Fort Bayard Medical Center

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect the following: 1. All eight (8) residents in the facility that were taking antibiotics. Residents identified using the list of residents taking antibiotics provided by the Administrator on 09/24/25. 2. R #59 who was taking antibiotics from 9/08/25 through 09/20/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics). The findings are: Antibiotic Monitoring A. Record review of the facility's Antibiotic Stewardship policy, dated 09/27/22, revealed the facility did not have a proper and adequate ASP that included: 1. Protocols to monitor/review response to antibiotics, and laboratory results when available, 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 Number of residents sampled: 2Number of residents cited: 2S483.10(f) Self-DeterminationThe resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.S483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.S483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.S483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.S483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities…

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 a review of records, the facility failed to ensure residents were free from unnecessary medications and properly manage psychotropic medications for two (R #5 and R #101) of 5 (R #4, R#5, R #10, R #22, and R #101) residents reviewed for unnecessary medications when staff failed to ensure psychotropic medications for R #5 and R #101 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 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 #5 A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had the following diagnoses: a. Alzheimer's Disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability 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 interview and record review the facility failed to update a resident care plan to reflect changes in the resident's treatments or interventions for 1 (R #3) of 2 (R #3 and R #101) residents reviewed for care plan accuracy. This inaccuracy has the potential of harm to a resident if the medical record does not provide correct indwelling catheter (a tube inserted into and left in the bladder to drain urine) information for staff to respond to the resident needs if the catheter had already been removed. The findings are: A. On 09/16/25 at 1:57 PM, during an interview, R #3 stated her indwelling catheter was removed about 1 month ago. B. Record review of R #3's PCP (primary care physician) orders dated 8/16/25 revealed R #3's indwelling catheter was to be removed. C. Record review of R #3's current care plan dated 09/18/25 indicated that R #3 has an indwelling catheter. D. On 09/18/25 at 11:10 AM during an interview, the nurse supervisor #1 verified R #3's indwelling catheter was listed on the care plan. She stated R #3 does not have an indwelling catheter, and this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #4 and R #10) of 7 (R #4, R #5, R #10, R #21, R #22, R #59, and R #101) residents reviewed for medication regimen and pressure injuries when staff failed to: 1. Follow facility protocols when a new wound was identified for R #4. 2. Monitor for adverse effects of antipsychotic medication for R #10. If the facility is not identifying new wounds and following facility protocols for newly developed wounds and monitoring for adverse effects of antipsychotic medications, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not recognizing changes in the resident's condition. The findings are: R #4 A. Record review of R #4's admission documents, no date, revealed R#4 was admitted to the facility on [DATE]. B. 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 observation, interview and record review, the facility failed to ensure a resident with limited mobility receives appropriate services and assistance to maintain or improve mobility with maximum practicable independence for 1 (R #10) of 2 (R #10 and R #112) residents reviewed for mobility and rehabilitation (specialized care provided to help residents recover from injuries, surgeries, or illnesses. These services typically include Physical therapy: Aims to restore mobility and strength. Occupational therapy: Assists residents in performing daily tasks independently. Speech therapy: Addresses communication and swallowing difficulties) and restorative (person-centered nursing care that is designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) services. This deficient practice is likely to result in a decrease in the resident's functional mobility. The findings are: A. On 09/15/25 at 10:40, during an interview and observation, 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 effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #129) of 2 (R #59 and R #129) residents reviewed for pain when the facility failed to administer medications as per physician's orders and notify the provider when residents have uncontrolled pain. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life. The findings are: A. Record review of R #129's admission Record (no date) revealed the following: 1. R #129 was admitted to the facility on [DATE]. 2. R #129's diagnoses include the following: a. Displaced intertrochanteric fracture of the left femur (broken bone on the bony protrusions in the area where the hip and thigh meet). b. Pain in left hip. B. Record review of R #129's physician's orders revealed the following: 1. An order dated 09/11/25, acetaminophen extended release (ER,…

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 ensure ongoing assessment of the resident's condition and monitoring for complications before and after dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment for 1 (R #87) of 2 (R #22 and R #87) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the residents' condition, potential complications and residents may not receive the appropriate monitoring and care. The findings are: A. On 09/15/25 at 12:50 PM during an interview with R #87, he stated he is assessed before leaving for dialysis. He leaves no later than 5:30 AM on Mondays, Wednesdays and Fridays, and he is usually assessed upon return between 11:00 and 11:30 AM. He stated there have been instances where he is not checked when he comes back and he has also received his medications late upon returning. B. Record review of R #87's admission Record (no date) 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.

