Nazareth Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges, and failed to provide a written notice of transfer/discharge to one resident (Resident #90) and/or resident representative when the resident was transferred to the hospital. The sample was 21. The census was 93. Review of the facility's Discharge Planning policy, dated 11/28/17, showed: -Purpose: To prepare the resident for and ensure a safe discharge from the facility; -The policy did not provide guidance related to notification to the Ombudsman regarding resident transfer and discharges; -The policy did provide guidance related to ensuring residents and/or resident representatives are provided with written notification as soon as practicable following a resident's transfer to the hospital. 1. During an interview on 3/6/25 at 2:07 P.M., the Ombudsman said he/she has not received monthly notification of transfers and discharges from the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for three residents (Residents #90, #195 and #194). The census was 93. Review of the facility's Comprehensive Assessments and Care Planning policy, revised [DATE], showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the Resident Assessment Instrument (RAI) specified by the State; -Policy: --The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plan includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address…

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 a plan of care specific to each resident's needs. Concerns were found in the care plans for three out of 21 sampled residents when the facilty failed to include the presence of side rails (Resident #52), presence of a urinary catheter (Resident #11), and presence of hospice services (Resident #20) in the resident care plans. The facility census was 93. Review of the facility's Comprehensive Assessments and Care Planning Policy, revised 9/27/23, showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental, and psychological functioning possible, a facility must make a comprehensive assessment of each resident's needs, using the Resident Assessment Instrument, (RAI, a federal assessment tool used to identify specific resident needs) specified by the State; -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 provide services to meet professional standards of practice when staff held medications for two residents (Residents #79 and #83) with low blood pressure and failed to notify the nurse so the nurse could notify the physician to initiate parameters. Staff failed to ensure medication was available for administration and to administer available medications for one resident (Resident #15), and the facility failed to have a sufficient system in place to track pharmacy refill requests. The sample was 21. The census was 93. Review of the facility's Change in Condition policy, undated, showed; -Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider; To inform the resident and/or resident's representative and attending provider with a significant change in a resident occurs; -Policy: When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter 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 ensure activities of daily living (ADL) care was provided for three of 21 sampled residents. The facility failed to ensure one resident had accurate skin assessments, trimmed nails and clean skin (Resident #82). The facility also failed to ensure two residents received facial hair grooming (Residents #65 and #20). The census was 93. Review of the facility's ADL policy, dated 2021, showed: -Policy: residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility; -Implementation: care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care, mobility (transfer and ambulation, including walking), elimination…

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 residents received care consistent with professional standards. Staff failed to obtain treatment orders for one resident (Resident #195) who had a recent hip surgery. The sample size was 21. The census was 93. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 9/1/18, showed: -Purpose: Maintaining intact skin is integral to the resident's health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur; -Procedure: Skin is observed daily with care; Documentation of the skin impairment is completed in the medical record; Notify the attending provider and the attending provider may provide additional orders. Review of Resident #195's, face sheet, undated, showed: -An admission date of 3/6/25; -Diagnoses that included; right hip fracture, right joint replacement, emphysema (a lung disease), history of falling, and high blood pressure. Review of the resident's record showed: -No baseline care plan was…

