Biltmore Haven Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to perform activities of daily living (ADL) care for a resident (Resident #30). This was for 1 of 11 residents reviewed for (ADL) care. Findings included: Resident #30 was admitted on [DATE] with diagnoses that included Parkinson's disease. A review of Resident #30's care plan dated 5/2/24 found he had a care plan for activities of daily living (ADL) self-care performance deficit related to generalized muscle weakness and impaired mobility. Interventions included improved level of function in ADL performance through next review date, clean, check nail length and trim on bath days. An additional intervention included revealed Resident #30 required set-up or clean-up assistance with personal hygiene. A review of Resident #30's quarterly Minimum Data Set (MDS) assessmnet dated 1/28/25 coded him as cognitively intact. Resident #30 had impairment to both sides for upper and lower extremities, needed maximum assistance with bathing, 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 observations, record review, resident and staff interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen and ensure the physician order included the oxygen flow rate (amount of oxygen administered in liters per minute) and delivery method (nasal cannula) for 1 of 1 resident reviewed for respiratory care (Resident #73). Findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (difficulty breathing). A physician's order dated 04/25/25 for Resident #73 read, respiratory: oxygen-continuous. The physician order did not indicate the oxygen flow rate to be administered or directions or how the oxygen was to be delivered, such as nasal cannula. The Brief Interview for Mental Status (BIMS) assessment (tool used to gauge an individual's cognition) dated 04/25/25 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 observations, record review, and staff interviews the facility failed to assess a resident for risk of entrapment prior to installing and/or using bed rails for 1 of 4 sampled residents reviewed for accidents (Resident #18). Findings Included: Resident #18 was admitted to the facility on [DATE]. Her cumulative diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebrovascular disease (conditions that affect blood flow to the brain) affecting the left dominant side, left knee contracture and chronic pain. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. She had impairment on one side of the lower extremity, was dependent on staff for assistance with bed mobility and did not use bed rails during the MDS assessment look-back period. During an observation and interview on 04/27/25 at 11:20 AM, quarter bed rails were observed in the upright position on each side…

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

Based on record review and staff interviews, the facility failed to have a system in place to ensure Nurse Aides (NA) were able to demonstrate the competency and skills necessary for providing care to meet the individual care needs of residents' that included hand hygiene during incontinence care for 3 of 5 employee files reviewed (NA #2, NA #3 and NA #4). On 04/30/25, NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment after providing incontinent care to a dependent resident. Findings included: This tag is crossed referenced to: F 880: Based on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse Aide (NA) #3 did not don (put on) a gown while providing urinary catheter (a tube that drains urine out of the body) care to Resident #65 who required enhanced barrier precautions (EBP) due to the presence of a urinary catheter and failed to follow their Hand Hygiene policy when NA #3 did not remove soiled gloves and perform…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records by not documenting when residents admitted to the facility, discharged from the facility or expired at the facility for 3 of 23 sampled residents (Residents #73, #71, and #72). Findings included: 1. The profile page in Resident #73's electronic medical record revealed she was admitted to the facility on [DATE]. Review of the staff progress notes for Resident #73 revealed no entry on [DATE] regarding her admission to the facility, such as the time of her arrival, condition or care needs. An unsuccessful telephone attempt was made [DATE] at 2:43 PM to interview Nurse #2 who had provided Resident #73's care on [DATE]. During an interview on [DATE] at 9:14 AM, the Director of Nursing (DON) stated she would have expected for the nurse to have written a progress note when Resident #73 admitted to the facility that included details such as the time she arrived to the facility and her condition upon…

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, record review, and staff interviews the facility failed to implement their infection control policies when Nurse Aide (NA) #3 did not don (put on) a gown while providing urinary catheter (a tube that drains urine out of the body) care to Resident #65 who required enhanced barrier precautions (EBP) and failed to follow their Hand Hygiene policy when NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #65. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (NA #3). Findings included: Review of the facility's Hand Hygiene policy last revised 02/05/21 read in part as follows: The CDC [Centers for Disease Control] defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel). Hand Hygiene should be performed before initiating a clean procedure,…

