Normandy Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) for two of two perineal care observations (Resident #26 and Resident #18). The sample was 19. The census was 95. Review of the facility's Incontinent Care policy, dated 7/21/25, showed: -Policy: the facility will provide incontinent care as directed by the plan of care. Incontinent care will promote hygiene; -Procedure: -Staff cleanse the perineal area with cleanser; -For female residents: separate the skin, cleanse one side and then the other, then cleanse down the center of the skin in a front to back manner; -Cleanse the thighs, area between the buttocks. 1. Review of Resident #26's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Cognitively intact, able to make needs and wants known; -Does not refuse care; -Physical impairments 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 provide care consistent with professional standards of practice to treat wounds for one of two sampled residents found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. Review of Resident #18's diagnoses list included peripheral vascular disease (reduced blood flow to the upper/lower extremities), muscle wasting and atrophy (decrease in size and weakness of the muscles), urinary tract infections (UTIs), overactive bladder (frequently feeling the urge to urinate), need for assistance with personal care, cerebral palsy (a congenital disorder…

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 care consistent with professional standards of practice to treat pressure related wounds for one of one sampled resident found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. Review of Resident #18's diagnoses list included peripheral vascular disease (reduced blood flow to the upper/lower extremities), muscle wasting and atrophy (decrease in size and weakness of the muscles), urinary tract infections (UTIs), overactive bladder (frequently feeling the urge to urinate), need for assistance with personal care, cerebral palsy (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dialysis agreements between the dialysis center and the facility for residents that receive dialysis (the process of filtering toxins from the blood in individuals with kidney failure). The facility identified two residents who receive dialysis. Both receive dialysis at different outside dialysis centers. Both were included in the sample and concerns were identified with both residents (Residents #35 and #60). The sample was 19. The census was 95. During an interview on 5/16/25 at 10:00 A.M., the Administrator said they do not have a dialysis policy. They just use the dialysis pre and post assessment forms. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff MDS, dated [DATE], showed: -admission date: 3/14/25; -The resident received dialysis; -Diagnoses included end stage renal disease (ESRD), stroke, and seizure disorder. Review of the resident's…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, three errors occurred, resulting in a 11.11% error rate (Resident #60 and Resident #1). The census was 95. 1. Review of the facility's Medication Administration policy, revised 8/14, showed: -Policy: medication are administered as prescribed in accordance with good nursing principles and practices; -Procedures: -Preparation: -Five rights: right resident, right dose, right drug, right route, right time are applied for each medication being administered; -Prepare the dose, the dose is removed from the container and verified against the label and Medication Administration Record (MAR); -If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit.…

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 were provided therapeutic diets as prescribed by the attending physician and/or according to their care plan, for one resident with an order for renal diet (Resident #35). In addition, the facility failed to ensure residents with orders for a mechanical soft diet received the appropriate texture after residents were served grilled cheese. This had the potential to affect all residents. The sample was 19. The census was 95. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/25, showed: -Severe cognitive impairment; -Receives dialysis; -Diagnoses included deep venous thrombosis (blood clots), heart failure, hypertension (high blood pressure), renal failure, hyperkalemia (high electrolyte potassium in the blood), thyroid disorder, hyperlipidemia (high level of fat particles in the blood), stroke, seizure disorder, schizophrenia (disorder that affects a person's ability to think, behave, or feel clearly),…

