Southern Ocean Center

Based on observations, interview, record review, and pertinent facility documents it was determined that the facility failed to provide appropriate treatment and care, based upon current standards of practice and the resident's comprehensive care plan specifically not securing a urinary catheter drainage bag properly resulting in the bag making contact with the floor. The deficient practice was identified for 1 of 3 (Resident # 15) investigated for Urinary Catheter. The deficient practice was evidenced by the following: A review of Resident # 15's admission Minimum Data Set (MDS; an assessment tool) dated 04/08/2024 revealed that he/she had an indwelling catheter (tube inserted into the bladder to assist in the flow of urine). A review of Resident # 15's Electronic Medical Record (EMR) revealed under Med Diag that he/she was diagnosed with but not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine) and Retention of Urine. A review of Resident #…

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.

NJ Complaint #159967, #159711, #169655, #170197, Based on interview, review of the Nurse Staffing Report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: On 04/29/24 at 10:30 AM, the surveyor held a Resident Council meeting with six residents in attendance. During the Resident Council meeting the surveyor asked all residents in attendance if they received showers, or assistance with showers. Four of the six residents in attendance told the surveyor that showers were not offered twice weekly (Resident #21, #84. #94, and #122). All were aware of their shower day schedule but stated they do not always receive them because of staffing issues. 1.For the week of Complaint staffing from 10/02/2022 to 10/08/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -10/02/22 had 6.5 CNAs for 111 residents on the day shift, required at least 14 CNAs. -10/03/22 had 8…

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 use appropriate infection control practices, specifically failing to adhere to the minimum time to lather hands during hand hygiene when providing wound care. The deficient practice was observed during wound care for 1 of 2 residents (Residents # 59) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 59's Quarterly Minimum Data Set (MDS; an assessment tool) dated 01/22/2024 revealed that he/she had wounds. A review of Resident # 59's Electronic Medical Record (EMR) revealed under Orders to Cleanse Right heel with wound cleanser. Pat dry. Apply hydrogel fluffed gauze. Cover with ABD, wrap with kling [gauze-style bandage] every day shift for open wound for 14 Days AND as needed. The order was initiated on 04/25/2024. A review of Resident # 59's EMR revealed under Care Plan a focus that Resident # 59 has a documented pressure ulcer to the right heel. The focus was initiated on 04/24/2024. 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 record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for the pneumococcal vaccination for 1 (Resident #4) of 5 residents whose MDS assessments were reviewed. Findings included: Reference: Review of the Centers for Medicare and Medicaid Services' [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] User's Manual for Version 3.0, revised in October 2023, indicated Coding Instructions O0300A, Is the Resident's Pneumococcal Vaccination Up to Date? Code 0, no: if the resident's pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. The Manual further indicated Code 2, Offered and declined: resident or responsible party/legal guardian has been informed of what is being offered and chooses not to accept the pneumococcal vaccine. A review of an admission Record indicated the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an…

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

Based on interview, record review, and facility policy review, the facility failed to maintain documentation of eligibility and consent to receive or refusal of the pneumococcal vaccination upon admittance into the facility for 1 (Resident #4) of 5 residents reviewed for immunizations. Findings included: Review of a facility policy titled Pneumococcal Vaccination, with a revised date of 11/15/2022, indicated, Upon admission, obtain the pneumococcal vaccination history of all patients. It further revealed 1.2 Document pneumococcal vaccination history in PointClickCare (PCC) and on the Pneumococcal Consent form under Vaccination History. 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. A review of an admission Record revealed the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an admission Minimum Data Set (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 interview and review of facility documentation, it was determined that the facility failed to consistently offer residents HS (hour of sleep) snacks. This deficient practice was identified for 5 of 5 residents (Resident #17, #23, #68, #44, and #25) during resident council meeting and was evidenced by the following: On 03/22/22 at 11:06 AM, the Surveyor conducted resident council meeting with five residents. During that time, the Surveyor inquired about HS snacks. All five residents commented that they do not always get offered bedtime snacks and that it would depend on the staff that evening. On 03/23/22 at 8:09 AM, the second floor Licensed Practical Nurse Unit Manager (LPN UM) stated that the process would be for the evening snacks to be delivered from the kitchen about 6:45 PM to 7 PM. The LPN UM stated some snacks are assigned to certain residents and the other snacks would be offered to the rest of the residents. The LPN UM stated that the Certified Nursing Assistants (CNAs) would either document…

