Troy Manor

Based on observation, interview and record review, the facility failed to ensure staff repositioned one resident appropriately (Resident #9), in a review of seven sampled residents. The census was 85. Review of the facility policy, Positioning the Resident, dated 03/2015, showed the following: -To move the resident up in bed when a resident is helpless with two staff lifting: -A nurse stands on each side of the bed or both on the same side; - Flex the residents' knees; -One nurse supports the head, shoulders and back by placing one arm across the back to the opposite axilla (arm pit). With the nurse's free hand, he/she lifts and arranges the resident's head so that it rests comfortably on his/her arm. Nurse places his/her arm across the small of the resident's back; -The second nurse places one arm across the back, the other under the thighs. If nurses are on the opposite sides of the bed, head and shoulders may be supported with a pillow; -Both nurses lift the resident into position desired; -When using a pull sheet under the resident use two staff with one staff on each side 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 observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their life for four residents (Residents #6, #34, #58, and #70), in a review of 23 sampled residents, and for one additional resident (Resident #89), who were cognitively impaired and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning based on a get up list without consideration of the resident's preferences for waking and for staff convenience. The facility census was 95. Review of the facility's undated Policy for Resident Rights showed the following: -It was the intent of the facility to promote and ensure that highest standards of conduct and reliability by it's employees and consultants to in turn produce environments in the facility that promoted the highest standards of care and security for the residents and the families of who they served; -Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five residents (Resident #1, #4, #34, #27 and #28) who required assistance with activities of daily living (ADL), in a review of 23 sampled residents, received the amount of assistance needed to complete ADL tasks. The facility census was 95. Review of the facility undated oral hygiene policy showed the following: -Purpose was to cleanse the mouth, teeth, and dentures; -Staff was expected to offer oral hygiene before breakfast, after each meal, and at bedtime. Review of the undated facility shower policy, showed the following: -Purpose was to maintain skin integrity, comfort and cleanliness; -Staff was expected to offer showers and encourage the resident to do as much of his/her own care as possible and supervise and assist as necessary. 1. Review of Resident #28's undated face sheet showed the resident's diagnoses included urinary tract infection, candidiasis (yeast infection), overactive bladder and panic disorder (anxiety…

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 of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being for three residents (Resident #4, #34, and #82) who resided in the facility's special care unit (SCU) and two residents who resided in the general population (Resident #1 and #58), of 23 sampled residents. The facility census was 95. Review of the facility policy, Activity, Volunteer, and Recreational Services, dated March 2012, showed the following: -The activity director, assistants and volunteers of this facility, believe that everyone has the right to achieve the maximum of his or her potential; have opportunities for social involvement on an individual or group basis; and have outlets for creative abilities offering opportunities for self-development that would afford personal interest, enjoyment and satisfaction provided through an ongoing activity program; -The facility provides an ongoing…

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, observation, and record review, the facility failed to ensure the safety of six residents (Resident #2, #4, #19, #34, #56, and #79), of 23 sampled residents. Staff failed to follow care plan interventions for fall prevention, including placement of proper footwear and fall mat use, and failed to ensure residents were transported safely in their wheelchairs when staff failed to place foot pedals on the wheelchair prior to transport. Staff also failed to prevent an elopement by not ensuring staff provided protective oversight for one resident (Resident #56), and failed to protect two residents (Residents #2 and #300) from Resident #79, who had a history of verbal and physical aggression toward other residents. The facility's census was 95. 1. Review of the facility Resident Elopement policy undated showed the facility provides 24 hour protective oversight and maintains the quality of life for each resident. Guidelines: 3. If a resident is admitted with no previous elopement potential, but…

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 assess resident's need for bed rail use and and obtain informed consent with description of the risks of bed rail use prior to installing and using bed rails for three residents (Residents #25, #58, and #62), in a review of 23 sampled residents. The facility census was 95. Review of the facility's undated policy, Bed Rails, showed the following: -Once the bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative; -After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well; (The policy did not address the frequency of bed rail assessments.) 1. Review of Resident #25's face sheet showed the following: -The resident had a responsible party; -Diagnoses included Alzheimer's disease (type of dementia that affects memory, thinking and behavior), falls, and weakness.…

