The Carrolton of Williamston

Based on record reviews and staff interviews, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week, to designate a director of nursing (DON) who worked on a full-time basis, and to have the DON only serve as a charge nurse when the average daily census was 60 residents or less for 23 of 39 days reviewed for staffing. Findings included: The nursing staff schedule and staff posting was reviewed from 2/1/24 through 3/10/24. The daily staff sheet indicated a Registered Nurse (RN) was not scheduled for at least eight consecutive hours a day on 2/3/24. Review of staff timecard dated 2/3/24 showed there was not an RN on duty at the facility that day. Review of the staffs' timecards dated 2/10/24 showed one RN worked. The RN was scheduled for the day shift 7:00 A.M. to 3:00 P.M. The timecard showed the RN worked from 7:49 A.M. to 3:29 P.M. for a total of 7 hours and 40 minutes. Review of the DON time punches for the week of 2/15/24 through 2/21/24 showed the DON worked 29.36 hours in the DON role. - 2/15/24, Thursday: DON hours logged…

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, North Carolina Board of Nursing Registry, observations, resident interviews, staff interviews and a Physician interview, the facility failed to provide effective leadership and oversight to ensure the Director of Nursing (DON) implemented her responsiblities in these areas: sufficiently staffing the facility to administer medications in a timely manner, having a registered nurse work eight consecutive hours daily and a DON who worked full time and only serves as a charge nurse when census was less than 60 residents, monitoring and tracking expiration of nursing licenses (Nurse #3) and nurse aide certifications (NA #9, NA # 4, NA #1, and NA #8), completing yearly performance evaluations for nurse aides (NA #4, NA #7, NA #6 and NA #5) and providing and monitoring 12 hours of annual training for nurse aides ( NA #4, NA #7, NA #6 and NA #5). This deficient practice had the potential to affect 105 of 105 facility residents. Findings included: This tag is cross reference to: F725: Based on observations, record review, resident interview, staff interviews and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to ensure bathrooms (room [ROOM NUMBER], #60, #61, #65, #67/69, #70) on the locked unit were free of fecal matter or black/brown matter on various surfaces for 6 of 10 bathrooms reviewed for clean and homelike living environment. The findings included: On 3/10/24, a Sunday, at 1:02 PM, an observation of the bathroom between rooms [ROOM NUMBERS], rooms on the locked unit, revealed the inner and outer parts of the toilet had multiple areas of dried black matter. room [ROOM NUMBER] was occupied by 2 residents, and room [ROOM NUMBER] was occupied by 1 resident. The residents of these rooms were able to use the bathroom on their own or with supervision assistance by staff. On 3/10/24 at 1:03 PM, an observation of the bathroom in room [ROOM NUMBER], a room on the locked unit, revealed brown matter on multiple areas of the toilet. room [ROOM NUMBER] was occupied by 1 resident. The resident of this room was able to use the bathroom on her own. On 3/10/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews and interviews with Wound Care Physician Assistant (PA), the facility failed to (1) perform wound care to a pressure ulcer per physician's order (Resident #19), (2) set the alternating pressure air mattress at the correct setting based on the resident's weight (Resident #104), and (3) change the treatment for a pressure ulcer when ordered by the Wound Care PA (Resident #77) for 3 of 4 residents reviewed for pressure ulcers. The findings included: 1. Resident #19 was admitted to the facility on [DATE], and diagnoses included dementia and right hip fracture. Resident #19's care plan dated 1/14/2024 included a focus for a right heel suspected deep tissue injury (SDTI). Interventions included administration of treatments as ordered by the physician and monitor effectiveness of treatments. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was moderately cognitively impaired and was receiving treatments for a pressure ulcer. Wound…

