonstration of the use of the resident's call light and intercom system. b. Instructions in procedures to be followed in an emergency which includes, but is not limited to: (1) Unusual occurrences with residents (i.e., accidents, wandering, missing, etc.); . (4) Accident prevention and emergency first…

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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of each resident. The facility failed to employ an activity director qualified for the position, failed to maintain an activity director in the past year for a sufficient length of time to develop and implement an effective activities program, and failed to employ sufficient numbers of activity staff. The facility failed to ensure there was a current activities schedule and failed to ensure scheduled activities occurred. The facility failed to provide outdoor activities per residents request and failed to provide activities per residents choice as identified on the Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), for three of four residents investigated for activities (Resident #35, #34, and #23). These failures had the potential to affect…

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 activities program was directed by a qualified professional. This affected all residents who resided in the facility. The census was 44. Review of the Facility Assessment, revised on 6/30/21, showed: -Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents: The facility included the activity director as a needed staff member; -In addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff positions/roles): The facility included the activity director as a needed staff member. Observation of the second floor activity calendar, on all days of the survey from 12/1/21 through 12/3/21 and 12/6/21 through 12/8/21, showed the following: -Activities for the month of: 2021, (no month listed); -Sundays: Blank; -Mondays: 10: 00 A.M., outside chat and 11:00 A.M., movies; -Tuesdays: Bingo, no time listed; -Wednesdays: 10:00 A.M., Bible study and craft; -Thursdays: Bingo, no…

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

Based on observation, 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. In addition, the facility failed to designate a RN to serve as the Director of Nursing (DON) on a full time basis. The census was 44. Review of the facility's Facility Assessment Tool, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Staff type, included: Administrator, DON, unit managers, RN, licensed practical nurses (LPNs), certified medication technicians (CMTs) and certified nursing assistants (CNAs); -Staffing plan: Total number needed, average, or range: -Licensed nurses providing direct care: 10 (agency also used); -Other nursing personnel (e.g., those with administrative duties): five; -This facility reviews and updates job descriptions annually. The facility administration also reviews the staffing needs and the needs of the residents on an ongoing basis. The facility works on recruitment and retention continually offering bonus programs for new hires, retention bonus programs for those…

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 conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. At the time of the survey, the facility assessment in use at the facility was a facility assessment for a sister facility. The census was 44. Review of the Facility Assessment Tool provided by the facility as their facility assessment, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Physical environment and building/plan needs: The facility is a large one-story community with 240 licensed skilled beds. Review of the facility layout, showed the facility had three levels. The ground level, first floor and second floor. Review of the facility's bed listing, showed a capacity of 120. Further review of the Facility Assessment Tool, showed the facility assessment belonged to a different facility. During an interview on 12/10/21 at 3:40 P.M., the administrator said she was not sure if there was another facility assessment or not. She is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee made good faith attempts to identify and correct quality deficiencies. The facility administrator had only been at the facility for a month at the time of the survey and had not yet held a QAPI meeting. The prior administration had no current performance improvement projects identified or implemented. The survey team identify quality deficiencies for infection control, staffing, wounds, weights and activities. This failure had the potential to affect all residents in the facility. The census was 44. Review of the facility's undated Quality Assurance and Performance Improvement Committee policy, showed: -This facility shall establish and maintain a QAPI Committee that oversees the implementation of the QAPI program; -The administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program; -The committee shall…

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 infection surveillance program and failed to ensure the infection preventionist acted in that capacity at the facility. During the time of the survey, the infection preventionist worked as the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) coordinator on a part time basis and had not yet implemented any aspect of the infection prevention and control program. The prior infection preventionist had left employment and had last implemented the program in May 2021, nearly 6 months prior. This resulted in one resident with a wound infection not to be identified by the facility as a resident with an infection (Resident #15). The facility failed to ensure staff used acceptable infection control procedures during perineal care, for one of three residents observed during personal care (Resident #3). The facility failed to ensure staff properly sanitized shared medical equipment before…

