Diversicare Of Amory

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that a resident was free from verbal abuse when one (1) of seven (7) residents reviewed for abuse was subjected to verbal threats by a staff member. (Resident #1) Findings include: Review of the facility policy titled, “Abuse, Neglect, Misappropriation, Exploitation Policy,” dated January 2019, revealed the purpose: “To prohibit and prevent abuse . in accordance with Federal and State laws.” The policy defined verbal abuse as: “May be considered a form of mental abuse. Verbal abuse includes written or gestured communication, or sounds to residents within hearing distance, regardless of age, ability to comprehend, or disability.” The policy further defined mental abuse as: “The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .” Resident #1 Record review of 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.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 10/19/23. This was for deficiencies re-cited during a recertification and complaint survey on 2/13/25. The re-cited deficiencies included F 584, F 656, F 677, F 684, F 761, and F 880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAPI program. This was for six (6) of 18 deficient practice citations. Findings Include: This citation is cross-referenced to: F 584, F 656, F 677, F 684, F 761, and F 880 Review of the facility policy titled Quality Assurance and Performance Improvement dated February 2017 revealed, Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care, and services in our centers. The activities of QAPI involve team members at all levels 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, resident and staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by: 1) not having procedures in place to monitor and test the water source for Legionella's Disease which had the potential to affect all residents in the facility; 2) storing of respiratory equipment on the floor for Resident #82, and 3) not using required Enhanced Barrier Precautions (EBP) Resident #11 and Resident #157 for three (3) of 23 sampled residents. Findings include: Record review of facility policy titled, Infection Control Guide, dated 2022, revealed, .In order to accomplish the primary goal of infection control, which includes preventing or reducing the risk of healthcare associated infections, an epidemiology plan needs to be designed to include the following oversight operations and responsibilities: . cleaning and disinfecting equipment . prevention of infections .Enhanced Barrier Precautions recommendations is to consider expanding the use of PPE (Personal Protective Equipment) 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, resident and staff interviews, and facility policy review, the facility failed to provide a safe, clean environment as evidenced by an unsanitary toilet in room C-7, resident wheelchair (Resident #60), overbed tables, and wall in disrepair affecting three (3) residents in the seventy-three resident occupied rooms observed. Resident #48, Resident #60 and Resident #99 Findings Include: Review of the facility policy titled, Resident Rights and Quality of Life Policy, dated 3/13/20, revealed, A patient or resident has the right: . to receive services in a center environment that is safe, clean, and comfortable . Review of the facility policy titled, Resident/Patient Room Cleaning, last reviewed 2/1/2025, revealed Policy: Room Cleaning: Rooms are to be regularly cleaned and disinfected with a particular focus on disinfecting high-touch surfaces such as light switches, bed rails, doorknobs, call lights, etc. Nursing staff provides the initial cleanup of blood and bodily fluids . Environmental services staff follow by disinfecting surfaces contaminated with a small,…

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, resident and staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for residents with personal hygiene needs (Resident #62, #74, #253), taking an antiplatelet medication (Resident #25), storage of respiratory equipment (Resident #82), and failed to implement a care plan for a resident on Enhanced Barrier Precautions (EBP) (Resident #11), Thromboembolic Deterrent (TED) (Resident #253), and receiving dialysis (Resident #8) for six (6) of 23 sampled residents. Residents #8, #11, #62, #74, #82, and #253 Findings Include Record review of facility policy titled, Care Plans with effective date of October 2021, revealed, Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #8 A record review of Resident #8's care plan…