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 physician interviews, the facility failed to obtain post dialysis vital signs, record post dialysis weights, and maintain ongoing communication with the dialysis facility for 1 of 1 resident reviewed for dialysis (Resident #58). Findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses which included renal insufficiency and dependence on renal dialysis. The quarterly Minimum Data Set, dated [DATE] revealed that Resident #58 was cognitive intact. He was also coded for dialysis. Review of Resident #58's care plan last reviewed 2/6/24 indicated a focus for dialysis related to renal failure with an intervention check and change dressing daily at access site and monitor for signs/symptoms of bleeding, hemorrhage, and septic shock. Review of Resident #58's Physician's orders revealed an order dated 2/29/24 record post dialysis weight and vitals upon return every Tuesday, Thursday, and Saturday. Review of Resident #58's February 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure 5 of 47 nurse aides employed at the facility remained listed on the NC Nurse Aide Registry with an active Nurse Aide I certification (NA #6, NA #9, NA #4, NA #1,and NA #8). Findings included: 1. On [DATE] at 8:12 a.m., NA #6, who was a Medication Aide, was observed passing medications to Resident #59. A review of NA #6's employment record reported a hired date as [DATE], and NA #6's verification report listed the NA I expiration date as [DATE] for the NC Nurse Aide Registry, and the NC Medication Aide Registry listed an expiration date of [DATE]. A review of daily nursing assignment schedules since [DATE] listed NA #6 assigned as a medication aide on the following dates: * [DATE] 7am-3pm; 8pm and 5am on the Skills and Sparks Unit. * [DATE] 7am-3 pm and 3 pm- 11pm on the Skills and Sparks Unit. * [DATE] 7am-3 pm and 3 pm- 11pm on the Skills and Sparks Unit. * [DATE]…

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

Based on staff interviews and record reviews, the facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #4, NA #7, NA #6, and NA #5). Findings included: 1. NA (Nurse Aide) #4's personnel file was reviewed and revealed a date of hire of 10/1/20. The personnel file for NA #4 did not include evidence a performance review had been completed since the NA's date of hire. Attempts were made to reach NA #4 for an interview were unsuccessful. An interview was conducted on 3/13/24 at 3:40 P.M. with the Director of Nursing (DON). During the interview, the DON stated she was unaware she was required to complete NA performance review until this past Monday 3/11/24. She shared the performance reviews had not been completed due to turnover in the position of the DON. The DON explained she had not provided individual training to NA #4 based on the outcome of her performance evaluation. An interview was conducted on 3/13/24 at 5:10 P.M. with the…

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

Based on a lunch meal tray line observation, staff interviews and record review the facility failed to provide a pureed food item with a smooth consistency. This failure had the potential to affect 9 of 105 residents with diet orders for a pureed diet texture. The findings included: A review of the Diet Order Report dated 3/12/24 revealed 9 residents with diet orders for a pureed diet texture. Review of the menus revealed the facility followed the National Dysphagia Diet (NDD) for residents with diet orders for a pureed diet texture. The NDD recorded a dysphagia pureed diet required all foods pureed and thickened, if necessary, to a pudding-like consistency, lump free, requiring little to no chewing. A continuous observation of the lunch meal tray line on 3/12/24 from 11:43 AM - 11:56 AM revealed [NAME] #1 recorded the internal temperature of the food items stored on the tray line intended for the lunch meal service, including pureed egg noodles. The pureed egg noodles were observed with a lumpy consistency smaller than pea-sized when the food was stirred. [NAME] #1 stated 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, North Carolina Board of Nursing (NCBON) verification registry and staff interviews, the facility failed to ensure Nurse #3, who was observed providing resident care at the facility, maintained a current and active professional nursing licenses with the NCBON for 1 of 12 nurses reviewed. Finding included: A review of the nursing licensure audit conducted by the facility on [DATE] reported Nurse #3's license expired on [DATE]. The electric NCBON Registry listed Nurse #3's license with an expiration date of [DATE]. A review of the employee time sheet for Nurse #3 indicated she had worked at the facility since [DATE] on the following dates: * [DATE] from 7:22 a.m. to 3:25 p.m. * [DATE] from 7:02 a.m. to 3:00 p.m. * [DATE] from 7:12 a.m. to 7:34 p.m. * [DATE] from 7:19 a.m. to 3:33 p.m. * [DATE] from 7:25 a.m. to 3:08 p.m. * [DATE] from 7:36 a.m. to 3:24 p.m. * [DATE] from 7:15 a.m. to 3:23 p.m. * [DATE] from 7:00 a.m. to 3:25 p.m. On [DATE] at 10:30 a.m., Nurse #3 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, Wound Care Physician Assistant interview, staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee following the recertification and complaint investigation surveys of 6/10/21 and 11/18/22 and the complaint investigation surveys of 2/27/23 and 9/7/23. This was for 6 deficiencies that were recited on the current recertification and complaint investigation survey of 3/13/24 in the areas of Resident Rights (F550), Environment (F584),Treatment and Services for Pressure Sores (F686), Supervision to Prevent Accidents (F689), Medication Storage (F761), and Complete/Accurate Medical Records (F842). The continued failure of the facility during four 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: F550: Based on record review…

