Grand Trace Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to send a Status Change for Preadmission Screening and Resident Review (PASRR) after a resident was admitted to an inpatient behavioral health unit for one (1) of two (2) sampled residents reviewed for PASRR, Resident #7. Findings included: A review of the facility ' s policy, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/08/21, revealed .The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines .Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission .4. If it is learned that after admission that a PASRR Level II screening is indicated it will be the responsibility of Social Services to coordinate and/or inform the appropriate…

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 interviews, record review, and facility policy review, the facility failed to implement the baseline care plan related to pain medications for one (1) of (1) residents reviewed for baseline care plan implementation. (Resident #169). Findings included: A review of the facility's policy, Plans of Care, with a revision date of 09/27/17, revealed, . An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Procedure: . Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed . A record review of the Baseline Care Plan 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, observation, and record review, the facility failed to adhere to accepted standards of practice for the timely replacement of oxygen tubing for one (1) of four (4) residents observed with oxygen in use, Resident #18. Findings included: A review of the facility policy Equipment Change Schedule, dated 11/30/14, revealed: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer ' s recommendations and standards of practice. Procedure: Equipment/When Changed . Nasal Cannula, every seven (7) days or when contaminated . On 03/24/25 at 12:58 PM, during an observation, Resident #18 was lying in bed. Oxygen was flowing at two (2) liters per minute via nasal cannula. The oxygen tubing was dated 02/10/24. There was no signage posted on the door indicating oxygen was in use. On 03/24/25 at 5:45 PM, during an interview and observation with the Licensed Practical Nurse (LPN)/Infection Preventionist (IP) in Resident #18 ' s…

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

Based on staff interviews, record reviews, facility policy review and Plan of Correction (POC) review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies originally cited during the recertification survey conducted on 03/07/2024, for three (3) of (17) deficiencies cited on the current recertification survey. Findings included: A review of the facility's QAPI policy, with a revision date of 10/24/22, revealed The center and organization has a comprehensive data-driven Quality Assurance Performance Improvement Program that focuses on indications of the outcome of care and quality of life. Important functional areas may include but are not limited to .c. Resident Assessments .d.Quality of care .e. Quality of Life . F677 - ADL Care During the recertification survey conducted on 03/07/2024, the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident. F641 - Significant Change Assessment During the recertification survey, the facility failed to complete a Significant…

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, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices during medication administration for one (1) of one (1) medication pass observations (Resident #169). Findings included: Record review of the facility policy titled Administering Medication, dated April 2019, revealed Medications are administered in a safe and timely manner and as prescribed . 25. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable . On 03/26/25 at 8:45 AM, during the administration of morning medications to Resident #169, Licensed Practical Nurse (LPN) #2 was observed entering the resident's room. The resident asked to see the medications prior to taking them. At this time, the nurse poured the medications into her bare, ungloved hand, and the resident proceeded to take the medications after inspecting them. On 03/26/25 at 8:55 AM, during an interview, LPN #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the presence of a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week as required, for eight (8) of (19) days reviewed. Findings included: On 03/27/25 at 11:50 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that she had been told by the facility's Nurse Consultant that the Director of Nursing (DON) could be counted as the RN and that she, as the LPN, could also be included on the staffing grid. She stated that at a previous facility, she was not allowed to count the DON or herself on the staffing report unless they completed direct care hours. She confirmed that the DON is the only RN in the facility Monday through Friday, although another RN occasionally serves as Charge Nurse. LPN #1 explained that the DON often counts herself as both the Charge Nurse and the DON and helps where needed, including acting as Charge Nurse when no one else is available. A record review of the facility's…

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

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's right to dignity and communication by not providing an accessible call light for one (1) of twenty (20) sampled residents (Resident #169). Findings included: A review of the facility ' s policy titled Resident Rights with an effective date of 11/30/14 revealed .The facility will ensure that the resident is not deprived of his/her rights . A resident shall be treated with dignity and respect . On 03/24/25 at 11:45 AM, during an observation and interview, Resident #169 was in bed with a touch call light at the foot of the bed. The resident explained he could not use that call light, as he was unable to raise his chin or head to activate the button. He stated he had experienced long wait times for staff assistance with repositioning. On 03/24/25 at 4:10 PM, during an observation and interview with Certified Nurse Aide (CNA) #1, observed Resident #169's push call light lying on the floor. CNA#1 stated this was her first time working with the resident and confirmed call lights…

