Laverna Manor Health & Rehabilitation

Based on observation, interview and record review, the facility failed to follow physician's orders for one resident (Resident #1)when the physician ordered for the resident to be sent to the hospital for X-rays and an evaluation after the resident fell from a mechanical lift sling and experienced pain, and was not. The facility census was 55.Review of the facility's undated policy titled, Medication Orders, showed: -The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders;-Supervision by a Physician: Each resident must be under the care of a Licensed Physician authorized to practice medicine in the state and must be seen by the Physician at least every sixty (60) days;-A current list of orders must be maintained in the clinical record of each resident;-Orders must be written and maintained in chronological order; -When recording treatment orders, specify the treatment, frequency and duration of the treatment. 1.Review of Resident #1's Face Sheet on 12/9/25, showed:-He/She had the diagnoses of cerebral infarction due 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 assure one resident (Resident #2) was free from misappropriation of his/her property when the resident's narcotic medications were found missing from the facility. The facility census was 58. Review of the undated facility abuse policy included: Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. Review of the Controlled Substances policy, revised April 2019, showed: - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Upon receipt: the nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substance being delivered. Both individuals sign the controlled substance record of receipt. - At the end of each shift: Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse doing off duty determine the count together. Any discrepancies in the controlled substance count are…

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 keep one resident (Resident #1) safe from sexual abuse when another resident (Resident #2) ran his/her hand up the inside of Resident #1's thighs and grabbed his/her genital area. The facility census was 61. On 5/5/25, the Administrator was notified of the past noncompliance which began on 4/14/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented including: Resident #1 and #1 were seperated immediately, the facility staff assessed both residents and neither resident had injuries, Resident #2 was placed on 1:1 monitoring on 4/14/25, Resident #2's physician ordered Sertraline (a medication to treat anxiety and depression) for Resident #2, Abuse training was started for staff on 4/15/25. The noncompliance was corrected on 4/17/25. Review of the facility's Abuse Prevention Program policy, dated July 2017, showed: -Residents have the right to be free from abuse. This includes, but 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 5. Review of R57's undated admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R57 was admitted to the facility on [DATE]. R57's diagnoses included acute on chronic combined systolic and diastolic congestive heart failure, atherosclerotic heart disease, and supraventricular tachycardia. Review of an MDS located in the EMR under the MDS tab, with an ARD of 09/17/24 indicated R57 was taking an anticoagulant agent. Review of R57's active Orders located in the EMR under the Orders tab revealed an order dated 09/07/24, for aspirin low dose oral tablet delayed release 81 mg (antiplatelet agent) but no order for an anticoagulant agent. During an interview on 10/07/24 at 1:15 PM and a second interview on 10/10/24 at 11:54 AM, the MDSC stated she received advisement from a consulting group that aspirin should be coded as an anticoagulant, so she had been coding all residents on aspirin as anticoagulant on the MDS assessment. During an interview on 10/10/24 at 1:05 PM 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 record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse for one of four residents (Resident (R) 42) reviewed for abuse out of 23 sample residents when R23, with a history of hitting another resident, hit R42 in the shoulder unprovoked. This failure had the potential to affect all the residents on the secured unit who were at risk of abuse. The facility census was 57. Findings include: Review of the facility's policy titled, ''Abuse Prevention Program,'' revised 10/16, revealed our residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation. 1. Review of R42's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder. Review of R42's admission ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/02/24…

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, interview, and policy review, the facility failed to ensure two of two residents (Resident (R) 29 and R61) reviewed for discharge to the hospital were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer, out of 23 sample residents. This failure has the potential to affect the residents by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. The facility census was 57. Findings include: Review of the facility's policy titled, Transfer or Discharge Notice, revised December 2016, showed: .Policy Interpretation and Implementation .2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The resident and/or representative (sponsor) 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 record review, interview, and review of facility policy, the facility failed to ensure two of two residents (Resident (R) 29 and R61) reviewed for facility initiated emergent transfer to the hospital received a written bed hold notice that included all required information of 23 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the residents' home following a hospitalization for residents transferred to the hospital. The facility census was 57. Findings include: Review of the facility's policy titled, Bed-Holds and Returns, revised March 2017, showed: Policy Statement. Prior to transfers and therapeutic leaves, residents or resident representative will be informed in writing of the bed-hold and return policy. Policy Interpretation and Implementation.3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding…