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

Based on record review, observations, and staff interviews the facility failed to: 1) maintain a clean and sanitary kitchen; 2) failed to remove gloves and perform hand hygiene after handling dirty dishes; 3) failed to date opened food items stored in the walk-in refrigerator ready for use; 4) failed to discard thickened juice by the date it could no longer be used; and 5) failed to seal and date an open bag of cereal for 1 of 1 kitchen. These practices had the potential to affect ninety-one (91) residents who resided in the facility. Findings included: The initial walk-through observation of the kitchen was conducted on 2/26/24 from 9:05 AM through 10:06 AM with the Dietary Manager (DM). The observations revealed the following: 1 a. During an observation on 2/26/24 at 9:14 AM a metal table with sliding cabinet doors used to store hot and cold beverage serving containers appeared dirty. The tracks on the metal table used to open and shut the cabinet doors had a thick buildup of black colored debris all along the tracks and the inside of the cabinets had crumb-like and paper debris…

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, record reviews and staff interviews, the facility failed to ensure a resident's toenails were trimmed for 1 of 3 sampled residents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and edema. A physician's order dated 09/27/23 for Resident #1 read, Podiatry as needed. A review of Resident #1's Activities of Daily Living (ADL) care plan, last revised on 12/04/23, addressed an ADL self-care performance deficit related to dementia. Interventions included: requires partial to moderate staff assistance with personal hygiene, staff to check nail length, trim and clean on bath day and as necessary, and report any changes to the nurse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 required partial to moderate staff assistance with bathing and personal hygiene and displayed no rejection of care during the MDS assessment period. During an…

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

Based on record review, observations, and interviews with staff the facility failed to store an unopened insulin pen in the refrigerator until needed for use for 1 of 4 medication carts (200/300 Hall medication cart) and failed to remove medicated mouthwash by the date it was to be discarded from 1 of 1 medication refrigerator reviewed for medication storage. Findings included: 1. Review of manufacturer's package insert recommended to store unused (unopened) insulin aspart in a refrigerator between 36°F to 46°F and in-use (opened) insulin at room temperature for 28 days. An observation of the 200/300 Hall medication cart was conducted with the Unit Manager (UM) on 2/26/24 at 3:54 PM. Stored on the medication cart and available for use was an unopened insulin aspart (fast-acting) pen. There was no date on the insulin pen to indicate when it was placed on the medication cart. During an interview on 2/26/24 at 3:54 PM the UM revealed the insulin aspart pen should be kept in the designated medication refrigerator until needed for use. She stated the nurses were expected to label the pen…

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, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on [DATE]. This was for a repeat deficiency in the area of label/store drugs and biologicals that was originally cited during the recertification survey completed on [DATE] and subsequently recited during the revisit and complaint investigation completed on [DATE]. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F761: Based on record review, observations, and interviews with staff the facility failed to store an unopened insulin pen in the refrigerator until needed for use for 1 of 4 medication carts (200/300 Hall medication cart) and failed to remove medicated mouthwash by 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 record review and interviews with staff, Nurse Practitioners and the Medical Director, the facility failed to have systems in place to prevent a delay in obtaining mental health services for 1 of 3 residents reviewed for behavioral and emotional status (Resident #19). The findings included: Resident #19's medical record contained a Preadmission Screening Resident Review (PASRR) Level II dated 8/23/23. The notification indicated that the resident's placement in a nursing facility was appropriate with a recommendation for resident to attend individual or group psychotherapy. The hospital Discharge summary dated [DATE] revealed Resident #19 was admitted to the hospital for suicidal ideation and urinary tract infection. She received antibiotics and was referred to a psychiatric provider. Psychiatry determined that Resident #19's suicidal thoughts/comments were due to grief about being lonely and not having anyone to care for her. Resident #19 also had diagnoses of bipolar disorder, depression, and anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 5 sampled residents reviewed for unnecessary medications (Residents #61). The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. A physician's order dated 11/15/23 indicated Resident #61 had an order to receive 1 tablet of Ativan 0.5 milligram (mg) by mouth once every 8 hours as needed for agitation. This active order did not have a stop date and the rationales for extended therapy beyond 14 days were not found in Resident #61's medical records. A review of the medication administration record (MAR) revealed Resident #61 had received 4 doses of PRN Ativan in November, 8 doses in December 2023, and 1 dose in January 2024 on 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 record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to prevent a significant medication error when nursing staff failed to follow physician's parameter as ordered during insulin and blood pressure medication administration. As a result, Resident #61 had received 6 doses of unnecessary Novolin insulin and 4 doses of blood pressure medication within 24 days. This affected 1 of 5 residents reviewed for unnecessary medications (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) and high blood pressure. A physician's order dated 11/11/23 indicated Resident #61 had an order to receive 1 tablet of metoprolol (blood pressure drug) 25 milligrams (mg) via percutaneous endoscopic gastrostomy (G tubes) 2 times daily for high blood pressure. The order set a parameter to hold the metoprolol if systolic blood pressure was less than 100 or pulse less than 60. 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 interviews, and record reviews, the facility failed to secure an opened tube of antifungal cream for 1 of 1 Resident (Resident #61) reviewed for medication storage, failed to record opening date for 3 opened insulin pens in 1 of 4 medication carts (500 Hall medication cart), and failed to remove expired over the counter (OTC) medications in accordance with the manufacturer's expiration date for 1 of 4 medication carts (500 Hall medication cart) and 1 of 1 medication room observed during medication storage checks (Main medication room). The findings included: a. During an observation conducted on 01/08/24 at 12:17 PM, an opened tube of antifungal cream containing approximately 100 grams of 2% miconazole nitrate was found left unattended on top of the over-bed table next to Resident #61's bed. Resident #61 was not in the room during the observation. An interview was conducted with Nurse #5 on 01/08/24 at 12:21 PM. She stated she had not been to Resident #61's room in the morning as she had administered her morning medications in the hallway. She denied…