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, interviews, record reviews, and facility policy review, the facility failed to provide a resident who was unable to carry out activities of daily living (ADLs) with the necessary services to maintain good grooming and personal and oral care for one (1) of (20) sampled resident reviewed for personal hygiene and grooming, Resident #67. Findings included: A review of the facility ' s policy titled Activities of Daily Living, dated 02/01/22, revealed Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing, and assistance as necessary. ADL includes bathing, dressing, grooming, hygiene, toileting . On 03/24/25 at 12:38 PM, during an interview and observation, Resident #67 was observed lying in bed with a moderate amount of gray hair under her chin. She stated she wanted her chin hair shaved and reported her last shower was on Thursday. She stated she used to receive bed baths three (3) times per week. On 03/25/25 at 8:55 AM, during an observation, Resident #67 was observed lying in bed with her eyes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents for one (1) of (20) sampled residents, with the potential to affect all residents, Resident #67. Findings included: A record review of a signed statement, undated, from the Interim Administrator revealed: Facility staffs according to census, acuity and/or facility assessment based on resident needs. A review of the Facility assessment dated [DATE] revealed: .Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident ' s needs . Licensed nurses providing direct care equaled 9, Nurse Aides equaled 21, Other Nursing personnel (e.g., those with administrative duties) equaled 3 . Describe your general staff plan to ensure that you have sufficient staff to meet the needs of the residents at any given time . Director of Nursing (DON) . 1 Registered Nurse (RN) DON . 1- RN as Assistant DON (ADON) . 1 Staff dev.…

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, interviews, record review, and review of the Facility Assessment Tool, the facility failed to provide sufficient nursing staffing resulting in incontinent care, grooming, and baths not being provided for six (6) of 18 sampled residents. Resident #15, Resident #20, Resident #40, Resident #44, Resident #57, and Resident #59. Findings include: A review of the facility's statement signed by the Administrator revealed the facility did not have a staffing policy and the facility was staffed according to census, acuity, and/or the Facility Assessment. A record review of the Facility Assessment Tool, dated 3/4/24, revealed .Part 3: Facility Resources Needed to Provide Competent Support and Care four our Resident Population Every Day and During Emergencies .3.2 Based on your resident population and needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time . For Licensed nurses providing direct care, the total number needed was indicated as 6-10. For Nurse aides,…

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, interviews, and record review, the facility failed to provide accommodation for a resident who required a larger bed for one (1) of 18 sampled residents. Resident #57 Findings Include: On 03/05/24 at 09:50 AM, in an interview and observation of Resident #57, she stated she needed a bigger bed because it was difficult for her to turn or reposition in bed. She explained that she had reported her needs to the facility staff, but nothing had been done about it. Record review of the admission Record' revealed the facility admitted Resident #57 on 7/20/23 and she had current diagnoses including Morbid (Severe) Obesity. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Record review of the Admission/readmission Data Collection document, dated 7/20/23, revealed Resident #57 weighed 434 pounds upon admission to the facility. Record review of the Weight Summary revealed Resident #57 most recent weight,…

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 resident and staff interviews, record review, and facility policy review, the facility failed to ensure the residents' right to receive mail when delivered on Saturday for two (2) of 11 residents reviewed in resident council. This had the potential to affect all 60 residents who reside in the facility. Resident #6 and Resident #51 Findings include: A record review of the facility's policy Mail, dated 11/01/21, revealed . Mail will be delivered to the resident on the day it was delivered by the postal service . On 03/05/24 at 1:30 PM, during the Resident Council meeting, Resident #6 and Resident #51 reported they do not receive mail that is delivered on Saturdays because there was no one at the facility to get it out of the mailbox. Resident #6 explained he received packages on Saturdays when they are shipped by United Parcel Service (UPS), but he did not receive anything from the regular mail. On 03/05/24 at 2:05 PM, during an interview with the Administrator, he explained he was not aware that residents were not getting mail that was delivered on Saturday. He stated that…

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

Based on staff interview, record review, and facility policy review, the facility failed to provide advanced beneficiary notices for a resident who had completed therapy services for one (1) of three (3) residents reviewed for advanced beneficiary notices. Resident #55 Findings Include: Record review of the facility's policy, SNF (Skilled Nursing Facility) Advance Beneficiary Notification (SNF) & The Notice of Medicare Provider Non-Coverage, revised 5/1/2018, revealed, The SNF Advance Beneficiary Notification .will be used to properly notify a Medicare Part A resident and/or responsible party of the clinical team decision that the resident, no longer meets the Medicare criteria for daily skilled services .SNF's must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no lather than two days (48 hours) before the effective date of the end of the coverage that their Medicare coverage will be ending . Record review of Resident #55 SNF Beneficiary Notification Review form revealed the facility did not provide the resident with a Skilled Nursing…