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, resident and staff interview, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 23 residents reviewed for Activities of Daily Living (ADL) care. Resident #62, #74 and #253. Findings include: Review of the facility policy titled, ADL's (activities of daily living), dated August 2021, revealed, Policy: Ensure ADLs are provided in accordance with accepted standards of practice. ADLs-(hygiene-grooming) . Resident #62 An observation and interview on 2/11/25 at 11:00 AM, revealed Resident #62's fingernails to be approximately 1/2 (one-half) inch long past the tips of the fingers, dirty in appearance with a dark brown substance under the nail beds. Resident #62 stated he would like to have them trimmed and confirmed he did not like them long. An observation on 2/12/25 at 1:30 PM, with Certified Nurse Assistant (CNA)#3 confirmed that Resident #62's nails were very long and dirty with a dried dark brown substance under 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, staff interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for treating skin concerns (Resident #303) and application of TED (thromboembolic deterrent) compression hose for two (2) of 23 sampled residents. Resident #253 and #303 Findings include: Review of the facility policy titled Skin Care Guideline unrevised, revealed under, Purpose: To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. A review of a statement on facility letterhead titled, Standards of Practice, revealed, The expectation set forth by (Proper Name) management is that nurses comply with current standards of practice in terms of following physician's orders. This includes following orders for application of medical devices such as TED hose. Resident #253 Record review of 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.

Based staff interview, record review, and facility policy review the facility failed to store controlled drugs in a locked permanently affixed compartment for storage as evidenced by an unopened box of Lorazepam Concentrate 30 milliliters sitting on a shelf in the refrigerator among other non-narcotic medications for one (1) of three (3) narcotics refrigerator storage observed. Findings include: Review of the facility policy titled, Medication Storage, last reviewed 4/23, revealed, .Procedure .Controlled medications---stored in a separately locked, permanently affixed compartment designated for that purpose . An observation of the A hall medication room refrigerator narcotic box with Licensed Practical Nurse (LPN) #1 on 2/12/25 at 8:35 AM, revealed an unopened box of Lorazepam Concentrate 30 milliliters sitting on a shelf in the refrigerator among other non-narcotic medications not in a secure affixed box. LPN #1 confirmed the Lorazepam was not stored appropriately and should have been in the secured lock box in the refrigerator. In an interview with the Director of Nursing (DON) on…

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, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents had the right to participate in smoking during rainy or inclement weather for two (2) of four (4) survey days. Resident #60, 65, A, and B. Findings include: Review of the facility policy titled, Resident Rights & Quality of Life Policy with an effective date of 3/13/20, revealed, It is the policy of proper name that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center .A patient or resident has the right: To be fully informed of his or her rights and all rules and regulations governing patient and resident conduct and responsibilities during the stay in the center. Review of Proper name Smoke Schedule undated, revealed Staff members are not allowed to take residents out to smoke during inclement weather, such as: Rain, Sleet, Snow, [NAME], Storms, Heat index…

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, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints as evidenced by restricting a resident's voluntary movement by body contact for one (1) of 23 sampled residents. Resident #88 Findings Include: Review of the facility policy titled Residents' Rights Summary unrevised, revealed under, Examples of Violations: . 12. Restraining a resident without a physician's order for the convenience of staff, or as a disciplinary measure. An observation on the Memory Care Unit on 2/11/25 at 3:49 PM revealed Resident #88 sitting in a wheelchair in the activity room and Certified Nurse Aide (CNA) #4 was standing in front of the resident with her right knee in between the residents' legs. The resident was anxious and asked the aide to take her to the bathroom. The resident tried to stand up from the wheelchair several times but was stopped. CNA #4 replied, No, you've got to stay right here while touching the resident's leg and instructing her to sit down because she had just went to the bathroom.…

