Complete Care at Bayshore LLC

C #: NJ00171641 Based on observation, interview, and review of medical records and other pertinent facility documentation on 2/14/24, it was determined that the facility failed to follow professional standards of clinical practice for a). the administration of medications and b.) following a physician's orders, and c). adhering to the facility's policy for using the Medication Administration Record for 1 of 3 residents (Resident #2) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or…

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.

Complaint # NJ 00159893 Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately document the administration of medications in the electronic medical administration record (eMAR), b.) clarify duplicate physician's orders for an over-the-counter medication, aspirin 81 mg, and c). failed to obtain a medication for pain. This deficient practice occurred for 3 of 24 residents, (Resident #58, #112, and #220) reviewed for medication review. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or…

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, interviews, record review, and a review of pertinent facility documentation, it was determined that the facility failed to a). follow appropriate infection control practices for proper hand hygiene, b). ensure staff wore the appropriate personal protective equipment (PPE) for three residents who were on transmission-based precautions (TBP) (Resident #19, #56 and #378) c).ensure communication that all COVID-19 positive residents were communicated from shift to shift accurately (Resident #99) and failed to d). ensure that multiuse medical equipment was properly disinfected on 2 of 4 nursing units (A-unit and the 2nd floor subacute unit). The deficient practice was evidenced by the following: 1. On 10/4/23 at 10:20 AM, during the entrance conference, the facility administration staff told the surveyor that all staff were required to wear full PPE prior to entering a COVID-19 (infectious disease cause by SARS-CoV-2 virus ) room. Full PPE included wearing a N95 mask (respirator mask), goggles, gown and gloves. On 10/4/23 at 12:45 PM, during the initial tour on the…

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

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan in a timely manner to include a fall intervention for 1 of 3 residents, (Resident #91), reviewed for falls. This deficient practice was evidenced by the following: On 10/4/23 at 1:04 PM, the surveyor observed Resident #91 sitting upright in a recliner across from the nursing station. The resident's eyes were closed, and he/she did not respond to the surveyor. The surveyor reviewed the medical record for Resident #91. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, difficulty walking, repeated falls, and fracture the of left pubis (either of a pair of bones forming the two sides of the pelvis). Review of a significant change Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 9/13/23, revealed that the resident had a brief interview for mental status…

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 Complaint # NJ000162720 Based on interview and review of medical records, it was determined that the facility failed to to follow professional standards of clinical practice with respect to a.) clarifing a Physician's Order (PO) for Betadine solution 10% on admission, b.) accurately transcribe a PO for Betadine Solution 10% onto the Feburary 2023 electronic treatment administration (eTAR) and c.) document a wound treatment order as administered on 1/30/23 and 1/31/23. This deficient practice was identified for 1 of 8 residents (Resident # 372) reviewed for closed records. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, 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 interviews, record review, and review of other facility documentation, it was determined that the facility failed to a.) ensure that a resident received the appropriate care to maintain a Peripherally Inserted Central Catheter (PICC) (a thin soft tube that is inserted into a vein in the arm for long-term intravenous (IV) antibiotics) consistent with professional standards of practice and b.) update the care plan for a resident with a PICC. This deficient practice was identified for 1 of 1 resident (Resident #30) reviewed for IV therapy. This deficient practice was evidenced by the following: The surveyor reviewed the Electronic Medical Record (EMR) for Resident #30. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in September of 2023 with diagnoses which included but was not limited to; acute osteomyelitis (a serious infection of the bone) left ankle and foot, sepsis (the body's extreme response to an infection), and Type 2 Diabetes. Review of the admission Minimum Data Set (MDS), an assessment tool used 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, interviews, and record review, it was determined that the facility failed to a.) ensure a physician's order was obtained for a resident receiving oxygen and b.) the care plan was updated to include the resident was receiving oxygen. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for oxygen therapy. This deficient practice was evidenced by the following: On 10/04/23 at 12:43 PM, the surveyor observed Resident #111 awake and in bed, wearing oxygen via nasal canula. The oxygen concentrator was set at two liters per minute (LPM). The resident stated that they needed oxygen before their admission to the facility. The surveyor reviewed the medical record of Resident #111. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in August of 2023 with diagnoses which included but was not limited to; Pneumonia and Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with Acute Exacerbation (COPD, a group 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 observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to accurately monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 1 resident (Resident #93) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/12/23 at 10:10 AM, the surveyor observed Resident #93 in bed. The resident was alert, oriented, and responded appropriately to the surveyor. The resident stated that he/she went to hemodialysis (HD) on Monday, Wednesday and Friday in the afternoon. The resident stated that the HD access site was in the right upper chest (the resident pointed to the area). Review of Resident #93's admission Record (an admission summary) reflected diagnoses which included but was not limited to; acute kidney failure and hypertension. Review of the Quarterly Minimum Data Set (MDS), an assessment tool to facilitate the management 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 observation, interview, record review, and review of other pertinent facility documents it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for COVID-19 related medications for a resident who tested negative for COVID-19. This deficient practice was identified for 1 of 24 residents (Resident #99) reviewed during medical record review and was evidenced by the following: On 10/5/23 at 10:00 AM, the surveyor observed Resident #99, self-propelling in their wheelchair toward the bathroom. The resident was alert and oriented but did not want to be interviewed. The surveyor observed the resident's room which had no stop sign or isolation signage on the door or wall, and no personal protection equipment (PPE) bin located outside of the resident's room. The surveyor reviewed the medical record for Resident # 99. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), cerebral…