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 communicate changes in their visitation policy to residents and representatives in a widespread or timely manner. This resulted in two sampled residents (Residents #41 and #34) and their family members to adhere to the more restrictive visitation policy, which denied the residents' rights to have visitors per their preference. This had the potential to affect all residents who would choose to have visitors. The sample size was 12. The census was 44. Review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation Covid-19 (Revised) Memorandum, revised on 11/12/21, showed: -CMS is committed to continuing to take critical steps to ensure America's healthcare facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE); -Visitation Guidance: CMS is issuing new guidance for visitation in nursing homes during the COVID-19 PHE, including the impact of COVID-19 vaccination;…

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 admission review (Residents #4, #34 and #244) and a yearly review (Residents #15 and #26) of code status (full code-if the heart stops beating or breathing ceases, all lifesaving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed). The sample size was 12. The census was 44. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admission date: [DATE]; -Independent with self care activities; -Diagnoses included high blood pressure and cirrhosis (late stage liver disease). Review of the resident's medical record, showed: -Resident is their own responsible party; -No order for code status; -No code status form signed by the resident; -Code status not addressed on the care plan. Review of the code status binder at the nurses' station, showed no information for the resident. During an interview on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents had a clean, comfortable and homelike environment when they served residents meals in Styrofoam containers and on cafeteria-style trays. The facility failed to maintain shower rooms in working order. In addition, the facility failed to ensure the walls, floors, and cove base in common areas and the medication and treatment carts were clean and in good repair. The census was 44. 1. Observations of the second floor dining room on 12/1/21 at 12:08 P.M., 12/3/21 at 9:09 A.M., and 12:41 P.M., 12/6/21 at 1:00 P.M., and 5:49 P.M. and 12/7/21 at 8:21 A.M., showed: -Residents were served trays with disposable Styrofoam food containers, plastic cups and plastic flatware; -Staff failed to remove the cafeteria- style trays from the tables after staff served food to the residents. During the entrance conference on 12/1/21 at 8:47 A.M., the administrator said there were no positive or suspected cases of COVID-19 in the building.…

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 each resident. This affected five residents (Residents #34, #30, #35, #23 and #2) out of 12 sampled residents. The facility's census was 44. 1. Review of Resident #34's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/6/21, showed: -Required total assistance from staff for dressing, personal hygiene, toileting, mobility and transfers; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure, stroke and choric obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has limited physical mobility related to weakness; -Goal: The resident will remain free from complications related to immobility, including contractures, thrombus formation (blood clot), skin breakdown,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for residents by failing to administer supplements as ordered by the physician (Resident #4), clarify conflicting physician orders (Resident #15) and ensuring staff did not substitute a medication for other medications, without a corresponding physician order (Resident #8). The facility failed to obtain an order for blood glucose monitoring which staff performed but also did not document (Resident #244). Additionally, staff failed to obtain and document monthly weights (Residents #26, #18, #2 and #25). The sample was 12. The census was 44. Review of the facility's undated Following Physician's Orders policy, showed: -The purpose of a physician's order is to communicate the medial care that a resident is to receive while in our facility, as well as to document the medications, treatments and tests that are to be/have been provided; -Once orders are obtained for a new resident,…

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

Based on observation, interview and record review, the facility failed ensure there are a sufficient number of skilled licensed nurses to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. The facility failed to ensure a licensed nurse was on duty each shift, which resulted in the administrator having to forego her administrative duties at the facility to work as the charge nurse on the floor. The administrator's office was located on the first floor and all residents resided on the second floor. This resulted in resident's not receiving a treatment as ordered and improper documentation that residents received their ordered medications (Residents #15 and #40). The sample was 12. The census was 44. 1. During the entrance conference on 12/1/21 at 8:47 A.M., the administrator said the facility does not currently have a Director of Nursing (DON). The facility does use agency staff intermittently. She is a Licensed Practical Nurse (LPN). All residents reside on the second floor. Review of the facility's Facility Assessment Tool,…

