Hibriten Mountain Nursing and Rehabilitation

Based on observations, record review, and staff interviews, the facility failed to follow their Infection Control policy and Hand Hygiene policy when Nurse Aide #1 did not perform hand hygiene before applying clean gloves and Nurse Aide #1 nor the Unit Manager applied gowns while providing suprapubic catheter care on Resident #26. This deficient practice occurred for 2 of 7 staff members observed for infection control practices (Nurse Aide #1 and Nurse #4).The findings included:Review of the facility's policy and procedure entitled Hand Hygiene revised June 2025 read in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Review of the facility's Enhanced Barrier Precautions policy last revised June 2025 read in part as follows: Enhanced barrier precaution (EBP) are utilized to reduce the transmission 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 record review and interviews with the resident's responsible party and staff, the facility failed to notify the responsible party of elopement for 1 of 3 residents reviewed for notification of change (Resident # 1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia.The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired.A review of Resident #1's medical record indicated a late entry nursing progress note dated 7/12/25 at 3:29 PM by Nurse #1 which read, in part: Nurse Aide (NA) #1 and NA #2 witnessed Resident #1 outside, walking past the C hall door at approximately 7:45 PM. NA #1 immediately ran outside to assist him back into the building while NA #2 came and alerted Nurse #1. Nurse #1 assisted NA #1 with guiding Resident #1 back into the building via C hall door. NA #2 went to find Resident #1's wheelchair, finding it in the dining room just outside the door going into…

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 protect a resident's right to be free from abuse when Resident #4 attacked Resident #5 which resulted in cuts above the right eye, bruising around the nose, and bleeding from his gums and required an emergency room visit. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #4). The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, and major depressive disorder.Review of Resident #4's care plan, last revised on 03/31/25 revealed no care plan areas for aggressive behaviors.Review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #4 was independent with mobility and was able to ambulate on his own.Resident #5 was admitted to the facility on [DATE] with diagnoses of dementia without…

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 and interviews with staff and the Medical Director, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of a wrong dosage and failure to have the resident rinse their mouth after being given a steroid inhaler (2 medication errors out of 31 opportunities), resulting in a medication error rate of 6.45% for 2 of 4 residents observed during medication pass (Resident #2 and Resident #3).The findings included:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included vitamin D deficiency.The Physician's Orders in Resident #2's electronic medical record indicated an active order dated 7/1/20 for Vitamin D3 tablet 25 micrograms (1000 units) (Cholecalciferol) - give 1 tablet by mouth one time a day related to vitamin D deficiency.On 7/16/25 at 9:19 AM, Nurse #2 was observed as he prepared and administered Resident #2's medications. Nurse #2 administered one tablet of Vitamin D 10 micrograms (400 units) 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, and staff and Adult Protective Services (APS) Intake Social Worker interviews, the facility failed to file a report with the state agency no later than 24 hours after becoming aware of an allegation of misappropriation of resident property and failed to report the incident to APS for 1 of 3 residents reviewed for abuse (Resident #70). The findings included: A review of the facility's abuse, neglect, exploitation and misappropriation policy and procedure revised 11/16/22 read in part: Reporting/Response: Once an allegation of abuse is reported, the Administrator, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. The Abuse Coordinator will refer any or all incidents and reports of resident abuse to the appropriate state agencies. Resident #70 was admitted to the facility 1/05/24. A review of the police department incident report indicated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed for bladder continence (Resident #74 and Resident #35). Findings included: 1. Resident #74 was admitted to the facility on [DATE] with diagnoses including a stage 4 pressure ulcer to the sacrum. A review of Resident #74's physician orders showed an order dated 10/21/2024 for a 16 French (FR) foley catheter with a 10 milliliter (ml) balloon due to stage 4 sacral pressure ulcer. A review of Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was marked as having an indwelling catheter in place but was always incontinent of bladder. An interview was completed on 12/12/2024 at 9:00 AM with the MDS Coordinator. During the interview the MDS Coordinator reported if a resident's MDS assessment was marked for an indwelling catheter then the continence needed to be marked as Not Rated. The MDS Coordinator explained…