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

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for one of one resident (Resident (R) 14) triggered for no assessment in over 120 days from 23 residents reviewed in the sample. This failure has the potential to adversely affect care planning and care provision for any resident that may not have received a thorough assessment. The facility census was 57. Findings include: Review of the facility's policy titled, Comprehensive Assessments, revised March 2022, revealed: .Policy Interpretation and Implementation. 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual . Review of the October 2023 RAI Manual revealed on page 2-18: Quarterly (Non-Comprehensive) .ARD [Assessment Reference Date] of previous . assessment of any type + 92 calendar days . On page 2-34: The ARD of an assessment drives the due date of the next…

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.

Please refer to Event ID: RX1712 Based on observation and interview the facility failed to ensure menus were prepared in advance when menus were developed and prepared to meet resident choice when menus were not posted in advance, residents were not offered to choose their menu options, and alternatives were not posted for residents to see. This deficient practice affected three of five sampled residents, (Resident #2, #3 and #4) The facility census was 58.

Please refer to Event ID: RX1712 Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature when hot food was not served at an appetizing temperature (Resident #1, #2, #3, and #4), when meat was too hard to be cut (Resident #5), and when condiments were not offered (Resident #1) for five of five sampled residents (Resident #1, #2, #3, #4, and #5). The facility had a census of 58.

Please refer to Event ID: RX1712 Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to maintain food temperatures during distribution from the kitchen to the steam table and from service point to resident delivery. The facility failed to maintain temperatures out of danger zone and did not temperature check foods on the steam table after reheating in the kitchen and transporting the food to steam table. The facility did not check the temperature of food warmed in the microwave to ensure it was at a safe temperature. The facility failed to cover all foods for transport to special care unit, failed to maintain safe food preparation when they reused meal trays for meal service delivery to other residents in the dining room. The facility failed to ensure their dishwashing temperatures were checked and documented on the temperature log daily. The facility census was 58 residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way when they served meals with plastic cutlery and Styrofoam for three (Resident #1, #2, and #3, ) of three sampled residents. The facility census was 74. Review of the facility provided policy, Resident Rights, dated December 2016 showed: -Rights include a resident's right to a dignified existence. Review of the facility provided policy, Dignity, dated February 2021 showed: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect for residents by honoring resident goals, choices and preferences. -Residents are provided with a dignified dining experience. 1. Review of Resident #1 quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by…

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 menus were prepared in advance when menus were developed and prepared to meet resident choice when menus were not posted in advance, residents were not offered to choose their menu options, and alternatives were not posted for residents to see. This deficient practice affected three of five sampled residents, (Resident #2, #3 and #4) The facility census was 58. Review of facility policy, The Dining Experience, dated 2021, showed: -Dining expererience will be person centered with purpose of enhancing each individual's quality of life being supportive of each individual's needs during dining. 1. Review of Resident #2's quarterly Minimum Data Set, (MDS, a federally mandated assessment tool completed by the facilty staff) dated 3/17/24, showed: -He/She had a Brief Interview fro Mental Status (BIMS) score of 13 and was cognitively intact; -He/She had clear speech, was able to make self-understood and had clear comprehension of others; -He/She 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 observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature when hot food was not served at an appetizing temperature (Resident #1, #2, #3, and #4), when meat was too hard to be cut (Resident #5), and when condiments were not offered (Resident #1) for five of five sampled residents (Resident #1, #2, #3, #4, and #5). The facility had a census of 58. Review of facility policy, the dining experience, dated 2021, showed: -The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. -Food will be at the proper temperature, texture, and/or consistency to meet each individual's needs 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, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to maintain food temperatures during distribution from the kitchen to the steam table and from service point to resident delivery. The facility failed to maintain temperatures out of danger zone and did not temperature check foods on the steam table after reheating in the kitchen and transporting the food to steam table. The facility did not check the temperature of food warmed in the microwave to ensure it was at a safe temperature. The facility failed to cover all foods for transport to special care unit, failed to maintain safe food preparation when they reused meal trays for meal service delivery to other residents in the dining room. The facility failed to ensure their dishwashing temperatures were checked and documented on the temperature log daily. The facility census was 58 residents. 1. Review of facility policy, food temperatures, dated 2021, showed: -The temperatures of all food items…

