Sunnyview Nursing Home & Apartments

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change assessment after a resident was started on hospice services for one of two residents (Resident (R) 7) reviewed for hospice of 16 sample residents. This has the potential to affect all residents with a Minimum Data Set (MDS) assessment ensuring proper care and services. The facility census was 46. Findings include: Review of the undated Minimum Data Set Resident Assessment Instrument (RAI) revealed Guidelines for determining the need for an SCSA [significant change in status assessment] for residents with terminal conditions. The key in determining if an SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a care plan for a resident receiving hospice services for one of two residents (Resident (R) 7) reviewed for hospice services of 16 sample residents. This has the potential to affect all residents receiving hospice services. The facility census was 46. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised March 2023, revealed the comprehensive, person-centered care plan was developed within seven days of the required MDS [Minimum Data Set] assessment. Review of R7's admission Record located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] and with diagnosis of mild intermittent asthma. Review of R7's quarterly MDS under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/08/24, revealed the Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for one of two residents (Resident (R) 22 and R37) reviewed for side rails of 16 sample residents. The lack of alternative side rail measures could lead to potential restraint or side rail entrapment. The facility census was 46. Findings include: 1. Review of R22's admission Record located in the Profile tab of the electronic medical record (EMR) revealed re-admission to the facility on [DATE] with a diagnosis of muscle weakness. Review of R22's annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/21/24 revealed a Brief Interview for Mental Status (BIMS) score could not be completed due to the resident rarely understood. Review of R22's care plan located under the ''Care Plan'' tab of the EMR and dated 07/08/22, revealed ''The resident had ½ side rails on bed for bed mobility. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents received the correct medication as ordered by the physician for two of eight residents (Resident (R) 20 and R38) reviewed for medications of 16 sample residents. This failure could result in unwarranted medication side effects and mismanaged medical conditions. The facility census was 46. Findings include: Review of the facility's policy titled, Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 1. Review of R20's Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R20 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure and essential (primary) hypertension. Review of R20's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 05/28/24, revealed R20 had a Brief…

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 facility policy review, the facility failed to ensure there was documented rationale and a stop date for a PRN (as needed) psychotropic medication for one of eight residents (Resident (R) 12) reviewed for medications of 16 sample residents. This failure has the potential to lead to unwarranted medication side effects. The facility census was 46. Findings include: Review of the facility's policy titled, Psychotropic Medication Use, dated July 2022, revealed PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Review of R12's Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R12 was admitted to the facility on [DATE] with diagnoses which included…

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 interviews, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 99) was free from significant medication errors when the facility administered R99 someone else's medication, out of 16 sample residents. This medication error had the potential to cause R99 to become hypotensive (low blood pressure). The facility census was 46. Findings include: Review of the facility's policy titled Administering Medications, dated 04/19, revealed Medications are administered in a safe and timely manner, and as prescribed .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band; (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel. Review of a professional reference titled Hypotension, dated 02/19/23 and retrieved from…

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 staff failed follow their policy when they failed to immediately notify facility administration after one Certified Medication Technician made a sexually inappropriate comment to a resident (Resident #1). The facility census was 57. Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, dated April 2021, showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. -The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, including but not necessarily limited to: a. Facility staff 6. Provide staff orientation…

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.

This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 3/22/22. Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This deficiency had the potential to affect all residents. The census was 53. Review of the May 2022 staffing sheets showed no RN coverage on: -May 14, 2022; -May 21, 2022; -May 22, 2022. Review of clock in times for May 14, May 21 and May 22, 2022 showed: -No clock in times for the Director of Nursing (DON); -No clock in times for RN A; -No clock in times for RN B . Record review of the staffing sheets showed: - 2 RNs: DON and RN A. Review of a letter from the DON, dated 5/24/22, showed: -He/she was available on May 14, May 21 and May 22, 2022 by phone and able to enter the facility as needed. Review of emails between the facility and Contracted Staffing Agency A showed: RN coverage requests for May 14, May 21 and May 22, 2022 were canceled by the DON. During an interview on 5/24/22 at 12:13 P.M., the Administrator said: -The facility…

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 interview, the facility failed to maintain the kitchen in sanitary condition and to store food in a sanitary manner. The facility census was 53. Review of the facility's policy titled, Food Labeling and Storage, dated 2/19/2020, showed it did not include seasonings on the list to be dated. Review of the facility's kitchen cleaning checklists showed the following: - Clean shelves under toaster- weekly; - Clean shelves- weekly. 1. Observation on 5/23/22 beginning at 10:35 A.M., showed the following in the kitchen: - There was a sticky substance on the drying rack that contained clean pots and pans; - The following seasoning containers were opened and did not contain a date: o 12.5 ounce (oz) Ground Ginger; o 16 oz. Ground Nutmeg; o 32 oz. Celery Salt; o 12 oz. Ground Oregano o 5 pound (lb) ground black pepper Observation on 5/25/22 beginning at 9:23 A.M.,showed the following in the kitchen: - Plastic tub containing lids and condiment bottles stored under food preparation table with brown liquid and food particles in the bottom of the plastic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable disease and infections and failed to have written standards, policies and procedures in place for their IPCP. Staff failed to ensure they completed a two step tuberculosis (TB) skin test (TST) accurately for three of five residents sampled for immunizations and TB testing (Residents #27, #53, and #54). The facility's census was 53. 1. Review of the Infections - Clinical Protocol, revised April 2012, showed: - Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection. 2. Infections may be suspected based on clinical signs and symptoms and/or temperature. 3. For any individual suspected of having an infection, or who has a change in function, appetite, mental…

