Crown Haven Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to provide a clean homelike environment when they failed to clean tube feeding formula off the feeding tube pole and floor in 1 of 3 resident rooms that had tube feeding formula (room [ROOM NUMBER]). The findings included: An observation was made of room [ROOM NUMBER] on 07/01/24 at 11:06 AM. There was a feeding tube pump hanging from a pole beside the bed. The pole and floor were observed to have dried light brown substances that appeared to be tube feeding formula. The dried formula covered the pole, the bottle of the pole, and the floor under the pole. An observation was made of room [ROOM NUMBER] on 07/01/24 at 12:35 PM. There was a feeding tube pump hanging from a pole beside the bed. The pole and floor were observed to have dried light brown substances that appeared to be tube feeding formula. The dried formula covered the pole, the bottle of the pole, and the floor under the pole. An observation was made of room [ROOM NUMBER] on 07/01/24 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 observations, record review, resident interview, and staff interviews, the facility failed to provide incontinence care when requested to 1 of 2 dependent residents (Resident #2) reviewed for activities of daily living. The findings included: The admission date for Resident #2 to the facility was 11/6/15 with diagnoses that included major depressive disorder, anxiety disorder, overactive bladder, urgency of urination, and urgency incontinence. The 8/2/23 annual Minimum Data Set (MDS) assessment recorded it was very important to Resident #2 to attend her favorite activities. The care plan, revised November 2023 indicated Resident #2 had bowel and bladder incontinence and depressive episodes related to immobility, and a neurogenic disorder. The care plan recorded that she may exaggerate events, make false claims and allegations at times. Interventions included encouraging effective communication, checking for incontinence, providing peri-care after each incontinent episode, modifying daily schedule to accommodate community life participation as requested by the resident 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, staff, and Medical Director interviews the facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for 1 of 3 residents reviewed with tube feeding orders (Resident #3). The findings included: Resident #3 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included gastrostomy status and sequelae of cerebral infarction. A physician order dated 05/05/24 read, tube feeding formula continuous at 65 milliliters (ml) per hour via gastrostomy tube. Flush gastrostomy tube with 100 ml of water every four hours. An observation was made of Resident #3 on 07/01/24 at 11:06 AM. Resident #3 was resting in bed with his head of bed elevated. There was a feeding tube pump hanging from a pole beside Resident #3's bed. There was no tube feeding formula hanging from the pole at the time. There was a bottle of tube feeding formula unopened sitting on Resident #3's counter in his room 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 observations, record review, staff, and Medical Director interviews the facility failed to change the dressing to a peripherally inserted central catheter (PICC line or an intravenous line) as ordered by the physician for 1 of 1 residents receiving intravenous medication (Resident #3). The finding included: Resident #3 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included osteomyelitis of pressure ulcer and an abscess. Review of a hospital Discharge summary dated [DATE] indicated that Resident #3 had a peripherally inserted central catheter (PICC) line inserted at the hospital on [DATE] at 3:46 PM. A physician order dated 06/20/24 read, intravenous (IV) catheter care instructions, inspect and clean right upper extremity and apply a clear dressing every Thursday on day shift. Review of the Medication Administration Record (MAR) dated June 2023 revealed that on June 20, 2024, and June 27, 2024, Nurse #2 initialed the MAR…

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 ensure that a tracheostomy (surgical airway in the front of the neck) dependent residents' oxygen was delivered at the prescribed rate, failed to clean the oxygen concentrator and oxygen concentrator filter for 1 of 3 residents reviewed for respiratory services (Resident #3). The findings included: Resident #3 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure status post tracheostomy. A quarterly Minimum Data Set, dated [DATE] indicated Resident #3 was severely cognitively impaired for daily decision making, had no shortness of breath, received oxygen therapy, and tracheostomy care during the assessment reference period. A physician order dated 06/28/24 read 4 liters of oxygen via tracheostomy collar continuous. Further review of physician orders revealed no order for cleaning of oxygen filters or oxygen concentrator. 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 and staff interviews the facility failed to maintain a complete an accurate medical record when Nurse #2 documented that she changed a peripherally inserted central catheter line (intravenous line) dressing on two occasions when the dressing was not changed as ordered for 1 of 1 residents reviewed who required intravenous medications (Resident #3). The findings included: A physician order dated 06/20/24 read, intravenous (IV) catheter care instructions, inspect and clean right upper extremity and apply a clear dressing every Thursday on day shift. Review of the Medication Administration Record (MAR) dated June 2023 revealed that on June 20, 2024, and June 27, 2024, Nurse #2 initialed the MAR indicating that she had cleaned and inspected Resident #3's right upper extremity and applied a clean clear dressing to the PICC line. An observation was made of Resident #3 on 07/01/24 at 11:06 AM. Resident #3 was resting in bed with his head of bed elevated. He was noted to have a PICC line in his right upper extremity that was covered with a clear dressing. The dressing…