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 maintain the kitchen in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth and to prevent physical contaminants from entering the food, b.) staff practiced appropriate hand hygiene and restrained hair appropriately, c.) food items were maintained in a manner to ensure they were not used past their use by date, and d.) a process was in place to ensure bottled water was maintained in a manner to ensure the water was not used by a use by date. The deficient practice was evidenced by the following: On 03/17/22 at from 9:32 AM to 11:30 AM, the Surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD), and observed the following: 1. The refrigerated walk-in unit had a dark spot affixed to the interior of the wall by the door, and what appeared as greenish dark stained areas throughout 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 interview, medical record review, and review of facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Activities of Daily Living (ADL's), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50) and was evidenced by the following: On 03/17/22 at 9:50 AM, the Surveyor observed Resident #50 in bed with their eyes closed. On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. The Friend informed the surveyor he had been trying to get Resident #50 a shower for the past two months. The Friend stated that the facility had not been able to accommodate Resident #50's preference for a shower. A Review of Resident #50's medical record revealed the following: 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: a.) follow the facility policy for Advance Directives to ensure a complete and updated Advance Directive was maintained in a resident's medical file, and b.) inform and offer educational material regarding Advance Directives. This deficient practice was identified for 1 of 1 resident (Resident #2) who was reviewed for Advance Directives. The deficient practice was evidenced by the following: On 03/17/22 at 9:43 AM, the Surveyor observed Resident #2 in their room with their spouse. Resident #2 spoke to the Surveyor and was confused at times. A review of Resident #2's medical records revealed the following: The admission Record revealed Resident #2 had been admitted to the facility with diagnoses, which included but were not limited, to dementia without behavioral disturbance, Transient Ischemic Attack (stroke-like attack wherein symptoms resolve within 24 hours), depression, lack of coordination, hyperkalemia (elevated blood potassium),…

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 documents, it was determined that the facility failed to: a.) administer oxygen per the physician order for 2 of 5 residents sampled for respiratory/oxygen (Resident #36 and Resident #17), b.) ensure that all oxygen supplies were changed, labeled and dated weekly for 4 of 5 residents sampled for respiratory/oxygen, and c.) post cautionary signage to indicate that oxygen therapy was in use for 4 of 5 residents reviewed for oxygen/respiratory (Resident #36, #17, # 63 and Resident #27). The deficient practice was evidenced by the following: 1. On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with eyes open wearing oxygen (O2) by way of nasal cannula (tubing used to deliver oxygen). The O2 was connected to an oxygen concentrator (an electronic device that removed nitrogen from room air and increased the oxygen concentration) that was sitting beside the bed and set to deliver 3.5 liters of oxygen per minute. On 03/18/22 at 9:24 AM, the Surveyor observed Resident #36 resting in bed with…

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

Based on observation, interview, review of the medical record and other pertinent facility documentation, it was determined that the facility failed to: a.) consistently communicate information to the dialysis center by failing to document an assessment and pre-dialysis treatment, on the Hemodialysis Communication Record (HCR), per facility policy, for 22 of 35 scheduled dialysis treatments, b.) document an assessment, post dialysis treatment, on the HCR, per facility policy, for 33 of 35 scheduled dialysis treatments, c.) accurately monitor and account for the intake of all fluids administered for a resident with a physician ordered fluid restriction, d.) ensure a physician ordered medication that required additional fluid for administration would not exceed the fluid restriction, and was documented. This deficient practice was evidenced for 1 of 2 resident's reviewed for dialysis (Resident #4) and was evidenced by the following: On 03/17/22 at 11:25 AM, during initial tour, the Surveyor observed Resident #4 lying in bed. Resident #4 stated that he/she received hemodialysis (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 interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure: a.) a resident was offered a shower on scheduled shower days, and b.) that residents were consistently offered evening snacks. The deficient practice was evidenced by the following: Refer to F561 and F809 The facility failed to: a.) follow the facility policy for Activities of Daily Living (ADLs), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50). On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. The Friend informed the surveyor he had been trying to get Resident #50 a shower for the past two months. The Friend stated that the facility had not been able 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 interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to develop a process to track and perform weekly: a.) COVID-19 testing for staff that did not receive a COVID-19 vaccination, and b.) COVID-19 testing for staff who were not up-to-date with all recommended COVID-19 vaccinations. This deficient practice was evidenced by the following: Reference: CMS QSO-20-38-NH dated revised 09/10/21, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their community transmission level as the trigger for testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site:https://covid.cdc.gov/covid-data-tracker/#county-view. Table 2: Routine testing Intervals by County COVID-19 Level of Community Transmission . Level of COVID-19 Community Transmission:…

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, medical record review and review of other pertinent documentation, it was determined that the facility failed to ensure resident dignity by failing to ensure a urinary collection privacy cover was in place over the urinary catheter collection bags. This deficient practice was identified for 2 of 4 residents reviewed (Resident #54 & Resident #69) for urinary catheter use. The deficient practice was evidenced by the following: a.) On 03/17/22 at 9:40 AM, during a tour of the facility, the Surveyor observed Resident #54 seated in the Dining Room (DR) with three other residents. The catheter drainage bag was underneath the chair and had a visible amount of urine inside the bag and did not have a privacy cover. On 03/17/22 at 10:36 AM, the Surveyor observed Resident #54 attending an activity in the DR with other residents present. The catheter drainage bag was observed half full with urine and was without a privacy cover. On 03/17/22 at 12:18 PM, the Surveyor, in the presence 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 interview, review of clinical records and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse to the state survey agency, Department of Health (DOH). This was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/18/22 at 8:55 AM, the Surveyor interviewed Resident #51 who stated that he/she remembered reporting a complaint about a Certified Nursing Assistant (CNA) to the human resources manager (HRM). The resident that stated that he/she reported that the CNA did not provide care to him anymore or since he/she reported it to the administration. The resident stated that the CNA was rude and was talking about him/her in the hallway loudly enough so that he/she could hear him/her. On 03/18/22 at 9:13 AM, the Surveyor interviewed HRM who identified herself as the Workforce Specialist which was the human resources director. The HRM told the surveyor that she remembered about one year ago that Resident #51 reported that he/she did not care for of his/her CNAs. 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.

Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to follow the facility Abuse Prohibition policy by failing to thoroughly investigate an allegation of abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/17/22 at 9:49 AM, during the tour the surveyor observed Resident #51 in his/her room in bed who stated that there were nurses and Certified Nursing Assistants (CNAs) in the facility that were mean. Resident #51 stated that last Saturday he/she requested the CNA to change him/her because he/she had a bowel movement (BM). Resident #51 stated that the CNA assigned to his/her care did not change him/her for four hours and he/she was left sitting in BM. Resident #51 stated that he/she did not report this concern, and gave the Surveyor permission to report the concern to the Social Worker (SW). On 03/18/22 at 8:55 AM, the Surveyor interviewed Resident #51 who stated that he/she remembered reporting a complaint about 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, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to update and revise resident Care Plans (CP) to include interventions for: a.) 1 of 3 residents reviewed for pressure ulcers (Resident #11), and b.) 1 of 4 resident reviewed for accidents (Resident #17). This deficient practice and was evidenced by the following: a.) On 03/17/22 at 10:05AM, during the initial tour the Surveyor interviewed Resident #11 in his/her room who stated that he/she did not remember when he/she developed the wound to the right heel. The Surveyor reviewed the clinical record which revealed the following information: The admission Record revealed that Resident #11 was admitted to the facility with diagnoses that included, but were not limited to, venous insufficiency and cellulitis. The admission Minimum Data Set (MDS), an assessment tool dated 12/23/21, revealed Section M (skin Conditions) indicated that there were no pressure ulcers, the resident…

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 interview, and review of pertinent facility documentation it was determined that the facility failed to follow standards of practice by failing to accurately document a locked emergency cart. This deficient practice was identified on 2 of 3 units (1st floor subacute unit and 2nd floor long term care unit) and was evidenced by the following: Reference: New Jersey Statutes, 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, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state 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 facility documents, it was determined that the facility failed to investigate an incident of unsafe smoking. This deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #17) and was evidenced by the following: On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with his/her eyes open. The Surveyor observed the resident had oxygen (O2) infusing by way of a nasal cannula (tubing used to deliver oxygen, flexible tube that is placed under the nose) that was connected to an oxygen concentrator (an electronic device that removes nitrogen from room air and increases the oxygen concentration). On 03/17/22 at 12:41 PM, the Surveyor observed Resident #17 self-propelling in a wheelchair in the hallway. On 03/17/22 at 12:50 PM, the Surveyor reviewed Resident #17's medical record which revealed the following: The admission Face Sheet (an admission summary) revealed that Resident #17 had diagnoses which included but were not limited to, chronic obstructive pulmonary disease…

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 provide foods at the appropriate hot and cold temperatures on 1 of 2 units, and for 1 of 3 Residents reviewed for food (Resident #57). The deficient practice was evidenced by the following: On 03/17/22 at 10:40 AM, Surveyor #1 conducted an interview with Resident #57. The resident stated that the food sat on the trays, there was no temperature control for the food, and the food was cold at times. The Surveyor reviewed the 02/24/22 Resident Council Minutes. Complaints for Food Committee revealed: Food is extremely cold- Not using plate warmers. On 03/22/22 at 12:04 PM, the Surveyor observed the tray-line in progress. At that time, the Surveyor reviewed the lunch meal food temperature log as identified by the Cook. The Surveyor observed that the temperature log was blank in the milk, dessert (peaches) and vegetable (broccoli) was not listed. On 03/22/22 at 12:07 PM, the Surveyor requested a test tray that included the main and alternate entree, milk and dessert. The tray exited 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 interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was evidenced for 1 of 7 residents reviewed for immunizations (Resident # 50). The deficient practice was evidenced by the following: On 03/25/22, the Surveyor reviewed Resident #50's medical record. A review of Resident #50's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, Parkinson's Disease (progressive nervous system disorder that affects movement), Chronic Obstructive Pulmonary Disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs) and presence of cardiac pacemaker (small device that's placed in the chest to help control the heartbeat). A review of Resident #50's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/4/22, reflected that the resident had a Brief Interview for…

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 documentation, it was determined that the facility failed to: a.) develop and implement a policy to track and securely document the COVID-19 vaccination status for all staff, and b.) ensure all staff were vaccinated for COVID-19. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services (CMS) QSO-22-07 ALL, dated 12/28/21, included the following: Within 30 days after issuance of this memorandum 2, if a facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending…

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.