Baptist Homes, Tri-County

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate infection control practices for six residents (Resident #59, #47, #1, #2, #9 and #36), in a review of 19 sampled residents, and for four additional residents (Residents #46, #60, #48 and #44). Facility staff failed to change gloves or perform appropriate hand hygiene during personal care and assistance with eating for Residents #59, #46, #47 and #60, failed to properly clean a multi-use glucometer (device used to obtain a blood sugar reading after obtaining a drop of blood from the resident that is then placed on a test strip and placed in the device), failed to maintain infection control when a barrier was not used during blood glucose checks for Residents #1, #2, #48 and #44, failed to maintain catheter bags and tubing to prevent infection for Resident #9, and failed to properly clean and store a nebulizer mask for Resident #36. The facility failed to develop written policies and procedures as required to outline 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 have an adequate audible system for residents to signal nursing staff for assistance and failed to ensure staff responded to call lights timely for two residents (Resident #19 and Resident #2) in a review of 19 sampled residents and two additional residents (Resident #39 and Resident #32). The facility census was 58. Review of the facility policy titled Resident Call System dated [DATE] showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation;-Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor;-Call system communication may be audible or visual. The system may be wired or wireless;-The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level 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.

Based on observation, interview, and record review, the facility failed to adequately address strong and pervasive urine odor at its source. The facility census was 58. No policy regarding addressing odors was received from the facility upon request. 1. Observation on 03/02/26 at 11:50 A.M. showed the following: A strong, urine odor in the hallway outside of Resident #28's room and adjoining resident rooms on the hall; -Resident #28's door was partially open; -The resident appeared to be sleeping and lay on his/her bed, unclothed, with his/her private area covered by a towel;-The fitted sheet beneath the resident had a dark, circular ring just beneath the resident's buttocks that appeared wet. Observation on 03/02/26 at 4:15 P.M. showed the following: -A strong urine odor noted in the hallway outside of the resident's room, and adjoining resident rooms in the hall; -The resident's door was partially open; -The resident sat on the side of his/her bed; -The fitted sheet beneath the resident had a dark, circular ring just beneath the resident's buttocks that appeared wet; -A partially…

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 monitor the drug regimen for unnecessary medications by not ensuring the as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #19 and #14), in a review of 19 sampled residents. The facility census was 58. Review of the facility policy, Antipsychotic Medication Usage, dated July 2022, showed the following:-Residents will not receive medications that are not clinically indicated to treat a specific condition;-Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review;-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness 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 develop a comprehensive care plan that included services to maintain the residents' highest practicable physical, mental, and psychosocial well-being, when the facility failed to include skin breakdown and pressure ulcers for one resident (Resident #9), and the use of a nebulizer due to chronic health conditions for one resident (Resident #36), in a review of 19 sampled residents. The facility census was 58.Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;-The comprehensive, person-centered care plan is developed within seven (7) days of the…

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

Based on observation, interview and record review, the facility failed to ensure staff transferred one resident (Resident #59), in a review of 19 sampled residents, using appropriate technique, consistent with the resident's abilities and condition, to ensure the resident's safety. The facility census was 58. Review of the facility policy, Safe Lifting and Movement of Residents, revised July 2017, showed the following:-In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents;-Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Manual lifting of residents shall be eliminated when feasible;-Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include 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 complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews for two Certified Nurse Aides (CNA F and CNA G), in a review of two CNA employee files. The facility census was 58. Review of the Facility Assessment, revised 04/01/2025, showed the following:-The facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for the resident population;-Required in-service training for nurse aides. In-service training must:-Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. 1.Review of Certified Nurse Aide (CNA) F's employee file showed the following:-Date of hire: 09/26/24;-No documentation of nurse aide evaluation/competencies or annual performance review. 2. Review of CNA G's employee filed 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 ensure the physician provided his/her rationale for not making a medication change as recommended by the pharmacist during the monthly drug regimen review for one resident (Resident #9), in a review of 19 sampled residents. The facility census was 58.Review of the facility policy, Antipsychotic Medication Use, revised July 2022, showed the following:-All antipsychotic medications will be used within the clinically recommended dosage guidelines or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours;-The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of the facility policy, Psychotropic Medication Use, revised July 2022, showed the following:-Residents on psychotropic medications…