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 an observation, staff interviews and record review, the facility failed to wash dishes in hot water and sanitize dishes per manufacturer recommendations in a quaternary sanitizing solution of at least 100 parts per million (ppm). This had the potential to affect 89 of 89 residents. The findings included: An observation of the Dietary Manager (DM) washing dishes (pots, sheet pans, whisks) in a three-compartment sink occurred on 02/08/24 at 12:15 PM. The water in the wash sink was cold to touch. The concentration of the quaternary sanitizing solution was less than 50 parts per million (ppm). The water in the sanitizing sink was above the WATER FILL LINE. Per manufacturer recommendations the concentration of quaternary sanitizing solution should be at least 100 ppm. The DM stated on 02/08/24 during the observation that she set up the three-compartment sink earlier that morning to wash the dishes from the breakfast meal, and that she checked the quaternary sanitizing solution which registered above 100 ppm at the time. The DM stated that she did not recall what time she…

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 and complaint investigation survey of 8/31/21, the complaint investigation survey completed on 1/19/22, the recertification and complaint investigation survey completed on 7/15/22, and the complaint investigation survey completed on 5/25/23. This failure occurred for four repeat deficiencies cited for resident, family, group and response, accuracy of assessments, food procurement, and increase, prevent decrease in range of motion and mobility that was subsequently recited on the current recertification and complaint investigation survey of 2/12/24. The continued failure of the facility during five 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:…

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, resident interviews and staff interviews the facility failed to provide updates or resolutions to group grievances (evening snacks, better meal choices, transportation to outings, and cold food) that were brought to Resident Council meetings for 4 of 4 months reviewed (October, November, December of 2023 and January 2024). The findings included: A review of Resident Council meeting minutes from October 2023 through January 2024 was completed. Each month's meeting minutes had an Old Business and a New Business section. Residents brought the following concerns to Resident Council: Review of the October 2023 minutes revealed under Old Business1. Residents would like a bigger bus for outings 2. Residents would like better meal choices such as soup, salads, and fresh fruit. The November 2023 Resident Council minutes noted, New Business 1. Residents would like a bigger bus for outings 2. Residents would like better meal choices such as soup, salads, desserts, and fresh fruit. Under Old Business 1. Residents would like a bigger bus for outings so that more residents…

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 interviews and record reviews, the facility failed to record opening date for 1 opened vial in 1 of 5 medication cart (100 Hall medication cart), failed to remove expired medication in accordance with the manufacturer's expiration date for 1 of 5 medication cart (100 Hall medication cart), and failed to store drugs in clean and sanitary environment for 1 of 2 medication room refrigerators (north side medication room refrigerator) during medication storage checks. Findings included: a. A medication storage audit was conducted on 2/6/24 at 1:42 pm in the presence of Nurse #6. The following medications were found in 100 Hall medication cart: 1. An opened vial of Lidocaine Hydrochloride 1% 10 milligrams per milliliters (an anesthetic agent that induced insensitivity to pain) without an opening date. 2. An opened bottle of multivitamin containing 174 tablets expired on 10/2023. During an interview on 2/6/24 at 1:42 pm, Nurse #6 confirmed that the multivitamin bottle was the only bottle of its kind in her medication cart. She revealed that she administered…

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 an observation of the lunch meal tray line, staff interviews and record review, the facility failed to provide the correct portion size of pureed food and large portions according to the planned menu for 1 of 1 meal observations. This practice had the potential to affect 2 residents on pureed diets and 12 residents who received large portions. The findings included: During a continuous observation of the lunch meal tray line on 02/08/24 from 12:11 PM until 12:35 PM, cook #1 plated pureed black-eyed peas and pureed chicken with a 2-ounce serving utensil. Additionally, [NAME] #1 plated a four-ounce serving of stewed tomatoes for a large portion. Review of the menu revealed the following portions were to be served on 02/08/24 for the lunch meal: - Pureed black-eyed peas - 4-ounce serving. - Pureed chicken - 4-ounce serving. - Large portion - one and one third serving. An interview with [NAME] #1 occurred on 02/08/24 at 12:37 PM. [NAME] #1 stated that she used the menu to know the portion of foods to serve, but sometimes the correct serving utensil was not available. [NAME] #1…