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

Based on observation and interview, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution when staff failed to keep the kitchen equipment and floors clean, free of dust, grease, and grime. Additionally, the facility failed to keep soap dispenser in the main kitchen filled. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 10. The census was 97. Review of the facility's Nutritional Service Sanitation policy, revised 11/21/24, showed: -Policy: Nutritional service shall ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety; -Responsibility: Dietary Aide, Dietary Cook, Registered Dietitian, and Dietary Manager; -Procedure: -Personnel shall be responsible for daily, weekly, and monthly cleaning assignment as determined by the dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not keep one resident's (Resident #5) shower clean and free of feces and failed to clean his/her bathroom, prior to the resident's bathroom being locked for service repair. The facility failed to maintain resident showers in good condition and/or repair by not having all sides of the shower wall finished (Resident #4) and failed to replace/repair the cove base that had separated from the wall of the shower in another resident's room (Resident #1). Additionally, the facility failed to keep clean the community bathroom and clean utility room sink on the 3rd floor. The sample size was 10. The census was 97. Review of the facility's essential functions of the Housekeeping Supervisor, revised 05/2022, showed: -The Housekeeping Supervisor will oversee and schedule a team responsible for creating a clean and comforting home for residents in long-term care. In addition 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 maintain an effective pest control program by not ensuring resident rooms were free from bed bugs (small, oval, brown insects that feed on the blood of animals and humans) (Residents #8 and #10). The sample was 10. The census was 97. Review of the facility's Pest Control policy, last reviewed 8/31/24, showed: -Policy: The facility maintains an effective pest control program to remain free of pest and rodents. Pest control strategies are developed emphasizing kitchens, cafeterias. Laundries, central supply areas, loading docks, construction activities, and other regions prone to pest infestations. Environmental services/Designee will maintain records of pest control protocol and contracts with pest control services; -Responsibility: Maintenance Director, Environmental Services, and Administrator; -Procedure: -General measures to decrease pests include the elimination of cracks and crevices; -A contract with a pest control company may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident (Resident #4) was hit in the face by another resident (Resident #9), which caused a scratch under his/her left eye. Resident #4 did not want to return to his/her room because of being fearful of being attacked again. The sample was 6. The census was 99. Review of the facility's Abuse Policy, dated 10/21/22, showed the following: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an…

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

Based on interview and record review, the facility failed to follow a physician's order to administer an antipsychotic medication prescribed for behaviors for one resident by the psychiatric Nurse Practitioner (NP) (Resident #1). The sample was three. The census was 100. Review of the facility Physician's Order Policy, dated 9/28/22, showed the following: -Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines; -Responsibility: Licensed Nurses, Nursing Administration, & Director of Nursing; -Procedure: -Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders; -Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders; -Physician Orders must be documented clearly in the medical record. The required components of a complete order: -Date and Time of Order; -Name of Practitioner Providing Order; -Name and Strength of Medication/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 interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #141, #140 and #87). The sample size was 18. The census was 88. 1. Review of Resident #141's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $30.64; -No documentation of TPL completed. 2. Review of Resident #140's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $842.44; -No documentation of TPL completed. 3. Review of Resident #87's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $4354.37 -No documentation of TPL completed. During an interview on [DATE] at 12:58 P.M., the Regional Business Office Manager said TPLs were not done for the residents. She was aware they should have been done within 30 days of a resident's death. During an interview on [DATE] at 10:50 A.M., 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 use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 88. Review of the facility's list of current employees, provided on 12/13/23, showed a Director of Nursing (DON). No other full-time RNs were employed. Review of the Facility Assessment Tool, last reviewed on 1/6/23, showed: -Number of licensed beds: 116; -Average daily census: 76. Review of the facility's payroll-based journal (PBJ) report, showed: -No RN hours in April 2023, on Saturday 4/15/23; -No RN hours in May 2023, on: -Saturday 5/6/23; -Saturday 5/13/23; -Sunday 5/14/23; -Saturday 5/20/23; -Sunday 5/21/23; -Saturday 5/27/23; -Sunday 5/28/23; -No RN hours in June 2023, on: -Saturday 6/3/23; -Sunday 6/4/23; -Saturday 6/10/23; -Saturday 6/17/23; -Sunday 6/18/23. Review of the facility's December 2023 staffing sheet, showed no RN scheduled. Observation showed the Regional Nurse Consultant (RNC) was in the facility on the week of the survey, from 12/12/23 through 12/15/23. He/She was not…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified six medication carts and three medications rooms. There were two medication carts and one medication room on each floor. Four medication carts and three medication rooms were checked, and issues were found with all. Staff failed to secure controlled substances (drugs or chemicals that have the potential to be addictive or habit-forming) under double lock on the second floor, failed to date medications and biologicals when they were opened on all floors, failed to separate medication from food items in the refrigerator on the first floor, and failed to separate medication and topical treatment medications on the third floor. The census was 88. Review of the facility's Storage of Medications Policy, dated: policy revised 11/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication…