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 ensure at least 12 hours of annual training to include dementia and areas of weakness as determined in the nursing aides' performance reviews were completed for 4 Nursing Assistants (NA #4, NA #7, NA #6, and NA #5) of 5 reviewed for staffing. Findings included: a) NA (Nursing Aide) #4's date of hire was 10/1/20. Review of NA #4's Education/In-service records did not include evidence of training for areas of weakness as determined in the NA's performance review. b) NA # 7's date of hire was 10/1/20. Review of NA #4's Education/In-service records did not include evidence of training for areas of weakness as determined in the NA's performance review. c) NA #6's date of hire was 9/7/22. Review of NA #4's Education/In-service records did not include evidence of training for areas of weakness as determined in the NA's performance review. d) NA #5's date of hire was 10/4/22. Review of NA #4's Education/In-service records did not include evidence of training for areas of weakness as determined in the NA's performance…

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 ensure staff communicated to a resident in a respectful and dignified manner for 1 of 2 resident reviewed for dignity (Resident #93). The reasonable person concept was applied to this deficiency as individuals have the expectation to be addressed by staff using language and tone that portrays respect and dignity. Findings included: Resident #93 was admitted to the facility on [DATE], and her diagnoses included intellectual disabilities. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #93 was cognitively intact and exhibited no behaviors in the seven-day look back period. The MDS assessment also indicated Resident #93 was incontinent of urine and stool and required assistance with activities of daily living including toileting and mobility in bed and transfers. A psychiatric physician note dated 1/18/2024 reported Resident #93 had an intellectual disability. The psychiatric physician recorded Resident #93's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interviews, the facility failed to implement effective interventions to prevent a severely cognitively impaired resident (Resident #46) from hitting another resident (Resident #31) in the face two days after he initially exhibited physically aggressive behaviors directed toward another resident (Resident #55). Resident #31 sustained a scratch to the face as a result of the incident. This was for 1 of 4 residents reviewed for accidents (Resident #46). Findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses which included dementia and schizoaffective disorder. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #46 was severely cognitively impaired and required supervision of 1 person for locomotion on the unit. Resident #46 was coded with no physical behaviors directed towards others. As of 7/24/23 Resident #46's comprehensive care plan revealed no evidence the resident had any physical behaviors…

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 secure the keys for a medication cart when Medication Aide #7 left the medication cart keys for the skilled-hall medication cart in Resident #211's room. This deficient practice was for 1 of 5 medication carts in the facility. Findings included: On 3/12/2024 at 11:05 a.m., Medication Aide #7 was observed locking the skilled-hall medication cart and positioning the medication cart against the wall outside Resident #211's door before walking down the hall away from Resident #211's door. On 3/12/2024 at 11:08 a.m., during an interview with Resident #211, she picked up a double ring key chain and stated the Medication Aide #7 had left the keys in her room after administering her medications. Three keys were observed on one ring and four keys were observed on the other ring. On 3/12/2024 at 11:11a.m., when Medication Aide #7 returned to Resident #211's room, Resident #211 was observed holding up the double ring key chain and stating, You forgot these. Medication Aide #7 with a surprise facial gesture stated, Oh and gathered…