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 one resident (Resident #82) had urinary catheter (tube that drains the urine from the bladder) orders and failed to flush one resident's urinary catheter who had a history of hematuria (blood in the urine) (Resident #1). The sample was 21. The census was 93. Review of the facility's Prevention of Catheter-Associated Urinary Tract Infections policy, undated, showed when a resident is admitted to the facility with a catheter in place, a thorough physical assessment, as well as history review will be completed. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/17/25, showed: -Cognitively intact; -The resident has an indwelling urinary catheter; -Diagnosis included cancer, benign prostatic hypertrophy (BPH, an enlarged prostate gland) and renal failure, and obstructive uropathy (blockage that makes it difficult for urine to pass); Review of the resident's care plan, in use at the time of survey, showed; Problem: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident had all the required physician's orders and documentation of oxygen usage (Resident #16), and failed to ensure one resident's discontinued physician's orders related to oxygen usage were reinstated after a hospital stay (Resident #2). The sample was 21. The census was 93. Review of the facility's oxygen therapy policy, dated 2017, showed: -Policy: Residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan; -Procedure: Obtain physician orders for specifics regarding administration. Administration of the oxygen therapy is completed by nursing associates. Document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary. Follow manufacturer recommendations for safe handling, cleaning, humidification, storage, 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 pain management for three of 21 sampled residents who experienced pain, consistent with professional standards of practice (Residents #195, #1, and #7). The census was 93. Review of the facility's Pain Management policy, dated 2022, showed: -Policy: Benedictine considers pain that impacts the function or quality of life of our residents a significant concern and evaluation will be ongoing. The Benedictine interdisciplinary team will strive to manage pain in residents experiencing mild to debilitating pain to the point where functionality and quality of life can be increased. Benedictine clinicians will be aware of the unique needs and circumstances of residents from different age groups, ethnic and cultural backgrounds. Current and historical medical diagnoses including substance use disorders and mental health diagnoses will be considered when implementing an effective pain management plan of care; -Procedure: Evaluate 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 follow their policy and failed to ensure residents using bed/side rails had adequate and on-going assessments to determine the side rails were appropriate and safe for use, obtained informed consent from the resident and/or responsible party, obtained physician orders per facility policy, and included the use of siderails in the resident's care plan. The facility identified 34 residents with side rails in use. Two of 21 sampled residents (Residents #16 and #52) had side rails but were not properly assessed for side rails. The census was 93. Review of the facility's Chemical and Physical Restraints Policy, revised 8/31/23, showed: -The resident has the right to be free from any physical or chemical restraints not required to treat the resident's condition. Chemical and/or physical restraints are only used as ordered by the physician; -Consent is obtained after a review of the risks/benefits. In order for consent to be obtained, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one resident (Resident #194) was free of significant medication error by not obtaining the residents prescribed antibiotic and antiviral medication in a timely manner. The sample size was 21. The census was 93. Review of the facility's Administrating Medications policy, revised, 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider in if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. Review of the facility's Medication Ordering, Receiving and Storage policy, revised July, 2016, showed: -Emergency pharmacy services are available 24 hour basis; The pharmacy phone number is posted at 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 observation, interview and record review, the facility failed to adequately develop and implement infection control practices to prevent the spread of infection caused by transmission-based conditions. The facility also failed to adequately follow its Enhanced Barrier Precautions (EBP) Policy (Residents #194 and #7). This failure had the potential to affect all residents and staff in the facility. The census was 93. Review of the facility's Enhanced Barrier Precautions policy, revised 4/1/24, showed: -Enhanced Barrier Precautions is a strategy in nursing homes to decrease transmission of CDC-targeted and other epidemiologically important multidrug-resistant organisms (MDROs, an infection resistant to common treatment therapies); -EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDROs; -Additionally, residents at risk for MDROs, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing will 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 staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for two residents (Residents #16 and #52). The facility identified 34 residents with side rails in use. The census was 93. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; -The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement; -Bed rails (commonly used synonymous…