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 sufficient nursing staff to meet the needs of two residents (Resident #2 and #8) in a review of nine residents when staff failed to provide incontinence care timely and maintain good personal hygiene and failed to ensure resident clinical assessments were completed and documented for Resident #2. The facility failed to provide sufficient staff on the memory care unit to ensure supervision of Resident #8. The facility also and failed to consistently have Certified Nurse Assistant (CNA) staff as identified in the facility assessment. The facility census was 54. Review of the facility policy Staffing, Sufficient and Competent Nursing, dated 8/2022 showed the following: -The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses 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, interview, and record review, the facility failed to ensure one resident (Resident #2), who staff identified as incontinent and required staff assistance with toileting and incontinence care, in a review of nine residents, was provided incontinence care timely and maintained good personal hygiene. The facility census was 54. Review of the facility policy, Urinary Continence and Incontinence, Assessment and Management, dated 8/2022 showed the following: -As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence; -Staff will check the resident for incontinence and change the resident at regular intervals using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24 showed the following: -Severely impaired cognition; -Frequently incontinent of urine; -Always incontinent of bowel;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) in a review of nine residents, was provided treatment and care in accordance with professional standards of practice when staff failed to assess the resident's clinical condition, failed to ensure a heart monitor was in place and functioning as ordered by the physician, failed to ensure the resident received therapy services following a hospitalization, and failed to ensure the resident's Care Plan was up to date and reflected the resident's current condition and care needs. The facility census was 54. Review of the facility policy admission Notes, dated 9/2012, showed the following: -Preliminary resident information shall be documented upon a resident's admission to the facility; -When a resident is admitted to the nursing unit, the admitting nurse must document the following information in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol; -The date 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 ensure infection control measures were followed when staff failed to utilize proper handwashing and gloving techniques while providing wound care and failed to utilize Enhanced Barrier Precautions (EBP, an infection control intervention that utilizes personal protective equipment to reduce the spread of multi drug-resistant organisms) during wound care for two residents (Resident #3 and #7) in a review of nine residents. The facility census was 54. Review of the facility policy, Handwashing/Hand hygiene, dated 8/2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors;…

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 sanitation and food storage practices were maintained in the main facility kitchen and the activity kitchen. The facility census was 47. Review of the facility policy, Food Storage (Dry, Refrigerated and Frozen), dated 2020, showed the following: -Food shall be stored on shelves in a clean, dry area free from contaminants; -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Store raw animal products such as eggs, meat, poultry, and fish separately from cooked and ready to eat food; -Raw animal foods such as eggs, meat, poultry and fish should be stored in drip proof containers. Review of the facility policy, Labeling and Dating…

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 maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 41 residents. The facility census was 47. 1. Record review of the facility maintained bank statements for months 01/2023 through 12/2023 showed no documentation of reconciliations. Record review of the facility maintained reconciliation forms, dated 01/2023 through 12/2023, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. During an interview on 02/07/24 at 9:50 A.M., the Business Office Manager said there was no Business Office Manager in the beginning of 2023 and he/she was only told to reconcile to the bank statement. He/She was not told to reconcile to the residents' current balance.

Based on interview and record review, the facility failed to complete required pre-employment screenings for three of seven sampled employees hired since the previous survey. The facility failed to request a criminal background check for three employees and complete an Employee Disqualification List (EDL) check for one employee, prior to hire. The facility census was 47. Review of the facility policy, Background Screening Investigations, revised March 2019, showed the following: - For purposes of this policy ''direct access employee'' means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. -The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access…

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 and residents on a dental soft (mechanical soft) diet received food in the proper form in accordance with their physician's orders. The facility census was 47. Review of the facility policy, Pureed Diet, dated 2022, showed the following: -The pureed diet is designed for individuals who cannot chew foods of the dental soft (mechanical soft) consistency and/or difficulty swallowing; -All foods are prepared in a food processor or blender, with the exception of those foods which are normally in a soft, moist and smooth state; -Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve the appropriate consistency (puddings, smooth mashed potatoes); -Process hot or cold items until they are smooth and homogenous in texture; -Add measured amounts of hot liquid for cooked foods and cold liquid (if required) for cold foods and process until a smooth consistency is achieved; -Scrape down sides and reprocess until very smooth like pudding; -Top…