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 update a resident's care plan after she ingested wound cleanser for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive. A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be severely impaired with no delusions, behaviors, or rejection of care. Resident #8 was coded as having wandering behaviors daily. Resident #8 required supervision with mobility and was coded as using a manual wheelchair. A review of facility incident and accident logs revealed a report dated 03/11/24 that indicated Resident #8 had obtained a bottle of wound cleanser and ingested an unknown amount. Per the incident report, Resident #8 was assessed along with telephone calls made to her representative, the on-call…

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 resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident for 1 of 5 residents reviewed for unnecessary medications (Resident #80). The findings included: Resident #80 was readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, neuropathy, and necrotizing fasciitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact and was marked as receiving routine and as needed pain medication. Review of a progress note written by Nurse #2 dated 12/8/2024 at 6:05 pm indicated Resident #80 was administered Baclofen (muscle relaxer) 10 milligram (mg) and Norco (pain reliever) 5/325 mg. Further review of the progress note revealed the on-call provider was notified and Nurse #2 was instructed to monitor the resident's level of consciousness, breathing, and cognition. A review of 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, record reviews, and staff, Resident, Wound Nurse and Medical Director interviews, the facility failed to provide care in a safe manner when a dependent resident (Resident #57) fell off the bed during incontinence care. The facility also failed to provide an environment free from a potential hazard when wound cleanser was left unattended on top of the treatment cart and an unmeasurable amount was ingested by Resident #8. This was for 2 of 4 residents reviewed for accidents. The findings included: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses that included Fredrick's Ataxia (a condition that mainly affects the neuromuscular system and the heart and causes poor muscle control and coordination). A review of Resident #57's admission nursing assessment dated [DATE] indicated she was alert and oriented to person, place, time and situation. A review of a baseline care plan dated 10/28/24 indicated Resident #57 required extensive assistance of one staff for bed mobility,…

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, resident and staff interviews, the facility failed to obtain an order for the use of supplemental oxygen and post oxygen cautionary signage for 1 of 1 resident (Resident #75) reviewed for respiratory care. Findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses that included left lower lobe pneumonia, sepsis and pleural effusion. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact. A review of Resident #75's medical record revealed there was no order for supplemental oxygen. A review of Resident #75's Medication Administration Record (MAR) for September 2024, October 2024, November 2024 and December 2024 indicated there was no order for supplemental oxygen administration on the records. On 12/09/24 at 10:23 AM an observation and interview were conducted with Resident #75 who was lying in bed and wearing continuous oxygen at 1.5 liters via nasal cannula. The Resident reported she has worn…

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 allow a resident with behaviors to remain in the facility and to provide written documentation which stated the reason the facility could not meet the residents needs for 1 of 3 resident (Resident #6) reviewed for transfer and discharge. The findings included: Resident #6 was admitted to the facility for respite services through Hospice on 5/09/24 and discharged on 5/09/24. Diagnosis included malnutrition, chronic pain, depression, and anxiety. Review of nursing note dated 5/09/24 written by the Director of Nursing (DON) at 4:06 PM revealed telephone call placed to Hospice Nurse, updated that Resident #6 is agitated and wanting to smoke. She stated Resident #6 was agitated at home; wife needs a break. She verbalized that he received Haldol (treat behavioral issues) 1 MG and Ativan (treat anxiety) 1 MG prior to leaving on transport to facility. Hospice Nurse speaks with Hospice provider, orders received for Xanax 1 MG by mouth now and to repeat in 1 hour: Rocephin (treat possible urinary tract infection) IM…

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, Hospice staff, Hospital Nurse Practitioner, and staff interviews, the facility failed to allow resident to return to the facility after being sent to the hospital for a medical evaluation using the residents' behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Residents #6). The findings included: Resident #6 was admitted to the facility for respite services through Hospice on 5/09/24 and discharged on 5/09/24. Diagnosis included malnutrition, chronic pain, depression, and anxiety. Review of nursing note dated 5/09/24 written by the Director of Nursing (DON) at 4:06 PM revealed telephone call placed to Hospice Nurse, updated that Resident #6 is agitated and wanting to smoke. She stated Resident #6 was agitated at home; wife needs a break. She verbalized that he received Haldol (treat behavioral issues) 1 MG and Ativan (treat anxiety) 1 MG prior to leaving on transport to facility. Hospice Nurse speaks with Hospice provider, orders received for Xanax 1 MG by mouth now and to repeat in 1 hour:…

