Warrenton Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for hospice services on two (Resident #53 and #187) of two sampled residents who receive hospice services, to obtain orders for an colostomy for one (Resident #187) out of one sampled residents, failed to document weekly skin assessments for three (Resident #15, #26, and #39) of four sampled residents. Facility failed to follow physician Liodcain Patch orders for one (Resident #11) of one resident. Faciliy failed to administer insulin appropriately for one (Resident #26) of four sampled residents. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a hospice policy. 2. Review of #53's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/10/25, showed staff assessed the resident as: -Severely cognitively impaired; -On hospice; -Diagnosis of dementia.…

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 provide assistance to maintain personal hygiene and grooming for eight (Resident #11, #34, #46, #51, #53, #55, #63, and #71) out of nine sampled dependent residents . The facility census was 83. 1. Review of the facility's Bath (Shower) policy, dated March 2015, showed the purpose of bathing was to maintain skin integrity, comfort and cleanliness. Review of the facility's Shaving the Resident policy, dated March 2015, showed the purpose of shaving was to remove facial hair and improve the resident's appearance and morale. Review of the facility's Nails, Care of (Fingers and Toes) policy, dated March 2015, showed the purpose was to provide cleanliness, prevent the spread of infection. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/19/25, showed staff assessed the resident as: -Cognitively intact; -Required moderate assistance with showering; -Diagnosis of diabetes mellitus 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, facility staff failed to provide an ongoing program of activities designed to support independence and interaction in the memory care unit. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a policy for Activities. 2. Observation on 03/18/25 at 9:40 A.M., showed the Activity Calendar, dated March 2025, hung in the hallway of the memory care unit. The calendar showed the following: -03/18/25: 9:00 A.M., Catholic Services, 10:00 A.M., musical bingo and 2:00 P.M., horse racing; -03/19/25: 10:00 A.M., Hair dresser and 2:00 P.M., country store; -03/20/25: 10:00 A.M., Movie and snacks and 1:30 P.M., Bingo; -03/20/25: 9:00 A.M., Communion and 1:30 P.M., Music and groove. Observation on 03/18/25 at 09:30 A.M., showed a religious service held in the entranceway of the facility not located in the memory care unit. Residents from the memory care unit were not present and did not have service on the unit. Observation on 03/18/25 at 2:18 P.M., showed a group of residents in 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, facility staff failed to provide safe mechanical transfer for two residents (Resident #30, and #55). Facility staff failed to provided safe wheelchair propulsion for two residents(Resident #13, and #30). Facility staff failed to safely administer medication to one resident (Resident #51). Facility staff failed to lock medication carts when not in use and failed to store hazardous materials in a manner to prevent accidents. The facility census was 83. 1. Review of the facility's mechanical lift policy, dated March 2015, showed staff are directed to follow the manufacturer's instructions when using any type of mechanical lift and does not direct staff on holding onto the resident while suspended in the air. Review of the mechanical lift operating manual, dated 10/18/18, showed: -It is recommended two staff perform mechanical lift transfers; -Staff are to use the straps or handles on the side and the back of the sling to guide the patient's hips as far back 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.

Based on interview and record review, the facility staff failed to ensure four Nurse Aide's ((NA) NA H, NA I, NA J and NA K) out of fourteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The census was 83. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Newly Hired NA Audit Tool, showed NA H's hire date as 05/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of Newly Hired NA Audit Tool, showed NA I's hire date as 10/17/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 4. Review of Newly Hired NA Audit Tool, showed NA J's hire date as 09/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 5. Review of Newly Hired NA Audit Tool, showed NA K's hire date as 09/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide…

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, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 83. 1. Review of the facility's policies showed staff did not provide a policy for Staffing and Scheduling Postings. 2. Observation on 03/18/25 at 10:49 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 3. Observation on 03/19/25 at 9:40 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 4. Observation on 03/20/25 at 10:23 A.M., showed staff did not post required nurse staffing…

