McClay Senior Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident safety for four residents (Residents #1, #13, #35 and #39) in a review of 16 sampled residents. Staff failed to use a gait belt while assisting one resident (Resident #13) and lifted the resident under both arms, staff failed to ensure a mechanical lift pad was appropriately placed under a resident, or stop the transfer when the resident expressed pain during the transfer for one resident, (Resident #39) and staff failed to ensure two residents (Resident #1 and #35), had foot pedals on their wheelchairs prior to staff propelling the residents in the facility. The facility census was 48. Review of the facility Gait Belt Policy dated 4/2020 showed the following: It is the policy of the facility that the therapy director will gait belt train all new staff upon orientation with the following guidance: -Gait belts must be used when transferring a resident who requires assist; -Gait belts are kept in each resident room; -Gait…

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 four residents (Resident #43, #27 and #35), in a review of 16 sampled residents, received a gradual dose reduction (GDR), of their psychotropic medications and/or a documented rationale as to why a GDR was decline and failed to ensure a PRN psychotropic drug did not extend beyond 14 days without a stop date and/or renewed order. The census was 53. Review of the undated facility policy Medications-Antipsychotics showed the following: -Monitoring and assessment of antipsychotic medications use includes ensuring that: -Within the first year in which a resident is admitted on an antipsychotic medication or has been started on an antipsychotic medication, the charge nurse must request that the resident's physician evaluate the resident for a Gradual Dose Reduction (GDR); a. The request for GDR evaluation must be made in two separate quarters of the year, (with at least one month between the attempts), unless clinically contraindicated;…

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 washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Resident #10, #26, #20, and #39) in a review of 16 sampled residents, failed to ensure one resident's (Resident #39's), urinary collection bag was kept off the floor, and failed to appropriately wear and change Personal Protective Equipment (PPE) upon entering a Covid positive resident's (Resident #155's) room, wearing a contaminated N95 mask to other resident rooms to deliver meals. Facility's census was 48. Review of the CNA in Long Term Care- 2001 Revision Manual shows the following: -Handwashing is the single most important means of preventing the spread of infections; -Instructions to wash hands before and after contact with residents; -Instructions to start with the cleanest area and work toward the dirtiest area when cleaning an item or body part; -Instructions to always…

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 resident call light system in place was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area. In addition the facility failed to answer call lights in a timely fashion for two residents (Resident #39 and #405) in a review of 16 sampled residents. The facility census was 48. Review of the undated facility policy Call Lights showed the following: -It is the policy of the facility to provide a working call light at each resident bedside and toilet; -The call light should be placed within reach; -Call lights should be answered promptly by staff; -The call light indicator will be displayed on the monitor at the nurses station and front desk; -An audible pager will be utilized by a staff member. Review of the undated facility policy Arial Call Light Logs showed the following: -It is the policy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure one resident (Resident #39), in a review of 16 sampled residents received personal care in a manner to protect the resident's personal privacy. The facility census was 48. Review of the facility policy, Resident Rights, dated 12/2018 showed the following: -All clients/residents have the right to be accepted and treated with dignity; -All clients/residents have the right to reasonable privacy, including privacy of self in their room and personal affairs. 1. Review of Resident #39's care plan, dated 4/19/22, showed the following: -Diagnoses include: unspecified dementia; -He/She has an indwelling urinary catheter (a tube inserted into the bladder to drain urine); -Ensure privacy with all catheter care; -He/She was incontinent of bowel; -Perineal cleansing and apply protective skin barrier after each incontinent episode. Review of the resident's significant change MDS, dated [DATE], showed the following: -Daily preference choices are important to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility staff provided two residents (Resident #15 and #405) in a review of 16 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 48. Review of the undated facility policy ADL Care for Dependent Residents Policy showed the following: -Residents who are unable to carry out activities of daily living should receive necessary services provided by facility staff to maintain good nutrition, grooming and personal and oral hygiene; -Assistance to the bathroom; may include commode, bedpan, urinal, transfer on / off toilet, peri-cleaning as necessary, changing absorbent pads or briefs, manage ostomy or catheter and adjust clothing will be provided by staff as necessary to ensure proper hygiene; -Shaving of face, legs and underarms as needed or requested by resident. Review of the undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one closed record (Resident #57), of 16 sampled residents and six closed records, received the necessary care and services in accordance with professional standards of practice. Resident #57 had oxygen saturation levels in the 80's on room air (normal range 95-100% on room air) in the morning on 7/27/22 which decreased even further when the resident spoke. Facility staff did not notify the resident's physician of the condition change or that oxygen was applied. The resident's condition continued to decline during the day and he/she was subsequently sent to the hospital. The facility census was 48. Review of the undated facility policy Change of Condition Notification showed the following: Policy statement: -The physician and family/responsible party will be notified when the charge nurse/designee identifies a change in the resident's condition; Procedure: 2. The charge nurse will notify the physician/designee of the noted change of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for two (Residents #10 and #27), in a review of 16 sampled residents. The facility failed to reposition two residents (Residents #10 and #27), who were identified as a risk for pressure ulcers, as directed per facility policy to prevent the potential development of pressure ulcers. The facility identified four residents had pressure ulcers on their Resident Matrix (mandated document used to identify resident's care areas). The facility census was 53. Review of facility's undated policy for positioning and preventative care showed the following: -It was the facility's policy to reposition residents who were not independent with movement. Preventing pressure sores and skin break down may be achieved by turning and positioning every two hours;…