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 adequate amount of staff to provide care and protective oversight for residents on the special care unit (SCU). Residents on the unit had impaired cognition, were at risk for falls and behaviors including resident to resident altercations. The facility utilized nurse aides (NAs) on the unit with no certified nurse assistant (CNA) to work with the uncertified NA. The facility census was 95. Review of an electronic notification from the administrator on 3/26/24 at 7:22 A.M. showed she was unable to locate the facility's staffing policy. Observation of the SCU on 3/18/24 at 11:47 A.M. (day shift starts at 6:00 A.M.) showed the following: -The census of the SCU was 15; -Two NAs and one activity aide were present on the unit. The unit was staffed with two NAs (NA E and NA L) and one activity aide. Observation of the SCU on 3/19/24 from 7:00 A.M. until 3:00 P.M. showed the following: -Two NA's (NA E and NA K) worked the unit; -There was no activity aide on the unit. -Residents were left unattended in the TV…

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 three nurse aides (NA) completed a certified nurse aide (CNA) training program within four months of their employment. The facility census was 95. Review of an electronic mail communication on 3/22/24 at 7:22 A.M., the Administrator said she could not locate a policy on Nursing Assistant and Certified Nursing Assistant training program. 1. Review of the facility provided list of employees hired since last annual survey showed NA E's date of hire was 7/5/21. Review of NA E's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the staffing schedule dated March 2024 showed NA E was scheduled to work as an NA on 3/1/24, 3/2/24, 3/3, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/13/24, 3/15/24, 3/16/24, 3/17/24, 3/17/24, and 3/19/24. During an interview on 3/18/24 at 11:47 A.M., NA E said she had been an NA since June of last year (2023) but had just finished classes. He/She was scheduled to take the knowledge portion of the certification…

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 scoops were not stored inside bulk containers with food items, failed to ensure food items were sealed when not in use, failed to maintain the exhaust vent over the dish machine to be free of a buildup of debris, failed to ensure two microwaves were easily cleanable and free of a buildup of debris, and failed to ensure the light bulb in the walk-in freezer was shielded. The facility census was 95. 1. Review of the facility policy, Receiving and Storage of Food, dated May 2015, showed the following: -The dining services manager is responsible for receiving and storing food and nonfood items; -Keep all foods in clean, undamaged wrappers or packages. Reseal open boxes effectively. Observation on 3/18/24 at 10:41 A.M. showed a large clear plastic storage tub with a green lid contained what appeared to be sugar (fine white crystals). The tub was not labeled. A blue measuring cup was stored inside the tub. Observation on 3/18/24 at 10:50 A.M. showed a metal scoop stored inside a bulk container of oats. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Resident #25, #58, and #62), in a review of 23 sampled residents who used bed rails/assist bars. The facility census was 95. Review of the facility's undated Bed Rails policy, showed the following: -Overview of FDA potential zones of entrapment with FDA dimension recommendations; 1. Zone 1: Within the rail; a. Any open space between the perimeters of the rail can present a risk of head entrapment; b. FDA recommended space: less than 4 ¾ inches; 2. Zone 2: Under the rail, between the rail supports or next to a single rail support a. The gap under the rail between the mattress, may allow for dangerous head entrapment; b. FDA recommended space: less than 4 ¾ inches; 3. Zone 3: Between the rail and the mattress; a. This area is the space between the inside surface of the bed rail…

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 reasonable accommodation of individual needs by ensuring call lights were in reach at all times for two residents (Resident #31 and #70), in a review of 23 sampled residents, and failed to accommodate Resident #31's need for an alternative means to contact staff when the resident could not physically use the type of call light provided in his/her room. The facility census was 95. Review of the facility's undated policy, Use of Call Light, showed the following: -When providing care to residents, be sure to position the call light conveniently for the resident's use; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility, dated 12/19/23, showed the following: -The resident was cognitively intact; -He/She had functional limited range of motion to bilateral upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for one resident (Resident #27), in a review of 23 residents. The facility census was 95. Review of the facility undated policy for comprehensive care plans showed the following: -An individualized comprehensive care plan that included measurable goals and time frames would be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan would be based on a thorough assessment that included, but was not limited to, the minimum data set (MDS; a federally mandated assessment to be completed by the facility); -A well developed care plan was designed to prevent avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence, manage risk factors to the extent possible or indicating the limits of such interventions, addressing ways to try to preserve 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 obtain an order for oxygen use and maintain equipment according to the facility policy for two residents (Residents #28 and #54), in a review of 23 sampled residents. The facility census was 95. Review of the undated facility policy, Physician Orders, showed the oxygen orders include the specific rate of flow, route, and rationale. Review of the undated facility policy, Cleaning Guidelines-Oxygen Equipment, showed tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and PRN (as needed) and marked with date and initials. Review of the undated facility policy, Oxygen Administration, showed the following: -Set the flow meter to the rate ordered by the physician, then place the oxygen cannula on the resident; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -At regular intervals, check liter flow contents of oxygen cylinder and fluid level in humidifier. 1. Review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #59), in a review of 23 sampled residents, was free of significant medication errors when staff failed to transcribe a new order to increase the resident's trazodone (a sedative/anti-depressant medication) and administered the incorrect dose for ten days. The facility census was 95. Review of the facility undated policy, Medication Administration Guidelines, showed residents are to receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. 1. 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.