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, record review, and facility policy review, the facility failed to provide written notification to the resident and/or Responsible Representative (RR) the reason for a transfer to an acute hospital in a language they understand for one (1) of one (1) resident reviewed for hospitalization. Resident #66 Findings include: A record review of the facility's policy Transfer/Discharge Notification & Right to Appeal, revised 10/24/22 revealed . Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to the Federal and/or State regulatory requirements . Record review of the admission Record revealed the facility admitted Resident #66 on 02/06/24 with diagnoses including Subdural Hemorrhage. Record review of the facility's .Hospital Transfer Form ., with the Date of Transfer listed as 2/13/24, revealed the reason for Resident #66's transfer was Decreased LOC (Level of Consciousness) - drooping left side of face - rales (type of abnormal breath sound) left lung fields. Record review of the facility's notification…

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, interviews, and record review, the facility failed to accurately code a Minimum Data Set (MDS) related to a resident who smokes for one (1) for 18 sampled residents. Resident #53 Findings include: A record review of the admission Record revealed the facility admitted Resident #53 on 12/22/22 and he had diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. On 03/05/24 at 2:28 PM, during an observation and interview, Resident #53 was outside in the designated smoking area. The resident stated that he has been smoking since he was admitted to the facility. The facility staff assisted the resident with lighting his cigarette. A record review of the Annual Minimum Data Set, with an Assessment Reference Date (ARD) of 12/26/23 revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. A review of Section J was coded as No for tobacco use. On 03/05/24 at 2:55 PM, in an interview with Registered Nurse (RN) #1/MDS/Care Plan nurse, she stated she's currently filling in and helping 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 interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 18 sampled residents. Resident #13 Findings include: A review of the facility's policy, Plans of Care, revised 9/25/2017 revealed, .An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable .Procedure .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . A review of the facility's policy, Trauma Informed Care, effective 10/24/22, revealed, .Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences…

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, interviews, record review, and the facility policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL), including shaving, received those services for one (1) of 18 sampled residents. Resident #40 Findings include: A record review of the facility's policy, Activities of Daily Living, dated 2/01/2022, revealed . To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing, and assistance as necessary. ADLs includes bathing, dressing, grooming, hygiene . On 03/04/24 at 12:10 PM, during an observation, Resident #40 had long, gray facial hair. On 03/06/24 at 10:00 AM, during an interview with Licensed Practical Nurse (LPN)#1, she explained the Certified Nurse Aides (CNAs) should shave residents when they are performing the resident's showers or baths. She confirmed Resident #40 had long facial hair. At 10:45 AM on 03/06/24, during an interview with CNA #2, she confirmed Resident #40 has long facial hair and that he had received a shower on Monday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 18 sampled residents. Resident #13 Findings include: A review of the facility's policy, Trauma Informed Care, effective 10/24/22, revealed, .Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization .Procedure .1. Residents are evaluated for trauma, triggers .on admission/readmission, quarterly and annually. 2. Develop resident-center interventions based on trauma triggers. 3. Develop a care plan and add interventions to the nurse aide [NAME] . Record review of the admission Record revealed the facility admitted Resident #13 on 1/5/2024 and she had a diagnosis of PTSD with an onset date of 1/5/2024. 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 interviews, record review, and facility policy review, the facility failed to ensure a resident was treated with dignity and respect for one (1) of 18 sampled residents. Resident #1 Findings include: A record review of the facility's Verification of Investigation, dated 2/8/24, revealed an allegation on 2/7/24 at 9:00 PM, that Certified Nurse Aide (CNA) #3 cursed resident about not being his job to put her in bed and used cursed words. A record review of the handwritten statement, dated 2/9/24, and signed by CNA #3 revealed, When I made it to work at 7 PM the aid I relieved gave me report on what she had done on the hall. I made the comment that I didn't come to work to put nobody in the bed because I had just got everybody up at 7 AM. I went to the resident room (Resident #1) and told her that she was going to have to stop procrastinating and let the shift that was here put her in the bed . On 3/04/24 at 3:48 PM, in an interview with Resident #1, she stated she could not remember much about what the CNA said to her, but she remembered that it happened. She was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Revised 4/6/22 Upon secondary review with Centers for Medicare and Medicaid Services (CMS) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of F565 was increased from a D to an E. Based on resident and staff interviews, a test meal tray, record review, and facility policy review, the facility failed to ensure Resident Council grievances related to food were resolved in a timely manner. This affected eight (8) of (52) residents who resided in the facility. Resident #18, Resident #19, Resident #22, Resident #23, Resident #27, Resident #32, Resident # 34, and Resident #37. Findings Include: The facility's grievance policy titled, Complaint/Grievances, dated 11/30/2014, revealed prior to or upon admission the resident's designated person will be informed of the right to file and the procedure for filing a complaint. If the resident or resident designated person feel or believe that the residents rights have been or are being violated by staff or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Revised 4/6/22 Upon secondary review with Centers for Medicare and Medicaid Services (CMS) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of F804 was increased from a D to an E. Based on observation, resident interview, staff interview, a test meal tray, written grievances review, record review and facility policy review, the facility failed to serve food that was palatable and at an appetizing temperature to eight (8) of (52) residents reviewed for food palatability. Resident #18, Resident #19, Resident #22, Resident #23, Resident #27, Resident #32, Resident #34, and Resident #37. Findings include: The facility's policy titled, Quality and Palatability, revised 9/2017 revealed, Policy Statement: Food will be prepared by methods that can serve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served a safe and appetizing temperature .Definitions: . Food palatability refers to the taste and flavor of the food.…