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 interviews and staff interviews, the facility failed to offer and deliver evening snacks to 10 of 12 residents (#78, #6, #69, #84, #60, #81, #34, #7, #25, #27) reviewed for evening snacks. The findings included: During an interview on 2/8/24 at 3:33 PM the Dietary Manager revealed she responded to resident council grievance in September 2023 by adding more evening snacks each night and nursing staff would sign off on receiving the snacks. A review of the December 2023 Resident Council Minutes revealed under New Business, Residents were still not receiving snacks at night and under Old Business, Residents would like to have snacks at night. A review of the January 2024 Resident Council Minutes revealed under, New Business, Residents were still not receiving snacks at night and under Old Business, Residents would like to have snacks at night. During an interview on 2/6/24 at 2:21 PM the Activities Director indicated she completed resident council grievances and passed them onto the Social Worker who assigned the grievances to department heads. If she did not receive…

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 administer the Influenza vaccination ( Resident #63) and failed to offer and administer the Pneumococcal vaccination (Resident #15, Resident #59 and Resident #68) to 4 of 5 residents reviewed for immunizations. The findings included: 1. Resident #63 was admitted to the facility on [DATE]. Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident did not receive the Influenza vaccine in the facility for the year's Influenza season and the Influenza vaccine was not offered. A review of Resident #63's electronic medical record revealed the consent to administer the Influenza vaccination was given by the responsible party on 11/28/23 but there was no record that the Influenza vaccine was given to Resident #63. An interview was conducted with the Infection Preventionist (IP) on 02/07/24 at 10:29 AM who reviewed the Resident #63's medical record and stated that she was not sure why the Resident did not receive 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 reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Gradual Dose Reduction for 2 of 5 residents (Resident #15 and Resident #20) reviewed for unnecessary medications. The findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, dementia and psychotic disorder. A review of Resident #15's physician orders dated 09/23/21 for Seroquel 100 milligrams (mg) (an antipsychotic medication used to treat symptoms of psychosis) by mouth twice a day and 06/12/22 for Seroquel XR Extended Release 50 mg by mouth once a day in the afternoon. A review of Resident #15's Psychiatry progress note dated 09/13/23 indicated to continue the current medications as prescribed at the current doses as any reduction attempted may cause decompensation of the resident. A review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident received an antipsychotic…

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 implement nutrition care plan interventions to monitor and document food/fluid intake at each meal for 2 of 2 sampled residents reviewed for nutrition care plans (Resident #142 and Resident #80). The findings included: 1a. Resident #80 was admitted to the facility 8/22/23. Diagnoses included type 2 diabetes mellitus, protein calorie malnutrition, hyperkalemia, end stage renal disease with hemodialysis, and anemia, among others. A nutrition care plan initiated 9/1/23 identified Resident #80 had potential for nutritional problems due to a therapeutic diet and 32-ounce fluid restriction. Interventions included for nursing staff to monitor food/fluid intake and record intake at each meal. A quarterly Minimum Data Set, dated [DATE] assessed Resident #80 with intact cognition, required set up/clean up assistance with meals and no weight loss or weight gain. A review of the electronic medical record revealed food intake was not recorded…

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, a family interview, interviews with the Physician, Nurse Practitioners and staff, the facility failed to obtain a STAT (immediately) chest X-Ray, transcribe an as needed order for Tylenol in response to a fever, follow a recommendation to monitor vital signs, and provide STAT lab results to the Nurse Practitioner for 1 of 3 sampled residents reviewed for hospitalization (Resident #142). The findings included: Resident #142 was admitted to the facility 11/15/23 and transferred to the hospital on [DATE] at the request of the family. Diagnoses included osteoarthritis knee pain, anxiety disorder, chronic obstructive pulmonary disease, essential hypertension, and atrial tachycardia (increased heart rate), among others. A care plan initiated 11/17/23 identified Resident #142 used medications that required monitoring. Interventions included nursing to report important lab results to the MD. An admission Minimum Data Set (MDS) dated [DATE] assessed Resident #142 with adequate…