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, facility staff failed to store medication in a safe and effective manor in one medication storage room, and three medication storage carts. The facility census was 83. 1. Review of the facility's Medication, Storage Of policy, dated March 2015, showed: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy of destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 03/19/25 at 2:47 P.M., showed the 100 hall medication storage room contained: -One intravenous (IV) administration set with an expiration date of 02/19/25; -One bottle Vitamin B-6 100 milligram (mg) with an expiration date of 06/2024. 3. Observation on 03/20/25 at 11:11 A.M., showed the 200 hall medication cart contained one loose red and white oval gel capsule. 4. Observation on 03/20/25 at 11:20 A.M., showed the 100 A hall medication cart contained one loose oval white tablet. 5. Observation…

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 staff failed to designate one or more individuals with specialized training in Infection Prevention and Control as the Infection Preventionist for the facility's infection prevention and control program. The census was 83. 1. Review of the facility's Infection Preventionist Control policy, undated, showed the IP will complete the Centers for Disease Control (CDC) Long Term Care IP module. Review of the current Infection Preventionist Certificate Of Completion, dated [DATE] showed: -4.0 credit hours; -Web training; -Covered introduction to infection control, transmission, prevention and control, hand hygiene, personal protective equipment, environmental controls, sharps and injection safety, occupational health and safety, and sepsis; -Expiration date of [DATE]. During an interview on [DATE] at 9:20 A.M., the IP said he/she was not aware the certification had expired. He/She is currently the only active IP person at the facility and is always reviewing infection…

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

Based on interview and record review, the facility staff failed to ensure the activities program was directed by a qualified professional. The census was 83. 1. Review of the facility's Role of the Activity Director policy, dated March 2012, showed the policy does not contain direction or guidance for director certification requirements. During an interview on 3/21/25 at 10:54 A.M., the activity director said he/she was not certified and did not know he/she should be certified. He/She has been in the activity director role for a while. During an interview on 3/20/25 at 8:29 A.M., the Administrator said the activity director is not certified but is working on getting him/her scheduled. He/She was not aware until a couple of weeks ago the director was not certified and started working on getting scheduled for the class.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff failed to maintain the ice machine in a sanitary manner to prevent cross-contamination. Facility staff failed to maintain the kitchen equipment and surfaces in a sanitary manner to prevent the growth of bacteria and cross-contamination. Facility staff also failed to perform hand hygiene as often as necessary to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 84. 1. Review of the facility's Receiving and Storage of Food policy, dated April 2011, showed: -The Dining Services Manager is responsible for receiving and storing food and nonfood items; -Follow the rule…

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 provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair and clean. The facility census was 84 with a capacity of 120. Review of the policies provided by the facility showed they did not have a policy for environment, maintenance repairs, and cleaning. 1. Observation on 04/15/24 at 10:01 A.M., showed occupied room [ROOM NUMBER] the wall above the bed with chipped paint. 2. Observation on 04/15/24 at 11:28 A.M., showed occupied room [ROOM NUMBER] walls with multiple large areas gouged. 3. Observation on 04/15/24 at 11:31 A.M., showed occupied room [ROOM NUMBER] with gouged dry wall and missing paint next to the first bed. 4. Observation on 04/15/24 at 11:35 A.M., showed occupied room [ROOM NUMBER] the walls with gouged dry wall and missing paint. The bathroom door gouged, chipped and missing green paint with areas of splintered wood. 5. Observation on 04/15/24 at 11:41 A.M., showed…

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, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy for five (Residents #18, #19, #23, #340, and #355) of 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Bed Hold Guidelines, undated, showed: -The facility will notify all residents and/or their representative of the bed hold guidelines; -This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. 2. Review of Resident #18's medical record showed staff documented the resident had transferred to the hospital on [DATE] and returned to the facility on [DATE], and transferred on 3/12/24 and returned to the facility on [DATE]. The resident's medical record did not contain documentation staff…