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, resident and staff interview, record review, and facility policy review, the facility failed to thoroughly develop a baseline care plan related to personal hygiene for (1) one of three (3) baseline care plans reviewed. (Resident #253) Findings include: Review of the facility policy titled, Baseline Care Plan Process, dated November 2017, revealed, The baseline care plan is developed to include: the instructions needed to provide effective and person-centered care . On 2/10/25 at 10:10 AM, an observation revealed Resident #253's fingernail beds to have a dark brown substance underneath them, and they were jagged in appearance. His facial hair was also observed to be unkept. On 2/11/25 at 1:53 PM, observation of Resident # 253 with Certified Nurse Assistant (CNA) #2 she confirmed the resident 's nails were jagged and had a brown substance under the nail beds. On 2/11/25 at 1:55 PM, an interview with Certified Occupational Therapist (COTA) she stated that she has Resident #253 on caseload for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and facility policy review, the facility failed to provide ongoing communication documentation with the hemodialysis center for one (1) of one (1) residents receiving hemodialysis reviewed. Resident #8. Findings include: Record review of the facility policy titled, Outpatient Dialysis Services and Compensation undated, revealed, .d When a resident is transferred to the Dialysis Unit for Services, the Facility shall: (i) transmit resident information necessary for Contractor's delivery of Services and in accordance with applicable law; (ii) make resident records available to Contractor as necessary for provision of Services and in accordance with applicable law; .5. Patient Records. Facility and Contractor shall each prepare and maintain records concerning Facility's residents receiving Services under this Agreement, in accordance with applicable federal and state laws, regulations and program guidelines . A record review of Resident #8's admission Record…

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, staff interview, and facility policy review, the facility failed to maintain a system of medication records that enables accurate reconciliation and accounting for all controlled medications for (1) one of (3) three narcotic storage areas reviewed. Findings include: Review of the facility policy titled, Controlled Substance Accountability Guideline, revealed, Chapter 2: Controlled Substances (General): Medication nurse on duty shall maintain possession of the keys to controlled substances. Chapter : Change of Shift Reconciliation: Two licensed nurses, typically the nurse arriving, and the nurse departing from duty, are to conduct the reconciliation of patient specific controlled substances and sign a signature attesting to the accuracy of the count. An observation during medication administration on 2/12/25 at 8:30 AM, on A-Hall with Licensed Practical Nurse (LPN)#1 revealed LPN #1 give the medication cart keys to the Medical Records nurse to get a medication out of the medication room for him. In an interview with LPN #1 on 2/12/25 at 8:35 AM, he confirmed…

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 staff interview and record review the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date for one (1) of six (6) resident medications reviewed. Resident #69 Findings Include: The facility provided a statement on letterhead, (Proper name of the facility) follows the guidance of CMS (Centers for Medicare and Medicaid Services) as psychotropic medications ordered for PRN (as needed) usage shall not exceed past 14 days without further medical provider assessment in the facility for continuation of medication for each reinstatement of the order. Record review of Resident #69's February 2025 Medication Administration Record (MAR) revealed an order dated 12/17/24, Ativan (antianxiety) Oral Tablet 1 MG (milligram) (Lorazepam) give 1 tablet by mouth every 24 hours as needed for anxiety and agitation with no stop date. An interview with Registered Nurse (RN) #4 on 2/11/25 at 3:42 PM, confirmed Resident #69's Ativan order did not have a stop date. She revealed the resident usually took it on his shower days because he became combative. An interview 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 observation, resident and staff interview, and facility policy review, the facility failed to honor a resident's beverage preference during dining for two (2) of three (3) residents reviewed for dining observation. Resident #13 and Resident #303 Findings Include: Review of the facility policy titled Dining and Food Preferences with a revision date of 9/17, revealed Policy Statement: Individual dining, food, and beverage preferences are identified for all residents/patients. An observation of Resident #13 on 2/10/25 at 11:44 AM, revealed she was lying in bed. Registered Nurse (RN) #4 entered the resident's room with her meal tray. The resident voiced she wanted to eat in the dining room and wanted a large glass of tea. RN #4 explained to the resident she could only have a small glass of tea because of the caffeine and stated, You can have a small glass of tea and some water, or you'll be climbing the wall. A large glass of tea was not provided. An observation of Resident #13 during the lunch meal on 2/11/25 at 11:52 AM, revealed the resident was eating in the dining area 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 interview, record review and facility policy review the facility failed to notify the physician and resident representative of an unwitnessed fall for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the facility policy on Falls dated February 2017 revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .Post fall .The physician and resident's representative are notified of the fall . Record review of the Investigation Template dated 1/18/24 revealed that Resident #1 was found on the floor sitting on her buttocks beside her bed on 1/16/24 at approximately 10:50 PM by a Certified Nursing Assistant who was passing by the room and saw her foot beside the bed. The investigation revealed that the resident repeatedly stated that she slid out of bed trying to walk to the bathroom. On 02/13/24 at 8:20 AM, a phone interview with Resident #1's son, revealed that on 01/17/24, his family went to the facility to visit his mom and found that she had a knot on her head, had two…