Based on observation, interview, and record review, the facility failed to ensure residents on a pureed diet received food in the proper form in accordance with their physician's orders. The facility census was 95. Review of the facility policy, Types of Diets, dated May 2015, showed the following: -Pureed Diet: This diet is for the edentulous resident and residents with swallowing difficulties; -Foods are blended to mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. Review of the facility's Order Report by Category from 2/18/24 through 3/18/24, printed by staff on 3/18/24, showed two residents had a physician-ordered pureed diet. Review of the Diet Spreadsheet menu for the lunch meal on 3/18/24 showed staff were to serve residents on a pureed diet the following items: -Pureed roasted new potatoes; -Pureed corn O'Brien; -Smooth thick gravy. Observation on 3/18/24 at 10:55 A.M. showed Dietary [NAME] G began to puree the corn. He/She placed an unmeasured amount of corn into the food processor. He/She obtained an unmeasured…

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 staff changed gloves and washed hands as indicated during the provision of care for two residents (Residents #11 and #12 ), in a review of 13 sampled residents and failed to implement a surveillance plan for identifying, tracking and monitoring communicable diseases and outbreaks among residents and staff. The facility failed to ensure staff were tracking and trending residents that were positive for COVID-19 (coronavirus disease, caused by the SARS-CoV-2 virus) and failed to use proper personal protective equipment (PPE) during resident testing. The facility failed to ensure staff wore masks according to facility policy. The facility failed to ensure unvaccinated staff were screened upon entrance to the facility at the beginning of their work shifts, and failed to monitor and track the screenings. The facility failed to ensure staff testing was completed according to the facility policy for COVID-19 during an outbreak. The facility also failed to ensure proper infection control procedures were followed…

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 provide a written notice of discharge with required information to the resident and/or resident representative for one additional resident (Resident #16), in a review of 13 sampled residents, when the facility initiated a transfer to the hospital and denied the resident re-admission to the facility. The facility census was 86. Review of the facility's undated policy Discharge/Transfer of Resident showed the following: -Purpose: To provide safe departure from the facility and to provide sufficient information for aftercare of the resident; -Explain discharge guidelines and reason to resident and give copy of transfer and discharge notice as required, include resident representative; -The attending physician is required to write a discharge order, telephone orders are acceptable; -If transfer, obtain a physician order for transfer unless it is a 911 emergency; -Call ambulance for transfer; -Explain transfer and reason to the resident and/or…

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

Based on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 111. Review of the facility policy, In Room Dining Distribution, dated May 2015, showed at the time of service to the resident, food must be at least 120 degrees Fahrenheit (F). (Inappropriate food temperatures are cause for a deficiency.) 1. During an interview on 10/12/20 at 10:57 A.M., Resident #58 said the food is always delivered cold; this is a consistent problem. During interview on 10/12/20 at 11:00 A.M., Resident #40 said the food was cold most of the time, especially breakfast. During an interview on 10/12/20 at 11:48 A.M., Resident #90 said the food was frequently served cold. During interview on 10/13/20 at 2:00 P.M., Resident #5 said the food frequently did not come to residents warm. During an interview on 10/13/20 at 11:20 A.M., Resident #18 said the food was never hot. Often the food was undercooked or burnt. During an interview on 10/14/20 at 8:46 P.M., Resident #85 said the baked potato for…

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 food items were not stored directly on the floor, failed to label, date, and cover food items, failed to keep trash cans covered when not in use, failed to wear hair restraints in the kitchen, failed to maintain floors to be free of an accumulation of debris, failed to use sanitary practices when handling eating utensils, failed to use sanitary practices when preparing and serving ready to eat food items, failed to ensure food items were not prepared on the steam table, failed to hold food at the proper temperature on the steam table, failed to utilize proper handwashing procedures, failed to maintain a freezer at 0 degrees or colder (to keep food items frozen solid) and failed to ensure the ice machine was properly maintained. The facility census was 111. Review of the facility's policy, Dietary Personnel Guidelines, dated May 2015, showed the following: -Personal Appearance: Employees of the dietary department handle the food that is eaten by everyone. For this reason, be conscious of clean and…