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, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for seven residents (Residents #1, #241, #347, #363, #366, #368 and #376) of 22 sampled residents. The census was 84. 1. Review of the policies provided by the facility showed they did not contain a policy for MDS assessments. Review of the RAI manual 3.0 version 1.18.11, dated October 2023, the RAI-Omnibus Budget Reconciliation Act (OBRA) required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type; 2. Review of Resident #1's Annual MDS, dated [DATE], showed the assessment in process and not submitted in the required time frame. All sections reviewed showed in progress and without information. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, had been completed no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual, manual used for guidance to complete assessments, for nine residents (Resident #4, #14, #19, #22, #30, #347, #363, #368, and #385) of 22 sampled residents. The facility census was 84. 1. Review of the facility policies provided did not contain a policy for MDS assessments. Review of the RAI manual 3.0 version 1.18.11, dated October 2023, the RAI-Omnibus Budget Reconciliation Act (OBRA) required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type. 2. Review of Resident #4's Quarterly MDS assessment, dated…

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 encode resident assessment data within seven days after a facility completed a resident's assessment and transmit the assessment timely for fourteen residents (Residents #1, #4, #14, #19, #30, #239, #241, #340, #363, #366, #368, #376, #383, and #385) of 22 sampled residents. The census was 84. 1. Review of the Minimum Data Set (MDS, a federal mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) user manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS completion date must be no later than 13 days after the entry date; -Encoding data: Within seven days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident #1's Annual MDS assessment,…

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 develop and implement a comprehensive person-centered care plan for seven residents (Resident #3, #18, #22, #33, #241, #340, and #376) out of 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed staff were directed as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS - a federally mandated assessment tool); -A…

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 ensure residents that were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to ensure residents remained clean, dry and free from odor for three residents (Residents #10, #18, and #347) and failed to provide hair care to two residents (Resident #376, and #383) of 22 sampled residents. The facility census was 84. 1. Review of facility's policy titled, Activities of Daily Living (ADL), dated March 2015, showed: -Purpose is to assist resident in achieving maximum function; -Gives step-by-step guidance with dressing residents. Review of the facility's policy titled, Shaving the Resident, dated March 2015, showed: -Purpose is to remove facial hair and improve the resident's appearance and morale; -Gives step-by-step guidance with shaving residents, does not address the frequency or preferences. Review of the facility's policy titled,…

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 lock the medication and treatment carts, and failed to store medications and chemicals in a safe manner. The facility census was 84 with a capacity of 120. 1. Review of the facility's policy titled Storage of Medication, dated March 2015, showed staff were directed to: -All medications must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile carts; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely; -All poisonous substances and other hazardous compounds, such as sterilization solutions, irrigation solutions, antiseptics, diagnostic agents, etc must be kept in a locked container; -An unattended medication cart must remain locked at all times, the cart must be locked before leaving it or secured in a locked medication room. 2. Observation on 04/15/24 at 11:12 A.M., showed the 100 hall treatment cart unlocked…

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 maintain a medication error rate less than five percent (%) out of 29 opportunities observed, six errors occurred which resulted in a 20.7% error rate which effected four residents (Resident #15, #18, #23, and #347) of the six sampled residents. The facility census was 84. 1. Review of the facility's policy titled Medications, Errors and Drug Reactions, dated March 2015, showed staff were directed to: -Report all medication errors and drug reactions immediately to the physician, Director of Nursing (DON), and administrator; -Provide emergency care to the resident; -Follow physician's orders; -Complete event report; -Chart in the resident's clinical record. Review of the manufacturer's recommendations for Kwik-Pens (ightweight pen that's prefilled with insulin), dated 10/18/15, showed staff were directed to: -Prime the pen before each injection; -To prime the pen turn the dose knob to two units; -Hold the pen with the needle pointing up,…