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 complete an accurate medical record related to documentation of the treatment for pressure ulcers for 1 of 4 residents reviewed for pressure ulcers (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. Physician orders dated 2/29/2024 included an order to cleanse the right heel with wound cleaner, to apply collagen particles before applying calcium silver alginate and a foam heel dressing and to secure the dressing with kerlix (a wrap to hold primary and secondary dressings in place) every other day for wound healing. A review of the March 2024 Treatment Administration Record (TAR) for Resident #19 indicated Nurse #3 recorded providing treatment of the right heel pressure ulcer on 3/11/2024. During observation of wound care to Resident #19's right heel pressure ulcer on 3/12/2024 at 10:05 a.m., the old foam dressing to the right heel was observed dated 3/9/2024 with Nurse Aide #6 initials. 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 interviews with the Resident Council members and facility staff, the facility failed to post information and contact information about the State Survey Agency and the local ombudsman program. This occurred for 6 of 6 cognitively intact residents who regularly attended the Resident Council meetings (Residents #35, 55, 22, 41, 390, and 25). The findings included: A review of the Resident Council meeting minutes from 10/21 through 11/22 revealed the resident rights section did not contain information on the contact information for the state survey agency or the local ombudsman. During a group meeting on 11/16/22 at 2:00 PM with Residents # 35, 55, 22, 41, 390, and 25, they stated they regularly attended the Resident Council meeting. The Residents stated they did not know the number to contact the state survey agency. The residents stated they did not know who the Ombudsman was or how to contact the Ombudsman. The residents further revealed that they did not know who their current Ombudsman was, and the information had not been posted for almost a year. An observation 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, and interviews with staff and residents, the facility failed to ensure residents who had perishable food items brought into the facility had a location to store their food. This deficient practice affected 5 members of the Resident Council (Residents #22, #25, #35, #41, #55) and 1 of 3 residents reviewed for choices (Resident #56). The findings included: Review of the Resident Council Meeting Minutes dated 10/25/22 indicated this was an emergency meeting for the purpose of reviewing the memo titled Food Safety and Resident Room Refrigerators. The minutes revealed that residents were informed that personal refrigerators would be removed. The memo read in part; Perishable food could not be left with the resident as they had nowhere to store perishable food. The memo also stated that food could not be placed in one of the facility ' s refrigerators because all opened food must have an expiration date and the facility could not place food in their refrigerators that had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review the facility failed to provide residents with access to the use of a telephone in a place where calls could be made without being overheard for 1 of 3 residents reviewed for privacy. (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a readmission on [DATE]. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 was cognitively intact. An observation was conducted on 11/15/22 at 1:06 PM of Resident #2 on the telephone at the nurse's station. Resident #2 could be heard talking on the phone. An observation was conducted on 11/17/22 at 2:22 PM of Resident #2 on the telephone at the nurse's station. Resident #2 could be heard talking on the telephone. There were multiple staff and residents present around the nurse's station. An interview was conducted with Resident #2 on 11/18/22 at 2:40 PM. Resident #2 stated that he hated having to talk on the phone at the nurse's station. He…