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

Based on observation and interview, the facility failed to ensure garbage dumpsters were covered at all times. The facility census was 111. Observation on 10/12/20 at 10:20 A.M. showed the following: -The facility had two garbage dumpsters located outside the facility; -One of two dumpsters was uncovered and both lids were open; -The open dumpster contained garbage bags of trash and was mostly full. Observation on 10/12/20 at 2:56 P.M. showed the following: -The facility had two garbage dumpsters located outside the facility; -One of two dumpsters was uncovered and both lids were open; -The open dumpster was mostly full and contained garbage bags of trash. Observation on 10/15/20 at 8:15 A.M. showed the following: -One of two dumpsters was uncovered and one of two lids was open; -The open dumpster contained garbage bags and boxes piled high up over the edges of the dumpster; -The lid would not properly close due to the large amount of garbage inside. During an interview on 10/13/20 at 2:10 P.M., the facility's consultant dietician said the dumpster lids should be closed when not in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report to the state survey agency three known incidents of resident to resident sexual abuse as required within two hours of the alleged sexual abuse allegation when staff witnessed resident (Resident #92) on top of a resident (Resident #33) attempting to have sexual intercourse, failed to report the resident groped another resident's breasts and placed his/her hands down the resident's pants. The facility also failed to report multiple staff witnessed incidents of one resident (Resident #51), groping one resident (Resident #33) in a sample of 27 residents and two additionally sampled residents (Resident#70, and #45). Further review showed the facility failed to report an allegation of staff to resident abuse within two hours of the reported allegation to the state survey agency for one resident (Resident #59). The facility certified census was 111. Review of the facility undated facility policy, titled Abuse Prohibition Protocol Manual showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete investigations as the facility policy directed for allegations of abuse, that failed to prevent further abuse involving eight residents (Resident #33, #40, #45, #51, #59, #70, #92, and #109) in a review of 27 sampled residents, for the protection of the residents'. The facility census was 111. Review of the facility undated facility policy, titled Abuse Prohibition Protocol Manual showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. The resident would also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Additionally, resident would be protected from abuse, neglect and harm while they were residing at the facility. No…

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

Based on interview and record review, the facility failed to provide a written notice of transfer with required information to the resident and/or resident representative for one resident (Resident #93) in a review of 27 sampled residents, two additional residents (Residents #114, and #216), and one closed record (Resident #117) when the facility initiated transfer to the hospital. The facility also failed to notify the ombudsman of facility initiated transfer/discharges to the hospital from March through October 2020. The facility census was 111. Review of the facility document Emergency Transfer Notice showed an example of a written letter which read in part: This letter is to serve as your emergency notice of transfer from (facility name) due to your need for urgent medical care which cannot be met in the facility. Federal Regulation states in relevant part that Notice must be made as required by the resident's urgent medical needs. You can receive more information on the discharge process from the State Long Term Care Ombudsman listed below. Example had space for facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform residents and resident representatives of their bed hold policy, or the duration of their bed hold at the time of transfer to the hospital for one resident (Resident #93) in a review of 27 sampled residents, three additional residents (Resident #114 and #216). The facilty census was 111. Review of the facility policy Bed Hold Guidelines, undated, showed: This facility will notify all residents, and /or their representative of the bed hold policy guidelines. This notification shall be given: 1. Upon admission to the facility, 2. At the time of the transfer to the hospital or leave; and 3. At the time of non-covered therapeutic leave. It is strictly voluntary for the resident or resident representative to reserve the room and pay a bed hold. If the resident or resident representative wants to hold the bed, a signed authorization of the Bed Hold Selection Notice must be obtained with each physician approved hospitalization or therapeutic leave 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 observation, interview, and record review, the facility failed to implement, develop, maintain, and update a plan of care consistent with residents' specific condition, needs, and risks for four of 27 sampled residents (Resident #60, #73, #97, and #463) and one additional resident (Resident #13). The facility census was 111. Review of the facility's policy Care Plan Comprehensive, from Nursing Guidelines Manual, March, 2015 showed the following: -An individualized comprehensive care plan that includes measurable goals and time frame will be developed to meet he resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -The IDT is responsible for the…