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, and resident and staff interviews, the facility failed to provide snacks for 7 out of 7 residents that requested bedtime snacks (Resident #67, #34, #65, #5, #10, #60, #74). The findings included: During a resident council meeting on 1/10/24 at 2:08 PM, the residents in attendance (Resident #67, #34, #65, #5, #10, #60, #74) all complained about not always receiving snacks at bedtime or whenever they requested some. Resident #60 stated she could ask for a snack whenever she needed them, but the dietary staff did not always remember to refill the snack room and there were not a lot of choices or variety in the snacks that they had. Resident #60 stated this concerned her especially at bedtime when she needed to eat a snack because she was a diabetic and they didn't have any snacks available in the nourishment room. Resident #34 voiced agreement and stated that this happened all the time. He added that the snack drawer was empty from the night before and the staff didn't have any snacks to give out to the residents. An observation on 1/10/24 at 2:30 PM with Nurse…

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, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on 06/24/22 and the complaint investigation survey conducted on 05/03/23. This was for a repeat deficiency in the area of accident hazards/supervision/devices that was originally cited on 06/24/22 during the recertification survey, and subsequently recited during the complaint investigation survey completed on 05/03/23, and recertification survey completed on 01/16/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F 689 - Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with…

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

Based on record review and staff interviews, the facility failed to provide behavioral health training that included the competencies and skills necessary to provide care for residents with substance use disorder for 9 of 9 nursing staff (Nurse Aide #3, Nurse Aide #6, Nurse Aide #5, Nurse Aide #7, Nurse Aide #9, Nurse Aide #10, Nurse Aide #8, Nurse #3 and Unit Manager) reviewed for education requirements. The findings included: Education records from 2/1/23 to 12/12/23 provided by the Administrator were reviewed for the following nursing staff: Nurse Aide (NA) #3: There was no behavioral health training recorded on the education records. NA #6: There was no behavioral health training recorded on the education records. NA #5: There was no behavioral health training recorded on the education records. NA #7: There was no behavioral health training recorded on the education records. NA #9: There was no behavioral health training recorded on the education records. NA #10: There was no behavioral health training recorded on the education records. NA #8: There was no behavioral health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to have accurate advanced directive information documented throughout the medical record for 1 of 5 residents reviewed for code status (Resident #81). The findings included: A yellow Do Not Resuscitate (DNR) form dated 12/13/23 was noted in Resident #81's electronic health record. Resident #81 was admitted to the facility on [DATE]. A pink Medical Orders for Scope of Treatment (MOST) form dated 12/17/23 was in Resident #81's electronic health record and in the MOST forms book at the nurses' station. This form indicated to attempt resuscitation when Resident #81 had no pulse and was not breathing. The form was signed by the Nurse Practitioner on 12/17/23 and by Resident #81 on 12/17/23. The Medical Director's History and Physical written on 12/21/23 indicated Resident #81's code status was Do Not Attempt Resuscitation (DNR/no Cardiopulmonary Resuscitation). The Medical Director wrote that Resident #81…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and staff interviews, the facility failed to develop and implement an individualized person-centered care plan that addressed substance use disorder for 1 of 3 sampled residents with a known history of substance abuse (Resident #52). The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, cervical intraspinal abscess due to history of intravenous drug use, and opioid dependence with other opioid-induced disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact and had no behaviors. The MDS further indicated Resident #52 received antipsychotic, antianxiety, antidepressant, opioid and antiplatelet medications. Resident #52's care plan last reviewed on 12/20/23 indicated Resident #52 had an ADL self-care performance deficit, hypotension (low blood pressure), was at risk for falls, had anemia, was on antipsychotic therapy, used anti-anxiety medications, used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #61). The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. A physician's order dated 11/15/23 indicated 1 tablet of Ativan 0.5 milligram (mg) by mouth once every 8 hours as needed for agitation was ordered for Resident #61. This active order did not have a stop date and the rationales for extended therapy beyond 14 days were not found in Resident #61's medical records. A review of the medication administration record (MAR) revealed Resident #61 had received 4 doses of PRN Ativan in November, 8 doses in December 2023, and 1 dose in January 2024. A review of medical records revealed the Consultant…