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 interviews and staff interviews, the facility failed to reschedule and transport a resident to a consultation with an eye doctor for 1 of 1 resident reviewed for vision services (Resident #28). The findings included: Resident #28 was readmitted to the facility on [DATE] with diagnoses inclusive of acute respiratory failure and peripheral vascular disease. A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #28 was cognitively intact, had impaired vision, was dependent on staff for toileting hygiene, dressing, chair to bed transfers and toilet; and required maximum assistance with personal hygiene, transfers to shower, and bed mobility. A physician's order dated 1/2/23 indicated Resident #28 had an active order for cataract surgery consult per patient request. A progress note dated 10/27/23 and written by Unit Manager #2 indicated the facility was unable to transfer Resident to eye appointment and that the appointment would be rescheduled once a method of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Medical Director interviews, the facility failed to identify and develop a treatment plan for a resident with a right-hand contracture. This was evident for 1 of 3 residents (Resident #63) reviewed for range of motion. The finding included: Resident #63 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA), spastic hemiplegia affecting the right dominate side and aphasia. Review of Resident #63's care plan dated 07/23/23 revealed the Resident had a self-care deficit in his activities of daily living (ADL) related to a history of a CVA with right sided hemiplegia, limited mobility and range of motion. The goal that Resident #63 would receive the assistance he needed for his ADL, and he would maintain his current level of functioning would be attained by anticipating his needs and providing assistance for ADL. The Resident was not care planned for a specific intervention for his right hand. The quarterly Minimum Data…

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, and record reviews, the facility failed to ensure that a smoking materials were secured by staff in accordance with their smoking policy for 1 of 3 residents observed for supervision to prevent accidents (Resident #18). Findings included: The facility's smoking policy dated 2/7/20 stated the center will retain and store matches, lighters, etc. for all residents. Resident #18 was admitted to the facility on [DATE] with diagnoses of cardiovascular accident and dementia. Resident #18's Quarterly Minimum Data Set on 1/5/24 revealed the resident was cognitively intact, had clear speech and easily understood others. She had a functional limitation in range of motion on one side of her upper and lower extremity and used a wheelchair for mobility. Resident #18's smoking evaluation dated 1/12/24 indicated the resident was a safe smoker and may smoke in designated areas without supervision. On 2/5/24 10:39 am, Resident #18 was observed self-propelling herself via…

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, staff and Resident interviews, the facility failed to secure a urinary catheter tubing to prevent tension or trauma for 1 of 2 residents (Resident #28) reviewed for urinary catheter. The finding included: Resident #28 was admitted to the facility on [DATE] with diagnoses that included neurogenic bladder. Resident #28's care plan dated 04/07/22 indicated the Resident had an indwelling urinary catheter and the goal to remain free from catheter related trauma would be attainted by interventions including keeping the catheter below the bladder and monitoring for signs of discomfort, pain and urinary tract infections. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 was cognitively intact and had an indwelling urinary catheter. A review of Resident #28's physician orders revealed: *01/15/24 Urinary Catheter #20 French with a 30 milliliters (ml) balloon. A review of Resident #28's Medication Administration Record (MAR) for 02/2024 indicated 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 observations, interviews and record review, the facility failed to serve a prescribed double portion protein therapeutic diet to Resident #80, a Resident at risk for nutritional decline, for 1 of 2 sampled residents reviewed for physician ordered therapeutic diets. The findings included: Resident #80 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, stage IV (ESRD), anemia in chronic kidney disease, dependence on renal dialysis, elevation of levels of liver transaminase levels, and protein calorie malnutrition, among others. A Care Area assessment dated [DATE] recorded Resident #80 was at potential nutritional risk regarding the requirement of a therapeutic diet for ESRD management. A diet order for Resident #80 dated 8/25/23 recorded a (brand name) high protein shake twice daily (BID) for additional calories and ESRD, 8 ounces BID. A diet order for Resident #80 dated 9/6/23 recorded a renal diet, regular texture regular/thin liquids consistency, fluid restriction per…

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's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 08/31/21. The area of infection control and prevention was originally cited during a recertification and complaint survey dated 08/31/21. The area was subsequently recited during the onsite revisit and complaint survey dated 12/13/23. 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: The tag is cross referenced to: F880- Based on observation, record review and staff interviews, the facility failed to implement their hand hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene prior to beginning treatments, or prior to donning gloves to remove soiled coverings with drainage from several wounds on a resident's (Resident #9) left leg…

