Rolette Community Care Center

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#4) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 09/11/24 at 10:40 a.m., an administrative manager (#2) confirmed the dietary manager (#4) lacked the required training for the position. The facility failed to ensure the dietary manager (#4) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and review of the federal database for Long-Term Care Survey, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for 3 of 12 sampled residents (Resident #4, #5, and #20) and one supplemental resident (Resident #75). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18), page 2-34, stated, . The MDS must be transmitted . electronically no later than 14 calendar days after the MDS completion date . Page 2-35 stated, . The ARD [assessment reference date] must be within 92 days after the previous OBRA assessment . The MDS completion date (item Z0500B) must be no later than 14 days after the ARD. Page 2-38 stated, Entry Tracking Records . Must be submitted no later than the 14th calendar day…

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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (Resident #1, #13, #16, #18, and #20). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2023, pages K-2 through K-11, stated, . K0200: Height and Weight . Weight . Base weight on most recent measure in the last 30 days, . K0520: Nutritional Approaches . PARENTERAL/IV FEEDING Introduction of a nutritive substance into the body by means other than the intestinal tract (e.g., subcutaneous, intravenous). FEEDING TUBE Presence of any type of tube that can…

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, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 7 of 12 sampled residents (Resident #1, #5, #7, #9, #10, #18, and #20). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred 09/11/24. This policy, revised March 2022, stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables. The comprehensive, person-centered care plan: . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . the interdisciplinary team reviews and updates the care plan . - Review of Resident #1's medical record occurred on all days of survey. Diagnoses included gastrostomy status. The current care plan stated, . Feeding Tube . Resident requires tube feeding . Observation…

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 interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1 of 2 sampled residents (Resident #13) transferred to the hospital. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #13's medical record occurred on all days of survey and identified a hospital transfer on 06/28/24. The medical record lacked evidence the facility provided the resident and/or representative with a written transfer notice. During an interview on 09/10/24 at 4:55 p.m., an administrative staff member (#6) confirmed the facility failed to complete a Notice of Transfer for Hospitalization for the resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #10) observed for insulin preparation. Failure to prime an insulin pen correctly may result in residents receiving an inaccurate dose. Findings include: Review of the manufacturer's guidelines titled Fiasp insulin aspart injection. Instructions for use. occurred on 09/11/24. This document, dated July 2023, page 8, states, . Priming your . Pen: Step 7: Turn the dose selector to select 2 units. Step 9: Hold the pen with the needle pointing up. Press and hold in the button until the dose counter shows0. A drop of insulin should be seen at the needle tip. Observation on 09/10/24 at 11:53 a.m. showed a nurse (#3) attached a needle to Resident #10's Fiasp FlexTouch insulin pen, selected two units of insulin, and depressed the plunger while the pen was in the horizontal position. The nurse (#3) failed to hold the pen with the needle…

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, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 2 of 4 sampled residents (Resident #5 and #11) reviewed for psychotropic medication use. Failure to limit as needed (PRN) psychotropic medication use to 14 days unless reevaluated by a practitioner, and failure to monitor the residents on psychotropics placed the residents at risk of receiving unnecessary medications and experiencing adverse drug effects and consequences related to their use. Findings include: Review of the facility policy titled Psychotropic Medication Use occurred on 09/11/24. This policy, dated July 2022, stated, . PRN orders for psychotropic medications are limited to 14 days. PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Resident receiving psychotropic medications are monitored for adverse consequences, including: .…

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, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications for 2 of 2 unlocked and unattended carts (medication and treatment carts). Failure to securely store medications may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Labeling and Storage occurred on 09/11/24. This undated policy, stated, Policy Statement. The facility stores all medications. in locked compartments. Medication Storage. 2. The nursing staff is responsible for maintaining medication storage. 3. Compartments (including, but not limited to, drawers, . carts, . ) containing medications. are locked when not in use, . carts used to transport such items are not left unattended if open or otherwise available to others. Observation on 09/11/24 at 8:18 a.m., showed an unlocked/unattended medication cart with medications on the top of the cart and an unlocked/unattended treatment cart in the 200-hallway. During an interview on 09/11/24 at 8:34 a.m., an administrative nurse (#1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THIS IS A REPEAT DEFICIENCY FROM THE PREVIOUS STANDARD SURVEY CONDUCTED ON 06/09/22. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 4 of 13 sampled residents (Resident #12, #17, #19, and #20) and 1 closed record reviewed (Resident #22). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans - Comprehensive occurred on 08/23/23. This undated policy stated, . care plans are revised as information about the resident and the resident's condition change. - Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . ADL [Activities of Daily Living] Functional Status: . Resident uses sit-to-stand [mechanical lift] unless Hoyer [mechanical full body] lift is appropriate for safety and 2 staff to transfer .…