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 procedures were implemented to address prevention of Tuberculosis (TB) for four staff members in a review of seven sampled employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. The facility census was 47. Review of the facility's policy, Employee Screening for Tuberculosis, revised March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; -Screening includes a baseline test for LTBI using either a TST or IGRA, individual risk assessment and symptom evaluation; -The employee health coordinator (or designee) will accept documented…

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 inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Residents #32, #33 and #15), in a review of 12 sampled residents, and for one additional resident (Resident #5). The facility census was 47. Review of the undated facility policy, Bed Safety and Bed Rails, showed the following: -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the Food and Drug Administration (FDA). -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. -The maintenance department provides a copy 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 record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for four residents (Resident #35, #39, #100 and #101). The facility census was 47. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 02/08/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #35 $1,455.70 #39 $2,540.75 #100 $92.40 #101 $57.60 Total $4,146.45 During email correspondence on 02/09/24 at 9:59 A.M., the Business Office Manager said he/she did not realize there could be no resident credits in the operating account.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, after two residents (Resident #1 and #39), in a review of 12 sampled residents, were admitted to hospice. The census was 47. Review of the facility's Change in a Resident's Condition or Status Operational Policy, revised February 2021, showed a significant change in condition is a major decline or improvement in the resident's status that: -a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); -limpets more than one area of the resident's health status; -creatures interdisciplinary review and/or revision to the care plan; and -d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Review of the Long-Term Care Facility Resident Assessment Instrument…

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 plan of care consistent with resident's specific conditions, needs, and risks for two residents (Residents #39 and #40), in a review of 12 sampled residents. The facility census was 47. Review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised [DATE], showed the following: -The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, 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.

Based on observation, interview, and record review, the facility failed to administer medications through a gastrostomy tube (g-tube; a tube placed through the abdomen directly into the stomach for nutrition and medications) in accordance with facility policy for one resident (Resident #3), in a review of 12 sampled residents. The census was 47. Review of the facility policy, A Stepwise Approach: Selecting Medications for Feeding Tube Administration, dated 2020, showed giving medications through an enteral feeding tube can be complicated. Clogging can be a major complication with feeding tubes. Inappropriate medication administration and inadequate flushing can lead to clogging. Generally, do NOT mix medications with tube feedings, mix medications together, or give multiple medications at the same time. Always flush tube before and after the administration of a medication with at least 15 to 30 milliliters (ml) of water. 1. Review of Resident #3's care plan, dated 11/23/23, showed the following: -Nothing by mouth (NPO), g-tube use; -Give fluids as ordered via tube; -Administer…

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 follow physician's orders and ensure one resident (Resident #11), in a review of 12 sampled residents, was free from a significant medication error, when staff failed to discontinue a medication for 34 days after the resident's physician ordered to discontinue the medication. The facility also failed to properly transcribe the physician's orders received upon the resident's readmission to the facility from the hospital to show the previously discontinued medication was to be given as needed (PRN). Staff administered the medication as scheduled and not PRN. The facility census was 47. Review of the facility policy for administering medications, last revised April 2019, showed the following: -Medications were administered in a safe and timely manner, and as prescribed; -The director of nursing services supervised and directed all personnel who administered medications and/or have related functions; -Medications were administered in accordance with…

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

Based on interview and record review, the facility failed to provide/designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis, and provide an RN eight consecutive hours a day, seven days a week. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Nursing services are provided 24 hours a day, seven days a week; -At least one registered nurse (RN) is on duty eight hours a day, seven day a week. (Due to recent staffing shortages, if a RN is unavailable for eight hours a day, seven days a week, a licensed practical nurse (LPN) will be utilized); -When staffing falls below normal numbers, attempts will be made to call in help; -Nursing staff will be scheduled extended shifts and not be allowed to leave their unit until the proper personnel relief including: RN's -All contracted nursing agencies will be notified; -If unavailable, nursing administration will be called to provide coverage and to assure safe levels of care and adherence to state requirements. 1. Review of the RN/LPN/CMT schedule,…

