Diversicare Of Tupelo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, record review, and facility policy review, the facility failed to honor residents' right to vote in the 2024 election for three (3) of six (6) residents sampled for resident's rights. Residents #4, #5, and #6 Findings Include: Record review of facility policy titled, Resident's Rights and Quality of Life, dated 5/1/12, revealed, It is the policy of (proper name removed) that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. A resident has the right to exercise his/her rights as a resident of the facility and a citizen or resident of the U.S. and be free of interference, coercion, discrimination, or reprisal by (proper name removed) or its employees for the exercise of such rights. During an interview on 1/16/25 at 11:10 AM, Resident #6 revealed she had told the staff several weeks before the 2024 presidential election that she wanted to vote with a mail-in…

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

Based on observation, resident and staff interviews, and record review, the facility failed to be administered in a manner that allowed it to use its resources effectively to ensure the well-being of its residents for four (4) of the four (4) days of the survey. Findings Include This tag is cross referenced to F 565, F 677, F 689, F 761, and F 880 A review of the typed statement on facility letterhead revealed that the facility did not have an Administration Policy and was signed by the Administrator. F 565 On 9/17/24 at 3:05 PM, during the resident council meeting held Resident #25 revealed that the food is terrible. She has complained about it in the resident council before, but nothing has improved. Resident #3 confirmed that they have complained about the food in resident council meetings every month and nothing is done. Resident #25 and Resident #50 stated that they never know when the resident council meeting is going to be each month because it is not put on the monthly activity calendar During an interview on 9/17/24 at 3:40 PM, with the Administrator confirmed that all…

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 Assessment (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 6/22/23. This was for deficiencies recited during a recertification survey on 9/16/24. The recited deficiencies included F 550, F565, F584, F656, F677, F689, F761, and F880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAA program. This was for eight (8) of 18 deficient practice citations. Findings Included: This citation is cross-referenced to: F 550, F 565, F 584, F 656, F 677, F 689, 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 organization to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving urinary catheter bags uncovered for two (2) of four (4) residents with a catheter. Resident #52 and Resident #190. Findings include: A review of the facility policy, Resident's Rights and Quality of Life dated 05/01/2012, revealed . all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. Resident #52 An observation on 09/16/24 at 9:25 AM and again at 10:25 AM, revealed Resident #52 lying in bed, with the bed against the right wall. Resident #52's urinary catheter bag and tubing were exposed with approximately 100 cc (cubic centimeters) of urine in the catheter bag with no privacy covering over the urinary drainage bag. An observation and interview on 09/16/24 at 3:15 PM with the Assistant Director of Nurses (ADON) revealed all urinary…

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 interview, record review and facility policy review the facility failed to ensure that all residents were made aware of the resident council meetings each month in order to make the choice to attend (Resident #27 and Resident #50) for two (2) of 16 residents reviewed. The facility also failed to resolve grievances for seven (7) of eight (8) resident council meetings. CROSS REFERENCE F804??????? Findings Include: Review of the facility policy titled Resident Council with an effective date of 5/1/12 revealed under Procedure .#4. Activity Director/SS Designee will provide written answers to questions, requests and grievances to the Resident Council. #5. The Activity Director/SS Designee shall communicate to all residents when and where resident council meetings are held . Record review of the Resident Council Meeting minutes confirmed that food concerns were discussed in the minutes for 9/24, 8/24, 7/24, 6/24, 5/24, 3/24 and 2/24. Food and menu concerns were mentioned and no resolution…

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, statement on facility letterhead and facility policy review, the facility failed to maintain a clean and safe environment, as evidenced by a dirty wheelchair, (Resident #71) and electrical wires exposed on a bed control (Resident #12) for two (2) of the 22 residents sampled residents. Findings Include: A review of the statement on facility on letterhead signed by the Administrator and dated September 18, 2024, revealed, (Proper Name) utilizes the Embrace Program for our wheelchair cleaning and inspection of bed controls and electrical connections. A review of the facility policy titled Resident's Right and Quality of Life, dated May 1, 2012, revealed, A resident has the right: to receive services in a facility environment that is safe, clean, and comfortable . Resident #12 On 09/16/24 at 10:10 AM, an observation revealed Resident #12's electric bed control in disrepair and laying beside her in bed on her right side. The cord was frayed, and it had an area that…