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

Based on interview and record review, the facility failed to provide documentation that the Quality Assessment and Assurance (QAA) met on a quarterly basis and included the appropriate attendees; failed to identify, develop, implement, monitor and evaluate system problems. This had the potential to affect all residents. The facility census was 59. Review of the facility's policy for Quality Assurance and Performance Improvement (QAPI) Program, revised April, 2014, showed, in part: - This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program to actively pursue quality of care and quality of life goals; - The primary purpose of the QAPI program is to establish data driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents; - The QAPI program has been developed with four strategic elements in mind. 1) Design and scope: the program is ongoing and comprehensive; it involves the full range of services and departments in the facility; it covers all…

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

Based on record review and interview, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 59. Review of the facility's policy for Quality Assurance and Performance Improvement (QAPI) Program, revised April, 2014, showed, in part: - This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program to actively pursue quality of care and quality of life goals; - The primary purpose of the QAPI program is to establish data driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents; - The QAPI program has been developed with four strategic elements in mind. 1) Design and scope: the program is ongoing and comprehensive; it involves the full range of services and departments in the facility; it covers all systems of care and management practices, with priority given to quality care,…

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

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 59. The facility did not provide a policy regarding their QAA committee. The facility was unable to provide any record or minutes of the QAA program. During an interview on 8/25/22 at 4:44 P.M., the Administrator said: - She had been in her position since June; - They have not had a formal QAPI meeting; - The committee would include herself, the Director of Nursing (DON), Social Services, MDS/Care Plan Coordinator and therapy.

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. Review of the facility's policy for antibiotic stewardship, revised December, 2016, showed: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program; - The purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the residents; - Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community; - Training and education will include emphasis on the relationship between antibiotic use and: gastrointestinal disorders; opportunistic infections; medication interactions; and the evolution of drug-resistant pathogens; - If an antibiotic is indicated,…

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 they designated staff to serve as their infection preventionist (IP) who is responsible for the facility's infection prevention and control program (IPCP). This affected all the residents in the facility. The facility census was 59. Review of the facility's undated policy for infection control guidelines for all nursing procedures showed, in part: - The purpose is to provide guidelines for general infection control while caring for residents; - Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: the facility protocols for isolation (standard and transmission based) precautions; the location of all personal protective gear; the location of medical waste disposal containers; the facility exposure control plan; and the facility protocol for occupational exposures to bloodborne pathogens; - Prior to having direct care responsibilities for residents, staff must have appropriate in-service…