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 daily weights were obtained as ordered (Resident #1). The resident sample was 6. The census was 87. Review of Resident #1's hospital discharge/transfer sheet, dated 5/29/24, showed: -Weigh daily; -Contact the physician if there is a weight gain of 3 pounds or more in a day or 5 pounds or more in two days. Review of Resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 6/4/24, showed: -admission date 5/29/24; -Cognitively intact; -Diagnoses included congestive heart failure (the heart does not pump enough blood); -Weight loss of 5% or more in last month or a weight loss of 10% or more in last six months; -On a physician's weight loss program -Weight 160 pounds. Review of the resident's electronic physician order sheet (ePOS), dated 5/29/24 through 6/27/24, showed the following orders: -Weigh daily; -Call physician for weight gain greater than 2.5 pound in 48 hours or 5 pounds above admission weight. Review of the resident's baseline care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacist reports any irregularities to the attending physician and the facility's medical director and director of nursing, and ensure these reports were acted upon. In addition, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident for four of seven residents investigated for the monthly medication regimen review (Residents #65, #68, #48, and #8). This had the potential to affect all residents with irregularities identified during the monthly medication review. The census was 86. Review of the facility's Consultant Pharmacist Service Provider Requirements policy, provided as the facility's policy and procedure for the required monthly medication review for residents, revised…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - 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 #191 and #101). The facility census was 86. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans were complete, accurate, reviewed, and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for five of 18 sampled residents (Residents #82, #83, #44, # 48, and #68). The census was 86. 1. Review of Resident #82's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/13/23, showed: -admitted [DATE]; -Cognitively intact; -Rolling from left to right, moving from sitting to lying and lying to sitting: Substantial/maximal assistance needed; -Diagnoses include kidney disease and diabetes; -Care Area Assessment Summary (CAAS) triggered and was identified as care planned by the facility for: Visual function, activity of daily living (ADL) functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, 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 establish a system of record for controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three controlled substance shift change count sheets reviewed. The census was 86. Review of the facility's Consultant Pharmacist Services Provider Requirements policy, revised August 2014, showed: -The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility; -Establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. 1. Review of the [NAME] Hall Certified Medication Technician (CMT) controlled substance shift change count sheet, dated 10/1/23 through 10/24/23, showed 25 out of 69 opportunities were left blank and undocumented for on-coming and off-going staff…

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 orders for psychotropic medications are limited to 14 days, except when the prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days, has documented the rationale in the resident's medical record, and indicated the duration of the as needed order. The facility failed to ensure a gradual dose reduction was attempted or documented as contraindicated for residents who receive psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted and documented prior to administration of a psychotropic medication, for three of five residents investigated for unnecessary psychotropic medications (Residents #65, #8, and #68). The census was 86. Review of the facility's Psychotropic Medication Use policy, last reviewed 9/7/23, showed: -Purpose: Psychotropic medications are used when ordered by medical providers after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental…

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 and stored in accordance with currently accepted practices. These practices affected two of four medication carts reviewed and one out of two medications rooms reviewed. The census was 86. Review of the facility's Medication Storage in the Facility policy, revised on 2014, showed: -Policy: -Medications and biologicals (vaccines) are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Procedure (includes): -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia. Medications are kept in containers; -All medications dispensed by the pharmacy are stored in the container with the pharmacy label; -Except for medications requiring refrigeration or freezing, medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide eating assistance to one resident (Resident #44) for two of two observed meals. The resident was observed feeding himself/herself with his/her fingers. Staff did not provide assistance. The sample was 18. The census was 86. Review of the undated Activity of Daily Living (ADL) policy, showed: -Purpose: To provide residents with care, treatment and services appropriate to maintain or improve the ability to carry out ADLs; -Policy: Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene; -Implementation: -Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks); -If residents with cognitive impairment or dementia exhibit behavioral expressions of resistance to…

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

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #92) was free from significant medication error when staff failed to ensure the resident's ordered breathing treatment was delivered timely. The resident was admitted to the facility from the hospital with respiratory failure and Covid-19. The resident did not receive the ordered breathing treatments all days of the stay, from 9/29/23 through 10/4/23. The sample size was 37. The census was 86. Review of the Verbal and Telephone Order policy, showed: -Purpose: To ensure timely and efficient verbal and telephone orders from the provider; -Policy: Verbal and telephone orders are obtained in a situation when the provider is unable to write or sign the order at the time of entry and are transcribed; -Procedure: The nurse receiving the verbal order will write it on the physician order sheet or enter it into the electronic health record (EHR). Review of Resident #92's medical record, showed: -admitted : 9/29/23; -discharged : 10/4/23; -Diagnoses included: respiratory failure related 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 follow acceptable infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections for one resident observed during personal care and transfer when staff failed to change gloves, sanitize hands, and sanitize shared medical equipment using acceptable standards of practice (Resident #82). The census was 86. Review of the facility's Using a Mechanical Lifting Machine policy, dated July 2017, showed lift care: -Disinfect lifting surfaces; -Wipe with a clean towel until dry. Review of the facility's Hand Hygiene policy, dated June 2017, showed: -Infection prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents; -It is the policy that all associates will be trained and competent…