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

Based on observation, resident and staff interview, record review, facility policy review, the facility failed to implement a comprehensive care plan related to Activity of Daily Living (ADL) for Resident #58, Resident #59 and for Resident #22 for smoking . For three (3) of 22 care plans reviewed. Findings Include: Facility policy titled, Care Plans, with no date, revealed, Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #22 Record review of Resident #22's Care Plans with a date initiated of 5/29/21 revealed , Focus: At risk for smoking related injury related to: Smokes independently .Interventions .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Patient is not to have cigarettes or smoking material on person During an observation of Resident #22 on 9/16/24 at 10:00 AM,…

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, record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) care for a resident requiring nail care (Resident #58, #59) and incontinent care (Resident #7) for three (3) of 22 sampled residents. Findings Include: Review of the facility policy ADL's (Activities of Daily Living) dated August, 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. An observation on 9/17/24 at 8:15 AM, revealed Resident #7 was lying in bed with eyes open, alert but confused and it was noted a very strong odor of urine in the room. An observation and interview with Certified Nurse Aide (CNA) #7 on 9/17/24 at 8:18 AM, confirmed the strong odor of urine in the room and confirmed the resident was incontinent and explained that she had not made a round on the resident since her shift started at 7 AM. The CNA revealed the last round would have been done…

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 ensure that a residents' environment was free from accident hazards, as evidenced by, medications left at bedside and smoking paraphernalia in rooms for two (2) of 22 sampled residents. Resident #22 and #34 Findings include: Review of the facility policy titled Safe Smoking with an effective date of 11/1/16 revealed under, Purpose: 1. To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents . Record review of a typed statement on facility letterhead, dated September 17, 2024, and signed by the Administrator revealed (Proper name of the facility) does not have a policy for Medication Left at Bedside. The center utilizes the Medication Administration Clinical Competency. An observation of Resident #22 on 9/16/24 at 10:00 AM, revealed he was lying in bed. with a cigarette box lying at the foot of the bed in a white and blue pack. Resident #22 revealed he was a smoker and stated, They don't let us keep…

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 medications were stored securely in a locked medication cart or locked storage room for two (2) of four (4) medication carts used in the facility. Findings Include Record review of a typed statement on facility letterhead, dated September 18, 2024 and signed by the Administrator revealed (Proper name of facility) does not have a policy for Storage of Medications on top of the medication cart. An observation on 9/16/24 at 9:04 AM, revealed an unattended medication cart sitting outside the dining room near the beginning of the B Hall. The top of the cart contained a medicine cup full of a red liquid, a bottle of magnesium, Colace and calcium sitting on the top of the medication cart. An observation and interview on 9/16/24 at 9:06 AM, with the Assistant Director of Nurses (ADON) confirmed there was a medicine cup full of a red liquid, and three bottles of over-the-counter medication that included magnesium, Colace and a bottle of calcium. She stated that medication should never be left…

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, record review and facility policy review, the facility failed to fully implement Enhanced Barrier Precautions (EBP) precautions and failed to follow infection control measures while providing resident care for two (2) of four (4) survey days that had the potential to affect 11 residents on EBP and Resident #2 and Resident #20. Findings Include Review of the facility policy titled, Policies and Practices - Infection Control with an effective date of 11/1/17 revealed .Policy Statement: This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Record review of a typed statement on facility letterhead, dated September 18, 2024 and signed by the Administrator, revealed (Proper name of facility) uses the CDC (Centers of Disease Control) guidelines for the implementation of Enhanced Barrier Precautions. An observation of the facility on 09/16/24 from 10:00 AM until 11:30 AM revealed there was one…