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 provide incontinence care to a resident prior to her wetting through her brief and her pants for 1 of 3 residents (Resident #4) reviewed for activities of daily living (ADL). The findings included: Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral vascular accident (CVA or stroke), hypertension, diabetes mellitus type II, congestive heart failure and muscle weakness. Review of Resident #4's Care Area Assessment (CAA) summary dated 01/15/24 for activities of daily living (ADL) revealed resident was to receive assistance of 1 to 2 staff members with ADL, transfers, mobility, and toileting to prevent falls or injury. Resident #4 was to receive peri-care every 2 hours and as needed to prevent skin breakdown and infection. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired, and staff were 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 observations, record reviews, and staff interviews, the facility failed to follow their Infection Control Policy for Enhanced Barrier Precautions (EBP), when the Wound Nurse failed to wear a gown while providing wound care to 2 of 3 residents (Resident #2 and Resident #3) reviewed for infection control. The findings included: Review of the facility's Infection Control Policy, Enhanced Barrier Precautions last updated on 08/2022 revealed the following: Under Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents. 2. EBPs employ targeted gown and glove use during high contact activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical…

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 and staff interviews, the facility failed to date opened items stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents. Findings included: A tour of the facility's dietary department on 10/23/23 beginning at 9:30 AM revealed the following items: Dry storage area: - A 35 ounce (oz) opened and undated bag of cereal - A large bag of opened and undated cake mix An interview with [NAME] #1 on 10/23/23 at 9:45 AM revealed they had been educated all items should be labeled and dated with an open/discard date. He stated the opened bag of cereal should have been sealed and labeled with the date it was opened. An interview with the Regional Dietary Manager on 10/24/23 at 1:38 PM revealed she was made aware of items that were unlabeled and dated in the dry storage area stated all items should be labeled and dated with an open and discard date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to ensure a resident had been assessed to self-administer over the counter medications located in a residen'st room. This occurred for 1 out of 3 residents reviewed for medication administration (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes and vascular dementia. Resident #3's self-administration of medication evaluation dated 09/15/23 completed by Director of Nursing (DON) revealed approval for self-administration of a pain ointment and pain relief topical 4% cream. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact requiring extensive assistance of one staff member for most activities of daily living (ADL). On 10/23/23 at 11:19 AM an observation was conducted of Resident #3's room revealed an open 32-ounce bottle half-full of hydrogen peroxide located on bedside dresser. During 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 observations, record review, resident and staff interview the facility failed to honor resident requests for two showers per week for 2 of 4 residents reviewed for choices (Resident #2 and Resident #4). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and required extensive assistance for bathing. Review of the facility's shower schedule revealed Resident #2 was scheduled for a shower on Mondays and Thursdays on second shift. Review of the facility shower documentation from 10/01/23 through 10/23/23 revealed no showers were documented as given to Resident #2. The documentation revealed Resident #2 was provided a bed bath instead of shower on the scheduled shower dates of: 10/02/23, 10/05/23, 10/09/23, 10/12/23, 10/16/23, 10/19/23, and 10/23/23. An observation and interview were conducted with Resident #2 on 10/24/23 at 11:55 AM. Resident #2 was sitting up in bed, her hair,…

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 4a. Resident #64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, anxiety, depression and fibromyalgia. The care plan dated 06/15/22 revealed Resident #64 had a self-care deficit. The goal the Resident would improve in her current level of function in her activities of daily living (ADL) would be attained by utilizing interventions such as: providing a sponge bath when a full bed bath or showers cannot be provided. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64's cognition was moderately intact and had no behaviors of rejection of care. The MDS indicated the Resident required extensive assistance of two staff for transfers, personal hygiene and dressing. The MDS also indicated the Resident was incontinent of bladder and bowel. A review of the Shower Schedule for room [ROOM NUMBER]-B revealed Resident #64 was scheduled to receive her showers on Wednesday and Saturday on first shift. A review of Resident #64's Bathing record from August 22,…