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

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for five residents (Residents #10, #13, #79, #85, and #302), in a review of 23 sampled residents. The facility failed to administer medications according to physician orders for Residents #10, #13, #79, and #85; failed to follow instructions to rinse Resident #302's mouth following administration of a steroid inhaler; and failed to ensure extended release medication was not broken or crushed prior to administration to Resident #79. The facility census was 95. Record review of the facility's undated policy for personalized medication schedule showed the following: -The facility should support safe and accurate medication administration for residents who elect to choose the time they take their medications and participate in the facility's Personalized Medication Schedule Program (the program); -The medication frequency and administration window: Three times per day (TID) minimum 4 hours apart from 4:00 A.M. to 10:00 P.M.; -The nurse or medication assistant should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility staff provided 14 residents (Resident #4, #18, #26, #43, #52, #56, #58, #69, #73, #80, #90, #93, #97 and #463) of 27 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 111. Review of the facility's policy for ADLs from Nursing Guidelines Manual dated March of 2015 showed no documentation that directed staff when to assist residents with ADLs such as bathing, shaving, oral hygiene, and basic grooming. Review of the facility's policy for bathing (tub/whirlpool) from Nursing Guidelines Manual dated March of 2015 showed the purpose of bathing was to maintain skin integrity, comfort, and cleanliness. Review of the facility policy, Nails, Care of (fingers and toes) dated 3/15 showed the purpose was to provide cleanliness, comfort and prevent the spread of infection. Note: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure four residents ( Resident #13, #43, #56, #110) in a review of 27 sampled residents, who had orders for restorative therapy received therapy as ordered. The facility census was 111. During interview on 10/20/20 at 5:30 P.M. the Director Of Nursing (DON) said the facility did not have a policy for the restorative nursing program, or a policy for prevention of contractures (shortening or hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 1. Review of Resident #43's Face Sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's Functional Maintenance Program, dated 6/26/19, showed the following: - Maintain range of motion and mobility of BUE(bilateral upper extremities) and BLE (bilateral lower extremities); -Sustained stretching of hamstrings and gastrocs 2 sets of 10 holding for 30 seconds each; -Balloon volley or card reaching at various heights; -Three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately assess and reassess the safety and effectiveness of 1/8th length bed rails in use for three residents (Resident #52, #93, and #97) and 1/4 length bed rail for one resident (Resident #56) in a review of 27 sampled residents who had bed rails in place on their beds. The facility census was 111. During interview on 10/20/20 at 5:30 P.M., the Director of Nursing said the facility did not have a side rail policy. Review of the Food and Drug Administration's Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm; -Assessment by the health care team will help to determine how best to keep the patient safe; -Potential risks of bed…

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 MO#00171896, MO#00172103, MO#00173330, MO#00173553, MO#00177333, MO#00177375 Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for 14 residents (Resident #4, #18, #26, #43, #56, #58, #69, #73, #90, #93, #97, #104 #110 and #463), in a review of 27 sampled residents and for one additional resident (Resident #13). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors, failed to respond timely to call lights, and failed to provide restorative therapy when the restorative aide (RA) was pulled to work as a Certified Nurse Aide (CNA) and was unable to complete duties for the restorative therapy nursing program. The facility census was 111. Review of the Facility Assessment, dated January 2020, showed it did not address the number of staff needed to meet resident needs. Review of the Facility Staffing Sheet, undated, showed the following staff needed: -Day shift- 3 licensed or registered nurses, 2…

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 each certified nurse aide (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified 14 CNA's employed by the facility for more than a year. Four CNAs were sampled and four out of four did not have the required 12 hours of in-service education. The facility census was 111. Review of the Facility Assessment, dated January 2020, showed the CNAs, at the least, required the mandated twelve in-service hours per year. 1. Review of CNA X's employee file and training log, showed the following: -Date of hire (DOH) 3/27/19 ; -Did not include evidence of any completed education. 2. Review of CNA E's employee file and training log, showed the following: -DOH 5/29/19; -Did not include evidence of any completed education. 3. Review of CNA F's employee file and training log, showed the following: -DOH 4/4/17 ; -Did not include evidence of any completed education. 4. Review of CNA H's employee file and training log, showed the…

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

Based on observation, interview, and record review, the failed to administer medication with an error rate of less than five percent (%) for one resident (Resident #97) of 27 sampled residents and two additional residents (Resident #102 and #271). There were 27 opportunities for errors with three errors, which resulted in an error rate of 11.11%. The facility census was 111. Review of the facility's policy, Medication Administration from Nursing Guidelines Manual, dated March of 2015 showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Read the label three times before administering medication to the resident: first when comparing the label with the medication sheet, second when setting up the medication, and third when preparing to administer medication to the resident; -Administer medication; -Record the medication given on the medication sheet. 1. Review of Resident #97's Physician Order Sheets (POS), dated October 2020, showed an order for FreshKote 2.7-2%, (a lubricating eye drop for dry eye syndrome) instill 1 drop…