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

Based on observation and interview, the facility failed to provide residents with super cereal (highly fortified food that provides extra calories and/or protein) for one breakfast. The census was 88. The sample was 18. Review of the facility's Nutritional Supplements Policy, dated 12/1/22, showed the following: -Policy: The Facility will have a formulary of Nutritional Supplements to be utilized as interventions to help ensure nutritional needs are met; -Procedure: Nutritional needs and nutritional intakes are reviewed by the Registered Dietitian upon admission and as needed. Supplements may be recommended and initiated by the Registered Dietitian and/or Nursing to address but not limit to weight loss and wound healing or altered labs. Nursing and/or Designee to monitor acceptance and tolerance. Supplements may be discontinued if not accepted or tolerated. Supplements delivered by the nutritional service department may not necessitate a Physician Order may include but not limit to house shake, magic cup (high calorie ice cream or yogurt), and fortified juice. Review of the…

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

Based on observation and interview, the facility failed to ensure the ice machine had an air gap. This had the potential to affect all residents. The census was 88. The sample was 18. Observation on 12/11/23 at 10:05 A.M., showed the ice machine in the dining room did not have an air gap. During an interview on 12/14/23 at 7:38 A.M., the Maintenance Director said he was not aware the ice machine did not have an air gap. He expected for the ice machine to have an air gap so the ice does not get contaminated if the pipes backed up. During an interview on 12/14/23 at 10:06 A.M., the Administrator said she was not aware the ice machine did not have an air gap. She expected for the ice machine to have an air gap.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information and education to each resident or the resident's representative for the pneumococcal vaccines. This affected four of five sampled residents (Resident #25, #19, #23 and #10). This deficient practice had the potential to affect all residents. The census was 88. Record review of the facility's Pneumococcal Vaccine policy, reviewed and approved on 4/28/22, showed: -Policy: The opportunity to receive the Pneumococcal vaccine will be extended to all residents, the facility will provide pertinent information regarding the risks/benefits of receiving the vaccine; -Procedure: -Residents will be offered the Pneumococcal vaccine upon admission. Administration of additional doses will be completed in accordance with Centers for Disease Control and Prevention (CDC) guidelines; -Resident/Resident Representatives will be notified of the availability of the Pneumococcal Vaccine; -Obtain consent. Consent Immunizations/Vaccine consent Form 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.

Based on interview and record review, the facility failed to ensure residents with a mental health disorder and/or individuals with intellectual disabilities had a DA-124 Level One Screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Annual Resident Review (PASARR) Level Two Screen was required), as required for one of two residents sampled (Resident #33) for PASARR. The sample was 18. The census was 88. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/23, showed: -Entry date (date of this admission/re-entry into facility): 11/21/23; -admitted : 1/14/22; -Diagnoses included dementia, depression, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's medical record, showed: -No DA-124 Level one screen; -No PASARR Level two screen. During an interview on 12/13/23 at 10:44 A.M., the Administrator said the resident had been at the facility for over a year. The facility did…

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 diets and supplements as ordered to ensure residents maintained acceptable nutritional status for one resident (Resident #69) who experienced a significant weight loss. The sample size was 18. The census was 88. Review of the facility's Weight Variances policy, revised 8/9/23, showed: -Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by the Registered Dietician (RD). Recommendations from RD to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes. Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing staff. Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be monitored by the RD for review and assessment; -Responsibility: Nursing Personnel, RD, Dietary Personnel and Dietary Manager;…