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, meal ticket review, and facility policy review, the facility failed to honor a resident's choice for sweet tea with meals for one (1) of twenty-two sampled residents. Resident #44 Findings Include: Review of the facility policy titled Resident's Rights and Quality of Life with a revision date of 5/1/12 revealed under, Policy Statement: It is the policy of (Proper Name) that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. An interview with Resident #44 on 9/16/24 at 11:06 AM revealed, she wanted sweet tea with meals, and it had been over a month since she had gotten it. She stated she had told them, but they keep sending unsweet tea and she just cannot drink it. An observation and interview with Resident #44 on 9/16/24 at 12:42 PM revealed, she received a glass of tea with her lunch meal. The resident revealed the tea was unsweet. The meal ticket provided with the lunch tray dated 9/17/24 read, Sweetened Iced Tea- 8 oz…

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 and resident interviews, record reviews, and facility policy reviews, the facility failed to ensure advance directives were addressed or correct for three (3) of the 22 sampled residents. Resident #43, Resident #63, and Resident #84 Findings Included: Record review of facility policy titled, Advance Directives, dated [DATE], revealed, Policy Statement, (Proper Name) recognizes the dignity and value of each Resident's right to make health care decisions and to be fully informed of his or her complete health status. Furthermore, (Proper name) recognizes the right of each Resident to issue Advance Directives regarding his or her health care . 8. (Proper name) will provide education and training to its staff regarding its policies and procedures regarding Advance Directives. Resident #43 Record review of Resident #43's Mississippi Physician Orders for Sustaining Treatment (POST) for Advance Directives dated [DATE] revealed Do Not Resuscitate (DNR). The resident did not sign his Advance Directive 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.

Based on observation, staff interview and facility policy review the facility failed to ensure resident information was kept confidential and not accessible to the public for one (1) of four (4) survey days. Findings Include: Review of the facility policy titled, Resident Rights and Quality of Life with an effective date of 5/1/2012 revealed under, The resident has the right to .personal privacy and confidentiality of personal and clinical records. An observation on 9/16/24 at 9:04 AM, revealed a medication cart sitting outside the dining room door leading to the B Hall with a visible list of resident names, room numbers, code status and if they were on hospice or dialysis laying on top of the medication cart for anyone to see. An interview and observation on 9/16/24 at 9:06 AM, with the Assistant Director of Nurses (ADON) confirmed the resident list of names was visible on top of the medication cart and would be a violation of the resident's privacy. She stated that the nurse should have put it away so that it could not be seen. She revealed the medication cart was Licensed…

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 ensure that a new employee had a background check completed prior to working for one (1) of five (5) new employee personnel records reviewed. Findings Include: Review of the facility policy titled, (Facilities Proper Name) Background Check Policy with a revision date of 2/13/17 revealed under, Policy .It is the policy of (Facilities Proper Name) Management Services, as part of its hiring procedures, to conduct criminal background checks on all applicants offered employment to support workplace productivity, safety and security. Record review of Registered Nurse (RN) Unit Manager's personnel file revealed she was hired by the facility on 8/13/24 and her background check was completed on 6/10/22 and was outdated. An interview on 9/19/24 at 11:10 AM, with the Administrator confirmed that new staff's background checks have to have been done within the last two years. She stated we have called to see if we could get a more up to date one but have not received an answer. An interview on 9/19/24 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.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure that a resident's comprehensive care plan was revised and updated for one (1) of 22 sampled residents. Resident #33 Findings Include: Record review of the facility policy titled, Care Plans with a revision date of 10/21 revealed under, Policy: . Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. An observation of Resident #33 on 9/16/24 at 9:38 AM and on 09/17/24 at 8:30 AM revealed, she was lying in bed with a raised perimeter air mattress intact to the bed. An interview with the Director of Nursing (DON) on 9/17/24 at 10:30 AM revealed, Resident #33 had a raised perimeter air mattress to keep her from rolling out of the bed. Record review of Resident #33's Fall Care Plan revealed, the care plan was not revised to add the secured perimeter air mattress. An interview with the Administrator (ADM) on 9/18/24 at 2:40 PM, revealed the purpose of the care plan was to provide the necessary…