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 and staff interviews the facility failed to maintain resident walls and lighting fixtures in good repair. This occurred on 3 of 4 halls ([NAME], Skilled and Sparks halls) reviewed for environment. Findings included: 1. Observation of [NAME] Hall revealed the following. a. room [ROOM NUMBER] was observed on 11-15-22 at 10:30am. The room was observed to have rust on the over the bed light fixture, the ceiling light had a missing cover exposing the florescent light bulbs and there was paint scrapped off the wall exposing the plaster at the head of the resident's bed. A second observation of room [ROOM NUMBER] was completed on 11-18-22 at 10:15am with the Maintenance Director and the Environmental Manager. The second observation revealed rust on the over the bed light fixture, the ceiling light had a missing cover exposing the florescent light bulbs and there was paint scrapped off the wall exposing the plaster at the head of the resident's bed. The Environmental Manager was interviewed 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 record review, observation, staff and Physician interview, the facility failed to initiate new treatment orders for pressure ulcer treatment and perform pressure ulcer treatment as ordered by the Physician for 1 of 4 resident (Resident #25) reviewed for pressure ulcers. Findings included: Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included pressure ulcer of buttock and hip unstageable. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was cognitively intact and was documented for her pressure ulcers. Resident #25's care plan dated 10-21-22 revealed a goal that her pressure ulcer would show signs of healing and remain free from infection. The interventions for the goal were administer medications as ordered, administer treatments as ordered. Physician order from the wound care clinic dated 10-28-22 revealed an order for Resident #25 to have her right hip wound cleaned with soap and water, then apply Prisma (wound treatment) to wound bed 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 observation, record review, staff and Physician interviews, the facility failed to follow infection control practices when 4 of 4 staff members (Medication Aide #2, Medication Aide #4, Treatment Nurse, and Housekeeper #2) failed to perform hand hygiene between tasks and don a gown when entering a resident's room (Resident #79) who was on contact precautions. Findings included: Review of the facility's Hand Hygiene policy dated 10-1-22 revealed in part; perform hand hygiene prior to donning gloves and immediately after removing gloves. 1. An observation of Medication pass occurred on 11-16-22 at 8:10am with Medication Aide #2. The Medication Aide was observed to don a pair of gloves, pick up the resident's medication from the medication cart, walk into the resident's room, place the medication on the resident's table touching the top of the table, providing the resident with his medication in pill form with a glass of water touching the rim of the cup after the resident had drank the water, then provided the resident his inhaler medication touching the mouth piece of 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, and staff interviews, the facility failed to maintain an effective pest control program for 1 of 4 halls reviewed for pests ([NAME] Hall). The findings included: Pest control summary of services from the pest control service were reviewed for the following dates of 1/24/22, 2/24/22, 3/18/22, 4/19/22, 5/19/22, 6/27/22. 7/25/22, 8/22/22, 9/29/22, 11/1/22. There were no recommendations on the materials summaries. Observation of the [NAME] unit on 11/15/22 at 12:52 PM flies were visible in room [ROOM NUMBER]. Resident #27 was observed to fan by his head to remove the fly. Observation of the [NAME] unit on 11/15/22 at 1:38 PM flies were visible in room [ROOM NUMBER]. Resident #44 was observed to swat a fly with a fly swatter he had in his hand. An interview was conducted with Resident #44 on 11/17/22 at 2:12 PM. Resident #44 was cognitively intact. Resident #44 stated that he always kept a fly swatter in his room. He stated that flies were an issue, and something needed to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review the facility failed to treat residents in a dignified manner by scolding a resident after the resident overturned a mop bucket for 1 of 3 residents reviewed for dignity (Resident #71). Findings included: Resident #71 was admitted to the facility on [DATE]. His active diagnoses included aphasia, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, flaccid hemiplegia affecting right dominate side, difficulty in walking, occlusion and stenosis of left carotid artery, and major depressive disorder. Resident #71's minimum data set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired and had no behaviors. His hearing was assessed as adequate with unclear speech. Resident #71 was sometimes understood and usually understood others. Resident #71's care plan dated 11/15/22 revealed he was care planned for a communication problem related to expressive aphasia. The interventions included to allow…

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, staff and resident interviews the facility failed to invite 1 of 1 resident (Resident #389) reviewed for care plan meetings. Findings included: Resident #389 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #389 was moderately cognitively impaired. Review of Resident #389's medical record revealed a progress note dated 11-16-22 written by the facility's Social Worker (SW) stating an interdisciplinary care plan meeting was held that included activities, SW and a nursing assistant. The note indicated Resident #389's legal representative did not attend, and the care plan was reviewed and updated. During an interview with the SW on 11-17-22 at 11:25am, the SW stated she had not invited Resident #389 to her care plan meeting on 11-16-22. The SW explained She did not invite the resident because the resident was moderately cognitively impaired, and she does not invite a resident to care plan meeting unless the resident was cognitively…

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, staff and Physician interview the facility failed to assess 1 of 4 resident (Resident #45) to determine if self-administration of medication through a feeding tube was clinically appropriate. Findings included: Resident #45 was admitted to the facility on [DATE] with multiple diagnoses that included moderate protein-calorie malnutrition and gastrostomy status. Review of the Resident #45's Physician orders since admission revealed no Physician order for Resident #45 to self-administer medication. Review of Resident #45's medical record revealed no documentation of a Medication Self-Administration Form, or documentation of education had been completed with Resident #45 to self-administer her own medication. Physician order dated 12-21-17 revealed an order for Resident #45 to have nothing by mouth (NPO). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance with one person for eating. The MDS…