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

Based on observation and staff interview, the facility failed to store and serve food in a safe and sanitary manner in 1 of 1 kitchen. Failure to store and serve food in a safe and sanitary manner may result in contaminated food, poor food quality, and potential spread of illness amoung residents, staff, and visitors. Findings include: Observation on 08/21/23 at 3:26 p.m. showed a pool of pale-yellow liquid on the floor and leaking from the ceiling in the walk-in cooler. The liquid leaked onto a cart which contained drinks and pudding for the next meal service and onto and under a bag of thawing hamburger. Observation on 08/21/23 at 12:23 p.m. showed a dietary staff member (#7) touched their hair, face, itched their arms and neck, and drank from a personal soda bottle and failed to sanitize their hands before touching resident plates and serving resident meals. During an interview on 08/21/23 at 3:36 p.m., a dietary manager (#6) stated she was aware of the leak and instructed staff not to store anything by liquid was leaking. During an interview on 8/21/23 at 3:45 p.m., 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 observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner that maintained or enhanced dignity for 1 of 2 sampled residents (Resident #12) and 1 supplemental resident (Resident #14) observed while being fed in the dining room. Failure to feed Resident #12 and #14 in a dignified manner does not promote their dignity or enhance their quality of life. Findings include: Review of the facility policy titled Dignity occurred on 08/23/23. The undated policy stated, . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Demeaning practices and standards of care that compromise dignity are prohibited . - Review of Resident #12's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive assistance required for eating. Observation on 08/22/23 at 12:10 p.m. showed Resident #12 sat at 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 record review, review of facility policy, and staff interview, the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment for 1 of 13 sampled residents (Resident #17) reviewed for advance directives. Failure of staff to ensure Resident #17's family/legal representative signed documentation regarding their wishes limited the facility's ability to communicate to direct care staff and emergency personnel the family/representative's wishes in the event of a medical emergency. Findings include: Review of the facility policy titled Advance Directives occurred on [DATE]. This policy, revised [DATE], stated, . The facility will . approach the . legal representative if the resident is determined not to have decision making capacities. During the care planning process, the facility will review with the . legal representative whether they desire to make any changes related to the Advanced directives. - Review of Resident #17's medical record occurred on all days of survey…

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, review of facility policy, and staff interview, the facility failed to provide a written notice of transfer that included all required content, to the resident and/or their representative for 1 of 2 closed records (Resident #23) reviewed. Failure of the facility to provide a written notice with all required content to the resident/representative limited their ability to make informed decisions. Findings include: Review of the facility policy titled, Transfer or Discharge, Emergency, occurred on 08/23/23. This undated policy stated, Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures . d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member . Review of Resident #23's medical record occurred on 08/23/23 and identified a hospital transfer on 07/12/23. A form titled, Notice of Transfer for Hospitalization, dated 07/12/23, identified the facility notified the resident's representative…

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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 13 sampled residents (Resident #16) and 1 supplemental resident (Resident #14). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: Section G - The Long-Term Care Facility RAI User's Manual, revised October 2019, pages G-9 and 11 stated, . Code totally dependent in eating: only if resident was assisted in eating all food items and liquids at all meals and snacks . and did not participate in any aspect of eating (e.g., did not pick up finger foods . or assist with swallow or eating procedure). Code 3, two+ person physical assist: if the resident was assisted by two or more…

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, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 2 sampled residents (Resident #3 and Resident #16) with a newly diagnosed mental illness and/or change in treatment. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual, revised 12/29/20, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory…

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, review of the facility policy, and staff interview, the facility failed to develop a comprehensive care plan for 1 of 13 sampled residents (Resident #16). Failure to develop a comprehensive care plan related to psychotropic medication use may negatively impact the resident's quality of care. Findings include: Review of the facility policy titled Care Plans - Comprehensive occurred on 08/23/23. This undated policy stated, . Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas . Reflect treatment goals, timetables and objectives in measurable outcomes . Review of Resident #16's medical record occurred on all days of survey. Diagnoses included major depressive disorder. Resident #16's current physician's orders identified the following psychotropic medications: *Aripiprazole (antipsychotic medication) 5 milligrams (mg) daily *Buproprion HCI (antidepressant medication) 150 mg daily *Buspirone (antianxiety medication) 10mg as needed *Doxepin (antidepressant medication) 25 mg daily *Sertraline (antidepressant 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.