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, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on 6/24/22 and the complaint investigation survey conducted on 5/3/23. This was for a repeat deficiency in the area of infection control that was originally cited on 6/24/22 during the recertification survey, and subsequently recited during the complaint investigation surveys completed on 5/3/23 and 12/28/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F880 - Based on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations 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 record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing a soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations on 2 of 2 residents reviewed (Resident #2 and Resident #3). The findings included: The facility's policy entitled Hand Hygiene Policies and Procedures which is part of their Infection Control Policies and Procedures last revised on 2/5/21 indicated that hand hygiene should be performed: * After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings. * When hands are moved from a contaminated body site to a clean body site during patient care. * After glove removal. a. An observation of wound care by Nurse #1 was made on 12/28/23 at 10:07 AM. Nurse #1 rubbed hand sanitizer to both hands and put on gloves. She removed the old dressing which included a packing on Resident #2's buttock wound. The old dressing including the packing had moderate…

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, record reviews, and staff interviews, the facility failed to establish and implement infection control policies and procedures to reduce the risk of growth and spread of Legionella in the building water systems which could affect 83 out of 83 residents. In addition, the facility failed to implement infection control policies and procedures when the Staff Development Coordinator failed to perform hand washing after the removal of gloves during wound care for 1 of 1 sampled resident (Resident #44) and when 1 of 7 Nurse Aides (NA #5) and the Staff Development Coordinator (SDC) failed to perform hand washing after the removal of gloves following the transfer of 1 of 1 resident (Resident #56) observed during a mechanical lift transfer. These failures occurred during a global pandemic. The findings included: 1. Review of the facility's Emergency Preparedness plan revealed no information related to a facility water safety management program to minimize the risk of transmission of Legionella Disease to the residents, staff, and visitors by testing the water. In an…

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 and staff interviews the facility failed to properly label and store personal items for 2 of 36 bathrooms (bathrooms of room [ROOM NUMBER] and room [ROOM NUMBER]), maintain clean and sanitary walls for 1 of 36 bathrooms (bathroom room [ROOM NUMBER]), maintain walls in good repair for 1 of 54 rooms (room [ROOM NUMBER]), and maintain clean and sanitary privacy curtains for 3 of 54 rooms (rooms [ROOM NUMBER]) reviewed for safe, clean, comfortable, and homelike environment. The deficient practice affected 3 of 5 halls (200, 300, and 400 halls). Findings included: 1. An observation and interview on 06/20/22 at 11:20 AM revealed Resident #38's privacy curtain in room [ROOM NUMBER] had several white stains scattered in the middle and lower part of the dark green curtain. Resident #38 voiced she did not like that her privacy curtain looked dirty and stained and stated when she mentioned it to facility staff, they were going to replace it with a new one but haven't. She added, maybe they could at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) review for residents with a new mental health diagnosis for 4 of 6 sampled residents reviewed for PASRR (Residents #10, #37, #62, and #69). Findings included: 1. A PASRR Notification letter dated 08/08/16 revealed Resident #10 had a Level 1 PASRR with no expiration date. Resident #10 was admitted to the facility on [DATE] with diagnoses that included anxiety and bipolar disorder. Review of Resident #10's list of cumulative diagnoses contained in his medical record revealed a new diagnosis of major depressive disorder with the onset date of 06/02/21. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. During an interview on 06/10/22 at 9:47 AM, the Social Worker (SW) explained she was new to the position and was unaware of the regulation…