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 implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 55. Observations in the kitchen on 2/15/22 between 10:30 A.M. and 2:00 P.M. showed the following: -The four-plex outlet, located above the food preparation table by the food processor, was soiled with food debris; -Brown debris was splattered along the wall above this food preparation table, behind the food processor, blender and wall-mounted knife rack; -Dusty and black debris on the vent cover for the ceiling mounted HVAC units throughout the kitchen; -A buildup of black debris on the fan cover and inside the fan in the reach-in double refrigerator unit; -Black mold-like debris on the wall, metal conduits, and floor under the dishwashing counter in the dishwashing room; -The wall in the dishwashing room next to the sink with the sprayer was pealing and not cleanable. An area approximately 12 inches by 3 inches 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 and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to ensure facility staff washed their hands after each direct resident contact when indicated by professional standards for one resident (Resident #207) in a sample of 19 residents and one additional resident (Resident #1). The facility also failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for six employees, in a review of ten sampled employees hired since the previous survey. The facility census was 55. Review of the facility's undated policy,Tuberculosis Testings, showed the…

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

Based on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure staff carried functioning pagers to alert them to residents' calls for staff assistance. The facility census was 55. Review of the facility policy, Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -The system will allow each charge nurse or Special Care Unit (SCU) supervisor to carry beepers with them while on duty during their shift; -The beepers will alert the charge nurse immediately when assistance is needed; -Computer monitors are also displayed at each nurse's station as well on the East and [NAME] halls for a visual alert for CNAs to see, in order to know which room has called…

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 care in a manner that enhanced resident dignity for three residents (Residents #43, #28, and #41), in a review of 19 sampled residents. Facility staff also failed to cover two residents' (Resident #2 and #30) urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bags with a dignity/privacy cover. The facility census was 55. Review of the undated facility policy, Residents Rights Policy, showed the following: -These resident rights ensure that at least, each resident admitted to this facility is/has: -Fully informed, as evidenced by the resident's written acknowledgement, prior to or at this time of admission and during stay, of these rights and of all rules and regulations governing residents conduct and responsibilities; -Treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care for his/her personal needs; -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 provide reasonable accommodations of needs for two residents (Resident #41 and Resident #45), in a review of nineteen sampled residents, when Residents #41 and #45 yelled out for assistance periodically throughout the day because they did not have access to a call light. The facility census was 55. Review of the facility's Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -No evidence to show the facility ensures that the staff are educated on the use of the call lights and correct placement of call lights for each resident. 1. Review of Resident #41's face sheet…

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, facility staff failed to ensure resident funds were placed in an account separate from the facility operating account and did not allow the residents/guardian the right to manage his/her financial affairs. The facility did not provide residents access to their funds as soon as possible for 20 residents (Resident #17, #29, #34, #47, #50, #200, #201, #202, #205, #206, #208, #209, #210, #211, #212, #213, #214, #215, #217 and #218). The facility also failed to ensure negative balances were not maintained for one deceased resident (Resident #229). The facility refunded more funds to the resident's responsible party than the resident maintained in the resident trust fund at the time of death, which resulted in refunding funds that belonged to other residents. The facility census was 55. 1. Record review of the facility's maintained Resident Accounts Receivable Aging Report for the period 02/01/21 through 02/28/22, dated 02/28/22, showed the following residents with personal funds held in the facility operating account: Resident Amount Held 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.

Based on record review and interview, the facility failed to reconcile the resident trust fund bank balance and resident petty cash with the current balance of the resident trust fund ledgers. In addition, the facility failed to provide quarterly financial statements to one resident (Resident #21). The facility census was 55. 1. Review of the facility's reconciliation, dated January 2021, showed the reconciled balance (bank statement balance minus the outstanding deposits and withdrawals) was $30,310.76. Review showed no evidence the facility included the resident petty cash balance maintained in the facility in the monthly reconciliation. Review of the Resident Trust Fund Current Balance Report (report with each resident's account balance including funds in the checking account and resident petty cash), dated 1/31/21, showed the total balance in the resident trust fund was $30,173.45. (The facility failed to reconcile the bank statements and petty cash to the resident's trust fund ledgers to ensure the ending balances were equal. The facility's bank balance (without petty cash…