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

Based on record review and interview, the facility failed develop and implement policies and procedures and to maintain documentation to show they established an infection prevention and control program (IPCP) which included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 53. Review of the facility's polices and procedures addressing infection control showed they did not have a policy and procedure to direct staff how to establish an IPCP, including an antibiotic stewardship program. Review of the Infection Summary Report, dated 5/1/22 through 5/31/22, form showed the form listed the source of the infection, if it was acquired in-house or of the resident admitted with the infection in a table at the top of the form. The types of infections listed were blood, ear, eye, gastrointestinal (GI), respiratory (URI), skin, urinary (UTI), and other. The form did not indicate the facility had had any blood, ear, eye or GI infections during the month. They indicated the following: - URI one;…

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 put measures in place to honor residents' or their responsible parties' do not resuscitate order when staff allowed a resident who had been deemed incapacitated to sign his/her Outside the Hospital Do Not Resuscitate (OHDNR) form, failed to transcribe physician's orders when the resident signed his/her OHDNR, and allowed a resident with severe cognitive impairment to sign their OHDNR. This failure affected three of 14 sampled residents (Residents #26, #40 and #53). The facility census was 53. 1. Review of the facility's undated Advanced Health Care Directives/Code Status Policy showed in part: - Annual discussion will be handled either in a group or one on one basis, in regards to their current advance directives and code status. In the event the resident is unable to comprehend what he/she is being told and the legal representative is unavailable, information and literature shall be sent to the legal representative and charted in the resident's…

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

Based on record review and interview, the facility failed assess residents using the quarterly assessment review instrument no less than every three months or at least every 92 days after the last assessment which affected four of 14 sampled residents (Residents #1, #2, #3, and #9). The census was 53. The facility did not provide a policy for completing the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. 1. Review of Resident #3's electronic medical record (EMR) on 5/31/22 showed: - A quarterly MDS assessment date of 3/15/22; - The MDS coordinator signed the MDS assessment on 5/17/22 that she completed sections A ,B, E, G, GG, H, I, K, M, N, P; - The MDS coordinator electronically signed that she completed sections C-Interview, D, D-Interview, J, J-Interview, L, O, Q, Z on 5/20/22; - The Director of Nursing (DON) had not signed the assessment to signify it as accurate and complete. 2. Review of Resident #2's EMR on 5/31/22 showed: - A quarterly assessment date of 3/2/22; - The MDS coordinator signed the MDS assessment on 5/17/22 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for six of 14 sampled residents (Resident #9, #18 #35, #39, #46 and #50). The facility census was 53. Review of the facility's policy for care plan, dated October 2010, showed in part: - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental, and psychological needs is developed for each resident. - Our facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. - The comprehensive care plan is based on a thorough…

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 ensure the proper use of bed rails when staff failed to complete assessments for the use of bed rails prior to applying to residents beds, failed to provide education and obtain consents for the use of bed rails from the residents and/or their responsible parties, failed to obtain physician's orders and failed to implement interventions for the use of bed rails for four of 14 sampled residents with bed rails (Residents #27, #39, #40, and #46). The facility census was 53. Review of the facility policy for Proper use of side rails, dated December 2010, showed in part: - The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a residents medical symptoms. - Physical restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting…

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 complete entrapment assessments for four of 14 sampled residents with side rails and/or therapeutic mattresses (Residents #9, #39, #40, and #46) to ensure the environment remained safe and free of accident hazards. The facility census was 53. Review of the facility policy for Bed Safety, dated December 2007, showed in part: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well a input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identity risks and…

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

Based on record review and interview, the facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) from Centers of Medicare and Medicaid (CMS) form 10055 to each resident. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibility. This affected two of the three sampled residents (Residents #36 and #46). The facility census was 53. The facility did not provide a policy regarding ABN. 1. Review of Resident #36's medical records showed: - The resident's Notice of Medicare Non-Coverage (NOMNC), a notice provided to the resident and/or their responsible party when the resident had skilled benefit days remaining, is being discharged from Part A services and will continue living the in the facility, showed the resident was being discharged from Part A services on 12/16/21 and was signed by the resident's representative on 12/14/21. There was not a record that an ABN had been provided. Records indicated 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 interview, the facility failed to provide a copy of their bed hold policy before transferring one of 14 sampled residents (Resident #26) to the hospital when they could not meet the needs of the resident. The facility's census was 52. Review of the facility's undated Bed Hold policy showed: - It is the policy of the facility that during the absence of any resident for any reason, the regular charge herein shall apply until the room is released and all belongings are removed, unless otherwise specified by administration. - The resident or their representative shall notify the facility's social service department regarding whether the resident's bed should be held, or whether the resident should be discharged . If notice is received, the resident's bed will automatically be held and charges will continue to accrue. - Upon a resident's discharge to the hospital, the business office or social service office will contact the resident's family on the 11th day following discharge to clarify…