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 staff served the correct portion sizes for residents on regular, mechanical soft, and pureed diets as directed by the dietary spreadsheet for the lunch meal on 10/12/20. The facility census was 111. Review of the facility policy, Dining Services Department, dated May 2015, showed the purpose of the department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of regular, texture altered and/or therapeutic diets in accordance with the attending physician's orders. Review of the facility policy, Food Preparation and Distribution, dated May 2015, showed measured utensils are used to serve proportions as described on menu. 1. During an interview on 10/12/20, at 11:30 A.M., Resident #91 said he/she did not get enough food. He/She said the portion sizes were so small. If he/she ordered the alternate, half the time staff would not give him/her the sides, so he/she just got a sandwich or hot dog for his/her entire…

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

Based on observation, interview, and record review, the facility failed to provide residents with nourishing, well-balanced diet, taking into consideration each resident's preferences. The facility failed to respect each resident's right to make choices about his/her diet and be provided with acceptable alternative choices or substitutions. The facility census was 111. Review of the facility policy, Dining Service, dated May 2015, showed this facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council. Review of the facility policy, Dining Services Department, dated May 2015, showed the following: -The purpose of the department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of regular, texture altered and/or therapeutic diets in accordance with the attending physician's orders; -Consideration is given to the resident's physical, psychological and social…

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 permit entry of hospice providers into the facility to provide direct care for one resident (Resident #52), who was to receive hospice services and did not allow new contracts for provision of hospice care for any other resident considering hospice. The facility census was 111. 1. Observation on 10/12/20, at 10:10 A.M., showed a sign at the facility's designated COVID (Coronavirus Disease 2019 - COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) entrance screening station, that read, Hospice staff is not allowed in the building without approval. During an interview on 10/15/20 at 12:07 P.M., the Director of Nursing (DON) said hospice services were not allowed in the facility due to COVID and the facility was not allowing any new hospice contracts (for additional residents to receive services). There were currently three residents at the facility that were on hospice from before COVID. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic, by not providing a safe environment for residents. The facility failed to maintain a surveillance log monitoring symptoms and testing for residents and staff. The facility also failed to complete a COVID-19 assessment on one resident (Resident #22), who was exhibiting symptoms that were not identified by the facility and subsequently tested positive for COVID-19. The facility also failed to follow transmission based precautions for one resident (Resident #35) and one additional resident (Resident #7) who were exhibiting respiratory symptoms and were tested for COVID-19. The facility failed to perform appropriate hand hygiene after direct resident contact and change gloves during direct resident personal care for three additional residents (Resident #107,…

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 inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Resident #52, #56, #93, and #97) of 27 sampled residents. The facility census was 111. During interview on 10/20/20 at 5:30 P.M., the Director of Nursing said the facility did not have a side rail policy. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and January 1, 2009, 803 incidents of patients caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported 480 died and 138 had non-fatal injuries; -Most patients were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body 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.

Based on interview and record review the facility did not make notification to responsible parties, including next of kin and the primary care physician, for one resident (Resident #13) in a review of 27 sampled residents. The facility census was 111. Review of the facility policy Condition Change, Resident dated 3/15 showed the purpose was to observe, record and report any condition change to the attending physician so that proper treatment can be implemented. Guidelines: After all resident falls, injuries or changes in physical or mental function, monitor. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. Complete an incident, accident or risk management report per facility guidelines. Notify resident's responsible party. Monitor resident's condition frequently until stable. Notify physician of condition change, need for treatment orders and/or medication order changes. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/5/20 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor one resident (Resident #98) in a sample of 27 residents, who the facility identified as wandered and at risk for elopement, who exited the facility without staff knowledge. Another resident heard Resident #98 yelling for help from outside and alerted staff. The resident was found on the ground in a puddle and cold. The facility census was 111. Review of the facility policy Elopement-Missing Resident dated 3/15 showed staff were to determine when resident was last seen and by whom, description of clothing and where they were last seen. Notify all departments and begin a thorough search of the facility and grounds, including bathrooms, closets, storage areas and crawl spaces. Search streets and neighborhood adjacent to the facility. Notify the Director of Nursing and Administrator, attending physician. Notify the responsible party and request notification if resident makes contact with them. If absence exceeds 30 minutes, notify…

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

Based on interview and record review, the facility failed to follow professional standards of practice for one dialysis resident (Resident #13) in a review of three sampled dialysis residents, by not completing and documenting a daily weight as ordered by the physician and failing to properly assess and document the resident's dialysis access site. The facility census was 111. Review of facility policy for care of a resident receiving dialysis from the Nursing Guidelines Manual dated March, 2015 showed the following: -Staff would utilize the following guidelines to provide care for a resident that was receiving dialysis; -Care for the AV shunt/fistula/graft (connection between an artery and a vein that is made for dialysis access) included to feel for the thrill sensation (rumbling sensation that can be felt to determine good blood flow rate) daily, monitor for signs of infection, watch for bleeding after dialysis, and inspection of the access for redness, swelling, or warmth; -At the AV site, feel for a pulse. The pulse is the blood flow through the access; -Nursing staff would…