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 notify the resident or his/her designee when the resident's account reached $200 less than the Supplemental Security Income resource limit of $5,000 (prior to [DATE] or $5,035 after [DATE]), for three residents (Residents #18, #226, and #227) who received Medicaid Benefit. The facility failed to refund resident funds within 30 days of discharge for four residents (Residents #55, #61, #219, and #225). The facility failed to provide a final accounting of resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for seven residents (Residents #202, #217, #220, #221, #222, #223, and #224). The facility census was 55. 1. Review of the facility's Resident Trust Fund Current Balance Reports showed the following for Resident #226: -The resident's primary pay source was Medicaid; -On [DATE], the resident's balance was $5,338.53; -On [DATE], the resident's balance was $5,405.42; -On [DATE], 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 maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) to ensure protection of the resident funds. The facility census was 55. Record review of the facility's resident trust fund reconciled bank statement for the period of January 2021 through December 2021 showed an average monthly balance of $42,709.45. Calculation showed the facility required a bond amount of at least amount $64,500.00. (The facility was unable to provide a monthly accounting of the money maintained in the resident petty cash to include in the calculation.) Record review of the facility's current surety bond showed the facility held a bond in the amount of $20,000.00. During an interview on 3/18/22 at 2:00 P.M., the Accounts Payable Staff said the individual in his/her position prior to his/her employment was responsible for ensuring the surety bond was sufficient, however he/she was not made aware if this was his/her responsibility. He/She had not evaluated 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 provide a clean, comfortable and odor free environment by failing to ensure flooring and walls in resident rooms, furnishings, hallways, ceiling vents, and common areas were clean and in good repair. The facility census was 55. Review of the facility policy, Homelike Environment, revised February 2021, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary, and orderly environment; b. inviting colors and decor; c. personalized furniture and room arrangements; d. clean bed and bath linens that are in good condition; e. pleasant, neutral scents. 1. Observation on 02/14/22 between 10:05 A.M. and 4:45 P.M., during the life…

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 transfer to the resident and/or the resident representative when four residents (Resident #2, #28, #42 and #48), in a review of 19 sampled residents, were transferred to the hospital. The facility census was 55. 1. During an interview on 2/16/22 at 4:25 P.M., the administrator said the facility did not have a policy regarding discharge notices for facility-initiated discharges. 2. Review of Resident #2's face sheet showed his/her admission to the facility on 1/13/21. Review of the resident's nurses notes, dated 1/11/22, showed the following: -The resident was being assisted by staff to stand and pull up his/her pants when he/she went limp, eyes rolled back in his/her head, and he/she stopped breathing; -Staff administered sternal rub and the resident started breathing again; -Upon assessment, breathing found to be labored with accessory muscle use; -Orders received to sent to the hospital via ambulance. Review of the…

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

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 bed hold with required information to the resident and/or resident representative for four residents (Resident #2, #28, #42, and #48) in a review of 19 sampled residents, when the facility initiated a transfer to the hospital. The facility census was 55. Review of the undated facility policy Bed Hold showed the following: -If facility beds are 95% occupied, there will be a bed hold charge and the resident will be billed the daily rate to reserve the same bed; -If occupancy is under 95% there will be no charge to hold the bed and it will be available when the resident returns; -All residents regardless of pay source will be treated equally. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's census report showed the following: -On 1/11/22 the resident was transferred to the hospital and was readmitted to the facility on [DATE]; -On 1/26/22 the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete comprehensive assessments timely for one resident (Resident #207) in a review of 19 sampled residents and for three additional residents (Residents #306, #208, and #355). The facility census was 55. Review of the facility policy, Comprehensive Assessments and the Care Delivery Process, revised December 2016, showed the following: -Comprehensive assessments will be conducted to assist in developing person-centered care plans; -Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions; -Comprehensive assessments are conducted and coordinated by a registered nurse (RN) with appropriate participation of other health professionals; -These assessments are used to develop, review, and revise the resident's comprehensive care plan. Review of the Centers for Medicare and Medicaid Services…

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 a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for three residents (Residents #11, #43 and #48), in a review of 19 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 55. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Shows consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes…

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 develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks to provide effective person-centered care that met professional standards of quality care, within 48 hours of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents, one closed record review (Resident #55), and one additional resident (Resident #208). The facility census was 55. Review of the facility's Baseline Care Plan Policy, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician…