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 treat each resident with respect and dignity for four of 15 sampled residents (Residents #27, #47, #159, and #260)when facility staff failed to keep residents clean and groomed, provide showers and incontinent care, transfer one resident to the dining room in a forward facing position, and allow one resident to handle to manager his/her finances. The census was 59. Review of the facility's Quality of Life - Dignity Policy with a revised date of February 2020 showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, feeling of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - Residents are groomed as they wished to be groomed; - Residents are encouraged and assisted to be dressed in their own clothes; - Residents may choose when to sleep, eat and conduct activities of daily living. 1. Review of Resident #47'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 record review and interviews, the facility failed to ensure they did not hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected 19 residents sampled for resident trust fund (RTF) review and review of the facility's Interim Aged Analysis Detail report (Residents #12, #19,#42, #50 #59, #60, #61, #62, #63, #64, #65, #66, #311, #312, #314, #315, #316, #317 and #318). The facility's census was 59. Review of the facility's Final Conveyance of Resident Funds and Credit Balances policy, revised April 2014, showed the facility maintains a system that assures a full, complete ,and sparate accounting, according to generally accpeted accounting principles for each resident's funds entrused to the facility on the resident's behalf. The systme precludes and commingling of resident funds with facility funds unless instruction has been obtained and authorizied by the resident/responsible party. 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 record review and interviews, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond amount covering the Resident Trust Fund (RTF) account which affected all 44 residents who held money in the RTF. The facility census was 59. Review of the DHSS database, which tracks the most up to date information regarding approved bonds for RTF accounts for all facilities that hold resident monies showed an approved bond amount of $45,000, approved by DHSS on 4/14/20. Review of the Resident Funds Bond Worksheet, a form used by DHSS to determine what the facility's bond should be and if they have the appropriate approved amount for their bond, showed: - The average balance for the previous twelve months in the facility's RTF bank account of $53,607.52; - After multiplying this amount by 1.5, the approved bond amount should be $81,000; - The business office manager (BOM) wrote on the form the facility's approved bond amount equaled $100,000. During an interview on 8/25/22 at 2:30 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff provided transfer or discharge notification to residents and/or their responsible party and the reasons for the transfer/discharge in writing in a language they understood and failed to provide information on those residents transferred to the Ombudsman's office. This affected three of 15 sampled residents, ( Resident #17, #19, and #40). The facility census was 59. The facility did not provide a policy for transfers and discharges. 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/22 showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for transfers; - Extensive assistance of one staff for dressing, toilet use and personal hygiene; - Diagnoses included cancer, coronary artery disease (coronary arteries narrow limiting blood flow and oxygen to the heart) and diabetes mellitus. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff issued a notice of their bed-hold policy prior to/upon transferring three of 15 sampled residents, (Resident # 17, #19, and #40) to the hospital. The facility census was 59. The facility did not provide a policy for a bed-hold with transfers. 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/22 showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for transfers; - Extensive assistance of one staff for dressing, toilet use and personal hygiene; - Diagnoses included cancer, coronary artery disease (coronary arteries narrow limiting blood flow and oxygen to the heart) and diabetes mellitus. Review of the resident's electronic medical record showed: - On 6/2/22 at approximately 8:30 P.M., the nurse was alerted by staff of the resident being unresponsive. The nurse found the resident in bed with eyes closed 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 observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care when staff failed to obtain an order for accuchecks (tests the blood sugar level to determine the dose of insulin) for three of 15 sampled residents ( Resident #5, #29, and #40), failed to follow the facility policy for blood glucose monitoring when staff did not allow alcohol to completely dry before obtaining the blood sugar readings, which affected four sampled residents (Resident #3, #5, #29, and #40). Staff failed to administer eye drops according to manufaturers' guidelines for one sampled resident (Resident #50). Staff failed to administer nose spray according to manufacturer's guidelines for one sampled resident, (Resident #35). The facility census was 59. Review of the facility's policy for obtaining a fingerstick glucose level, revised October 2011, showed, in part: - The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three out of 15 sampled residents, (Resident #21, #40, and #209) and the failed to ensure showers were completed for four sampled residents (Residents #19, #26, #27, and #47). The facility census was 59. The facility policy titled Activities of Daily Living (ADL) Supporting, with a revised date of March 2018, showed residents who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy directed the following: - Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care (POC), including appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected seven residents (Residents #4, #21, #27, #28, #47, #209 and #260). The facility census was 59. The facility did not provide a facility policy or job description for activities as requested. Review of the facility's Quality of LIfe - Dignity Policy with a revised date of February 2020 showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, feeling of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Residents are groomed as they wished to be groomed; -Residents are encouraged and assisted to be dressed in their own clothes; -Residents may choose when to sleep, eat 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 be consistent with professional standards of practice to prevent, provide necessary treatment and services to promote healing, preventing infection, and prevent new pressure ulcers from developing. This affected three of the fifteen sampled residents, (Resident #26, #36 and #159). Facility census was 59. Review of the facility policy titled Prevention of Pressure Injuries with a revised date of April 2020 showed: -Preparation: review the resident CP and identify the risk factors as well as interventions designed to reduce or eliminate those considered modifiable. -Skin assessment: Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). a) Identify any signs of developing pressure injuries (i.e. color, temperature, consistency.) b) inspect pressure points (bony areas) c) wash the skin after any episodes of incontinence using Ph balanced skin cleanser. d) moisturize dry skin…