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 complete a significant change in condition comprehensive assessment for one of 14 sampled resident's (Resident #9). The facility census was 53. The facility did not provide a policy for determining a significant change condition and completing the comprehensive assessment timely after the change had been identified. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by the facility staff, dated 12/16/21, showed: - A brief interview of mental status (BIMS) score of 10, which indicated a moderate cognitive impairment. - Resident required extensive assistance with all activities of daily living (ADLs). - Resident was occasionally incontinent of bowel and bladder. - Resident was at risk of pressure ulcer. Required staff to assist with turning and repositioning. - The resident was not and had not been receiving hospice services. Review of the ADL care plan (CP), dated 12/16/21, showed: - On 01/12/22 the resident returned from emergency room (ER) with diagnosis of…

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

Based on observation, interview, and record review, the facility failed implement pressure ulcer precautions for one resident (Resident #46) per physician orders and facility care plan. This affected one of 14 sampled residents. The facility census was 53. Review of Prevention of Pressure Ulcer policy dated October 2010 showed in part: Purpose of this procedure: Is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Preparation: - Review the residents' care plan to assess for any special needs of the resident. - See policy and procedure for specific tasks, such as bathing, incontinence care, and repositioning. General Guidelines: - Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing decrease of circulation to that area. - The most common site of pressure ulcer is where the bone is near the surface of the body. - Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. - Pressure ulcers are often made worse by continual…

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 interview, the facility failed to provide an environment free from accident hazards when staff did not implement interventions to prevent falls for one of 14 sampled residents (Resident #27) who was at risk for falls and who had both experienced multiple falls. The facility census was 53. The facility did not provide a policy for falls. 1. Review of Resident #27's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/22, showed: - A Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; - Extensive assistance with bed mobility; total dependence on staff for transferring, moving on and off the unit, personal hygiene, toilet use, dressing, and eating; - Diagnoses included stroke and one sided paralysis; - No falls in the six months prior to admission, and now falls since admission; - Neurological surgery prior to admission; - No restraints or bed rails in use. 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 observation, interview, and record review, the facility failed to ensure staff provided care to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter (a catheter which enters the bladder through the lower abdomen) which affected one resident (Resident #46) out of 14 sampled residents. The facility census was 53. Review of the facility policy regarding perineal care, dated October of 2010, showed in part: - If the resident has an indwelling catheter, gently wash the junction of the tubing from the urethra down the catheter tubing about 3 inches. Gently rinse and dry area. Hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. -The policy does not show where to place the bedside drainage bag during or after care. 1) Review of resident #46 Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/22, showed: - Resident was readmitted on [DATE] - A brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident #27) received the appropriate treatment and services to prevent complications of enteral feeding when staff failed to enter orders for upgrading the resident's diet, failed to monitor intake and output to ensure the resident received adequate calories when staff upgraded his/her diet, and failed to implement interventions after the resident's diet was upgraded. The facility census was 53. Review of the facility's policy on enteral nutrition, revised December 2011, showed adequate nutritional support through enteral feeding will be provide to residents as ordered. The policy interpretation and implementation included: - The interdisciplinary team (IDT), including the dietitian will conduct a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings and will include: a. Evaluation of the resident's current nutritional status…

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

Based on interview and record review, the facility failed to ensure one resident (Resident #46) of 14 sampled residents received a gradual dose reduction (GDR), and/or a rationale from the physician as to why the GDR was not attempted and failed to contact the physician once the resident no longer needed an antipsychotic medication. The facility census was 53. The facility policy titled psychotropic medication use, dated January 2022, showed in part: - Psychotropic medication is prescribed for a diagnosed condition and not being used for convince or discipline. - Facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social, and environmental cause of the residents behaviors. -Gradual dose reduction is used in an effort to discontinue antipsychotic medications. 1. Review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/07/2022, showed in part: - A Brief Interview for Mental Status (BIMS) of 7…

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 collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. This affected one of 14 sampled residents (Resident #9). The facility census was 53. Review of the facility's contracted agreement with hospice providers, dated 08/25/2020, under Provision of Services, showed in part: - Hospice plan of care (HPOC) must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have ben agreed upon and included in the HPOC. - HPOC reflects participation by the hospice, facility, patient and patient's family. - Discussions of changes to the HPOC with the facility or patient. - Design of POC states facility shall coordinate with hospice in developing a POC. Review of facility policy regarding shower/tub baths, dated October 2010, showed in part; - No mention of frequency of showers for residents and when to provide/offer. 1) Review of Resident #9's quarterly Minimum Data Set (MDS),…

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.