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, staff interview and facility policy review the facility failed to ensure that opened food items stored in the refrigerator were dated and labeled for two (2) of four (4) kitchen tours. Findings include: Record review of the facility policy revised 9/2017 and titled, Food: Preparation documented under Procedures the following, .17. All TCS (Time/Temperature Controlled for Safety ) foods that are to be held for more than 24 hours at a temperature of 41 degrees F (Fahrenheit) or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by date' (Day 7). On 10/16/23 at 10:10 AM, a brief tour of the kitchen revealed an opened 32-ounce bottle of lemon juice which was approximately three-fourths full with no labeled date on the bottle. There was also approximately 2 cups of brownish purple substance observed in a clear covered bowl which the Dietary Manager (DM) identified as peanut butter and jelly and there was no label or date on the container. There was also a gallon zip lock bag with light colored meat inside undated and unlabeled. This meat 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 resident and staff interviews and facility policy review the facility failed to ensure a resident's preferences was honored for one (1) of 20 sampled residents. Resident #70 Findings include: A record review of the facility policy titled, Resident Rights & Quality of Life with a revision date of March 13, 2020, revealed that it is the policy that all residents and patients have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center. An interview on 10/16/23 at 11:00 AM with Resident #70 revealed he didn't have coffee on his tray one morning a couple of weeks ago and he asked about it, he revealed one of the Certified Nursing Assistants (CNAs) stated, Well they didn't put it on your breakfast tray, and I'll have to walk all the way back to the kitchen to get it. He revealed I didn't get any coffee that morning. An interview on 10/18/23 at 11:40 AM with Resident #70 revealed he did not get coffee again this morning for…

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

Based on observation, staff interviews, and facility policy review, the facility failed to ensure a clean environment as evidenced by multiple areas of a circular black substance on two ceiling air vents for two (2) of four (4) survey days. Findings include: Review of the facility policy titled 5-Step Daily Room Cleaning undated, revealed, PURPOSE: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility .2. Horizontal Surfaces- disinfected . Use your high duster to dust hard to reach areas, such as the tops of closets, high lights, and ceilings areas as needed . An observation on 10/16/23 at 12:42 PM, of the Dementia Care Unit, revealed two (2) square ceiling air vents with multiple areas of a circular black substance. The air vents had a total of 10 to 17 areas in total and ranged in different sizes of one-half (1/2) inch to two (2) inches. An observation and interview with Licensed Practical Nurse (LPN) #2 on 10/17/23 at 1:08 PM, revealed the air vents on the ceiling were an environmental concern related…

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, resident and staff interviews, record review, and facility policy review the facility failed to develop a comprehensive care plan for a resident on hospice services (Resident #50) and failed to implement an Activity of Daily Living (ADL) care plan for shaving and oral hygiene for Resident #21, for two (2) of 20 residents reviewed. Findings include: Record review of the facility policy titled Comprehensive Care Plans undated, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #50 An interview on 10/19/23 at 9:27 AM, the Licensed Social Worker (LSW) revealed she is responsible for developing the hospice care plans. She confirmed that the hospice care plan was not developed for…