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

Based on observation, record review, and interview the facility staff failed to count narcotic medications each shift for three of three medication cart, failed to reconcile one resident's (Resident #242) liquid lorazepam (narcotic antianxiety medication) of 84 sampled residents, failed to separate treatments in one treatment cart of one sampled cart, failed to date medications when opened for ten residents (Resident #238, #240, #18, #351, #21, #27, #348, #345, #350) out of 84 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Narcotic Count, dated March 2015, showed staff were directed to: -Complete a physical inventory of narcotics at each shift change to identify discrepancies; -One Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of shift; -Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by…

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

Based on observation, interview, and record review, facility staff failed to 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 infections when staff failed to perform hand hygiene in a manner to reduce the spread of infection for four residents (Resident #15, #18, #23, and #347) of four sampled residents, and failed to disinfect a multi-use glucometer (a medical device for determining the approximate concentration of glucose in the blood) between two residents (Resident #15, and #23) of two sampled residents. The facility census was 84. 1. Review of the facility's policy titled, Blood Glucose Monitoring, dated March 2015, showed staff were directed to: -Place the equipment on a clean surface such as a clean towel; -Put on gloves; -Obtain blood sugar; -Disinfect glucose monitor; -Remove gloves and wash hands. Review of the facility's policy titled Handwashing, dated March 2015, showed staff were directed to use a disposable hand towel to dry hands well and turn…

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 maintain resident dignity by leaving one resident (Resident #12) exposed to the hallway and failing to properly cover a urinary drainage bag for one resident (Residents #355) of 22 Sampled residents. The facility census was 84. 1. Review of the facilities policies showed the policies did not contain a policy for dignity. 2. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/28/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required maximal assistance from staff for dressing, personal hygiene and bed mobility; -Dependent on staff for transfers. Review of the resident's care plan, dated 04/15/24, showed staff documented the resident with impulsive behaviors and impaired decision making due to cognitive deficits. Review showed the care plan directs staff to provide assistance of one to two staff members for transfers. Observation on 04/15/24 at…

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, facility staff failed to complete a baseline care plan within 48 hours of admission for three residents (Resident #33, #36, and #383) out 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Care Plan, Temporary, dated March 2015, showed: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) process. 2. Review of Resident #33's medical record showed staff documented the resident was admitted to the facility on [DATE]. The record did not contain a baseline care plan. 3. Review of Resident #36's medical record showed staff documented 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, facility failed to ensure two Nurse Aides ((NA) NA DD and NA P) of three sampled staff completed the nurse aide training program within four months of employment in the facility. The facility census was 84. 1. Review of the facilities policies did not contain a policy for NA training or qualifications. Review of NA DD's personnel file showed a hire date of 05/18/23. The file did not contain documentation NA DD completed the nurse aide training program. Review of NA P's personnel file showed a hire date of 08/28/23. The file did not contain documentation NA P completed the nurse aide training program. Review of the facility's payroll, dated April 2024, showed NA DD and NA P worked at the facility as NA's. During an interview on 04/16/24 at 2:16 P.M., the administrator said he/she did not know the facility had two NA's who were not compliant with training. The administrator said the Minimum Data Set (MDS) Coordinator schedules and monitors the NA's online classes. During an interview on 04/16/24 at 2:25 P.M., the MDS Coordinator said he/she did…

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, facility staff failed to notify one resident (Resident #1's) out of six sampled residents family and physician of a fall which resulted in an injury. The facility census was 81. 1. Review of the facility's physician notification, unknown date, showed the facility will immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is an accident which resulted in injury to the resident and has the potential in requiring physician intervention. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/9/24, showed diagnoses of Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors), pain, and insomnia. Review of the resident's plan of care, dated 3/10/24, showed staff assessed the at risk for falls. Review of the resident's fall risk assessment, dated 12/30/23, showed the resident assessed at a high risk for falling. Review of the resident's nurses…