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 appropriated treatment and services consistent with acceptable standards of practice for one resident (Resident #39), in a review of 16 sampled residents with an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Staff failed to provide appropriate catheter care during personal cares and did not keep the level of the catheter tubing below the resident's bladder during a transfer. The facility census was 48. Review of the undated facility policy Urinary Catheter Care showed the following: 1. CNAs should do catheter and perineal care with A.M. and P.M. care, after each of the resident's bowel movements and as needed; a. Always wash your hands before and after handling the catheter, tube or bag and wear gloves following standard precautions for infection control; b. Clean the area where the catheter is inserted by wiping away from the insertion site to prevent germs from being moved from the anus to the…

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

Based on observation, interview and record review, the facility failed to ensure that resident records were complete and accurate as demonstrated by documentation of completed treatments (showers) performed for residents by staff who did not provide that care. This affected two residents (Resident #1 and Resident #405) out of a sample of 16 residents. The facility census was 48. Review of the undated facility policy Nursing Documentation showed the following: 1. General charting guidelines: e. Document objective facts, observations, and data, what was done for the resident; 4. Do Not: b. Never amend someone else's documentation. 1. Review of Resident #1's admission Care Plan (CP) dated 08/23/22 showed the following: -I require assist with ADL's r/t impaired mobility and impaired balance; -Assist me with bathing body parts that I am unable to clean, assist x1; -I require assist x1 with dressing and hygiene; -I require assist x1 at times to transfer; 2. Review of Resident #405's Care Plan (CP) dated 08/10/22 showed the following: -I require assist with ADL's r/t impaired mobility 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 and interview, the facility failed to follow proper sanitation and food handling practices in the kitchen. The facility census was 53. Observations on 11/19/19 at 11:28 A.M. showed the following: -There was no area for racking dishes, -There was no area for dish rack storage; -A buildup of a black and mold-like substance as well as a buildup of a sticky substance on the gasket on the condiment refrigerator; -A heavy buildup of charred debris and whole pieces of old food on the stove; -A brown buildup of debris on the outside of the stacked ovens and a buildup of debris on the handles; -A heavy buildup of black debris inside the stacked ovens; -Dishes stacked in drawers and in the cabinets were put away wet; -Scoops, spoons, and knives stacked inside the drawers were put away with debris on them; -The bowl for the stand mixer had debris on the sides and bottom; -The paddle for the stand mixer had a buildup of debris; -A scoop was stored in the flour container and the handle was in direct contact with the flour. Observation on 11/19/19 at 11:59 A.M. showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required for 14 of 16 sampled residents (Resident #41, #23, #30, #18, #36, #151, #26, #150, #12, #40, #299, #253, #251, #45 and #250) and three additional residents (Resident #8, #38 and #299) of which three residents (Resident #36, # 37 and #8 ) developed pneumonia. The facility also failed to document if residents received the pneumococcal vaccine or did not receive the vaccine due to medical contraindications, previous vaccination or refusal and failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 53. 1. Review of the facility undated policy Vaccine Administration showed the following: -A licensed nurse would perform the resident vaccinations to prevent or limit infectious disease…