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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for one of one narcotic book reviewed. In addition, the facility failed to account for all controlled drugs when a narcotic removed from stock was not accounted for (Resident #15). The census was 44. Review of the facility's Controlled substance policy, revised December 2012, showed: -The facility shall comply with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record must be made fore each 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 observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 40 opportunities observed, nine errors occurred resulting in a 22.5% error rate (Residents #37, #25, #8 and #15). The census was 44. Review of the facility's undated Following Physician's Orders policy, showed: -The purpose of a physician's order is to communicate the medial care that a resident is to receive while in our facility, as well as to document the medications, treatments and tests that are to be/have been provided; -Once orders are obtained for a new resident, the charge nurse is to transcribe them onto a physician's order sheet and the physician then called to verify those orders. Once this is completed, the charge nurse must sign off that all orders have been verified; -After orders are written for a new resident, this is the responsibility of the charge nurse to process these orders and advice the various departments that may be involved in carrying out the procedures,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals are stored and labeled in accordance with currently accepted practices, and include the appropriate expiration date. The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. In addition, the facility failed to ensure narcotic medications were separately locked, behind two locks. These practices affected four of four medication/treatment carts and one of one medication room reviewed. The facility identified five medication/treatment carts and one medication room in use at the facility. The census was 44. Review of the facility's Storage of Medications policy, revised April 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure and orderly manor; -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received; -The nursing staff shall 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 observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two trays sampled. The census was 44. 1. Review of Resident #18's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/24/21, showed: -Cognitively intact; -Independent with eating; -Diagnoses included diabetes mellitus, high cholesterol, stroke and anxiety. During an interview on 12/1/21 at 10:49 A.M., Resident #18 said he/she doesn't like the food served at the facility. He/she can't eat the food without feeling sick and it upsets his/her stomach. The food is poor quality and it doesn't taste good. He/she is on a mechanical soft diet because he/she has issues with choking. Something is wrong with his/her throat and the food does not always want to go down. They grind the meat up in a…

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

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented. An agency nurse contracted to work at the facility had a certified medication technician (CMT) document the administration of medications administered by the nurse (Resident #15). When working the floor as the charge nurse, in addition to having administrative responsibilities at the facility, the administrator failed to document the administration of medications (Residents #15 and #40). Staff failed to document a resident's complaint of pain, administration of medication or effective of the medication (Resident #39). In addition, staff documented the administration of medications that had not been administered (Residents #37, #25 and #8). The census was 44. 1. Review of Resident #15's nurse electronic medication administrator record (eMAR), reviewed on 12/3/21 at 10:29 A.M., showed all 9:00 A.M. nurse eMAR medications documented as administered by CMT A. Observation on 12/3/21 at 9:35 A.M., showed CMT A stood at 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 implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. During the time of the survey, the infection preventionist worked as the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) coordinator on a part time basis and had not yet implemented any aspect of the antibiotic stewardship program. The prior infection preventionist had left employment and had last implemented the program in May 2021, nearly 6 months prior. This resulted in one resident with a wound infection that required antibiotic use to not be identified by the facility as a resident on antibiotics (Resident #15). This had the potential to affect all residents who require antibiotic use. The census was 44. Review of the Facility Assessment Tool, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Services and care we offer based on our residents' needs: -Infection prevention and control: Identification and containment 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 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 39. 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: -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 3/15/22 at 10:00 A.M., the administrator said the facility does not have an IP at this time. The Director of Nurses (DON) started working with the facility yesterday,…

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 COVID-19 vaccine boosters as requested for 10 residents (Residents #504, #35, #20, #505, #38, #403, #501, #23, #30, and #500). The sample was 18. The census was 39. Review of the facility's Resident Covid Vaccination Policy, updated 12/1/21, showed: -Policy: To protect the health and safety of our residents and staff, this facility strongly encourages the COVID-19 vaccination for residents; -Policy interpretation and implementation: -Residents will be offered the opportunity to receive the vaccine at no cost. The vaccination process is a two-step vaccination. If receiving the Moderna vaccine, the second vaccination will occur no earlier than 28 days from the initial vaccination. If receiving the Pfizer vaccine, the second vaccination will occur no earlier than 21 days from the initial vaccination. To be fully protected from being infected with COVID-19 you will need to receive both vaccinations and booster vaccinations when indicated; -The policy failed to provide guidance regarding COVID-19 vaccination boosters.…

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 thoroughly investigate an allegation of verbal abuse for one resident (Residents #245). The sample was 18. The census was 39. Review of the facility's Abuse Investigation and Reporting Policy showed, undated, showed: -Policy Statement: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Role of the Administrator: -If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown origin is reported, the administrator will assign the investigation to an appropriate individual; -The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation; -The administrator will keep the resident and his/her representative (sponsor)…