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 their abuse and neglect policy and complete a prompt and thorough investigation for an allegation of abuse, for three of 19 sampled residents (Residents #42, #3 and #13). The census was 81. Review of the facility's Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. Concerns, incidents and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrences; -Abuse prevention plans. The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility; -The plan shall contain an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for controlled substances, for five of six medication carts. The census was 81. 1. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for [NAME] Hall, showed the following: -No signature by the on-coming nurse, total of five shifts; -No signature by the off-going nurse, total of five shifts; -Total narcotic drug cards not documented as counted, a total of five shifts; -Total narcotic drug cards not legible counted, a total of one shift. 2. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for FontBonne Hall, showed the following: -No signature by the on-coming nurse, total of three shifts; -No signature by the off-going nurse, total of two shifts; -Total narcotic drug cards not documented 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.

Based on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were reviewed and the facility failed to notify the physician, medical director, and director of nursing of irregularities, for two of 9 residents sampled for medication review (Residents #57 and #29). In addition, the facility's policy failed to include time frames for the different steps in the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident. The sample was 19. The census was 81. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/1/07, showed: -The facility should ensure that facility physicians/prescribers are provided with copies of MMRs; -Facility should encourage physician/prescribers or other responsible parties receiving the MMR and the Director of Nursing to act upon recommendations contained in the MMR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon…

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 labeled drugs and biologicals per acceptable standards of practice when staff failed to date insulin flexpens (prefilled injectable insulin) once they were opened, ensure legible dates and resident names were on the label and failed to discard opened insulin flexpens for residents discharged from the facility, for two of four medication carts checked. The census was 81. 1. Observation on 10/6/20 at 7:56 A.M., of the nurse's medication cart, front hall of [NAME], showed the following: -One Novolog (fast acting) insulin flexpen opened without a date written when opened. Licensed Practical Nurse (LPN) B said the resident was discharged ; -One Lantus (long acting) insulin flexpen opened without a date written when opened; -One Humalog (fast acting) insulin flexpen opened without a legible date written when opened and labeled with illegible resident's name; -One Novolog flexpen opened without a legible date written when opened 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 acceptable infection control standards were used when staff failed to clean/disinfect a gait belt (a device used to transfer residents from one position to another) that is used on multiple residents, before or after use for one resident (Resident #66) and failed to clean/disinfect the sit to stand lift (mechanical lift) that is used on multiple residents, before/after use for one resident (Resident #57). In addition, staff failed to wash or sanitize their hands after removing gloves while providing personal care to one resident (Resident #69) and failed to cover clean laundry that was hanging in the hall, five out of five days observed. The resident sample was 19. The census was 81. Review of the facility's Cleaning, Disinfection and Sterilization-Overview Policy, dated 2017, showed: -Purpose: To prevent the growth of organisms on equipment thus preventing the transmission of infection; -Policy: Cleaning, disinfection, and/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.