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, record review, and facility policy review, the facility failed to provide a written notice of transfer to the Resident Representative (RR) for two (2) of two (2) residents reviewed. Resident #5 and Resident #24. Findings include: A record review of the facility Policy and Procedures with the Subject listed as Transfer/ Discharge Notification & Rights to Appeal, with a revision date of 3/26/2018 revealed, .Notice Before Transfer: Before a center transfers or discharges a resident the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reason for the move in writing (in a language and manner they understand) . Resident #5 Record review of the Transfer/Discharge Report revealed the facility admitted Resident #5 on 6/26/21. Record review of the Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 1/12/22 revealed Resident #5 was transferred to an acute hospital on 1/12/22. Record review of the nurse Progress Note dated 1/12/22 at 3:57…

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, record review and facility policy review, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for four (4) of 21 MDS reviewed. Resident #2, #3, #23, and #48. Findings include: Review of facility policy titled, Minimum Data Set (MDS), revised 9/25/17, revealed, .using the federal and/or state required RAI. Procedure .Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Resident #2 A record review of Resident #2's admission Record revealed the facility admitted Resident #2 on 9/11/18 with diagnoses including Schizophrenia, Unspecified Psychosis not due to a substance or known Physiological condition, Major Depressive Disorder, and Anxiety. A record review of Resident #2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/25/21 indicated a No response to question A-1500 which indicated Resident #2 did not have a serious mental illness. Resident #3 Review of the Transfer and Discharge Report for Resident #3 revealed an admission date of…

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

Based on observation, staff interview, record review and facility procedure review, the facility failed to properly clean a wound for one (1) of one (1) wound care observations. Resident # 205. Findings Include: Review of the facility's procedure, Dressings, Dry/Clean, undated, revealed Steps in the Procedure .15. clean from the least contaminated area to the most contaminated area (usually from the center outward) . On 1/19/22 at 3:45 PM, during an observation of wound care for Resident #205, Registered Nurse (RN) #1 did not wash or sanitize her hands between changing her gloves after she had removed the soiled dressing and before she cleaned the wound. RN #1 cleaned the wound bed by using moistened gauze in a circular motion beginning from the outer portion of the wound bed moving toward the center of the wound. RN #1 also did not wash or sanitize her hands between changing her gloves after she cleaned the wound and before she applied calcium alginate to the wound bed. On 1/19/22 at 4:07 PM, in an interview with RN #1, she stated she should have cleaned the wound from the center…

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 staff followed infection control measures during wound care for one (1) of one (1) resident observed for wound care. Resident # 205. Findings Include: Review of the facility's policy tilted, Policies and Practices - Infection Control, with a revision date of 10/2018, revealed Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe sanitary, comfortable environment to help prevent and manage transmission of disease and infection . Review of the facility's Policies and Procedures, dated 11/30/2014 revealed Subject: Handwashing .Policy: An essential component of infection control is handwashing . On 1/19/22 at 3:45 PM, during an observation of wound care for Resident #205, Registered Nurse (RN) #1 did not wash or sanitize her hands between changing her gloves after she had removed the soiled dressing and before she cleaned the wound. RN #1 cleaned the wound bed by using moistened gauze in a circular motion…

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.