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 update interventions in the resident's care plan to reflect current care needs for three residents (Resident #2, #28, and #41), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; 3-The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility staff provided bathing and hygiene needs for six residents (Residents #6, #28, #37, #41, #43, #44), in a review of 19 sampled residents who were unable to perform their own activities of daily living (ADL's). The facility census was 55. Review of the undated facility policy, Routine Resident Care/ADL's, showed the following: -Routine care rendered by all nursing staff includes attention to physical, emotional, social, spiritual, and life style preferences according to individual job descriptions; -Residents are given routine daily care by a certified nursing assistant (CNA) under the supervision of a licensed nurse; -Routine care by a nursing assistant includes the following: a. Assisting resident in personal care, bathing, dressing, eating, and encouraging participation in physical, social, and recreational activities; c. Observing and recording all aspects of personal care including bathing, food intake, ambulation…

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 staff failed to design and provide an activity program to meet the needs, interests, physical, mental, and psychosocial well-being for five residents (Residents #6, #11, #28, #43 and #48) in a review of 19 sampled residents. The facility census was 55. 1. Review of the Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, Chapter 3, revised October 2019, showed the following: -Most residents capable of communicating can answer questions about what they like; -Obtaining information about preferences directly from the resident, sometimes called hearing the resident's voice, is the most reliable and accurate way of identifying preferences; -If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences; -Quality of life can be greatly enhanced when care respects 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 provide restorative nursing services to assist three residents (Resident #41, #43, and #48), in a review of 19 sampled residents and one additional resident (Resident #21) in attaining or maintaining their highest level of functioning. The facility failed to prevent the development of limited range of motion for residents who were not admitted with a limited range of motion, or prevent further worsening of limited range of motion or development/worsening of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative plans with goals, frequency of task, number of repetitions, or length of time, or direction to staff to meet the resident's needs. The facility census was 55. Review of the facility policy, Restorative Nursing Services, revised July 2017, showed the following: -Residents will receive restorative nursing care as…

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 bed rails in use for 11 residents (Residents #2, #207, #28, #11, #18, #48, #45, #47, #41, #43, and #6), in a review of 19 sampled residents. The facility census was 55. Review of the undated facility policy, Restraint Use and Use of Assist Handles, showed the following: -The need of each resident for restraint use is assessed on admission, quarterly (during care plan reviews), and as needed; -The Device Decision Guide will be used to determine whether or not a device is a restraint and if it should be used; -If it is determined not to be a restraint, it will be care planned for its purpose; -A side rail form should also be completed each time any change in side rail use is made; -A physician order will be signed for use of one or two assist handles on a resident bed; -When a need for an assist handle arises, instruct the resident as to their purpose and correct use; -Inform…

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 sufficient nursing staff to meet residents' needs for two residents (Resident #28, and #43) in a review of 19 sampled residents and three additional residents (Resident #14, #21 and #54). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors and failed to respond timely to call lights. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Consideration is given to the patients' and resident's needs when the composition of the nursing staff is determined; -Nursing services are provided 24 hours a day, seven days a week; -Sufficient personnel are assigned and on duty to assure safe, effective nursing care, including relief personnel during vacations, holidays, emergencies, and sick leaves; -Time schedules indicated the number of and classification of nursing personnel are developed; -These schedules are maintained and posted for each unit…

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 adequately document appropriate diagnoses/behaviors to justify the implementation or continued used of antipsychotic medications for two residents with a diagnosis of dementia (Residents #28 and #42), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy Antipsychotic Medication Use, revised December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the…

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

Based on observation, interview, and record review the facility failed to remove and destroy expired medications for four residents (Residents #35, #36, #41 and #46) in a review of 19 sampled residents. The facility also failed to destroy expired stock supply of over the counter medications. The facility census was 55. Review of the facility policy, Storage of Medications, revised April 2007, showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, container or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed; -Medications…

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 three staff members (Feed Aide/Activity Aide BB, Feed Aide CC and Feed Aide DD) had successfully completed a State-approved training program for feeding assistants and failed to ensure these staff members were not providing feeding assistance to five residents (Residents #11, #18, #28, #44, and #48) in a sample of 19 residents with complicated feeding problems. The facility census was 55. Review of the undated facility policy, Paid Feeding Assistant, showed the following: -The regulation requires that paid feeding assistants must work under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN), and they must call the supervisory nurse in case of emergency; -Therefore, a facility that has received a waiver and does not have either an RN or LPN available in the building cannot use paid feeding assistants during those times; Interdisciplinary Team (IDT) Assessment of Resident Eligibility for Feeding Assistance:…