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 interview, record review, and facility policy review, the facility failed to follow nursing standards of practice for a resident with a physician order for intravenous (IV) antibiotics for one (1) of 22 sampled residents. Resident #20 Findings Include: Record review of a typed statement on facility letterhead, dated September 19, 2024, and signed by the Administrator revealed (Proper name of facility) does not have a policy on Standards of Practice. Record review of the August 2024 Medication Administration Record (MAR) for Resident #20 revealed, an order dated 8/4/24, Meropenem Intravenous Solution Reconstituted 500 MG (milligrams) use 500 MG (milligrams) intravenously every day shift for infection Urinary Tract Infection (UTI) for 5 (five) days in sodium chloride 0.9% (percent) 100 ml (milliliters) IVPB (intravenous piggyback). The MAR was initialed as administered on 8/5/24 and 8/7/24, with no documentation to support medication was administered on 8/6, 8/8, and 8/9 with the MAR left blank. An interview with Resident #20 on 9/19/24 at 8:35 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.

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 were properly assessed and consent obtained for bed rails for two (2) of 22 sampled residents. Resident #33 and #60 Findings Include: Record review of the Facility policy titled, Restraint with an effective date of 11/28/16 revealed Process: . When a patient/resident is determined to need a restraint, an evaluation will be completed at least on a quarterly basis or with a significant change in the patients/residents condition. This evaluation will assist in determining continued need or possible reduction/elimination . Resident #33 An observation of Resident #33 on 9/16/24 at 9:38 AM, revealed, she was lying in bed, arousable with one-half (1/2) side rails that were up on both sides of the bed and a raised perimeter air mattress was intact to the bed. An observation on 9/17/24 at 8:30 AM, revealed Resident #33 was lying in bed with her eyes closed with one-half (1/2) side rails up on both…

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 serve food that met the residents' choices and failed to serve the food in an attractive and palatable manner for four (4) of twelve residents reviewed for dining. Resident #20, #27, #43, and #50. Findings Include: CROSS REFERENCE F565 Record review of the facility policy Menus revised 10/2022 revealed Menus will be planned in advance to meet the nutritional needs of the residents .6. Menus will be served as written, unless a substitution is provided in response to preference . Resident #20 An interview on 9/16/24 at 10:57 AM, with Resident #20 revealed, she did not like the food that she was served. An observation of the lunch meal on 9/16/24 at 12:50 PM revealed, Resident #20's meal ticket read, Renal and listed the foods as, Baked chicken breast on a bun, grilled cheese sandwich, garden pasta salad, green peas, apple crisp, soup, unsweetened tea 8 ounces. The food on the tray was untouched,…

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 ensure that a resident was treated with dignity when she asked for assistance with toileting and a staff member refused for one (1) of eight (8) residents reviewed. Resident #1. Findings Include: Record review of the facility policy, Resident's Rights and Quality of Life dated May 1, 2012, revealed It is the policy of Advocate that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility . On 06/11/24 at 10:30 AM, an observation and interview with Resident #1 revealed her sitting in a wheelchair propelling herself in her room. She revealed that she was not able to walk, that she wore briefs and required help to use the bathroom. She revealed that she pressed the call light when she needed her brief changed and they usually came within a few minutes. Resident #1 stated, I'm so tired of pissing my clothes. Resident #1 revealed that when she asked for help to the…

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

Based on observation, interview, record review and facility policy review the facility failed to implement Activities of Daily Living (ADL) care plans for two (2) of eight (8) residents reviewed. Resident #1 and Resident #8. Findings Included: Record review of the facility policy, 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 #1 Record review of Resident #1's Comprehensive Care Plan initiated on 09/22/2023 revealed that she had a self-care deficit related to decreased functional abilities, weakness and had interventions that included extensive assistance with personal hygiene and to provide cueing, supervision, and assistance with ADLs as needed. An observation and interview with Resident #1 on 06/12/24 at 10:20 AM revealed facial hair, one approximately two (2) inches long on her left lower jaw and there…