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

Based on observation, interview, and record review, the facility failed to provide one resident (Resident #10) on a vegetarian diet (regular with no meat) with nourishing and palatable food items in accordance with the spreadsheet menu. The facility census was 111. Review of the facility's policy, Dining Service, dated May 2015, showed this facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council. Review of the facility's policy, Dining Services Department, dated May 2015, showed the following: -The purpose of the department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of regular, texture altered and/or therapeutic diets in accordance with the attending physician's orders; -Consideration is given to the resident's physical, psychological and social needs. Recognition is also given to the resident's individual eating habits, which are sometimes influenced…

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 housekeeping and maintenance services were provided to maintain a clean and comfortable environment for residents. The facility census was 107. 1. Observation on 01/07/19 from 10:00 A.M. through 2:15 P.M. showed the following: -The main dining area had a persistent urine odor; -A round ceiling vent, in shower room [ROOM NUMBER] by the front nurse's station, had a heavy buildup of a black mold-like substance. A 4 inch by 6 inch ceiling vent was covered in a thick layer of dust; -A round ceiling vent in the 300 hall dirty utility room was covered with a black mold-like substance; -room [ROOM NUMBER] had a strong urine odor (no residents were in the room at the time of the observation); -room [ROOM NUMBER] had a strong feces smell (no residents were in the room at the time of the observation); -The bathroom light in room [ROOM NUMBER] did not turn on. Observation on 01/08/19 from 7:34 A.M. through 12:00 P.M. showed the following: -The ceiling vent in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a grievance policy and procedure that included all required components; failed to act promptly upon the grievances identified by the resident council; failed to provide the members of the resident council with responses, actions and rationale taken regarding their concerns; and failed to document and communicate their response to formal written grievances submitted by two residents (Resident #2 and #87), in a review of 23 sampled residents. The facility census was 107. 1. Review of the facility's policy Resident Grievances, dated April 2006, showed the following: -A complaint must be in writing and contain the name and address of the person filing it; -The Section 504 Coordinator (or designee) shall conduct an investigation of the complaint to determine validity. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504…

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 provision of necessary care and services to maintain good personal hygiene, prevent body odor, oral (mouth) care and showers for seven of 23 sampled residents (Residents #4, #5, #50, #58, #60, #63 and #100), who were unable to perform their own activities of daily living. The facility census was 107. 1. Review of the facility's Perineal Care policy from the Nursing Guidelines Manual, dated March 2015, showed the following: -Purpose: To cleanse the perineum and prevent infection and odor; -For female perineal care: Wet a washcloth and make a mitt with it. Apply soap lightly. Use one gloved hand to stabilize and separate the labia, with the other hand wash front to back. Rinse and pat dry; -For male perineal care: Follow the above instructions for female perineal care but instead wash the pubis and penis. If uncircumcised, pull back foreskin of penis and wash. Carefully dry and return foreskin to normal position. Make sure the shaft…

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 turn and reposition two residents (Residents #5 and #60), who were at risk for developing pressure ulcers; failed to provide care, consistent with professional standards of practice, to a promote healing and prevent infection for one resident with a pressure ulcer (Resident #5); and failed to report newly identified pressure ulcers and obtain treatment orders for one resident (Resident #40), in a review of 23 sampled residents. The facility census was 107. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009 showed the following: -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In…

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 consistently implement and modify interventions as necessary, in accordance with current standards of practice, to reduce the risk of falls for three residents (Residents #4, #5, and #47), who had a history of falls. Facility staff failed to use appropriate transfer technique with a gait belt during a transfer for one resident (Resident #60), in a review of 23 sampled residents. The facility census was 107. 1. Review of the facility's Fall Prevention Policy, dated June 2006, showed the following: -A resident fall occurs when the resident unexpectedly or in an unplanned manner sustains bodily contact with the floor. A fall may occur during transfers assisted by nursing personnel who are unable to maintain control of the transfer, therefore slipping the resident to the floor; -When a resident is found on the floor and there is no witness to the event, it must be assumed that the resident fell; -If a resident is determined to be at ongoing…