Based on interview and record review the facility failed to ensure residents obtained dental services for 1 (R #2) of 2 (R #2 and R #59) residents sampled for dental services, when staff failed to ensure R #2 received routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice could likely cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are:A. Record review of R #2's medical record revealed an admission date of 03/03/24. B. On 09/16/25 at 11:33 AM during an interview, R #2 said she needed to see a dentist because she has a lot of teeth that need to be replaced. C. On 09/18/25 at 10:54 AM, during an interview, the Unit Manager (UM) stated R #2 had not been to the dentist since she was admitted to the facility. The UM stated R #2 was waiting to get approved for Medicaid to cover the cost. The UM confirmed that R #2 had been approved for Medicaid and that an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #101) of 4 (R #4, R #21, R #59, and R #101) residents reviewed for pressure injury and involuntary seclusion when staff failed to do the following: 1. Accurately document R #101's skin assessments. 2. Ensure R #101's medical record contained the results of preadmission screening. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #101's admission documents, no date, revealed R #101 was admitted to the facility on [DATE]. B. On 09/16/2025 at 8:25 AM, during an interview, R #101's family member (FM) stated that R #101 had a pressure ulcer on her butt. R #101's FM stated R #101 had the pressure ulcer since before she was admitted to the facility. C. Record review of R #101's physician's order dated 04/22/25, revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the medical records contained documentation each resident received or was offered pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) and influenza (an acute respiratory infection caused by influenza viruses) immunizations for 2 (R #59 and R #101) of 5 (R #4, R #11, R #59, R #87, and R #101) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: R #59 A. Record review of R #59's admission documents, no date, revealed R #59 was admitted to the facility on [DATE]. B. Record review of R #59's entire medical record, no date, revealed the following: 1. R #59 did not receive the pneumococcal vaccination. 2. Staff did not document whether R #59 received education about the pneumococcal vaccination. 3. Staff did not document whether R #59 refused the pneumococcal…

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 ensure the residents' medical record contained documentation each resident received or was offered covid-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) immunization for 1 (R #59) of 5 (R #4, R #11, R #59, R #87, and R #101) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. Record review of R #59's admission documents, no date, revealed R #59 was admitted to the facility on [DATE]. B. Record review of R #59's entire medical record, no date, revealed the following: 1. R #59 did not receive the covid-19 vaccination. 2. Staff did not document whether R #59 received education about the covid-19 vaccination. 3. Staff did not document whether R #59 refused the covid-19 vaccination. C. On 09/22/2025 at 12:47 PM, during an interview, the Infection Preventionist (IP) confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report all injuries of unknown origin and the results of all investigations to the State Survey Agency for 1 (R #21) of 3 (R #19, R #20, and R #21) residents reviewed for falls. If the facility fails to report injuries of unknown origin and the results of investigations within five (5) business days to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are:A. Record review of R #21's admission documents, no date revealed R #21 was admitted to the facility on [DATE]. B. Record review of the facility's incident log, no date, revealed R #21 had an injury of unknown origin on the following dates:1. 06/22/25, bruise on chin measuring 5cm x 2 cm.2. 06/25/25, large scratch 51cm x .1 cm from shoulder to hip and skin tears to knees.3. 06/28/25, skin tear (possibly self-inflicted) to right shin 5.5cm x 2.5 cm. C. Record review of R #21's progress notes, multiple dates, revealed the following:1. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #17) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are:A. Record review of R #17's admission documents, no date revealed R #17 was admitted to the facility on [DATE]. B. Record review of R #17's physician order, dated 06/28/25, revealed an order for Lorazepam (medication used to treat anxiety disorders) 0.5 mg, on Mondays and Thursdays (shower days) for anxiety/agitation. C. Record review of R #17's entire medical record, no date revealed staff did not document a consent to take Lorazepam. D. On 07/10/25 at 2:17 PM, during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. Are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary for 2 (R #17 and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications, when staff failed to ensure: 1. Psychotropic medications for R #17 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Psychotropic medications ordered to be given as needed (PRN) for R #18 were not prescribed for longer than 14 days without a rationale from the provider for why the medication was needed for longer than 14 days. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications.This deficient practice has the potential to negatively impact on the care staff provided to meet residents' needs due to missing or inaccurate records and resident information.The findings are:A. Record review of R #18's admission documents, no date, revealed the following:1. R #18 was admitted to the facility on [DATE]. 2. With the following diagnoses: a. Unspecified dementia (a general term for a decline in mental ability severe enough to interfere with daily life), unspecified severity, with other behavioral disturbances. b. Insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early, despite having adequate opportunities for sleep). B. Record review of R #18's provider progress note, dated 05/04/25, revealed R #18 had a diagnosis of Moderate…

