Fort Bayard Medical Center

Based on observations and interviews, the facility failed to provide a homelike environment with comfortable sound levels for 3 (R #73, R #86, and R #99) of 3 (R #73, R #86, and R #99) residents reviewed for homelike environment. This deficient practice could likely cause residents to feel anxious or depressed and feel that they are not valued. The findings are: A. On 08/06/24 at 9:48 AM, during an observation of the D Unit, a loud sound could be heard down the hall, five doors away from the room where the sound was coming from. B. On 08/06/24 at 9:50 AM, during an interview with CNA #21, stated the following 1. The loud sound was a bathroom door alarm. 2. The bathroom alarms are set off when the bathroom door is opened and will turn off when the door is closed so they know when someone who is a fall risk goes into the bathroom. 3. Every new resident gets a bed, chair, and bathroom door alarm until the staff assesses the resident for fall risk. C. On 08/06/24 at 9:54 AM, during an interview with Unit Manager #21, confirmed the following: 1. Bed alarms, chair alarms, and bathroom…

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

Based on observations, record reviews and interviews the facility failed to keep residents free from physical restraints for 5 (R #30, R #34, R #45, R #82 and R #98) of 5 (R #30, R #34, R #45, R #82 and R #98) residents reviewed for physical restraints, when staff used the following: 1. Wheelchair alarms on R #30, R #82, and R #98 2. Bed alarms on R #30, R #34, R #82, and R #98 3. Bathroom alarms on R #30, R #45, and R #98 These deficient practices could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. On 08/06/24 at 9:50 AM, during an interview with CNA #21, he revealed that every newly admitted resident gets a bed, chair, and bathroom door alarm until the resident is assessed for fall risk. B. On 08/06/24 at 9:54 AM, during an interview with Unit Manager #21, confirmed the following: 1. Every resident who is admitted gets a chair alarm, bed alarm, and bathroom door alarm. 2. Nursing, therapy, and the physicians assess the resident for the need for alarms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 1 (R #35) of 1 (R #35) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #35 A. Record review of R #35's admission record revealed she was admitted to facility on 10/21/14. B. On 08/07/24 at 11:32 AM, during an observation of R #35's bed, the bed had bilateral half side rails. C. Record review of R #35's nursing progress note dated 09/15/2015 (document provided by the facility) revealed the following: 1. R #35 bed has two half side rails. 2. R #35's side rails are not considered restraints as [Name of R #35] is in comatose (being in a coma, unconscious or unable to communicate for a prolonged or indefinite period) condition with no voluntary movement. D. Record review of R #35's medical record 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.

Based on record reviews and interviews, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or that the physician provided a rationale for not following the consultant pharmacist's recommendation for 2 (R #31 and R #50) of 5 (R #31, R #44, R #50, R #51, and R #82) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #31 A. Record review of the pharmacy's Note To Attending Physician/Prescriber for R #31, dated 06/29/24, revealed: 1. R #31 was currently receiving omeprazole (used to treat certain conditions where there is too much acid in the stomach) 20 mg every day. 2. Please evaluate continued need for this medication . 3. The Note To Attending Physician/Prescriber did not include any…

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 ensure: 1) Residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record, and 2) Have the consent of resident/representative for psychotropic medications for 2 (R #31 and R # 44) of 5 (R #31, R #44, R #50, R #51, and R #82) residents reviewed for unnecessary psychotropic medications. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #31 A. Record review of R #31's medical record, no date, revealed following diagnoses: 1. Unspecified psychosis (commonly used if there is inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition. 2. Dementia (loss of cognitive functioning-thinking,…