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 revise the comprehensive care plan in the areas of pressure ulcers (Resident #67) and antianxiety medication (Resident #50). This was for 2 of 23 residents whose care plans were reviewed. Findings included: 1. Resident #67 was admitted to the facility on [DATE]. A review of Resident #67's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He was at risk for pressure ulcers. He had no unhealed pressure ulcers. A review of the comprehensive care plan for Resident #67 revealed a focus area initiated on 7/29/22 of suspected deep tissue injury to bilateral heels. The goal last revised on 11/16/22 was for Resident #67 to show signs of healing. An intervention was pressure relieving boots bilaterally. On 11/15/22 at 3:05 PM Resident #67 was observed in bed. He was not observed to be wearing pressure relieving boots. On 11/17/22 at 11:21 AM Resident #67 was observed in bed. He was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and record review the facility failed to provide a hazard free environment by leaving an electrical outlet uncovered with exposed wires for 1 of 6 residents reviewed for accidents (Resident #4). Findings included: Resident #4 was admitted to the facility on [DATE]. Resident #4's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. During observation of Resident #4's room on 11/15/22 at 2:43 PM an electrical outlet cover was observed ajar, and electrical wires were observed uncovered in Resident #4's room under the room's air-conditioning unit. During an interview on 11/15/22 at 2:45 PM Resident #4 stated it did not bother her that the outlet was uncovered but understood it could be a safety issue for someone else. During observation on 11/16/22 at 2:50 PM the electrical outlet was observed to still have exposed electrical wiring and the cover was still ajar. During an interview on 11/16/22 at 2:54 PM Medication Aide #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility failed to keep medications locked while unattended for 1 of 1 treatment carts observed and failed to refrigerate insulin for 1 of 3 medications carts observed (Treatment Cart #1, Medication Cart #1). Findings included: During observation on [DATE] at 10:49 AM Treatment Cart #1 was observed unattended in the main entry hallway with a housekeeper next to the unlocked cart. At 11:50 AM a therapist was observed passing the unlocked treatment cart. During an interview on [DATE] at 10:51 AM the Treatment Nurse stated treatment carts were to be locked when left unattended due to the medications in the cart. She further stated she remembered something she forgot and left the cart in the entrance hallway unlocked and forgot to lock it and should have locked it. During observation with the Treatment Nurse on [DATE] at 10:52 AM the treatment cart was observed to contain items including barrier film normal saline, vitamin A&D ointment barrier spray, Minerin cream,…

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 have a barrier between a nurse aide's (Nurse Aide #1) bare hands and ready to eat food for 1 of 4 dining observations. This practice had the potential to affect food served to a resident. Findings included: During observation on 11/16/22 at 7:34 AM Nurse Aide #1 was observed providing a meal tray to a resident in their room. She was observed to move the tray over the bed, adjust the height of the tray, and then remove the heat top off the tray. She then held the resident's piece of toast with her bare hand as she spread jelly on the toast. During an interview on 11/16/22 at 7:41 AM Nurse Aide #1 stated she knew not to touch resident food and to hand sanitize following touching resident items, but she was moving fast and did not realize it. During an interview on 11/16/22 at 7:45 AM the Director of Nursing stated staff were not to touch resident food with bare hands and the nurse aide should not have touched the toast. She concluded staff had been educated on this.

Based on observations, resident and staff interviews and record review, the facility's Quality Assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the survey 11/22/19 and 6/10/21 in order to achieve and sustain compliance. This was for 5 recited deficiencies on a recertification survey on 11/18/22. The deficiencies were in the areas of dignity, the right to forms of communication in private, care plan timing and revision, storage of drugs and biologicals, and sanitary food service. The continued failure during these federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross-referenced to: F550 - Based on observation, staff interviews, and record review the facility failed to treat residents in a dignified manner by scolding a resident after the resident overturned a mop bucket for 1 of 3 residents reviewed for dignity (Resident #71). During the recertification and complaint investigation survey of 6/10/21 the facility was cited for failing to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to provide a pneumococcal vaccine (a vaccine which can prevent a type of bacterial lung infection) in accordance with the signed informed consent. This was for 1 of 5 residents (Resident #80) reviewed for immunizations. Findings included: A review of the Advisory Committee on Immunization Practice (ACIP) recommendations titled Use of 15-Valent Pneumococcal Conjugate Vaccine (PCV) and 20-Valent PCV Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices dated 1/28/2022 revealed in part, Recommendations for use of 15-valent PCV in series with 23-valent pneumococcal polysaccharide vaccine (PPSV) or 20-valent PCV in PCV-naïve adults aged greater than or equal to19 years; Adults aged greater than or equal to 65 years who have not previously received PCV or whose previous vaccination history is unknown should receive 1 dose of PCV (either PCV20 or PCV15). When PCV15 is used, it should be followed by a dose of PPSV23.…

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.