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

Based on observations, staff interview, record review and facility policy review, the facility failed to provide activities of daily living (ADLs) for a resident dependent on staff for shaving and oral hygiene for one (1) of 20 residents sampled. Resident #21. Findings include: Record review of the facility policy titled Activities of Daily Living (ADLs) undated, revealed, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care .Policy Explanation and Compliance Guidelines .2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . During an observation on the Dementia Care Unit on 10/16/23 at 11:01 AM, Resident # 21 was sitting in a chair and noted a buildup of a thick white…

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 staff interviews, record review and facility policy review the facility failed to coordinate the hospice care for one (1) of four (4) residents receiving hospice services. Resident #50 Findings include: Record review of the facility policy/Health Care Services Agreement, dated [DATE], revealed, Exhibit A . In order for this agreement to be mutually beneficial for both Hospice and Facility, the parties agree to develop mutually acceptable procedures for the following: A . Obtaining and recording physician orders .E. Developing and updating plan of care . Record review of the facility Physician Orders for Resident #50 revealed an order to be admitted to hospice for diagnosis of congestive heart failure with a revision date of 10/18/2023. Record review of hospice (Proper name) Facility Notification of Hospice Admission/Change revealed Resident #50 was admitted to hospice services effective 6/14/2023. An interview on 10/18/23 at 3:25 PM, with Licensed Practical Nurse (LPN) #1 revealed Resident #50 has been…

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, staff interviews and facility policy review, the facility failed to ensure a medication cart was locked while unattended for one (1) of four (4) survey days. Findings include: Record review of the facility policy titled Medication Storage with a revision date of 04/22 revealed, .Procedure: . It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use (during times other than medication pass and in between residents during medication pass) During an observation of C Hall on 10/18/23 at 8:12 AM, the Survey Agency observed Licensed Practical Nurse (LPN) #3 walk away from the medication cart and enter room C11 without locking the medication cart. After several minutes, she exited room C11, walked over to the medication cart, opened the top drawer to obtain a lancet, shut the drawer and re-entered room C11 without locking the medication cart. An observation and interview on 10/18/23 at 8:23 AM, with LPN #3 confirmed that she had left the medication cart unlocked and unattended while entering a resident's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by a nebulizer and tubing not properly stored, hand hygiene not performed with incontinent care, and an isolation cart being transported in and out of a transmission-based precautions room for two (2) of 20 sampled residents reviewed. Resident #39 and Resident #83 Findings include: A review of the facility policy titled Nebulizer Therapy, undated, revealed, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Care of the Equipment: . 7. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. 8. Change nebulizer tubing every seventy-two hours or per facility policy. 9. Periodically disinfect unit per manufacturer's recommendations . Record review of the facility policy titled Transmission-Based…

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

Based on observations, interviews, record review and facility policy review, the facility failed to implement a care plan related to Activities of Daily Living (ADL) for residents who were dependent on the staff for care for two (2) of five (5) residents reviewed. Resident #3 and Resident #4. Findings include: Review of the policy titled, Comprehensive Care Plan, with an effective date of May 1, 2012, revealed the interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care. Resident #3 Record review of the care plan for Resident #3 with a date initiated of 12/28/21 and a revision date of 5/5/2023 revealed a focus of: I have a physical functioning deficit related to: Self-care impairment. The intervention for the focus included: I usually am dependent on staff for locomotion, dressing, toileting, personal hygiene, and bathing. Assist with turning 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, staff and visitor interview, and facility policy review the facility failed to provide timely incontinent care for two (2) of five (5) residents reviewed. Resident #3 and Resident #4. Findings include: Review of the facility policy titled, Incontinence, undated, revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines revealed the facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Resident #3 An observation, on 8/30/23 at 9:30 AM revealed Resident #3 in the day room in a wheelchair with other residents. An observation at 10:20 AM, 11:15 AM, and 11:30 AM revealed…

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.