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 facility policy review the facility failed to provide oral care for a resident (Resident #8) and failed to shave residents (Resident #1 and Resident #8) for two (2) of eight (8) residents reviewed. Findings Include: Record review of the facility policy, ADL's (Activities of Daily Living) dated August 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodations of the resident's choices and preferences . RESIDENT #1 On 06/12/24 at 10:20 AM, an observation and interview with Resident #1 revealed facial hair, one approximately two (2) inches long on her left lower jaw and there was an area approximately three inches by three inches with scattered black hairs that measured approximately one-half inch to three-fourths inch on her lower chin. Resident #1 revealed that she didn't like to have facial hair and wanted it gone. She revealed that the Certified Nursing Assistants (CNAs) had shaved it before but hadn't lately. She stated, I don't like to have…

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 ensure that a comprehensive care plan was implemented for one (1) of nine (9) residents reviewed for Activities of Daily Living (ADLs). Resident #1 Findings Include: Record review of the facility policy, MDS (Minimum Data Set) and Care Plans with effective date of August, 2019 revealed,Policy: Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of Resident #1's Care Plan initiated on 05/11/2023 revealed Focus: Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, pain, weakness .Interventions . Assist with bathing as needed . Nail, hair, and oral care daily and as needed. Observe skin for alterations in skin integrity during baths and ADL (Activities of Daily Living) care - report to nurse as needed . During a phone interview on 02/08/24 at 12:50 PM, with Resident #1's Resident Representative (RR) revealed that the care at the facility was pretty good, but that they sometimes left…

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, family, and staff interviews, record review, and facility policy review the facility failed to ensure that a resident received her scheduled baths in January and failed to provide nail care for one (1) of nine (9) residents reviewed for Activities of Daily Living (ADLs). Resident #1 Findings Include: Record review of the facility policy titled, ADL's (Activities of Daily Living), with effective date August 2021, revealed Policy: Ensure ADLs (Activities of Daily Living) are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences . On 02/07/24 at 10:30 AM, an observation and interview with Resident #1, revealed her lying in bed in her room. Resident #1's right hand was closed tightly and resting on the bed down by her side. Resident #1 revealed that she normally got a bath every other day but had missed a few baths over the last few weeks and revealed that they washed her hair about once a week. On 02/08/24 at 12:50 PM, a phone interview with Resident #1's Resident…

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

Based on observation, resident and staff interviews the facility failed to provide enough staff to meet the needs of the residents for four (4) of 4 days of survey. Findings include: The facility Administrator provided a statement on 6/23/23 that the facility follows the state regulations for 2.8 staffing ratio and they do not have a policy to staff according to acuity level. An interview on 06/19/23 at 12:45 PM, with Resident #6 on the A hall revealed the resident stated he was wet. He stated that he had not been changed since the night shift. An observation on 6/19/23 at 12:48 PM revealed Licensed Practical Nurse (LPN) #4 and Certified Nursing Assistant (CNA) #3 provided incontinent care to Resident #6. The resident's brief was saturated with dark yellow colored urine and CNA #3 stated the resident's brief should not be that wet. She stated that he should have already been changed and that they get here and start checking residents and then the trays come out, so they have to stop and pass the meal trays out. She stated she had to help change out a mattress on a bed. She stated…

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 resident interview, and facility policy review, the facility failed to promote the dignity of a resident as evidenced by failure to change a brief when wet for one (1) of sixty-seven residents with incontinence. Resident #6 Findings include: Review of the facility policy, undated, titled Your Resident Rights and Protection Under State and Federal Law, revealed as a resident of a nursing home, you have the same rights and protections as all United States citizens. Nursing home residents also have certain rights and protection under state and federal law. Under Quality of Life, it was revealed that a nursing home must care for you in a manner and environment that promotes the maintenance and enhancement of your quality of life. Under Dignity and Respect, you have the right to be treated with consideration and respect in full recognition of your dignity and individuality. During an interview, on 06/19/23 at 12:45 PM, Resident #6 stated he was wet and that he had not been changed since the night shift. An observation and interview on 6/19/23 at 12:48 PM…