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 4. Resident #57 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia without behaviors, major depressive disorder and history of stroke. A review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #57 to be cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #57 was coded as receiving antipsychotics 1 of 7 days during the lookback period but was coded as not receiving antipsychotics since her admission or entry to the facility or since the prior Minimum Data Set assessment. A review of Resident #57's physician orders revealed no current, completed, or discontinued orders for the use of an antipsychotic. A review of Resident #57's August Medication Administration record revealed no antipsychotics were provided to Resident #57 in the Month of August. An interview with MDS Nurse #1 on 09/07/23 at 3:42 PM revealed she completed Resident #57's quarterly Minimum Data Set assessment dated…

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

Based on observations, record reviews and staff interviews the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for receiving two showers a week, failed to honor a resident's request to get out of bed and the facility failed to provide nail care for 5 of 5 residents reviewed (Resident #36, #23, #39, #60, and #64) for choices and activities of daily living. The findings included: This tag is crossed referred to: F-561: Based on observations, record review, resident, and staff interviews, the facility failed to honor resident request for two showers per week (Resident #23, Resident #39, Resident #60, Resident #64, Resident #6, and Resident #36) and the facility also failed to honor a resident's request to get out of bed (Resident #64) this affected 6 of 6 residents reviewed for choices. F-677: Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36). An interview…

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 reviews and Director of Nursing (DON) interview the facility failed to ensure the DON for the Skilled Nursing Facility worked full time as the DON of the facility. The DON served as a charge nurse having a resident care assignment that included working on the medication cart with a facility census of greater than 60 residents for 8 of 8 days reviewed for sufficient nurse staffing. 07/24/23, 07/25/23, 08/09/23, 08/10/23, 08/14/23, 08/29/23, 08/30/23 and 08/31/23. The findings included: A review of the staffing schedules revealed: On 07/24/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 92. On 07/25/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 90. On 08/09/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 85. On 08/10/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 84. On 08/14/23 the DON worked the 10:45 PM - 7:15 AM shift with an average daily resident census of 83. On 08/29/23 the DON worked the 10:45 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 observations and staff interviews, the facility failed to label and date leftover food items available for resident consumption stored in 1 of 1 reach in refrigerator and failed to date pre-filled bowls of cereal stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents. Findings included: A tour of the facility's dietary department on 9/5/23 beginning at 10:00 AM revealed the following items: Dry storage area: A 35 ounce (oz) opened and undated bag of cereal 3 Meal trays which contained 47 bowls filled with various cereal unlabeled or dated Reach in refrigerator: 1 plastic gallon container of fruit cocktail labeled 8/29 1 large bag of salad mix which was yellow and brown lettuce unlabeled or dated ½ cucumber cut and undated 1 package of sliced ham undated 1 small bag of shredded carrots undated 1 small bag of shredded red cabbage undated 1 package of bologna opened and undated An interview with [NAME] #1 and Dietary Aide #1 on 9/5/23 at 10:30 AM revealed they had been educated all items should be…

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 3/21/22. This was for six repeat deficiencies that were cited in the areas of self-determination, accuracy of assessment, care plan timing and revision, activities of daily living care provided for dependent residents, sufficient nursing staffing, and label and storage of drugs and biologicals that were originally cited during a recertification and complaint survey dated 3/21/22 and subsequently recited during the recertification and complaint survey dated 9/8/23. 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: F561- Based on observations, record reviews, resident and staff interviews, the facility failed to honor a resident's request to receive two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY ed on record review, family, staff, and Nurse Practitioner interviews the facility failed to change Resident #82's advance directive (code status) as directed by his power of attorney (POA) for 1 of 1 resident reviewed for advance directives. The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, Alzheimer's Disease, and others. Review of a facility document titled; Advance Directive Discussion Document dated [DATE] indicated Resident #82 wished for cardiopulmonary resuscitation (CPR). The form was signed by Resident #82. Review of a Medical Order for Scope of Treatment (MOST) form dated [DATE] indicated that Resident #82 was to receive full scope of treatment which included the use of intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, medical treatment, intravenous fluid, etc. also provide comfort measures. Transfer to hospital. The form was signed by the Nurse Practitioner (NP) and by…