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 of the CMS-10055 Form and interview, the facility failed to inform residents when changes in coverage were made to items and services covered by Medicare and/or by Medicaid for 1 (R #9) of 3 (R #9, R #31, and R #256) residents reviewed for beneficiary notices when staff failed to provide R #9 with Form CMS-10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage [form used to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.] This deficient practice can likely confuse the resident or their representative as to what services they receive or do not have financial coverage for under Medicare and/or Medicaid. The findings are: R #9 A. Record review of the CMS-10055 form for R #9's revealed the form was not completed or given to R #9 prior to services ending on 07/15/24. B. On 08/07/24 at 4:15 PM, during an interview with the Office Manager (OM), she stated R #9's beneficiary notification was not completed because…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to provide effective and person-centered care immediately upon their admission to the facility) within 48 hours of admission for 1 (R #103) of 2 (R #103 and R #104) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #103's admission record no date revealed R #103 was admitted into the facility on [DATE]. B. Record review of R #103's physician's order revealed an order date 05/13/24, Do Not Resuscitate (DNR; a legally recognized order signed by a physician at a patient's request, stating the resident does not want…

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, and interview, the facility failed to ensure care plan revision occurred for 6 (R #30, R #34, R #35, R #45, R #82, and R #98) of 6 (R #30, R #34, R #35, R #45, R #82, and R #98) residents reviewed for care plans, when they failed to: 1. Update R #30, R #34, R #45, R #82, and R #98's care plans for intervention for the wheelchair, bed, and bathroom alarms. 2. Update R #35's care plan for removal of bed alarm. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #30 A. On 08/06/24 at 3:08 PM, during an observation of R #30's room, R #30 had an alarm on her wheelchair, bed, and bathroom door. B. Record review of R #30's care plan dated 10/11/23 revealed the care plan did not contain any interventions for wheelchair, bed, and bathroom door alarms. R #34 C. On 08/06/24 at 11:57 AM,…

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

Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #14) of 2 (R #25 and R #62) residents sampled for nutrition, when staff failed to follow protocols for identifying weight loss when R #14 had severe weight loss. This deficient practice could likely result in residents losing weight without the facility being aware causing physical and mental health issues. The findings are: A. Record review of R #14's medical record revealed the following diagnoses: 1. Tourette's Disorder (a disorder that involves repetitive movements or unwanted sounds (tics) that can't be easily controlled). 2. Paranoid Schizophrenia (a type of schizophrenia accompanied by paranoia. Delusions and hallucinations are the two symptoms). 3. Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). 4. Hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood) 5.…

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 ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medication at the time of discharge for 3 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident. The findings are: R#1 A. Record review of R #1's Electronic Medical Record (EMR) revealed: 1. Resident was discharged from the facility on 03/28/24. 2. The Recapitulation of Stay form, effective date 03/28/24, was not completed until 04/02/24 (five days after the resident's discharge) and did not contain R #1's discharge medication list. R #2 B. Record review of R #2's EMR revealed: 1. Resident was discharged from the facility on 02/20/24 with home health services. 2. A discharge medication list was in 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 record review and interview, the facility failed to ensure residents have a written, signed, and dated progress note from the provider (physician or nurse practitioner) at each visit for 3 (R #2, R #4 and R #5) of 3 (R #2, R #4 and R #5) residents reviewed for physician's visits. This deficient practice could likely result in the resident's needs not being met due to facility staff being unaware of resident's status related to lack of written, signed, and dated progress notes at the time of the visit. A. Record review of R #2's progress notes revealed: 1. Nurse Practitioner (NP) note: New patient encounter, effective date 01/26/24. The NP did not sign the note until 01/28/24. B. Record review of R #4's progress notes revealed: 1. Medical Doctor (MD) note: Progress note, effective date 03/03/24. The MD did not sign the note until 03/06/24. C. Record review of R #5's progress notes revealed: 1. Medical Doctor note: Chronic Care Management, effective date 05/31/24. The MD did not sign the note until 06/03/24. D. On 06/11/24 at 4:39 PM, during an interview with the Health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an effective discharge plan for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for discharge planning (the process of transitioning a resident from one level of care to the next), when staff failed to: 1) Involve R #1's Insurance Case Manager (ICM) in obtaining services through Mi Via (a self-directed waiver program for individuals with diagnosed intellectual and developmental disabilities), 2) Obtain services through Mi Via for R #1 (that he had prior to admission) and was brought up by family during a meeting on 11/09/23 prior to discharge on [DATE]. This deficient practice is likely to result in complicated or unsafe transitions from the facility to the residents' post-discharge settings. The findings are: A. Record review of R #1's admission Record, no date, revealed R #1 was admitted into the facility on [DATE] and discharged to a private residence on 03/28/24. B. Record review of R #1's progress notes revealed: 1. Social Worker's…