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 maintain call lights within reach of the resident for two (2) of twenty-six residents reviewed. Residents #6 and Resident #20 Findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, undated, revealed the purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow the residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy explanation and compliance guidelines reveal each resident will be evaluated for unique needs and preferences to determine special accommodation that may be needed in order for them to utilize the call system. Call light is within reach of the resident and secured as needed. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, 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 resident and staff interviews, record review and facility policy review the facility failed to resolve a resident grievance in a timely manner for five (5) of 17 residents reviewed for unresolved grievances in the resident council meeting. Resident #26, 38, 51, 55 and 80 Findings Include Review of the facility policy titled, Customer Concern Grievance Policy with a revision date of July 2018 revealed under Purpose .Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. The goal is to encourage open communication of customer concerns in an environment free from reprisal, retaliation, or discrimination. We have a commitment to customer service and have systems in place to address concerns. Our Grievance Official is the center Administrator. The Grievance Officials contact information, including phone number and email…

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, and facility policy review, the facility failed to create a clean and safe environment as evidenced by a dirty wheelchair and black substance on a resident's refrigerator for two (2) of 26 residents sampled. Resident #26 and #77. Findings include: A review of the facility policy on letterhead dated June 22, 2023, revealed, (Proper Name) utilizes the EMBRACE guideline to manage cleaning of equipment . Observation to review .Access wheelchairs for cleanliness. An interview and observation on 06/20/23 at 4:30 PM, Resident #26 voiced concern about his wheelchair not being cleaned. He revealed he takes a napkin and tries to clean it off but doesn't think it has ever been cleaned. The wheelchair had a thick black and gray substance on the frame and the spokes of the wheels. An interview on 06/21/23 at 8:15 AM, with the Director of Nurses (DON) revealed the nurses and Certified Nursing Assistants (CNAs) are supposed to clean the wheelchairs on the 11 PM-7 AM shift.…

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 interview, record review and facility policy review the facility failed to send a written transfer/discharge notice to a resident or resident representative for a hospital transfer for one (1) of five (5) residents reviewed for hospitalization. Resident #84 Findings Include: Review of the facility policy titled, Transfer & Discharge with a revision date of November 1, 2016, revealed under Notice Requirements .#4 Before (Proper name of the facility) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman. Record review of Resident #84's electronic record revealed there was no discharge/transfer notice for the resident's hospital stay on 5/1/23. An interview on 6/20/23 at 1:30 PM, with the Administrator confirmed that Resident #84 was discharged to the hospital on 5/1/23 and did not have a discharge/transfer notice…

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 interview, record review and facility policy review the facility failed to notify the resident or resident representative of the bedhold amount for a hospital discharge for one (1) of five (5) residents reviewed for hospitalization. Resident #84 Findings Include Review of the facility policy titled, Bed Hold Policy with a revision date of November 1, 2016 revealed under Policy Statement .(the facilities proper name) will, in accordance with Federal and State regulations, hold a Resident's bed during a temporary hospitilazation or therapautic leave. This review revealed under Procedure .#1 Before the Center transfers a Resident to a hospital or the Resident goes on therapeutic leave, the Center shall provide Resident or his or her Resident Representative this Bed Hold Policy. Record review of Resident #84's electronic record revealed there was no bedhold notice for the resident's hospital stay on 5/1/23. An interview on 6/20/23 at 1:30 PM, with the Administrator confirmed that Resident #84 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 staff interviews, facility policy review and record review the facility failed to develop or implement a care plan for four (4) of 26 care plans reviewed. Resident #6, 20, 25, 30. Findings include: Review of the facility policy, titled, Care Plans, revealed care plans will be developed for all residents based upon 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 #6 Record review revealed a care plan in place for Resident #6 with a focus of alteration in elimination related to bladder and bowel incontinence with an intervention to check and change every two (2) hours and prn (as needed). Record review revealed a care plan in place for Resident #6 related to risk for fall and an intervention to place call light in easy reach on right side. An interview on 06/19/23 at 12:45 PM revealed Resident #6 stated he was wet and that he had not been changed since the night…