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 staff failed to ensure menus were followed when staff did not prepare all food items as directed by the recipe. The facility census was 65. 1. Review of facility's Food Preparation and Distribution policy date April 2011 showed recipes should be followed on each item prepared. Review of the Philly cheese steak sandwich recipe showed ingredients for 100 servings as follows: -12 pounds plus eight ounces of Philly beef steak -Seven pounds plus four ounce of sliced onions -Six pounds plus four ounces of sliced American cheese Observation on 12/29/2022 at 2:40 P.M., showed [NAME] N added a two pound bag of chopped green peppers to a pan of cooked beef steak. He/She poured an unmeasured amount of Mozzarella cheese from two previously opened bags into the pan of beef and stirred. The Philly cheese steak was served at the evening meal. During an interview on 12/29/2022 at 3:20 P.M., [NAME] N said he/she follows recipes when preparing meals. He/She said the beef steak was given to him/her to prepare so he/she did not know how…

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, facility staff failed to maintain correct dishwasher water temperatures and follow proper procedures for ware washing in the three compartment sink. This failure had the potential to affect all residents. The census was 65. 1. Review of the facility's Dish machine Temperature policy dated April 2011 showed: -Actual wash and rinse temperatures must be observed and logged at the beginning of the dishwashing period by the dish machine operator; -Report temperatures that are below the required levels to the Dietary Services manager immediately. Review of the dishwasher general operating instructions wall poster in the dishwashing area showed: -It is recommended that 140 degree water be used; -Report to your supervisor if it is lower than 120 degrees F or higher than 160 degrees. Review of the dishwasher daily start up procedures showed: -Fill machine with water using fill switch; -If water temperature gauge has not reached 120 degrees Fahrenheit (F) when the water level is just below overflow, drain water from the machine and continue…

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 staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed to maintain the lids to cover the outdoor dumpster in good repair. The facility census was 65. 1. Observation on 12/29/22 at 8:00 A.M., showed trash bags stacked inside the outdoor dumpster high above the top of the dumpster. Further observation showed the two lids to cover the dumpster pushed inside of the dumpster and the bottom half of each lid missing due to breakage. During an interview on 12/29/22 at 8:00 A.M., the maintenance director said the dumpster lids had been broken for a while. The Maintenance Director said he/she called the trash company about two weeks ago and asked them for a new dumpster and they said they would not provide one. The Maintenance Director said he/she did not ask the company to replace the broken lids and he/she had not contacted anyone else to have the lids repaired. During an interview on 12/29/22 at 2:15 P.M., the administrator said the dumpster…

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 facility staff failed to ensure the Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) (CMS-10055) was completed for three residents (Resident #265, #41, and #269). The facility census was 65. 1. Review of the facility policies showed the facility did not provide a policy addressing Advanced Beneficiary Notices. 2. Review of Resident #265's SNFABN review form completed by the facility showed the facility documented: - Medicare part A skilled services started 10/26/22; - Last covered day of part A service was 11/17/22; - The resident did not document a payment option before the CMS-10055 was signed. 3. Review of Resident #41's SNFABN review form completed by the facility showed the facility documented: - Medicare part A skilled services started 9/6/22; - Last covered day of part A service was 9/30/22; - The resident did not document a payment option before the CMS-10055 was signed. 4. Review of Resident #269's SNFABN review form completed by the facility showed the facility 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 facility staff failed to ensure four residents (Residents #4, #50, #264 and #269) who required staff assistance were provided with adequate assistance to maintain good grooming and hygiene. The facility census was 65. 1. Review of the Facility's shower policy, dated March 2015, showed staff were directed as follows: -Purpose is to maintain skin integrity, comfort and cleanliness; -Encourage the resident to do as much as possible; -Wash face and entire body, shampoo hair and rinse well; -Dry the resident well; -Dress the resident and dry hair well, comb and style hair. 2. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/04/2022 showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene; -Diagnoses included neurogenic bladder (lack of bladder control), vertigo and muscle 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide safe mechanical lift transfers for three residents (Residents #7, #12 and #47) in a manner to prevent accidents. The facility staff also failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents. The facility census was 65. 1. Review of the Invacare Reliant 600 Heavy-Duty Power Lift instruction guide, dated 2018, showed the guide instructed operators of the lift that the legs must be kept in the maximum open position for stability and safety. Review showed if it is necessary to close the legs of the lift to maneuver the lift under a bed, the guide instructed operators to close the legs only as long as it takes to position the lift over the patient, then return the legs to the maximum open position. Review of the facility's Hydraulic Lift (Hoyer Lift) policy, dated March 2015, showed the policy directed staff to open the lift to the widest point and set the brakes. 2. Review…