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.

THIS IS A REPEAT DEFICIENCY FROM 08/09/24 Based on observation, record review and interview, the facility failed to ensure residents were free from physical restraints unless being used to treat a specific medical condition (indication or characteristic of a medical, physical or psychological condition) as identified through an assessment for 3 (R #1, R #2, and R #8) of 3 (R #1, R #2, and R #8) reviewed for physical restraints. This deficient practice could likely result in physical restraints being used for staff convenience; unnecessarily preventing residents from freedom, movement, and/or activity. The findings are: A. Record review of a complaint dated 12/24/24, an anonymous staff member revealed the facility had removed alarms for residents after the last survey and then they started using bed alarms again for residents without conducting an assessment or having a physician's order. R #1 B. On 01/23/25 at 5:14 PM, during an observation of R #1, revealed R #1 had an alarm attached to her wheelchair. C. On 01/23/25 at 5:14 PM, during an interview, CNA #1 confirmed R #1 had 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 record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised for 1 (R #1) of 3 (R #1, R #2, and R #8) residents reviewed for care plans when they failed to revise the care plan with the most current resident information. This deficient practice 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: A On 01/23/25 at 5:14 PM an observation of R #1 revealed R #1 had an alarm attached to her wheelchair. B. On 01/23/25 at 5:14 PM, during an interview with CNA # 1, revealed the following: 1. CNA #1 stated R #1 did not have any alarms because they had been discontinued. 2. CNA #1 then made an observation of R #1 and stated R #1 had a wheelchair alarm. C. On 01/24/25 at 12:06 PM, during an interview, RN # 1 confirmed that the alarm attached to R #1's wheelchair was actually a seat belt alarm…

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 post nurse staffing data on a daily basis for all 105 residents in the facility (residents were identified by the census list provided by the Administrator on 08/05/24), when staff failed to: 1) Post Staffing Information that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. 2) Retain 18 months of staff posting records. These deficient practices could cause residents anxiety not knowing what staff are working. The findings are: A. On 08/08/24 3:45 PM, during an interview with Administrator, he stated the facility does not post resident census numbers or staffing numbers. The administrator stated the units will write which staff are working per shift on a whiteboard inside each unit. B. On 08/09/24 at 9:22 AM, during an observation of Unit C, 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 record review of the facilities Legionella Water Management Program policy and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all (105) residents who live in the facility (residents were identified by the Resident Matrix provided by the Administrator on 08/05/24). If the facility fails to maintain an effective infection control program, then infections could spread to residents…

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, observations and interviews, the facility failed to treat resident with dignity when staff failed to: 1. Provide nondisposable cutlery and dishware to all 75 residents, who did not use adaptive equipment were not on enteral feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) (residents were identified by the adaptive equipment list provided by the Administrator on 08/13/24 and the resident matrix provided by the Administrator on 08/05/24), and 2. Let R #98 self-determine (choice) her use of a belt alarm (an alarm for a wheelchair). These deficient practices could likely cause residents to feel anxious or depressed and like they are not valued. The findings are: Use of Disposable Dishware and Cutlery A. On 08/06/24 at 12:28 PM, during an observation of the D Unit's lunch service, the residents were served meals on disposable plates and given disposable cups for drinks. B. On 08/06/24 at 12:30 PM, during an observation, residents in the memory care main dining area, residents ate with disposable plates,…

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

Based on observations and 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.