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, interview, and review of pertinent facility documents, it was determined that the facility failed to a). secure medications in 1 of 4 nursing units inspected, b). secure medications in 1 of 4 emergency kits (E-kits) inspected, and c). properly label, store and dispose of medications in 3 of 10 medication carts and 1 of 4 medication rooms inspected. This deficient practice was evidenced by the following: 1. On 10/05/23 at 2:10 PM, the surveyor observed two bags containing medications on the A unit nursing station, no residents were in the vicinity. The two bags included the following medications: Eliquis (blood thinner), Tessalon (medication for coughing), Vitamin D (vitamin), Norvasc (blood pressure), Diltiazem (blood pressure), Tradjenta (diabetes), Carafate (stomach medication), Xarelto (blood thinner), Nadolol (blood pressure) and Sevelamer (phosphate binder). At that same time, the surveyor interviewed a Licensed Practical Nurse (LPN #1 ) who stated that the medications inside the two bags were discontinued medications that were going to be returned to 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.

b) On 07/19/22 at 9:57 AM, Surveyor #2 conducted an initial tour on A wing and observed Resident #101 sitting in the day room with other residents. Resident #101 was at a table alone. There were birthday balloons tied to the back of the wheelchair. Surveyor #2 observed that there was no staff interaction observed with the residents. There were music videos playing on the television (TV). The surveyor observed the activity calendar that was posted on the wall in the hallway on the unit. The activities listed for 7/19/22 included: Ice Cream Day, AM Activities, Chronical & Coffee Delivery, Interesting Ice Cream Facts around the world, Ice Cream Detective, Afternoon Highlights and Strolling Ice Cream Cart. There were no times listed for the activities. On 07/20/22 at 11:23 AM, Surveyor #2 observed Resident #101 in the A wing day room at a table alone and was facing the TV. There were other residents present in the room. There was music videos playing on the TV and the residents did not appear to be watching the TV. On 07/21/22 at 9:42 AM, Surveyor #2 observed Resident #101 sitting in a…

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

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the activities program was directed by a qualified therapeutic recreation specialist or activity professional. The deficient practice was evidenced by the following: Refer to 679F On 07/26/22 at 10:30 AM, the surveyor conducted a resident meeting with six alert and oriented residents. Resident (R1) stated that the facility has not had a Director of Recreation for about six months, and it had affected the residents. R #1 stated that the residents had felt that they were not getting enough activities, and there were no activities during the weekend. R #1 stated we just sit here. R #1 stated there was not much offered during the week, and once a week we might do a craft. R1 stated that there were no outside trips since the pandemic began (approximately a two-year time span). R #1 stated the resident council was concerned and wanted to know what the facility was providing to ensure the confused residents received activities since the alert and oriented…

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, the resident council meeting, review of medical records and other pertinent facility documentation it was determined that the facility was not consistently offering nighttime snacks to all residents on a nightly basis. This deficient practice was identified for 9 of 47 unsampled residents on 1 of 4 units (A-wing) and was evidenced by the following. On 07/26/22 at 10:31 AM, the surveyor conducted the Resident Council Meeting with six (6) alert and oriented residents. The residents at the resident council meeting were all in agreement that snacks were not consistently being offered at night. On 07/29/22 at 10:01 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the A-Wing who stated that she worked 12 hour shifts, usually 7:00 AM to 7:00 PM and had seen that trays of snacks were delivered approximately 7:00 PM in the evening right before she was ready to leave for the night. However, she added that she was not in the facility when snacks were being handed out to the residents so she was not sure who was offered snacks at night. She stated that…