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 observations, resident and staff interviews, facility policy review, and record review the facility failed to provide care to maintain hygiene as evidenced by failure to provide shower, and nail care for two (2) of twenty-six residents reviewed. Resident #25 and Resident #30. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs) revealed under, Policy: . Care and services will be provided for the following Activities of Daily living: 1. Bathing, dressing, grooming, and oral care; . Also revealed under, Policy Explanation and Compliance Guidelines: .3. 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. Resident #25 An observation on 06/19/23 at 10:55 AM, of Resident #25's nails revealed long nails on both hands with a brown substance underneath, fingers bent inwards toward palms and nails were impressed into the skin in the palms. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and facility policy review the facility failed to ensure the safety of resident as evidenced by failure to secure smoking materials for one (1) of 18 smokers in the facility. Resident #57. Findings include: A review of the facility policy titled, Safe Smoking with an effective date of November 1, 2016, revealed, Purpose .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents. Procedure .4. Staff members will monitor or obtain fire-igniting materials (matches/lighters) for the benefit of smokers at the nurses' station or other designated location . 5. Tobacco materials (cigarettes/cigars/chewing tobacco/snuff/electronic smoking devices) themselves, in addition to fire igniting materials, may have increased control or be removed if smoking policy violations have occurred or as a general safety policy for all residents . An observation and interview on 06/19/23 at 02:55 PM,…

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 the facility failed to provide incontinent care in a timely manner to a resident that was incontinent for one (1) of sixty seven incontinent residents. Resident #6. Findings include: An interview, on 06/19/23 at 12:45 PM, revealed Resident #6 stated that he was wet. He stated that he had not been changed since the night shift. The State Agency (SA) informed Licensed Practical Nurse (LPN) #4 the resident needed assistance. Resident #6 told LPN #4 that he was wet and not been changed since the night shift was there. LPN #4 requested Certified Nursing Assistant (CNA) #3 to assist with incontinent care. An observation, on 6/19/23 at 12:48 PM, revealed LPN #4 and CNA #3 provided incontinent care to Resident #6. The resident's brief was saturated with dark yellow colored urine. CNA #3 stated the resident's brief should not be that wet and that he should have already been changed. CNA #3 confirmed that she was assigned to Resident #6 and stated they get here and start checking residents and then the trays come out, so they have to stop…

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, facility policy review, the facility failed to store controlled medications in a separately locked permanently affixed compartment in the medication room refrigerator for one (1) of (1) medication storage rooms observed. Findings include: Record review of the facility policy titled Controlled Substances revealed, . Medications listed in Schedules II, III, IV and V shall be stored under double lock Charge nurse shall maintain possession of the key(s) to controlled substances secured in the medication room refrigerator including individual resident/patient refrigerated controlled substances emergency drug kit medications requiring refrigeration An observation and interview on 6/21/23 at 7:55 AM, of the medication storage room with Licensed Practical Nurse (LPN) #2 revealed that the facility had a refrigerator that stored controlled substances that must be refrigerated. The State Agency (SA) observed a pad lock on the refrigerator handle. An observation inside the refrigerator revealed a small black lock box that was removed by LPN #2 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by failure to use a barrier during medication administration of a respiratory inhaler, for one (1) of 37 medications observed. Resident #9 Findings include: Record review of a typed document dated 6/22/23 and signed by the facility Administrator revealed Re: Barrier Usage with Medication Pass . We utilize both [NAME] & [NAME]. 8th Edition, Clinical Nursing Skills and Techniques and Clinical Nursing Skills & Techniques, Skills Performance Checklist as our resource guide for clinical standards. Record review of the PERFORMANCE CHECKLIST SKILL 21-1- ADMINISTERING ORAL MEDICATIONS revealed .IMPLEMENTATION: 1 .c. Arranged medication tray and cups in preparation area or on cart outside of room . An observation on 06/21/23 at 9:05 AM, of Licensed Practical Nurse (LPN) #1 while preparing medications for Resident #9 revealed she placed an albuterol inhaler on the surface…

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.