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

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 99 residents in the facility, based on the resident census provided by the Administrator on 05/22/23; by not following the menu. These deficient practices are likely to result in resident weight loss, frustration, and not meeting their nutritional needs. The findings are: A. On 05/23/23 at 12:46 pm, during observation of the lunch service, there was no bread or rolls being served. B. Record review of the facility weekly menu dated Monday, May 24, 2023 revealed, Lunch: Teriyaki chicken, garden rice, salad greens with berries, bread or roll and margarine, and peach pie. C. On 05/24/23 at 12:33 pm, during observation of a sample lunch tray, it was observed that there was no bread or roll and margarine. D. On 06/01/23 at 3:48 pm, during an interview with the Dietary Manager, she stated that if bread or roll and margarine are on the menu, residents should be getting it unless they are on a special diet.

Based on record review and interview the facility failed to provide a qualified, trained or certified Infection Preventionist (IP) affecting all 98 residents in the facility (residents were identified by the facility census provided by the Director of Nursing (DON) on 05/22/23). This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are: The findings are: A. Record review of the [name of facility] Key Personnel (undated) revealed that the IP status is Vacant. B. On 06/01/23 4:21 PM during an interview, the DON confirmed the facility does not have a certified IP and revealed that the DON, ADON and a LPN are sharing the tasks as the acting IP and no one has the specialized training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident/resident's representative(s) of the transfer in writing for 1 (R #82) of 1 (R #82) resident sampled for hospitalizations when they failed to: 1. Notify the resident and the resident's representative(s) of the transfer or discharge in writing and in a language and manner they understand. 2. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 3. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, and their rights to advocate and make informed decision regarding their healthcare. The findings are: A. Record review of R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 1 (R #82) of 1 (R #82) resident sampled for hospitalizations when they failed to provide documentation of written Bed Hold Policy notice R #82. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room or the next available room upon return from the hospital. The findings are: A. Record review of R #82's Discharge summary revealed R #82 was transferred to the hospital on [DATE] for stroke symptoms. B. No documentation of Bed Hold Policy being provided to R #82. C. On 05/25/23 at 3:12 PM, during an interview with R #82 she said that she was not provided any papers when she left the facility. D. On 06/01/23 at 4:22 PM, during an interview with the DON, she said that there was no documentation that written notice 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 record review and interview, the facility failed to develop an accurate, effective, person-centered Baseline Care Plan within 48 hours of admission for 2 (R #95 and R #98) of 2 (R #95, R #98) residents sampled for baseline care plans. If resident's Baseline Care Plans are not accurate, residents are not likely to get the care and services needed. The findings are: R #95 A. Record review of R #95's admission Record/Face Sheet revealed: 1. admission date 02/28/2023 2. admission diagnoses: a. OTHER ACUTE OSTEOMYELITIS (an acute or chronic inflammatory process involving the bone) of the RIGHT ANKLE AND FOOT b. PRESSURE ULCER STAGE 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure such as tendon, or joint capsule) OF RIGHT HEEL and OF LEFT HIP c. PRESSURE ULCER STAGE 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) OF SACRAL REGION (Sacrum) d. SACROILIITIS (pain in one or both sacroiliac joints: where the lower spine and pelvis meet) e. UNSPECIFIED…