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, interviews, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 07/19/22 from 9:47 AM until 11:17 AM, the surveyor toured the kitchen in the presence of the Director of Dietary Services (DDS) and observed the following: 1. The DDS wearing a surgical mask with short facial hair observed on both cheeks and long white facial hair observed on his chin hanging out of the bottom of the surgical mask. 2. In walk-in refrigerator #3, there was one box filled with individual containers of cream cheese with no dates on the box and no dates on the containers. There was one black quarter container of individual cream cheese with no dates.…

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, interview, record review and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the implementation of surveillance techniques to minimize sources and transmission of COVID-19 virus (an acute disease in humans caused by a Coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) by not appropriately ensuring that residents were screened, in Phase 0 of reopening, in accordance with the requirements in the New Jersey Department of Health's (NJDOH) Executive Directive No. 20-026¹ and the Center for Disease Control and Prevention (CDC) guidance for 2 of 3 residents (Resident #89 and #436) reviewed; b.) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner to reduce the further spread of infection during a Candida Auris (an emerging fungus that presents a serious global…

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, record review, and other pertinent facility documentation it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 1 residents reviewed (Resident #101) for reportable incidents. This deficient practice was evidenced by the following: According to the admission Record, Resident #101 was admitted with diagnoses which included, but were not limited to, Dementia and anxiety. Review of the Minimum Data Set (MDS), an assessment tool, dated 6/14/2022, Resident #101 had a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated that Resident #101 had severely impaired cognition. The MDS documentation also indicated that Resident #101 required extensive staff assistance for Activities of Daily Living (ADLS). Review of Resident #101's Care Plan (CP) revealed a Focus: Anticoagulant therapy, risk for injury bleeding, and/or bruising due to use of anticoagulant secondary to anticoagulant use. Effective 3/24/2021, Interventions: Assess for signs of abnormal bleeding (bruising,…

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, record review and pertinent facility documents, it was determined that the facility failed to thoroughly investigate an Injury of Unknown origin for 1 of 2 residents (Resident #101) reviewed for injury of unknown origin. This deficient practice was evidenced by the following: According to the admission Record, Resident #101 was admitted to the facility with diagnoses including but not limited to: Dementia and anxiety. Review of the Minimum Data Set (MDS), an assessment tool dated 06/14/2022, Resident #101 had a Brief Interview for Mental Status (BIMS) score of 2/15, indicating that Resident #101 had severely impaired cognition. The MDS documentation also indicated that Resident #101 required extensive staff assistance for Activities of Daily Living (ADLS). Review of Resident #101's Care Plan (CP) revealed Focus: Anticoagulant therapy, risk for injury bleeding, and/or bruising due to use of anticoagulant secondary to anticoagulant use. Effective 3/24/2021, Interventions: Assess for signs of abnormal bleeding (bruising, bleeding gums, tarry stools, petechiae),…

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, interviews, record reviews and review of pertinent facility documentation, it was determined that the facility failed to develop a resident-centered care plan with objectives and time frames to meet the needs of a resident who had an 8.9 pound (lb) weight gain. This deficient practice was identified for 1 of 28 residents (Resident #114) reviewed for Care Plans (CP). This deficient practice was evidenced by the following: During tour on 07/20/22, the surveyor observed Resident #114 lying in bed and was not responding to the surveyor. The surveyor observed a tube feeding pump with no feeding being infusing at that time. A review of the medical records revealed that Resident #114 h,ad been recently admitted to the facility with diagnoses which included but were not limited to, persistent vegetative state, Diabetes (elevated blood sugar) due to underlying condition, and moderate protein-calorie malnutrition. A review of the most recent Significant Change Minimum Data Set (MDS-an assessment tool) dated 06/28/22, revealed under Section G that Resident #114 was…