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 serve food at a safe and appetizing temperature. The facility census was 107. 1. During an interview on 1/7/19 at 5:26 P.M., Resident #49 said he/she ate all meals in his/her room. The meals were always cold when he/she received the meal tray. The resident did not want to eat cold food and would sometimes not eat due to the cold temperature of the food making it unappetizing. During an interview on 1/8/19 at 7:55 A.M., Resident #24 said the food in the facility was often served cold. He/she ate meals in the dining room. The resident said sometimes he/she would order a salad to avoid being served cold foods that should be served hot. 2. Observations on 1/7/19 at 01:27 P.M. of the test tray provided after the last resident was served showed the temperature of the meatloaf was 114 degrees Fahrenheit (F), and the temperature of the spinach was 116 degrees F. All temperatures were taken with a calibrated, analog, metal stem-type thermometer. Observations on 1/8/19 at 01:35 P.M. of the test tray provided by 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 interview and record review, the facility failed to offer residents a daily bedtime snack. Three of nine residents (Resident #17, #65, and #84) participating in group interview and three additional residents (Resident #30, #58 and #722) reported snacks were not offered on a routine basis at the facility. The census was 107. 1. Review of the facility's policy Bedtime Snacks, dated March 2015, showed the following: -Purpose: Offer/provide all residents a snack at bedtime as desired; -The dietary department will provide snacks for all residents according to the menu; -The snack cart will be delivered to the nurse's station prior to closing the kitchen; -An aide on the evening shift will be assigned to pass the hydration cart and snacks at bedtime; -The aide assigned will take the hydration cart to each resident room and offer each resident a snack and a drink from the cart; -At the end of the snack/hydration pass, the cart will be returned to the kitchen. 2. During the group interview on 1/8/19 at 3:00 P.M., residents said following: -Resident #17 said staff put snacks at the…

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

Based on observation, interview, and record review, the facility failed to ensure staff washed their hands when indicated by professional standards of practice during personal care for three residents (Residents #5, #40 and #60 ), in a review of 23 sampled residents. The facility staff failed to ensure infection control measures were appropriately followed when obtaining blood samples to test blood sugar levels and failed to properly sanitize the glucometer (a device that is used to evaluate blood glucose levels), between use for two residents (Residents #24 and #84). The facility census was 107. 1. Review of the facility's policy on gloves from the Nursing Guidelines Manual, dated March 2015, showed the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and or persons with a rash. Gloves must be changed between residents and between contacts with different…

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 the corridor was equipped with firmly secured handrails on each side of the hall. The facility census was 107. Observation on 01/07/19 from 10:00 A.M. through 2:30 P.M., during the life safety code tour of the facility, showed the following: -The handrail by the medical records office was loose, causing the handrail to move back and forth; -Two handrails by the back nurse's station were loose; -The handrail by the assistant director of nursing's office was loose, causing the handrail to move back and forth; -The handrail by room [ROOM NUMBER] was loose, causing the handrail to move back and forth. Observation on 01/08/19 from 7:34 A.M. through 12:00 P.M., during the life safety code tour of the facility, showed the following: -The handrail by the laundry area was loose, causing the handrail to move back and forth; -The handrails on both sides of room [ROOM NUMBER] were loose, causing the handrail to move back and forth; -The handrail by room [ROOM…

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 administer insulin according to the manufacturer's recommendations for three different types of insulin pens, for two residents (Residents #24 and #84 ), in a review of 23 sampled residents. The failure had the potential to result in residents not receiving their full dose of ordered insulin. The facility census was 107. 1. Review of the manufacturer's instructions for use for the Novolog (insulin) FlexPen (injection cartridge device) showed the following: -Before each injection, small amounts of air may collect in the cartridge during normal use; -To avoid injection air and to ensure proper dosing, turn the dose selector to two units; -Hold the Novolog FlexPen with the needle pointing up; -Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards and press the push button all the way in; -A drop of insulin should appear at the needle tip, if not, change the needle and repeat the procedure no more than six times; -If…

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

Based on observation, interview, and record review, the facility failed to provide meals in accordance with one resident's (Resident #208) preferences. The facility census was 107. 1. Review of the facility diet orders, dated 1/7/19, showed Resident #208 had a physician's order for a regular vegan diet (a diet consisting of all plant based foods; consuming no animal or animal byproducts including egg or dairy). Review of the posted facility menu showed the meal for 1/7/19 was meatloaf, gravy, baked potato, buttered spinach, and a dinner roll. No vegan substitute was posted. Review of the facility spreadsheet for 1/7/19 showed residents on a vegan diet were to receive one cup of vegetable chili. Observations on 1/7/19 between 12:56 P.M. and 1:25 P.M. during meal service showed staff served Resident #208 a grilled cheese sandwich. During interview on 1/7/19 at 1:40 P.M., the dietary supervisor said residents on a vegan diet can have a grilled cheese or a salad with egg on it as a meal and protein substitute. During interview on 1/8/19 at 1:55 P.M., Dietary B said staff does not…

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