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

Based on observation, record review and staff interviews, the facility failed to implement their hand hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene prior to beginning treatments, or prior to donning gloves to remove soiled coverings with drainage from several wounds on a resident's (Resident #9) left leg and foot wound, and right inner thigh wound. The Treatment Nurse doffed her gloves after removing the coverings and donned new gloves without sanitizing her hands and proceeded to apply the treatment to the wounds and covered them with border gauze dressings. This occurred for 1 of 2 residents reviewed for wound care. The findings included: The facility's policy entitled Hand Hygiene which is part of their Infection Control Policies and Procedures last revised on 02/05/21 under Process read in part: Hand hygiene should be performed: Before initiating a clean procedure Before and after patient care After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings After glove…

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, observation, resident, and staff interviews, the facility failed to apply bilateral lower leg splints for 1 of 1 resident reviewed for contractures/limited range of motion (Resident #5). Findings included: Resident #5 was admitted to the facility 7/15/2019 with diagnoses to include a progressive neurological disorder. A physical therapy discharge note dated 3/30/2022 documented that physical therapy had provided services to reduce pain and joint stiffness and to increase range of motion of Resident #5's bilateral knees. The discharge note documented that Resident #5 showed improvement of the range of motion of both knees and Resident #5 was able to tolerate wearing splints for 6 hours at a time. The note documented a nursing assistant had been instructed how to apply the splints with instructions for Resident #5 to wear the splints for up to 6 hours or as tolerated. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #5 to be cognitively intact and…

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

Based on record review, observation, and staff interviews, the facility failed to maintain a medication administration error rate of less than 5% as evidenced by a medication error rate of 22.22% (7 out of 27 opportunities) (Resident #66). Findings included: 1. Review of the facility policy Medication administration via enteral tube dated 11/30/2014 and revised on 3/6/2019 specified finely crush each medication with a pill crusher, or open capsule and pour powder into a medication cup with 5-15 milliliters (ml) of water and dissolve . there should be one medication per cup. Do not mix medications unless there is a specific physician order to do so . pour at least 15 ml of water into the syringe and allow to drain into the tube prior to medication administration. Pour one liquefied mediation in the syringe and allow gravity to drain each medication, follow each medication with at least 15 ml of water to flush the tube. A. An observation of medication administration was conducted on 7/14/2022 at 9:12 AM. Nurse #1 removed Resident #66's medications from the medication cart and placed…

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 provide the resident with a care planning conference to participate with the interdisciplinary team in the development of a comprehensive care plan for 1 of 1 resident (Resident #42) reviewed for care plans. The findings included: Resident #42 was admitted to the facility on [DATE] with medical diagnoses which included: diabetes, hypertension, and neurogenic bladder. Review of Resident #42's 5/23/22 Annual Minimum Data Set (MDS) assessment revealed resident was cognitively intact and required limited assist with Activities of Daily living (ADL). Review of Resident #42's care plan revealed it had been updated on 5/23/22. Interview with Resident #42 on 7/11/22 at 12:31 PM revealed that she had not been invited to participate in a care plan meeting. Resident #42 further stated it had been a long time since she had attended a care plan meeting. There was no evidence in the medical record that Resident #42 was invited to a care plan meeting in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to check residual prior to administering gastrostomy tube (G-tube) medication and failed to flush the G-tube before medication administration for 1 of 1 resident reviewed for G-tube medication administration (Resident #66). Findings included: Resident #66 was admitted to the facility 6/10/2022 with diagnoses to include dysphagia, gastrostomy, and epilepsy. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #66 to be rarely or never understood and severely cognitively impaired. The MDS documented Resident #66 received more than 51% of her calories per day by G-tube. A physician order for Resident #66 dated 7/13/2022 ordered enteral feed by bolus 4 times per day with 100 milliliters (ml) flush of sterile water before and after the bolus feeding. An observation of medication administration was conducted on 7/14/2022 at 9:12 AM. Nurse #1 mixed approximately 50 ml of sterile water with the crushed medications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure a call light was functioning for 1 of 6 resident rooms (room [ROOM NUMBER]) on 1 of 4 halls. The findings included: An observation on 07/11/22 at 11:39 AM revealed call light was activated and the light inside of the room [ROOM NUMBER] was on. Observation further revealed the light outside of room [ROOM NUMBER] was not illuminated. Further observation revealed room [ROOM NUMBER] was not illuminated at the nurse's station call light panel and was occupied by Resident #44. Resident #44 was interviewed at the time of the observation and he indicated there were no concerns with his call light functioning properly. In an interview on 07/11/22 at 11:42 AM Nurse #1 stated when the resident pressed the call light in the room it would light up outside of the door and at the nurses' station call light panel. She further revealed there were no call lights activated at the doors on the 500 hall at this time. She stated there were also no lights…

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