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, observation, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 4 (R #3, R #39, R #74 and R #79) of 6 (R #3, R #39, R #40, R #43, R #74 and R #79) residents reviewed for care plans: 1. Failing to include the primary diagnosis in the care plan for R #3 2. Not implementing the notification to the provider of R #39's severe bruising, or tiny red or purple spots on skin. 3. Not developing a care plan for R #74 and R #79's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). Failure to develop a comprehensive person-centered care plan is likely to result in staff's failure to understand and implement the needs and treatments for residents to achieve their highest level of well-being. The findings are: R #3 A. Record review of R #3's admission record (undated) revealed: Principal diagnosis: Schizoaffective Disorder, Bipolar type (mental health disorder that can include hallucinations or delusions, with periods of heightened emotion,…

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 revise the care plan for 2 (R #58 and R #99) of 3 (R #27, R #58 and R #99) residents reviewed for care plans when they failed to: 1. Update R #58's care plan for Lorazepam 2. Update R #99's care plan to show that he was placed on palliative care (comfort care for the terminally ill and their families). These deficient practices could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #58 A. Record review of R #58's face sheet (undated) revealed an admission date of 10/16/18 B. Record review of R #58's Medical Records revealed: 1. An order for Lorazepam dated 05/18/2023 (treats anxiety and sleeping problems) C. Record review of R #58's Care Plan dated 05/16/23 revealed: 1. No care plan for Lorazepam. D. On 06/01/23 at 04:44 PM during an interview, the DON confirmed that R #58's care plan was not updated to reflect the use of Lorazepam. R #99 E. Record review of R #99's Nurse's…

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

Based on observation, record review, and interview, the facility failed to provide respiratory care (breathing support) consistent with professional standards for 1 (R #27) of 3 (R #27, R #34 and R #43) residents reviewed for respiratory care when the facility failed to monitor R #27's oxygen levels. If the facility fails to monitor the residents oxygen levels they may fail to provide the resident with supplemental oxygen (administered of oxygen to maintain oxygen levels above 90%) as needed. The finding are: A. On 05/23/23 at 10:21 AM, during an observation and interview, R #27 was lying down in bed, resident did not have her oxygen on and stated, I've been so tired. I use my oxygen, but I don't know I'm just so tired. I need to take a nap. B. Record review of R #27's Physician's orders revealed: Order Date 07/15/22: O2 (oxygen) AT 1-10 LPM (liters per minute) VIA NC (given by nasal cannula/tubing) /FM (facemask) PRN (as needed) DYSPNEA (shortness of breath)/RESPIRATORY DISTRESS (difficulty breathing) MAY TITRATE (change number level of oxygen being given) TO KEEP SATS (oxygen…

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 interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety by not ensuring food/food products are discarded by their expiration dates, and ensuring food items in the refrigerator were sealed after opening. These deficient practices are likely to affect all 99 residents in the facility, as identified by the resident census provided by the Administrator on 05/22/23, who eat food prepared in the kitchen. If the facility fails to adhere to safe food handling practices, residents are likely to be exposed to foodborne illnesses and become sick. The findings are: A. On 05/22/23 at 1:12 PM, during observation of the kitchen revealed: 1. The following spices were expired: a. 1 container of Poultry Seasoning opened 01/01/21 b. 1 container Ground [NAME] opened 11/30/21 c. 1 container Allspice opened 5/22/22 d. 1 container Fennel seeds, no open date (expiration date is determined by date product is open). e. 1 container Fajita Marinade opened 11/1/22 f. 1 container of Caraway Seed…

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 ensure documents in resident records were complete and accurate for 4 (R #6, R #9, R #40 and R #43) of 8 (R #3, R #6, R #9, R #27, R #34, R #40, R #43 and R #57) residents reviewed for advanced directives (legal document in which a person specifies what actions should be taken for their health when they are no longer able to make decisions for themselves due to illness or incapacity). This deficient practice could likely result in staff not knowing a resident's medical intervention wishes and could result in delay of care, or going against a resident's wishes. The findings are: R #6 A. Record review of R #6's Medical Orders For Life Sustaining Treatment (MOLST) dated 05/06/21 noted: 1. Section G: Designation of alternative decision maker was blank. 2. Section H: Signature of patient or surrogate (person who is legally responsible to make healthcare decisions for the patient/resident when they cannot make decisions for themselves) signature line was blank. B. Review of R #6's Electronic Medical Record (EMR) revealed no…