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 weekly showers were provided to two sampled residents (Residents #34 and #30). The facility also failed to have a system in place to track resident showers to ensure they were offered. The sample was 12. The census was 44. Review of the facility's Shower/Tub Bath policy, revised October 2010, showed: -Purpose: To promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed; 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath; 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath; 4. How the resident tolerated the shower/tub bath; 5. If the resident refused the shower/tub bath, the reason(s) why…

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 proper treatment and care to maintain good foot health for one of 12 sampled residents. The resident's feet were extremely dry with large areas of skin that flaked and peeled (Resident #30). The census was 44. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/24/21, showed: -Moderate cognitive impairment; -Required extensive assistance from staff for mobility, dressing and personal hygiene; -Total dependence on staff for showers and toileting; -Foot problems: blank; -Diagnoses included high blood pressure, stroke, dementia and depression; -At risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Review of the resident's order summary report, showed an order, dated 4/1/21, for a weekly skin assessment, every Thursday evening. Review of the resident's care plan, showed no information regarding the resident's feet. Review of the resident's podiatry treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician's orders for weight loss prevention and nutritional needs and ensure acceptable parameters for nutritional status were maintained to prevent weight loss for three sampled residents. One resident experienced a 11.86% weight loss within a six month period and a 6.0 % weight loss within a month period (Resident #32), one resident experienced a weight loss of 8.24% within a month period (Resident #30), and one resident experienced who was fed via a tube feeding, had inconsistently documented weights and weight fluctuations (Resident #15). The census was 44. Review of the facility's Resident Census and Condition of Residents form, dated 12/2/21, showed residents with unplanned significant weight loss/gain: 12. Review of the facility's Weighing and Measuring the Resident policy, revised March 2011, showed: -The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing…

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 necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behavior which included picking and scratching at his/her skin to the point of drawing blood. The facility failed to develop nonpharmacological interventions to help ease the resident's anxiety (Resident #35). The facility failed to notify the physician in a timely manner. The sample was 12. The census was 44. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/21, showed: -Cognitively intact; -No behavioral symptoms; -No skin issues; -Independent with locomotion and eating. Required supervision with toileting and personal hygiene; -Diagnoses included high blood pressure, anxiety and depression. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has reported a problem of picking at skin when he/she feels anxious; -Goal: Resident will have no evidence 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 interview and record review, the facility failed to timely provide or obtain the required services from an outside resource, for one of four residents sampled for rehab and restorative services (Resident #244). The resident was admitted to the facility with orders for physical and occupational therapy evaluations that were not completed timely. The census was 44. Review of Resident #244's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/30/21, showed: -admission date: 11/17/21; -Independent with activities of daily living (ADLs); -Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD, lung disease), sickle-cell anemia (a group of disorders that cause red blood cells to become misshapen and break down), anxiety and depression. Review of the resident's hospital records, dated 11/14/21 through 11/16/21, showed: -An occupational therapy progress note dated 11/15/21, showed the resident would continue to benefit from skilled…

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 generally accounting principles were followed, when they did not keep resident ledgers updated, ensure all monthly bank statements were reconciled and provide documentation regarding quarterly statements. This affected 50 residents whom the facility held their funds of which 8 were sampled (Residents #15, #16, #17, #43, #56, #49, #6 and #44). The census was 71. 1. Record review of the facility resident trust fund for the previous 12 months, showed they could only provide the months of January 2019 through July 2019 of reconciled bank statements. 2. Record review of the resident ledgers, showed the following: -Resident #15's ledger had a balance of $210.03 and had not been brought current for several months as noted by the administrator (a sticky note was on the form). It could not be determined since when, as the ledger was not dated; -Review of Resident #16's ledger had an undated ending balance of $2588.25, but showed no deposits for his/her surplus spending money since April 2019. The ledger showed no ending…