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 During observation, interview, and record review, the facility failed to ensure residents were safe, free of accidents for six of 15 sampled residents (Residents #2, #28, #29, #50, #159, and #260) when staff failed to complete a gait belt transfer properly and safely for (Resident # #28), failed to ensure staff used a mechanical lift to transfer properly and safely and failed to assess a resident who is a smoker and has oxygen in his/her room without orders. This affected residents (#159 and #260). The facility failed to ensure the floors were dry for three Residents, (Resident #2, #29 and #50). The facility census was 59. Review of facility provided policy titled Lifting machine, using a mechanical, with a revised date of July 2017 showed in part: --General Guidelines 1) At least 1-2 nursing assistants are needed to safely move a resident with a mechanical lift. 2) Mechanical lifts may be used for tasks that require; b) transferring a resident from bed to chair, e) toileting or bathing, and f) repositioning. 4)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to properly clean oxygen concentrator filters for three of 15 sampled residents, (Resident #17, #26 and #260) and when staff failed to obtain an order for oxygen therapy which affected Resident #26 and #260. The facility census was 59. Review of the facility's policy for oxygen administration, revised October 2010, showed, in part: - The purpose of this procedure is to provide guidelines for safe oxygen administration; - Verify that there is a physician's order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - The policy does not address how often the oxygen tubing should be changed or if it should be dated and when the filters should be cleaned. Review of facility provided policy titled Oxygen Administration, with a revised dated of October 2010 shows in part; - Purpose - to provide guidelines for safe oxygen…

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

Based on record review and interviews, the facility failed to ensure they staffed a registered nurse (RN) at least eight consecutive hours a day, seven days a week on the day shift, which had to potential to affect all residents. The facility's census was 59. The facility did not have a policy addressing RN coverage. Review of their June 2022 staffing schedule showed: - The following days without RN coverage 6/3/22 through 6/5/22; 6/10/22 through 6/11/22 6/13/22 through 6/15/22 6/20/22 - The following days did not have RN coverage during the day shift 6/6/22 6/8/22 through 6/19/22 6/22/22 through 6/28/22. Review of the July 2022 staffing schedule showed: - The following days without RN coverage: 7/9/22 7/21/22 through 7/25/22 7/29/22 - The following days did not have RN coverage during the day shift 7/1/22 7/9/22 7/10/22, had an RN scheduled for 7.5 hours on the evening shift 7/11/22 and 7/12/22 7/15/22 through 7/18/22 7/21 through 726/22 7/30/22 and 7/31/22. Review of the August 2022 staffing scheduled showed: - The following days without RN coverage. 8/2/22 8/4/22 and 8/5/22…

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, record review and interviews, the facility failed to ensure nurse aides met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program and who was at least [AGE] years of age. Review of the facility's job description of a nurse aide (NA), dated January 2017, showed the NA works under the supervision of the charge nurse to provide residents with basic bedside care and assistance with activities of daily living in accordance with the standards, policies and practices of the department. NOTE: For continued employment beyond 120 days following date of hire, the NA must complete the state required certified nurse aide (CNA) course of training and pass the examination. Qualifications included the NA must be enrolled in a CNA program. Review of the list of current staff provided by the facility on 8/22/22 showed: - NA B began employment on 10/26/21 as an NA; - NA C began employment on 11/11/21 as an NA; - NA D…

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 pharmacy Drug Regimen Reviews (DRR) were completed and in the resident's medical record monthly for two of 15 sampled residents (Resident #17 and #22). The facility census was 59. Record review of the facility's policy titled Medication Therapy, revised April 2007 showed: -Each resident's medication regiment shall include only those medications necessary to treat existing conditions and address significant risks; -The consultant pharmacist shall review each residents medication regiment monthly.1. Review of Resident #17's quarterly MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for transfers; - Required extensive assistance of one staff for dressing and toilet use; - Diagnoses included cancer, diabetes mellitus, renal insufficiency and coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart). Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 25 opportunities for error which resulted in a medication error rate of 20%, which affected four of 15 sampled residents, (Resident #3, #29, #35 and #40). The facility census was 59. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner and as prescribed; - The expiration/beyond use date on the medication label is checked prior to administering; - When opening a multi-dose container, the date opened is recorded on the container; - Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident. Review of the leaflet for Novolog Flexpen, revised 3/2021,…

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

Based on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored within the medication carts and medication rooms, failed to ensure insulin pens had a pharmacy label on them to indicate who they belonged to and failed to ensure medication was not placed in the resident use refrigerator, failed to record temperatures within the medication refrigerator, failed to ensure medication labels matched the physicians order sheet, and failed to ensure the narcotic count was reconciled each shift. This affected nine of nine sampled residents, (Resident #3, #6, #19, #22, #28 #49, #50, #110, and #260 ). The facility census was 59. Review of the facility's policy for storage of medications, revised April 2019, showed, in part: - The facility stores all drugs and biological's in a safe, secure, and orderly manner; - Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls; - Drugs and biological's are stored in the packaging, containers or other dispensing…