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 ensure that 8 staff (CNA #1, CNA #2, CNA #3, CMA #1, RN #1, RN #2, RN #3 and RN #4) of 10 staff (CNA #1, CNA #2 CNA #3, NA (Nurse Assistant) #1, CMA #1, LPN #1, RN #1, RN #2, RN #3 and RN #4) had annual training on abuse, neglect, and exploitation and dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) management. This has the potential to affect all 99 residents in the facility, as identified by the resident census provided by the Administrator on 05/22/23. This deficient practice could likely result in residents not receiving the services that they require to provide the optimal quality of care and quality of life. The findings are: A. Review of the trainings for CNA #1 revealed Annual Resident Abuse Prevention & Reporting was last completed 02/01/22. CNA #1 was not enrolled in the course for 2023. CNA #1 was enrolled in 2022 Annual Dealing with Dementia scheduled date 01/10/22, but had not completed it; and was not enrolled in the dementia…

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, and interview, the facility failed to ensure a resident was given the right to maintain and improve their self-esteem and self-worth by not being given a choice to remain at an activity being held by the facility; and not respecting a resident's choices for 1 (R #65) of 1 (R #65) resident reviewed for Resident Rights. This deficient practice is likely to negatively impact resident's self-esteem and self-worth. The findings are: A. On 05/23/23 at 9:54 am, during an observation of a scheduled resident activity in main dining room of [name of unit], R #65 was removed from the scheduled activity byCNA #2 without being asked, and was not told where he was being taken to. B. On 05/23/23 at 10:00 am, during an interview with CNA #2, when asked about R #65's removal from the activity, CNA #2 said R #65 was having a new wheelchair delivered at that time. CNA #2 acknowledged she should have asked R #65 if he wanted to leave the activity and explained to him why he was being taken from the activity. C. On 05/23/23 at 12:07 pm, during an interview with R…

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 record review, the facility failed to ensure that 1 (R #65) of 1 (R #65) resident reviewed for food and drink were provided food prepared in a form designed to meet the resident's needs. This deficient practice is likely to negatively impact a resident's nutritional intake and result in weight loss. The findings are: A. On 05/25/23 at 1:03 pm, during an observation of [name of unit] dining room, R #65 was leaning over his plate, having difficulty eating a sandwich provided by CNA #1. B. Record review of R #65's meal ticket slip indicated to cut food into bite-size pieces. C. On 05/25/23 at 1:05 pm, during an interview with CNA #1, she verified that R #65's meal ticket slip indicated that his food was to be cut into bite-size pieces and R #65's sandwich was cut in half. D. On 05/25/23 at 1:08 pm, during an interview with the DON, when asked about why R #65 had been given a sandwich for lunch that was cut in half, but did not match his meal ticket instructions to be cut into bite-sized pieces, DON said the sandwich should have been cut into smaller…

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, the facility failed to ensure that residents received mail on Saturdays. This has the potential to affect all resident in the facility (residents were identified by the Resident Matrix provide by the ADON on 02/21/22). This deficient practice could likely result in residents not receiving timely communication, which could result in feelings of isolation. The findings are: A. On 02/22/22 at 10:00 AM, during a Resident Council meeting all residents present [8 present] stated that no mail was being delivered on Saturdays. B. On 02/22/22 at 12:10 PM, during an interview with the Social Services Supervisor, she stated that no mail is being delivered to the facility due to no mail drop off from the Post Office. She further stated that this facility has a PO box at the post office for resident mail but that there is no one to pick up mail on Saturdays.