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 discharged residents received their money from the resident trust account timely and failed to notify third party liability (TPL) within 30 days when a resident expires. This affected six residents who left the facility or expired (Residents #240, #241, #242, #243, #69 and #244). The census was 71. 1. Review of Resident #240's Checkbook balancer, showed a starting balance of $1044.28 and an ending balance of $3073.28. During an interview on [DATE] at 1:10 P.M., the administrator said he/she was discharged on [DATE]. 2. Review of Resident #241's Checkbook balancer, showed a starting balance of $129.28 and an ending balance of $164.28. During an interview on [DATE] at 1:10 P.M., the administrator said he/she was discharged on [DATE]. 3. Review of Resident #242's Checkbook balancer, showed a starting balance of $844.66 and an ending balance of $7189.66. Review of the admit/discharge form dated [DATE], showed he/she expired on [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 and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment by failing to maintain resident rooms, equipment, walls, air conditioner covers, and water fountains in good repair. The census was 71. 1. Review Resident #19's quarterly MDS, a federally mandated assessment instrument, dated 8/18/19, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, and personal hygiene. Observations on 9/3/19 at 9:37 A.M. and 2:00 P.M., 9/4/19 at 1:41 P.M. and 5:44 P.M. and 9/5/19 at 12:22 P.M., showed resident in his/her bed. The controller box for the low air loss mattress hung on the foot of the bed. The controller box on and the top cover missing, exposing the electronic wires. During an interview on 9/3/19 at 9:37 A.M., the resident said he/she does not get out of bed often. He/she was aware that the controller box at the foot of the bed was missing the cover. The wires had been exposed for over a year. During an interview on 9/6/19…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain a physician order for residents who require dialysis. In addition, the facility failed to provide a pre and post assessment of residents who are receiving dialysis service. The facility identified two residents as receiving dialysis (Resident #370 and #24). Both residents were included in the sample of 19 and issues were found with both. The census was 71. 1. Review of Resident #370's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 8/25/19, showed: -admitted [DATE]; -Brief Interview for Mental status (BIMS) score: 11, showed moderately impaired cognition; -Activities of daily living: needs assistance of one staff member for grooming, bathing, dressing and hygiene. Needs assistance of two staff members for transfers and toileting; -Diagnoses included: Atrial fibrillation (irregular heart beat), coronary artery disease (the narrowing or blockage of the coronary…