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, interview, and document review, it was determined that the facility failed to follow professional standards of practice by ensuring that staff did not utilize personal equipment, a personal blood pressure (BP) monitor, for resident care. This deficient practice was identified for 1 of 2 Licensed Practical Nurses (LPN) observed during medication administration, and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and clinical record reviews, and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide personal care for 1 of 27 residents reviewed for activities of daily living (ADLs), Resident # 18, and b.) provide a resident (Resident #85) 1 of 27, with the care needed to meet the resident assessed needs. This deficient practice was evidenced by the following: a) On 07/19/22 at 11:47 AM, the surveyor toured the B Wing of the facility and observed Resident #18 lying in bed. The resident's right hand was partly closed and some jagged, fingernails were exposed with a dark embedded debris underneath. The fingers of the resident's left hand were observed curled into the palm of that hand. When the resident was asked if he/she could open their left hand, he/she opened both hands and the fingernails were observed to be long with a dark coated debris approximately ½ inch underneath the nails. Another observation on 07/20/22 at 9:25 AM, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure: 1.) a resident who required enteral nutrition (EN) support via a tube feeding (liquid nutrition provided directly via a tube into the stomach) and sustained a 17 % weight weight loss over eight days was re-weighed per facility policy, and 2.) conduct a nutrition assessment upon admission and assess and report a weight gain of 8.9 pounds (lbs). This deficient practice was identified for (Residents #239 and #114) 2 of 7 residents reviewed for nutrition/hydration and tube feedings. The deficient practice was evidenced as follows: 1) On 07/19/22 at 11:07 AM, the surveyor observed Resident #239 in bed, with eyes closed, appeared thin, and EN support was being infused at 65 ML (milliliters) per hour via a pump. On 07/20/22 at 12:55 PM, the surveyor reviewed the medical record for Resident #239, which revealed the following: The Resident Face Sheet revealed diagnoses that…

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, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was properly positioned while the resident received enteral nutrition support ([NAME]) via a gastric tube (a form of nutrition that is delivered into the digestive system via a tube as a liquid) for 1 of 4 residents reviewed for tube feeding (Resident #239). This deficient practice was evidenced by the following: On 07/19/22 at 11:07 AM during the initial tour, the surveyor observed Resident #239 in bed with [NAME] being administered at 65 ML (milliliters) per hour via a feeding pump and the resident appeared thin. 07/20/22 at 12:55 PM, the surveyor reviewed Resident #239's medical record. The Resident Face Sheet indicated that Resident #239 was admitted with diagnoses that included, but were not limited to, dysphasia (swallowing difficulty), cerebrovascular disease, chronic kidney disease and diabetes mellitus (DM). The Physician Order Activity Detail…

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, interview, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen therapy consistent with physician orders and infection control measures. This deficient practice was identified for 1 of 2 residents reviewed for oxygen therapy, Resident #89 and was evidenced by the following: On 07/19/22 at 9:45 AM during the initial tour of the facility, the surveyor observed (B Wing) and Resident #89 sitting in a chair next to the bed receiving oxygen at a flow rate of 1.5 liter per nasal cannula (NC) by way of a concentrator. The Oxygen [O2] tubing was observed on the floor and not labeled or dated. There was no signage at the door to alert of Oxygen being in use. On 07/19/22 at 11:57 AM, the surveyor observed Resident #89 sitting on the bed eating lunch, their O2 tubing noted on the floor. On 07/19/22 at 1:15 PM, the surveyor observed Resident #89 sitting in the chair in the room. The surveyor observed the O2 setting at 1.5 liters delivery via NC. On 07/20/22 at 9:07 AM, the surveyor observed Resident #89 in…

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

Based on observation, interview and the review of the medical record and other facility documentation, it was determined that the facility failed to provide a gradual dose reduction (GDR) of psychoactive medication in the absence of behaviors and ensure the appropriate use and monitoring of psychotropic medications for 1 of 5 (Resident #81) residents reviewed for psychoactive medications and was evidenced by the following: On 07/19/2022 at 10:00 AM during tour, the surveyor observed Resident #81 in bed with the head of bed up, non-verbal with eyes half open. The resident was not tracking (scanning) the surveyor with his/her eyes and had a blank gaze in his/her eyes. The surveyor was unable to interview the resident due to severe cognitive impairment. The resident was observed with a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) and a tube feeding (a means of providing nutrition by way of a feeding tube inserted into the gastrointestinal tract) was hanging on a pole next to the resident's bed. The surveyor also observed that a…

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

Based on observation, interview, and review of other pertinent facility documentation it was determined that the facility failed to consistently a.) serve foods at temperatures preferred by residents for 5 of 6 residents at the Resident Council Meeting that complained of undesirable food temperatures. b.) serve hot and cold foods at acceptable temperatures, and c.) follow the facilities policy for Food holding. The deficient practice was observed in 1 of 1 test trays on 1 of 4 units (B-Wing) and was evidenced by the following: On 07/26/22 at 10:31 AM, the surveyor conducted the Resident Council Meeting with six (6) alert and oriented residents in which 5 of 6 unsampled residents at the meeting complained that the food did not always get delivered fast enough to the residents, so sometimes the food was cold. They stated that the food was delivered on time from the kitchen, but then once the food truck was on the unit, the nurses and certified nursing assistants do not pass them out quickly enough so that the food temps were not palpable. On 08/02/22 at 11:39 AM, two surveyors…

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.