Based on observation, and interview, the facility failed to ensure that food items in the pantry were labeled and dated. These deficient practices could likely lead to foodborne illnesses that could affect all 99 residents in the facility (residents were identified on the census list provided by the Administrator on 02/22/22) who eat food prepared in the kitchen. The findings are: A. On 02/22/22 at 10:07 AM, an observation of the Kitchen revealed the following items in separate containers with no name, expiration or use by date: 1. Dry onion, 2. Red beans, 3. [NAME] beans, 4. Red beans, 5. Lima beans, 6. Lentils beans, 7. [NAME] navy beans 8. Split peas B. On 02/22/22 at 09:06 AM during an interview, the Dietary Manager confirmed that the items in the containers should be labeled and dated.

Based on record review and interview, the facility failed to ensure they had a functional antibiotic stewardship program (coordinated program that promotes the appropriate use of antimicrobials [medication that kills microorganisms; microscopic organism; bacteria, fungus or virus or stops their growth], improves patient outcomes, reduces microbial resistance [antibiotics, antiviral and antifungal medications no longer kill or inhibit growth], and decreases the spread of infections caused by multidrug resistant organisms [common microorganisms that have developed resistance to multiple types of antimicrobials]) which include procedures and protocols for antibiotic/antimicrobial use, when they failed to: 1. Educate staff (including contracted providers) and residents about antibiotic stewardship, 2. Failed to include leadership support and accountability via the participation of the medical director, pharmacist as well as nursing and administrative leadership. 3. Review the antibiotic stewardship program and policy on an annual basis or as needed This deficient practice could likely…

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 record review the facility failed to ensure that residents were treated with respect and dignity for 1 (R #4) of 1 (R #4) residents randomly sampled for dignity, when the facility failed to accommodate resident shower request times. This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth. The findings are: A. On 02/22/22 at 10:58 AM, during an interview, R #4 reported that a few weeks ago (no date provided) she requested her showers to be only once a week for 45 minutes instead of two showers a week at 30 minutes each. R #4 reports being told that the staff do not have time to spend 45 minutes with her because they have other residents to tend to. The resident became very emotional because she feels like a burden and at times, she doesn't want to use her call light to bother the staff. B. Record review of Psychology Notes dated 01/20/22 revealed: .strategies to ensure that [name of resident #4] receives appropriate care, yet eliminates excessive demands related to obsessive-compulsive features…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide notice of transfer and notice of bed hold policy for resident transfers to the hospital for 2 (R #38 and R #63) of 2 (R #38 and R #63) residents reviewed for transfers, when they failed to provide R #38 and R #63 with a written notice of transfer to the hospital and notice of the facilities bed hold policy. This deficient practice could likely result in residents and family members being unaware of the reason for transfer and their right to return to the facility after the hospital. The findings are: R #38 A. Record review of R #38's medical records revealed he was transferred to the hospital on [DATE] and 11/21/21. No notice of transfer or bed hold policy was found. B. On 03/02/22 at 11:42 AM during an interview with Social Work Director revealed that the facility has not been consistent with the bed hold packet for all residents. She confirmed that R #38 did not receive notification of transfer or bed hold policy. R #63 C. Record review of R…

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 ensure that Care Plans were revised within 7 days after the completion of the comprehensive assessment for 1 (R #62) of 3 (R #36, R #62 and R #71) residents reviewed for Care Plans. When they failed to updated R #62's Care Plan for a wound to her left heel. This deficient practice could likely result in staff having inaccurate information and therefore being unable to meet the resident's current and changing needs. The findings are: A. Record review of R # 62's Progress Notes revealed, nurses note dated 10/07/21 3:27 PM During care noted a closed blister to resident's Lt (left) heel, measured 3.5 cm X 4.0 cm. Supervisor, and the Provider was notified for further evaluation. POA (Power of Attorney) was also notified over the phone. Also sent a wound screening consult to the wound nurse. Wound nurse came and evaluated the resident. New order for a Yellow Foam Posey ( foam cushion device placed on heels to help alleviate pressure and friction) boot at all times. B. Record review of R #62's Weekly Wound Observation Tool 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to keep residents free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 1 (R #17) of 5 (R #17, R #26, R #38, R #69, and R #85) residents sampled for unnecessary medications, when they failed to have a diagnosis for R #17's antipsychotic (used to treat psychotic symptoms such as hallucinations, and delusions) medication Risperidone on the physicians orders. This deficient practice could likely result in residents receiving psychotropic medications for reasons unknown to the staff and resident. The findings are: A. Record review of R #17 Physicians Orders revealed the following: 1. 09/09/21 Risperidone 0.5 ml (milliliters) no diagnosis everyday between 7 AM and 7 PM. B. Record review of the MAR for February 2022 revealed Risperidone documented as given as ordered. C. On 02/25/22 at 12:10 PM, during an interview the E Unit Manager ([NAME]) confirmed that there was no…