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 notify one resident's (Resident #500's) responsible party after the resident fell and re-opened a skin tear requiring treatment. The resident's responsible party learned of the resident's fall from another resident when he/she visited the facility. The facility census was 56. Review of the undated facility policy titled, Accident/Incident Event Report, showed the following: PROCEDURES: 1. Notify family; 8. The family should be notified immediately. Review of the facility policy titled, Assessing Falls and Their Causes, revised October 2010, showed the following: -Steps in the Procedure: -After a Fall: 4. Nursing staff will notify the resident's family in an appropriate time frame; -Reporting: 1. Notify the following individuals when a resident falls: a. The resident's family. 1. Review of Resident #500's admission Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 4/13/22, showed the following: -Mild cognitive impairment; -Required extensive assistance of two staff for 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.

Based on interview and record review, the facility failed to ensure all staff who worked in the facility did not have a finding (Federal indicator) entered into the State certified nurse aide (CNA) registry concerning abuse, neglect, or misappropriation of property. Licensed Practical Nurse (LPN) PP, began work in the facility on 12/22/19 and had a Federal indicator preventing him/her from working in the facility. The facility failed to identify the LPN had a federal indicator. The facility census was 56. Review of the facility's undated Abuse Prevention Plan, showed the facility will not hire or maintain employment with a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities. This facility will not employ or otherwise engage individuals who: -Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by court of law; -Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their…

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 develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care within 21 days of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents and three additional residents (Resident #306, #355, and #208). The facility census was 55. Review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, showed the following: -The facility's Care Planning/Interdisciplinary Team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. Review of the Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual,…

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 physician orders for one resident (Resident #500), who had orders for lab work (blood and urine testing), out of seven sampled residents. The facility census was 56. 1. Review of Resident #500's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/13/22, showed the following: -Date of admission 4/6/22; -Brief Interview for Mental Status (BIMS) (brief screener that aids in detecting cognitive impairment) of 14 (BIMS scores range from 0-15, the higher the score, the lower the impairment to the cognitive response); -No problems recalling three words; -Could recall the year; -Could recall the week; -Missed the month by six days to one month; -Resident was usually understood; -Resident understands others; -Always continent of bowel and bladder; -Rejection of cares one to three days out of the last seven. Review of the resident's discharge MDS, completed by facility staff, dated 6/1/22, showed the following: -Date of discharge 6/1/22; -BIMS score decreased to…

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

Based on interview and record review, the facility failed to develop a policy and procedure based on current standards of practice, to address the care of residents receiving dialysis services. The facility failed to consistently monitor the dialysis access site (fistula) according to the resident's physician's orders, and failed to complete post dialysis assessments to ensure no significant changes in the resident's condition following dialysis treatments for one resident (Resident #4), in a review of 19 sampled residents. The facility census was 55. Review of Nursing Management: The Journal of Excellence in Nursing Leadership, October 2010, Volume 41, Issue 10, Caring for a Patient's Vascular Access for Hemodialysis showed the following: -A patient in end-stage kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. For the most effective hemodialysis, the patient needs good vascular access with an arteriovenous (AV) fistula or an AV graft (access used to artificially connect a vein with an artery, so that a higher blood…

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 implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program when the facility did not have a director of nursing and no other nursing staff or nursing administration attended any QA/QAPI meetings. The facility census was 55. Review of the facility's undated Quality Assurance Process Improvement QAPI Program policy showed the following: Purpose: -To provide ongoing and comprehensive procedures that will guide the facility in monitoring resident care and services and will provide systems which facilitate the identification and correction of deficiencies and gaps in systems or processes; Goals: -The QAPI program will provide the structure for decision making and will guide our day to day operations; -The QAPI program will establish and maintain support and document ongoing monitoring and evaluation resident care and services; -The QAPI program encompasses all aspects of care including clinical care, quality of life, resident choice and care transitions; -The QAPI program will assist…

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.