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

Based on observations, interviews and record review, the facility failed to assure staff served food to the residents that was palatable, attractive, and served at a safe and acceptable temperature to the residents. The facility census was 59. No facility policy on food temperatures was provided. Observation of the kitchen on 8/24/22 at 9:12 A.M., showed: -All the pureed foods already prepared. During an interview on 8/24/22 at 9:25 A.M., The Dietary Manager in Training said: -He/she prepares the pureed food early so it will be ready for the next meal; -The pureed foods are already prepared and in the oven to be kept up to temperature until serving time; -Lunch was scheduled to be served at or around 12:00 P.M. Observation of the kitchen on 8/25/22 at 6:56 A.M., showed: -All the pureed foods already prepared and on the steamtable. Observation of the regular meal test hall tray on 8/25/22 at 8:A.M., showed: -Scrambled eggs was 83 degrees Fahrenheit; -Gravy was 101 degrees Fahrenheit; -Sausage was 78 degrees Fahrenheit, Observation of the pureed meal test tray on 8/25/22 at 8:58 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided a nourishing snack at bedtime and suitable, nourishing alternative meals and snacks that must be provided to residents who want to eat at nontraditional times or outside of scheduled meal service times, consistent with the residents' plan of care. This affected four of fifteen sampled residents, (Resident #17 and #22). The facility census was 59. Review of the facility's policy titled Snacks (between Meal and Bedtime) Serving with a revised date of September 2010 showed the purpose of this procedure is to provide the resident with adequate nutrition. The policy directed the following: - Preparation 1) review the resident's care plan and provide for any special needs of the resident. 3) Check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. - Steps in the procedure: 1) Place the snack on the over…

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, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 59. Review of the facility's Food Storage: Dry Goods policy, with a revised date of September 2017 showed: - All items will be stored on shelves at least six inches above the floor; - All packaged and canned foods items will be kept in clean, dry and properly sealed; - Storage areas will be neat, arranged for easy identification and date marked as appropriate. Review of the facility's Food Storage: Cold Foods policy, with a revised date of April 2018 showed: - All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below; - All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's Environment policy, with a revised date of September 2017 showed: - The Dining Services Director with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure staff treated one of 3 sampled residents, selected for the closed record review (Resident #61) with dignity and respect when staff held the resident in a four-point physical restraint while they provided perineal care while the resident struggled to free him/herself during an aggressive behavior episode. The facility's census was 59. Review of the facility's Use of Restraints policy, revised April 2017, showed restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. The policy interpretation and implementation…

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 to prevent urinary tract infections for those residents that are incontinent of bladder and bowel and/or have an indwelling Foley catheter. This affected two of fifteen sampled residents, (Resident #26 and #159). Facility census was 59. Review of the facility's policy regarding peri care showed the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. The policy provided the following direction: - Preparation - review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. - Equipment - wash basin, towels, wash cloths, soap (or other authorized cleansing agent) and person protective equipment (e.g. gowns, gloves, mask etc. as needed.) - Steps in the procedure - *place equipment on the bedside table and arrange 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 record review and interviews, the facility failed to provide one of three sampled residents, selected for the closed record review (Resident #61) the necessary behavior health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The facility's census was 59. Review of the facility's Behavior Assessment, Intervention and Monitoring policy, revised March 2019, showed: - The facility will provide and residents will received behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance it the comprehensive assessment and plan of care. - Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. - Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents; - Residents will have minimal complications associated…

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 collaborate with the hospice provider in the development of a coordinated Plan of Care (POC) and documentation ensure the residents' receiving hospice services needs are addressed and met, failed to ensure each resident's written (POC) included both the most recent hospice POC and facility's POC to maintain the residents' highest practicable physical mental and psychosocial well-being. This affected two of the fifteen sampled residents, (Resident #36 and #159). The facility census was 59. Review of the facility's policy regarding Hospice Program services within the facility, with a revised date of July 2017 showed: - In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: a. 24- hour room and board care; b. Administering…

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.