Based on interview and record review, the facility failed to report alleged violations of abuse to the Department of Health and Senior Services (DHSS) immediately, but not later than 2 hours after the allegation was made, after two allegations of abuse. This affected one of 19 sampled residents (Resident #42). The facility census was 81. Review of the facility Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. Concerns, incidents and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrences; -Identification of possible incidents which need investigation: -Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial…

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 meet professional standards of practice when staff failed documented the fluid and meal intake of two residents as indicated in their plan of care (Residents #27 and #179). In addition, the facility failed to ensure daily weights were obtained as ordered (Resident #179). The resident sample at 19. The census was 81. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 8/5/20, showed: -Severe cognitive impairment; -Required supervision with meals; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months, marked yes. Not on physician prescribed weight loss. Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnosis included: anxiety, dementia, and contracture of left hand (rigidity of the muscles). Review of the resident's electronic physician order sheet (ePOS), dated 10/7/20,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to shave and provide nail care for two residents who were dependent on staff for care needs (Residents #23 and #29). The sample was 19. The census was 81. Review of the facility policies, showed; -No policy for fingernail care, shaving care or oral; -A staff skill competency check form for fingernail care, oral care and shaving with electric razor (dated 2009). The competency check forms did not indicate how often to provided nail care or shaving care or when this care would be indicated as needed. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/20, showed extensive assistance required for personal hygiene. Review of the resident's electronic medical record (EMR), showed diagnoses included altered mental…

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 received Restorative Therapy (RT) as indicated for three resident's (Residents #23, #30 and #22) sampled who had orders for RT. The sample was 19. Census was 81. Review of the facilities Restorative Program policy, dated 2017, showed: -Purpose: To ensure residents are comprehensively assessed/reassessed for restorative needs; -Policy: To provide a basic outline and guidance for implementation and tracking of restorative programs established so that each resident can attain and maintain highest physical, mental and psychosocial well-being. Restorative nursing care promotes resident's highest level of independence in each of the following areas: -Activities of Daily Living (ADLs); -Splints/brace; -Range of Motion (ROM); -Ambulation; -Bed Mobility; -Procedure: Upon admission/readmission/significant change in status the resident will be assed for potential restorative needs; -Analysis of the assessment will determine which…

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 each resident received adequate assistance to prevent accidents when staff transferred a resident improperly when using a mechanical lift for one of three transfers observed. In addition, staff failed to investigate the cause of a skin tear so interventions could be implemented to prevent further injury for one (Resident #23). The sample size was 19. The census was 81. Review of the facility's policies showed: -No mechanical lift policy; -A staff skill competency form for mechanical lifts, dated 2009 provided. Review of the undated staff skill competency form, showed: -Obtain assistance from experienced team member; -Instruct your assistant to guide resident to chair. Watch that arms, legs and tubing are safe; -Check that the base of the legs for the lift are properly positioned to support resident weight. Review of the manufacturer's instructions for the facility's Hoyer lift (mechanical lift), showed it included the following: -Before lifting or transferring the resident, the base legs MUST be LOCKED…

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 thorough assessments, monitoring and ongoing communication with the dialysis center. The facility also failed to obtain a dialysis contract. The facility identified one resident receiving dialysis (Resident #40). The resident sample was 19. The census was 81. Review of the facility's 2017 dialysis (process for removing toxins from the blood for individuals with kidney failure) policy, showed: -Policy: Dialysis is provided via contract with an external agency. Care for residents that requires dialysis will be managed by licensed associates and through communication with a certified dialysis service; -Procedure: Residents are informed of the dialysis services the community can accommodate at the time of admission and dually informed if such services are required for the resident following admission; -The licensed nurse and other professionals provide ongoing assessment of the residents' condition from a multidisciplinary standpoint and monitoring for complications before and after dialysis treatments…

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 as needed psychiatric medications were evaluated after 14 days of use for one of seven residents reviewed for unnecessary psychotropic medications (Resident #66). The sample was 19. The census was 81. Review of Resident #66's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/20, showed diagnoses included Alzheimer's disease, heart failure and diabetes. Review of facility's policy for psychotropic medication use, dated 2018, showed: -Psychotropic medications ae given upon a medical provider order; -The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-review; -As needed (PRN) orders for psychotropic drugs are limited to 14 days. Review of the resident's electronic physician order sheets (ePOS), showed the following: -An order dated 9/11/20, for Ativan (used to treat anxiety) 0.5 milligrams (mg), one tablet, every six…

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.