Based on record review, review of facility policy, and staff and resident interviews, the facility failed to provide services to maintain or improve abilities in activities of daily living (ADLs) for 3 of 9 sampled residents (Resident #12, #16, and #17) with recommendations for restorative therapy (RT). Failure to provide the residents with RT may result in decreased mobility and safety. Findings include: Review of the facility policy titled Restorative Nursing occurred on 08/23/23. This undated policy, stated, . Nursing personnel are trained . maintenance, restorative nursing care . The training may include . assisting with any exercises according to the plan of care. Assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate . Residents . will receive services from restorative aides when they are assessed to have a need for such services . These services may include: . Passive or active range of motion. Restorative aides will implement the plan for a designated period of time, performing the activities, 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, facility policy review, and staff interview, the facility failed to provide an ongoing program of meaningful activities designed to meet the interests and physical, mental, and psychosocial well-being for 1 of 13 sampled residents (Resident #19) dependent on staff for activities. Failure to provide meaningful activities for residents with visual impairments limited Resident #19's ability to reach his highest practicable level of physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Activities occurred on 08/23/23. This undated policy, stated, . 'Activities' refer to any endeavor . that is intended to enhance . his sense of well-being and to promote or enhance physical, cognitive, and emotional health. Each resident's interests and needs will be assessed on a routine basis. Activities will . Reflect resident's interests . Special considerations will be made for developing meaningful activities for resident with . special needs. Review of Resident #19's medical record occurred on all days of survey.…

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, review of professional literature, and staff interview, the facility failed to ensure 1 of 3 sampled residents (Resident #12) received the services necessary to attain the highest degree of safety possible while being fed in the dining room. Failure to ensure staff provided proper positioning and cueing when giving foods and liquids placed Resident #12 at risk for aspiration. Findings include: The facility failed to provide a policy addressing feeding assistance and/or positioning as requested. Swigert's The Source for Dysphagia, 4th Edition, 2019, Pro-Ed, Inc., Texas, pages 19 and 130 stated, . Signs of Dysphagia . DROOLING/INCREASED SECRETIONS . WEIGHT LOSS . COUGHING OR CHOKING . POCKETING . for the patient seated in a chair, the 90 [degrees] angle is necessary before and during feeding. Being at 90 [degrees] allows the patient to control material in the oral cavity with a minimal impact of gravity. The position must be maintained during and following the meal.…

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, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 1 sampled resident (Resident #16) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed interventions to aid in the healing of the pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol occurred on 08/23/23. This policy, revised April 2018, stated, . the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; . staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Review of Resident #16's medical record occurred on all days of survey. Diagnoses included a non-pressure chronic ulcer of the right heel and type 2 diabetes mellitus. A physician's order, 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 observation, record review, review of the facility's policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 2 sampled residents (Resident #19) observed during stand-lift transfers. Failure to ensure proper use of a mechanical sit-to-stand lift placed Resident #19 and other residents at risk for possible accidents with/without injury. Findings include: Review of the facility policy titled Safe Lifting and Movement of Residents occurred on 08/23/23. This undated policy, stated, . Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: . Resident's mobility (degree of dependency) . Weight-bearing ability. - Review of Resident #19's medical record occurred on all days of survey. Diagnoses included adult failure to thrive, bilateral degeneration of the retina (resulting in vision loss)…

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, review of facility policy, and staff interview, the facility failed to ensure residents received the care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #16) receiving hemodialysis outside the facility. Failure to ensure physician's orders for hemodialysis and to assess/monitor hemodialysis vascular access site (arterial-venous fistula) on a regular basis can result in missed dialysis appointments and complications related to the fistula. Findings include: Review of the facility policy titled, Dialysis Arrangement occurred on 08/21/23. This undated policy, stated, . Development and implementation of the resident's care plan: 1. The care plan for all residents receiving dialysis will be developed and implement4ed [sic] and updated by the interdisciplinary team at the [facility name] . the plan of care will include how to handle emergencies and medical complications, medication and adverse effects if indicated, shunt/fistula care,…

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, review of facility policy, and staff interview, the facility failed to ensure a regimen free of unnecessary medications for 1 of 2 sampled residents (Resident #12) with a history of urinary tract infections (UTIs). Failure obtain a culture and sensitivity (lab test to identify the bacteria and antibiotics susceptible to the bacteria) before starting an antibiotic may result in treatment for a non-existent UTI, administration of a wrong antibiotic, and the risk of experiencing side effects related to the antibiotic. Findings include: Review of the facility policy titled Antibiotic Stewardship - Orders for Antibiotics occurred on 08/23/23. This undated policy, stated, . Prior to calling a physician . the nurse will . have the following information available . Clinical signs and symptoms of suspected infection . A history of the present illness . Appropriate indications for use of antibiotics include . criteria met for clinical definition of active infection . pathogen susceptibility, based on culture and sensitivity, to antimicrobial . Review of the facility…

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, review of facility policy, and staff interview, the facility failed to follow standard infection control practices for 3 of 13 sampled residents (Resident #1, #13, and #19) observed during personal cares. Failure to follow infection control practices related to hand hygiene/glove use has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled Policies and Practices - Infection Control occurred on 08/23/23. This undated policy stated, . infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infection. Review of the facility policy titled Handwashing/Hygiene occurred on 08/23/23. This undated policy stated, . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. - Observation on 08/21/23 at 11:31 a.m. showed two certified nurse aides (CNAs) (#9 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.