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 residents with reasonable access to a telephone and privacy for phone conversations when three of 12 sampled residents (Residents #173 and #20 and #75) were observed making a personal phone calls in the open area of the 200 and 100 halls. The census was 25. 1. Review of Resident #173's medical record, showed the following: -An admission date of 5/11/20; -Diagnoses included diabetes, respiratory disorder and paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves including delusions and hallucinations). Observation of the 200 hall on 9/14/20 at approximately 9:45 A.M., showed the resident sat in the open area across from the nurse's station at an over the bed table where the 200 hall resident phone was located. The resident used the phone while facility staff and other residents stood and sat nearby. The resident's conversation could be overheard from the nurse's station. During an interview on 9/14/20 at 9:50 A.M., the resident said he/she did not have 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 ensure all physician's orders were followed by not properly performing pain assessments, not administering pain medicine as ordered, not obtaining an order for oxygen (O2) administration and not recording heart rate as ordered before medication administration. The facility also failed to clarify orders with the physician regarding a medication's dosage, the correct diagnosis for a medications administration and have a diagnosis to support the administration of another medication. Furthermore the facility failed to return a controlled substance medication to the pharmacy after it was discontinued, failed to obtain orders for the administration of two different medications and failed to administer all morning medications for two different residents. These deficient practices affected 6 out of 12 sampled residents (Residents #16, #10, #20, #173, #74 and #75) The census was 25. 1. Review of Resident #16's medical record, showed diagnoses included quadriplegia (paralysis of the body from the neck down), chronic…

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 showers as scheduled and on a routine basis. In addition, staff failed to shave three residents on a consistent basis and failed to provide fingernail care for one resident who repeatedly asked for assistance. These deficient practices affected four of 12 sampled residents (Residents #16, #20, #8, and #2). The census was 25. 1. Review of Resident #16's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/20, showed the following: -Adequate short term and long term memory; -Independent decisions, consistent and reasonable; -Required extensive assistance with bed mobility, dressing and personal hygiene; -Unable to ambulate. Review of the medical record, showed diagnoses included quadriplegia (paralysis from the neck down), contracture of the right hand (inability to move and stretch the hand) and need for assistance with personal care. Review of the…

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

Based on observation, interview, and record review, the facility failed to maintain an infection control program during a Coronavirus disease 2019 (COVID-19) pandemic, by not following current infection control standards. Staff failed to properly wear facemasks while preparing and serving food and failed to provide soap on the second floor hall resident use bathrooms. The sample size was 12. The census was 25. Review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes, updated 6/25/20, showed the following: -Implement Source Control Measures: -Health care personnel (HCP) should wear a facemask at all times while they are in the facility; -Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices: -Hand Hygiene Supplies: -Make sure that sinks are well-stocked with soap and paper towels for handwashing. Review of the CDC Using Personal Protective Equipment (PPE), updated August 19, 2020, showed the following: -Facemasks Do's and Don'ts for HCP: -When putting on your facemask, clean your hands and put 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, two errors occurred, resulting in an 8% error rate (Resident #6). The census was 25. Review of Resident #6's medical record, showed the following: -Diagnoses included heart failure, lung disease, bipolar (a mental health condition that causes extreme mood swings that include emotional highs and lows) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); -An order, dated 4/30/20, to administer Lithium (mood stabilizer used to treat bipolar) 300 milligrams (mg), one tablet daily; -An order, dated 7/30/20, to administer Vitamin D 2000 units, one tablet daily. Observation on 9/11/20 at 8:22 A.M., showed Certified Medication Technician (CMT) C, administered the resident's morning medications. He/she did not administer Lithium or Vitamin D. Review of the electronic medication administration record e(MAR) on 9/11/20 at 9:55 A.M., showed Vitamin D and Lithium signed as administered. During an…

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