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 and interview, the facility failed to ensure each resident was afforded the right to manage his/her financial affairs, when the facility failed to advise residents of money held in the facility operating account that belonged to the resident. The facility failed to deposit funds in excess of $100 in an interest bearing account that was separate from any of the facility's operating accounts, and credit all interest earned on resident funds to that account. The deficient practice affected 27 residents (Residents #1, #4, #6, #11, #13, #14, #16, #17, #21, #23, #28, #38, #40, #149, #151, #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311, and #312 ). The facility census was 53. 1. Record review of the facility's maintained Accounts Receivable Aging Report for the period [DATE] through [DATE], showed the following residents with personal funds held in the facility operating account: -Resident #14 had $4,818.41; -Resident #6 had $4,775.04; -Resident #40 had $565.75; -Resident #312…

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 maintain a system that assured a complete accounting of each resident's personal funds, in accordance with generally accepting accounting principles for nine residents (Residents #1, #17, #21, #23, #38, #149, #151, #350, and #351) who elected for the facility to keep their money in the resident trust since February 2019. The facility failed to reconcile the resident trust fund ledgers with the reconciled bank statements and petty cash reconciliations and failed to reconcile petty cash totals monthly. The facility also failed to provide three residents (Residents #1, #38, and #151) with their monthly personal spending allowance. The facility census was 53. 1. Review of the residents' trust fund ledgers for February 2019 showed a total of $2,054.06 in the resident trust fund account. The residents' ledgers did not differentiate between the amounts maintained in petty cash and in the resident trust fund bank account. (The facility identified Resident #350, Resident #351, Resident #17, Resident #151, and Resident #21's money…

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 and interview, the facility failed to provide a final accounting of individual resident fund balances maintained in the facility's operating account within 30 days to the individual or probate jurisdiction administering the resident's estate, in accordance with state law, for ten residents (Residents #302, #304, #305, #309, #310, #311, #312, #313, #314, and #315). The facility census was 53. Record review of the facility's maintained Accounts Receivable Aging Report for the period [DATE] through [DATE], showed the following residents with personal funds held in the facility operating account: -Resident #302 (deceased [DATE]), $9000.00; -Resident #304 (deceased [DATE]), $1021.60; -Resident #305 (deceased [DATE]), $1828.38; -Resident #309 (deceased [DATE]), $3711.50; -Resident #310 (deceased [DATE]), $1531.00; -Resident #311 (deceased [DATE]), $1969.33; -Resident #312 (deceased [DATE]), $6000.00; -Resident #313 (deceased [DATE]), $1570.53; -Resident #314 (deceased [DATE]), $5000.00;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for three residents (Residents #34, #41 and #18) in a review of 16 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 53. 1. During interview on 11/26/19 at 12:00 P.M. the Director of Nursing (DON) said the facility followed the RAI 3.0 process for completion of all MDS assessments. Staff should complete a significant change MDS when there were two or more areas of change either improvement or decline and the change was sustained. 2. Review of the Long Term Care Facility RAI User's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure five of 16 sampled residents (Resident #12, #34, #45, #151, #253) and two additional residents (Resident #2, and #354) received care in a manner appropriate to address the residents' safety when staff transferred a resident who did not bear weight with a gait belt, transported residents in wheelchairs without foot pedals, failed to follow a resident's plan of care resulting in a fall from bed, or when the facility failed to review interventions/ add appropriate interventions after an incident/accident to prevent further accidents from occurring. The facility's census was 53. 1. Review of the facility's undated Post-Fall Protocol policy showed the following: -An episode where a resident lost his/her balance and would have fallen were it not for staff intervention, and a fall without an injury were still considered falls; -When a resident was found on the floor, most logical conclusion was that a fall had occurred. The facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to report any irregularities to the attending physician and act on irregularities noted by the pharmacist during the monthly medication regimen review for three residents (Resident #23, #41, and #36) in a review of 16 sampled residents. The facility census was 53. 1. Review of the facility's undated policy for Pharmacy Consultants showed the following: -The consultant pharmacist provided consultations on all aspects of the provision of pharmacy services in the facility; -The consultant pharmacist reviewed each medication of all residents in the facility once per month to examine for supporting diagnosis, and unnecessary medication use; -The pharmacist would report any irregularities, issues, or problems to the resident's physician and the Director of Nursing (DON); -The DON would give the charge nurse a copy of the unit's monthly consultation report; -The charge nurse would ensure that all of the recommendations were acted upon, all of the recommendations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure three residents (Residents #253, #26, and #41) in a review of 16 sampled residents' orders for as needed (PRN) antipsychotic medications were limited to 14 days and PRN antianxiety medications were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility also failed to ensure residents had an appropriate diagnosis for use of antipsychotic medications for two residents (Resident #253 and #26), and failed to incorporate into the comprehensive care plan for one resident (Resident #26), resident centered anti-psychotic medication related goals and parameters for monitoring the resident's condition, including the likely medication effects and potential for adverse consequences. The facility census was 53. 1.…