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 interview, the facility failed to properly store medications in a treatment and a medication cart on the E Unit. This could likely affect all 53 residents on the E Unit (residents were identified by the Resident Matrix provided by the ADON on 02/21/22) that were randomly sampled. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: Medication Cart A. On 02/25/22 at 9:23 AM, during observation in the E Unit revealed the Treatment cart was left unlocked and unattended. B. On 02/25/22 at 9:25 AM during an interview, RN #11 confirmed that he left the treatment cart unlocked and unattended. C. On 02/25/22 at 9:32 AM during an interview, the Unit manager confirmed that the treatment cart should not be left unlocked and unattended. D. Record review of the Medication/Treatment Cart Safety and Security Policy effective date 06/30/18 revealed the following: Medication/Treatment carts when used on resident care areas, must be locked when out of line of sight, and cart keys…

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 ensure documents in resident records were complete and accurate for 5 (R #9, R#17, R #34, R #36, and R #38) of 6 ( R #9, R#17, R#20, R #34, R #36, and R #38) residents reviewed for Advanced Directives (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity (physical or mental inability to do something or to manage one's affairs). This deficient practice could likely result in staff not knowing the status of resident's medical intervention wishes resulting in a delay of care, lack of care or going against residents wishes. The findings are: R #9 A. Record review of R #9's Medical Orders for Life Sustaining Treatment (MOLST) form (legal document detailing the wishes of medical intervention [action that alters the course of a disease, injury, or condition by initiating a treatment or performing a procedure] during an emergency) signed by the resident's representative on 07/12/17 revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that 1 (R #48) of 1 (R #48) residents reviewed for behavioral health concerns were receiving necessary behavioral health care to meet their needs. This deficient practice could likely result in the residents not receiving the behavioral or mental health care and assistance they require to improve mood and reduce depression. The findings are: A. On 02/23/22 at 11:09 AM, during an observation R #48 was laying in her bed with a flat affect (low or lack of an emotional expression). B. On 02/23/22 at 11:10 AM, during an interview R #48 stated that she is having a hard time being away from her significant other (a person with whom someone has an established romantic or sexual relationship) who is in a different facility. C. Record review of R #48's Care Plan initiated on 10/30/18 revealed: 1. [name of resident] is taking an ANTIDEPRESSANT (medication used to treat major depressive disorder, some anxiety disorder, some chronic pain…

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 schedule an appointment for dental services for 1 (R #88) of 1 (R #88) residents sampled for dental services, when they failed to schedule an appointment for R #88 after her Physician had made an order for dental service. This deficient practice could likely result in resident continued dental pain. The findings are: A. On 02/22/22 at 10:37 AM, during an interview R #88 stated that she has dental pain sometimes and that she is waiting for an appointment. B. Record review of R #88's Physician Orders revealed the following: 01/26/22 order for dental appointment because R #88 had continued pain. C. On 02/25/22 at 3:35 PM, during an interview the E Unit Manger was asked about R #88's order for dental services, she stated that the Scheduler would make the appointments for residents once the order is made. D. On 02/28/22 at 8:26 AM, during an interview the Scheduler stated she did not have any knowledge of R #88's order for the dental services until the E Unit staff told her on the afternoon of 02/25/22. The Scheduler stated, I…

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.