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, record review, resident and staff interviews, the facility failed to treat a resident in a dignified manner, when a nurse spoke abruptly to a resident (Resident #44) without looking at her to acknowledge her request for a cup of ice. This affected 1 of 4 residents reviewed for dignity and respect and made Resident #44 feel bad. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident or stroke, and hemiplegia. Resident #44's annual Minimum Data Set (MDS) assessment revealed she was severely cognitively impaired and was on a therapeutic diet with thin liquids. Resident #44's assessment also revealed the resident was always understood and always understands. Observation on 06/21/22 at 3:05 PM of Resident #44 revealed she was at the nurse's station sitting in her wheelchair holding a white cup. Nurse #4 walked in front of the resident and the resident asked Nurse #4 for a cup of ice. Nurse #4 without looking at 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 record review, observations, resident, and staff interviews the facility failed to honor a resident's request to get out of bed to attend a scheduled activity for 1 of 5 residents reviewed for choices (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses including lack of coordination and heart failure. Review of the annual Minimum Data Set (MDS) dated [DATE] assessed Resident #16's cognition was intact with no refusal of care during the lookback period. The MDS also indicated Resident #16 required total assistance by 2-person using a mechanical lift for transfers. The Care Plan (CP) revised on 01/26/22 revealed Resident #16 was independent for meeting social needs but due to immobility and physical limitations might need encouragement and reminders to activities. The CP goals included to attend and participate in activities of choice. The interventions directed nursing staff to assist and escort and listed bingo as one of Resident #16's preferred…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interviews, the facility failed to provide bathing as scheduled for 1 of 9 residents dependent on staff for activities of daily living (Resident #68). The findings included: Resident #68 was admitted to the facility on [DATE]. Resident #68's diagnoses included cerebrovascular accident (loss of blood flow to the brain) and chronic obstructive pulmonary disease (restricted airflow to the lungs). The Care Plan last revised on 05/16/22 identified Resident #68 as having a self-care performance deficit related to impaired balance and limited mobility. The goal was for Resident #68 to remain at her current level of functioning and included the intervention to provide extensive to total assistance with showers per protocol and as necessary. Review of Resident #68's activity of daily living documentation for April, May and June 2022 revealed bathing was scheduled during evening shift on Wednesday and Saturday. For the month of April bed baths were documented as given on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interviews, the facility failed to prevent a fall during a transfer with a mechanical lift which resulted in the resident bumping his head and right hand on the floor for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] with diagnoses of spinal cord injury. Review of Resident #56's care plan dated 07/21/20 and revised on 05/19/21 revealed in part, he had a self-care deficit in the area of activities of daily living and required total assist of 1-2 staff to turn and reposition in bed as necessary. He also required a mechanical lift with the assistance of 2 staff members for transfers between his wheelchair and bed. The care plan also indicated Resident # 56 was at risk for falls. Fall prevention interventions included in part, reminders to keep his call bell within reach and providing re-education for Resident # 56 on the risks of keeping his bed in a…

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

Based on observations, record review, resident and staff interviews, the facility failed to maintain sufficient nursing staff to ensure a resident's (Resident #16) request to get out of bed was honored. The facility also failed to ensure showers or complete baths were provided as scheduled (Resident #68). These failures affected 2 of 14 residents sampled in areas of choices and activities of daily living. The findings included: This tag is cross referenced to: 1. F 561: Based on record review, observations, resident, and staff interviews the facility failed to honor a resident's (Resident #16) request to get out of bed to attend a scheduled activity for 1 of 5 residents reviewed for choices. 2. F 677: Based on observations, record review, resident, and staff interviews, the facility failed to provide bathing as scheduled for 1 of 9 residents dependent on staff for activities of daily living (Resident #68). Review of the nursing staff scheduled from 06/18/22 through 06/24/22 revealed during first and second shifts there were assignments with one Nurse Aide (NA) on the hall for 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.