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 staff failed to communicate pharmacy recommendations to the physicians for four residents (Resident #3, #11, #37, and #41) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 65. 1. Review of the facility's Drug Review policy, dated March 2015, showed: -All medications given to each resident will be reviewed on a monthly basis in order to insure adherence to stop orders; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with physician; -Determine the most acceptable time frame to attempt reduction of drug dosage from behavior evaluation. Review of the facility's Physician Services policy, dated March 2015, showed: -The resident's attending physician is responsible for prescribing new therapy, to ensure that the resident receives quality care and medical…

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, facility staff failed to ensure that as needed (PRN) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) orders were limited to 14 days unless a specific duration and clinical rationale were provided for one resident (Resident #37) and failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for two residents (Resident #11 and #57). The facility census was 28. 1. Review of the facility's Drug Review policy, dated March 2015, showed: -All medications given to each resident will be reviewed on a monthly basis in order to insure adherence to stop orders; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with physician; -Determine the most acceptable time frame to attempt reduction of drug dosage from behavior evaluation.…

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, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage carts. The facility census was 65. 1. Review of the facility's Medication Storage Policy, dated March 2015, showed staff are directed as follows: -No discontinued, outdated, or deteriorated drugs and biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. Observation on 12/29/22 at 9:00 A.M., showed the 100 hall medication cart contained: -One Meclizine 25 mg tablet pack with 26 tablets remaining with an expiration date of 8/5/22; -One loose white tablet with 66/422 stamped on it; -One Zinc 50 mg bottle with and expiration date of 6/22; -Two loose blue tablets with #41 stamped on it; -One loose yellow tablet with #81 stamped on it; -One loose yellow tablet with #8 stamped on it; -Six loose white tablets unknown; -One loose yellow tablet with #33 stamped…

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

Based on interview and record review, the facility staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per policy for five out of ten sampled employees (Dietary Aide S, Registered Nurse T, Licensed Practical Nurse U, Housekeeper V, and Certified Nurse Assistant P). The facility census was 65. 1. Review of the facility's Tuberculosis Control Policy, undated, showed: -Recommendations for employees: --Initial examination: provide a tuberculin skin test (Mantoux, five tuberculin units (TU) of PPD to all employees during pre-employment procedures, unless a previous reaction greater than 10 millimeters (mm) is documented. If the initial skin test is 0-9 mm, a second test should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline in determining treatment and follow-up of these…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a discharge summary was completed upon discharge for one sampled resident (Resident #61) out of three sampled closed records. The facility census was 65. 1. Record review of the facility's Discharge Planning policy dated April 2006 showed: -The Social Service Department will have primary responsibility for discharge planning within the facility; -The discharge summary will include the events leading to admission, the diagnosis, prognosis, treatment and adjustment of the resident, and plans at discharge. Review of Resident #61's Face Sheet showed the resident was admitted to the facility on [DATE] with a diagnosis of profound intellectual disabilities and was discharged on 10/03/2022. Review of discharge note dated 10/04/2022 showed the Social Services Director (SSD) documented the resident was discharged to another facility on 10/03/2022. Review of the resident's electronic medical record showed the record did not contain documentation 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.