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 appropriately label insulin pens for three residents (Resident #13, #22, and #33) who were diagnosed with insulin dependent diabetes and required the use of insulin to treat, and one stock bottle of insulin (for resident use), with the date they were opened to ensure staff did not administer expired insulin. The facility census was 53. 1. Review of the manufacturer's guideline for use for Tresiba insulin showed that it was good for eight weeks after it was opened. 2. Review of the manufacturer's guideline for use for Novolog insulin Flex Pen showed the cartridges should be discarded 28 days after opening. 3. Review of the manufacturer's guideline for use for Humalog insulin Flex Pen showed the cartridges should be discarded 28 days after opening. 4. Review of the manufacturer's guidelines for use of Lantus insulin showed it should be discarded 28 days after opening. 5. Review of the facility's policy dated November of 2018 showed 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 follow spreadsheet menus for serving sizes for all residents, failed to serve bread and butter to all residents, and failed to served the pureed desserts to residents as directed on the spreadsheet menu. The facility census was 53. 1. Review of physician diet orders showed four residents had physician orders for a mechanical soft diet and four residents had orders for a pureed diet. 2. Review of the facility spreadsheet menu for lunch on 11/19/19, showed staff were to serve the following to residents on a mechanical soft diet: -A 4 ounce (oz) serving of ground meatloaf; -A slice of bread with butter; -A 2 inch by 2.5 inch piece of cheesecake. Review of the facility spreadsheet menu for lunch on 11/19/19, showed staff were to serve the following to residents on a pureed diet: -A 4 oz serving of pureed meatloaf; -A #20 (1.75 oz) scoop of pureed bread and butter; -A #12 (3.25 oz) scoop of pureed cheesecake. Observation on 11/19/19 between 11:35 A.M. and 11:55 A.M. showed the following: -Staff used a 2-ounce…

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, facility staff failed to follow acceptable infection control practices and prevent cross-contamination during the provision of cares. Staff failed to wash hands and change gloves when indicated by professional standards of practice during personal care for two sampled residents (Resident #151 and #253), and failed to properly sanitize the glucometer (a device used to evaluate blood glucose levels) in between use and after becoming soiled for one sampled resident (Resident #34) and for two additional residents (Resident #33 and #13), in a review of 16 sampled residents. The facility staff also failed to screen and administer and/or record tuberculin skin testing (TST) for ten sampled residents (Resident # 151, #12, #26, #150, #45, #250, #251, #41, #23 and #30) and for two additional residents (Resident #38 and #22) upon admission. The facility census was 53. 1. Review of the Tuberculosis (TB) Screening for Long Term Care Residents flowchart, revised 3/11/14,…