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 develop a comprehensive care plan within 7 days of the completion of a resident's admission Minimum Data Set assessment (Resident #83) for 1 of 2 residents reviewed for discharge. The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, muscle weakness, age related physical debility, type II diabetes mellitus, and hypertension. A review of Resident #83's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident was coded as requiring supervision with bed mobility, toilet use, and personal hygiene. Resident #83 required limited assistance with transfers, walk in the room and corridor, locomotion on and off the unit, and dressing. Resident #83 was independent with eating and needed extensive assistance with bathing. Review of Resident #83's medical record revealed 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, resident, and staff interviews the facility failed to invite 2 of 2 residents to a care plan meeting (Resident #39 and Resident #60) that were reviewed for care plans. The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, weakness, chronic pain, and others. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #39 was cognitively intact. Review of Resident #39's medical record revealed no evidence of a care plan meeting being held with Resident #39 or his family. An interview was conducted with Resident #39 on 09/05/23 at 10:15 AM, Resident #39 stated that he had been at the facility for over two years, and he did not recall ever being invited to a care plan meeting about his stay in the facility or any discharge plan that may or may not be in place. Resident #39 stated that he would be eager to participate in the care plan meeting if he would have known about it. The Social Worker…

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, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact and required extensive assistance for personal hygiene and was dependent for bathing. It further indicated no rejection of care or behaviors. Review of the nurse's progress notes from 8/21/23 through 9/8/23 revealed no notes regarding Resident #36 refusing showers or personal hygiene care. Review of the Nurse Aide (NA's) documentation of the same period revealed no indication Resident #36 refused nail care. An observation and interview with Resident #36 on 9/5/23 at 11:41 AM revealed Resident #36 lying in bed with fingernails on both hands that extended out past the end 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, resident, and staff interviews the facility failed to ensure that oxygen was delivered at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of a physician order dated 10/13/21 read; oxygen continuous at 3 liters. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #13 was cognitively intact and used oxygen during the look back period. The MDS also revealed Resident #13 had no shortness of breath during the look back period. An observation of Resident #13 was made on 09/05/23 at 11:41 AM, she was resting in bed with her eyes closed. Resident #13 had an oxygen canula in her nose with oxygen being delivered at 5 liters per minute. Resident #13 appeared to be in no respiratory distress. An observation of Resident #13 was made on 09/06/23 at 9:47 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with residents, staff, Pharmacist and Nurse Practitioner (NP #1), the facility failed to acquire medications ordered for administration which resulted in 2 missed doses of the controlled substance medication prescribed for pain for 1 of 2 residents reviewed for the provision of pharmaceutical services (Resident #289). The findings included: An undated document provided by the pharmacy read in part, Labor Day [pharmacy name] will be operating and delivering with modified hours on September 4th in observance of the Labor Day holiday. New orders received after 4 PM on Monday, September 4th will be shipped by 6 PM. New orders received after 4 PM and refill orders received after noon will be shipped on Tuesday, September 5th at regular shipments times. Please contact [phone number provided] for emergency needs. Fax early and often. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #289 was cognitively intact, had pain present constantly, and received 6 days of…

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

Based on observations, record reviews and staff interviews, the facility failed to discard expired medications and failed to store a controlled substance in a permanently affixed compartment in the refrigerator in 1 of 1 medication room (main medication room) for review of medication storage. The findings included: 1. On 09/06/23 at 11:47 AM an observation of the main medication room was conducted accompanied by Nurse #1. On the cabinet shelf was an opened box of Ipratropium bromide/albuterol nebulizing solution (vials of 0.5 milligram (mg) and 3 mg / 3 milliliter (ml) ipratropium / albuterol inhalation solution) used to treat chronic obstructive pulmonary disease. The solution was prescribed for Resident #4 with the delivery date of 07/04/23. The box contained an open and undated foil pouch that had 20 out of 30 vials left in the foil pouch. The manufacture's instructions on the box indicated to discard unused vials in opened foil pouch within 14 days. An interview conducted with Nurse #1 on 09/06/23 at 11:48 AM revealed the Nurse stated the medication was stored in the medication…

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.