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 used in the facility were stored in accordance with currently accepted professional principles, by failing to ensure all controlled substances were stored under double locks and ensuring medication and food used for medication administration was stored properly. This effected one of the two medication rooms and four of five medication/treatment/insulin carts reviewed. The census was 71. 1. Observation on 9/4/19 at 10:03 A.M., the first floor medication room, showed: -Two bottles of lorazepam intensol (narcotic medication used to treat anxiety) located inside the medication refrigerator. One bottle on a shelf in the back of the refrigerator and the other bottle located on shelf on the inside door of the refrigerator, behind only one lock. The door to the medication room locked. The door to the refrigerator not locked; -One container of pudding inside the medication refrigerator. 2. Observation on 9/4/19 at 10:03 A.M., the 100 [NAME] medication cart, showed: -Two push locks on 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 ensure the residents' right to request, refuse and/or discontinue treatment and to formulate advance directives was followed by failing to ensure residents' code status listed on the physician order sheet matched the resident's code status form for two of 19 sampled residents (Residents #17 and #19). The census was 71. 1. Review of the facility's advance directive policy, updated August 2019, showed: -The code status order and the code status form must match; -All code status will be reviewed quarterly in care plan meetings and with significant change in condition; -If any code status updates or changes are made with the social services directives; social services will immediately notify nursing and the Director of Nursing (DON), and update the code status books and the care plan. 2. Review of Resident #17's medical record, showed: -A signed code status form, dated 6/17/19, with a code status of do not resuscitate (DNR, no lifesaving methods are performed); -Physician order sheet (POS), dated 9/1/19 through 9/30/19, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided by the facility meet professional standards of quality of care for 3 of the 19 residents sampled. The facility failed to obtain physician orders for two residents (Residents #60 and #3), failed to document an infection for one resident (Resident #3) and failed to follow a physician order by not obtaining a diagnostic test for one resident (Resident #50). The census was 71. 1. Review of Resident #60's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/18/19, showed: -Brief Interview for Mental Status (BIMS) score: of 15 out of a possible 15, which indicates cognitively intact; -Diagnoses included: Cancer, anemia and paraplegia (paralysis of the legs and lower body); -Special treatments, procedures, and programs: chemotherapy was marked for both, while not a resident and while a resident. Interviews with the resident, showed: -On 9/3/19 at 10:00 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 provide thorough personal care for two of three care observations (Residents #53 and #66). The facility also failed to provide grooming and nail care to one resident (Resident #50) of 19 sampled residents. The census was 71. 1. Review of facility's perineal care (cleansing the front of the hips, between the legs and buttocks) policy, revised 10/2010, showed: -Purpose: To provide cleanliness and comfort to the resident, to prevent infection, skin irritation and to observe the resident's skin; -Procedure: -Wet the washcloth and apply soap or skin cleansing agent; -Wash the perineal area, wiping from the front to the back; -Separate the skin folds and wash downward from the front to the back. Wash moving from inside to the outside including the thighs, alternating from side to side and use downward strokes. Do not reuse the same washcloth or water to clean in between the skin folds; -Rinse the skin in the same direction, use fresh water and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident by failing to provide documented one to one individual activities to three of 19 sampled residents. In addition, the facility failed to adequately document the activities provided and the length of time of the activity (Residents #19, #52, and #66). The census was 71. 1. Review of the facility's activity calendar, showed one to one activities was scheduled on the following dates and times: -Monday through Friday at 5:30 P.M.; -Saturday and Sunday at 11:30 A.M. 2. Review of the Resident #19's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/18/19, showed: -Brief Interview for Mental Status (BIMS), a screening tool used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of six resident's investigated for pressure ulcers resident's (Residents #19 and #169). The sample was 19. The census was 71. 1. Review Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/19, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, and personal hygiene; -Diagnoses included high blood pressure, multiple sclerosis (MS, neurological disorder), depression, osteomyelitis (bone infection), bacterial infection, and vitamin D deficiency; -One stage VI (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining 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 observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion by failing to follow the physician's order for restorative therapy, for one of 19 sampled resident (#50). The census was 71. Review of Resident #50's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/19, showed: -Moderate cognitive impairment; -Extensive one person physical assist required for bed mobility, transfer, dressing, toilet use and personal hygiene; -No restorative therapy provided; -Diagnoses included anemia, high blood pressure, blood clots and diabetes. Review of the resident's physician order, dated 6/1/18, showed he/she will receive restorative nursing program 3 times a week for maintaining function. Review of the resident's care plan, dated 6/25/19, showed: -Problem: History of falls due to cognitive loss, weakness and incontinence; -Interventions: Encourage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents environment remains as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents by failing to ensure medications were secured and not accessible to residents, ensure proper transfer techniques were used during resident transfers, and failed to follow physician's orders for tubi-grips (tubular bandage) used to prevent injury, for three of 19 sampled residents (Residents #15, #53 and #50). The census was 71. 1. Review of the facility's storage of medication policy, revised 4/2017, showed: -Policy statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner; -Policy interpretation and implementation: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean and safe manner; -Drugs shall be stored in an orderly manner. Each resident's medications shall be assigned…

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 acceptable parameters of nutritional status and offer a therapeutic diet when there is a nutritional problem and failed to follow physician's orders and provide additional meal supplements as ordered for one resident with a significant weight loss (Resident #44) out of 19 sampled residents. The census was 71. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/22/19, showed: - Severe cognitive impairment; -Set up help and supervision required with eating; -Wheelchair for mobility; -Weight loss of 5% or more over the last month or 10% or more over the last six months; -No swallowing disorders; -Weight 120 pounds (lbs.); -Nutritional approach: None; -Diagnoses included high blood pressure, diabetes, osteoporosis (weak and brittle bones), dementia and depression. Review of the resident's recorded weights, showed: -On 2/7/19 at 2:20 P.M., 135.4 lbs.; -On 3/19/19 at 1:25 P.M., 132.4 lbs.; -On 4/22/19 at 10:00 A.M., 129.6…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to follow their policy for one resident who was on isolation out of 19 sampled residents (Resident #67). The census was 71. Review of the facility's Isolation-Notices of Transmission-Based Precautions policy, showed: -Policy Statement: -Appropriate isolation notices will be used to alert staff of the implementation of transmission-based precautions, while protecting the privacy of the resident; -Policy interpretation and implementation: -When transmission-based precautions are implemented, an appropriate sign (example: color coded) will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of transmission-based precautions and to alert visitors to report to the nurses' station before entering the room, while respecting…

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.