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 develop and implement written policies to report abuse and/or neglect for suspicion or allegations that do not result in serious bodily injury within 24 hours as required. The facility census was 53. 1. Review of the facility's policy Abuse and Neglect Prohibition and Prevention Policies and Procedures, undated, showed the following: -Definitions: a. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being: 1. Verbal abuse: The use of oral written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of age, ability to comprehend or disability; 2. Sexual abuse: Non-consensual sexual contact of any type with a resident, including but is not limited to sexual…

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 report injuries of unknown origin to the state agency as required for one additional resident (Resident #2). The facility census was 53. 1. Review of the facility's policy Abuse and Neglect Prohibition and Prevention Policies and Procedures, undated, showed the following: -Prohibit and prevent abuse, neglect, exploitation of residents and/or misappropriation of resident property; -Definitions: a. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; 2. The injury is suspicious because the extent of the injury or the location of the injury, (e.g. the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time; b. Immediately: Immediately for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete investigations as the facility policy directed for two instances of injuries of unknown origin for one additional resident (Resident #2). The facility census was 53. 1. Review of the facility's policy Abuse and Neglect Prohibition and Prevention Policies and Procedures, undated, showed the following: -Abuse Investigation: a. All reports of abuse (mistreatment, neglect or abuse, including injuries of unknown origin, exploitation and/or misappropriation of property) are promptly and thoroughly investigated; b. When an allegation of abuse is made, the employee should first ensure the safety of the resident; c. The Administrator/Director of Nursing/Designee will being an immediate investigation with the assistance from other key personnel to assist with reporting, investigation and follow up. The investigation will consist of at least the following: 1. nature of alleged incident; 2. interview with reporting person(s), written statement(s); 3.…

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 dependent on the staff for care received services to meet the hygiene needs for two residents (Resident #23, and #34) , of 16 sampled resident's. The facility census was 53. 1. Review of the facility undated policy Dining Room Meals showed the following: -CNA staff should assist resident to perform appropriate hygiene prior to the meal; -Dress residents appropriately for dining; -Assist residents with hygiene and cleanliness after meals. Staff should assist with clean clothing, wash hands and face. 2. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -Activities of personal care section: a. cleanliness - taking a tub or shower bath once or twice weekly may be sufficient because the skin in elderly people became dryer and thinner. Some people preferred daily baths; d. shaving - evaluate the resident's need for shaving daily. Let residents shave themselves if…

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 appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for one resident of 16 sampled residents (Resident #151) who had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine). The facility identified one resident with an indwelling urinary catheter. The facility census was 53. 1. Review of the facility's undated policy for Urinary Catheter Care showed the following: -Certified Nursing Assistants (CNA) should do catheter and perineal care with A.M. and P.M. care, after each bowel movement, and as needed (PRN): a. Always wash hands before and after handling the catheter, tube or bag and wear gloves following standard precautions for infection control; b. Clean the area where the catheter was inserted by wiping away from the insertion site to prevent germs from being moved from the anus (the opening from which feces 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 identify weight loss, notify the physician and dietician of further weight loss, implement interventions, provide quarterly dietitian visits, provide adequate servings of food and fluids, and evaluate effectiveness of the interventions for one resident (Resident #34), who had significant weight loss and signs of dehydration, in a review of 16 sampled residents. The facility census was 53. 1. Review of the facility's policy Weight Loss, undated, showed the following: -Ensure each resident maintains parameters of body weight unless the resident's clinical condition demonstrates that this is not possible; -Ensure each resident is weighed monthly or as ordered by the physician; -Ensure all residents with unplanned weight loss are monitored the physician and dietitian; -Monitor all residents with unplanned weight loss to ensure interventions and documentation are appropriate; -Monitor intake records to ensure they are recorded appropriately;…

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.