Lefa Seran SNF

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Infection Prevention and Control Plan included a method of ongoing surveillance of active infections in the facility. This deficient practice had the potential to result in a delay in recognition of infection outbreaks and reversible trends going unrecognized leading to missed opportunities for staff education and infection spreading among residents and staff in the facility. Findings include: On 04/10/2025 at 9:24 AM, the Infection Preventionist (IP) verbalized the IP would compile a spreadsheet at the end of every month for residents in long term care with culture results and antibiotic orders. The IP was unable to provide an ongoing surveillance tool with locations of infections within the facility and verbalized the IP did not have a tool to monitor trends including location of infections, staff providing care to infected residents, residents colonized with multi drug resistant organisms, or infections not requiring antibiotics. The IP verbalized the facility was small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure resident consents for the COVID-19 (Covid) vaccination were offered or completed correctly for 2 of 5 residents sampled for vaccinations (Resident #18 and #21). This deficient practice had the potential to result in residents wishing to receive a Covid vaccination not receiving the vaccine and experiencing severe or prolonged illness, hospitalization, or death as the result of infection with the Covid virus. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain. A Covid vaccine consent and declination form for Resident #18 had both the checkboxes for consent and declination completed and was signed by the resident and a facility employee on 10/29/2024. The Immunization Record for Resident #18 documented the resident's most recent dose of the Covid vaccine was administered on 04/21/2022. On…

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

Based on interview, personnel record review, and document review, the facility failed to ensure initial communications training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented communication training completed on 11/30/2024, 40 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed communication training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:01 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of communication training…

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, personnel record review, and document review, the facility failed to ensure initial resident rights training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented resident rights training completed on 01/11/2025, 82 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented resident rights training completed on 11/23/2024, 33 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed resident rights training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.…

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, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #8). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented elder abuse prevention training completed on 12/07/2024, 47 days late. Employee #8 Employee #8 was hired as a Certified Nursing Assistant on 04/27/2023. Employee #8's personnel record documented elder abuse prevention training completed on 01/02/2024, and annual elder abuse prevention training completed on 01/24/2025, 22 days late. On 04/09/2025 at 2:27 PM, the Human Resources (HR) Manager verbalized all staff were required to take elder abuse prevention training before stepping foot on the floor and annually. The HR Manager verbalized Employee #4's personnel record lacked elder abuse prevention training completed prior to 12/07/2024, and…

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

Based on interview, personnel record review, and document review, the facility failed to ensure initial infection control training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented infection control training completed on 11/30/2024, 40 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented infection control training completed on 11/21/2024, 31 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed infection control training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On…

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

Based on interview, personnel record review, and document review, the facility failed to ensure initial compliance and ethics training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented compliance and ethics training completed on 11/30/2024, 40 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented compliance and ethics training completed on 11/23/2024, 33 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed compliance and ethics training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be…

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, personnel record review, and document review, the facility failed to ensure initial behavioral health care training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented behavioral health care training completed on 12/23/2024, 63 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed behavioral health care training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 2:56 PM, the HR Manager confirmed Employee #4's personnel record lacked documented…

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 clinical record review, interview, and document review the facility failed to ensure residents were screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined 19 of 20 residents sampled for immunizations (Resident #17, #2, #13, #19, #15, #9, #6, #8, #14, #3, #5, #18, #16, #12, #7, #11, #4, #1, and #10). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain unspecified, edema unspecified, and acute embolism and thrombosis of other specified deep vein of left lower extremity. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis and acute cholecystitis. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, personal history…

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 document review, the facility failed to provide a comfortable, homelike environment when the facility utilized an overhead paging system to communicate with the adjoining hospital staff and temperatures in the facility were below 71 degrees. The overhead paging system and the temperature had the potential to affect the entire facility census. Findings include: Overhead Paging System On 05/22/2024 at 11:12 AM, an overhead page was heard calling a Code Gray in room [ROOM NUMBER]. On 05/22/2024 at 11:12 AM, the Director of Nursing (DON) verbalized the code was called for room [ROOM NUMBER] of the adjoining hospital. The DON explained hospital pages were heard on the skilled nursing home side of the facility because the intercom system was for the entire building. The DON confirmed overhead pages from the hospital did not contribute to a homelike environment for residents residing in the skilled nursing facility. On 05/22/2024 at 11:20 AM, an overhead page was heard announcing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to obtain informed consent prior to placing the resident in a scoop mattress for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with anxiety, and pain. On 05/20/2024 at 11:20 AM, Resident #14 was in bed sleeping in a mattress that came up around the edges like a scoop. On 05/21/2024 at 8:04 AM, Resident #14 verbalized the resident had a weird mattress and did not know why. The resident explained the mattress was what the facility had and did not recall an explanation for use or signing documents regarding the mattress. Resident #14's clinical record lacked a care plan for the use of a scoop mattress. Resident #14's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian and the resident had been assessed for the 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 clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 2 of 12 sampled residents (Resident #17 and #2). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain unspecified, edema unspecified, and acute embolism and thrombosis of other specified deep vein of left lower extremity. Anticoagulant A physician's order dated 02/26/2024, with a start date of 03/04/2024, documented Eliquis oral tablet five milligrams (mg). Give five mg by mouth two times a day related to acute embolism and thrombosis of other specified deep vein of left lower extremity. Resident #17's care plan, with a focus initiated on 02/29/2024, documented the resident was prescribed Eliquis 5 mg twice a day. Resident #17's April 2024 Electronic Medication Administration Record (EMAR) documented Eliquis oral tablet 5 mg, was administered to the resident twice daily 04/14/2024-04/21/2024.…

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, clinical record review and document review the facility failed to update a fall care plan with new interventions for 2 of 12 sampled residents (Resident #1, and #5) and to include the use of a scoop mattress in a resident's care plan for 1 of 12 sampled residents (Resident #14). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and epilepsy, unspecified, not intractable, without status epilepticus. On 05/21/2024 at 7:20 AM, Resident #1 was in bed asleep with a fall mat on the floor on the right side of the bed. A pressure alarm was on the floor mat. A Personal Care Technician (PCT) was seated next the resident's room. On 05/21/2024 at 7:21 AM, the PCT verbalized the PCT was stationed outside of Resident #1's room because Resident #1 was a fall risk. The PCT explained the resident had a position…

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, clinical record review, interview and document review, the facility failed to remove floor mats from the bedside when residents were not in bed for 1 of 12 sampled residents (Resident #5), and assess a resident with a scoop mattress for risk of entrapment for 1 of 12 sampled residents (Resident #14). The deficient practices had the potential to increase falls and injury in the facility. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter. On 05/20/2024 at 11:08 AM, Resident #5 was in bed with a fall mat at the bedside. The resident's walker was up against the resident's bed, with the back half on the floor mat and the front half on the tile floor. On 05/20/2024 at 11:09 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure cognitive assessments for the use of a grab bar device (Halo Safety Ring) were completed quarterly for 1 of 20 residents residing in the facility (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, hereditary and idiopathic neuropathy, unspecified, and peripheral vascular disease, unspecified. On 05/20/2024 at 4:08 PM, Resident #12's bed had a Halo Safety Ring on both upper sides of the bed. On 05/21/2024 at 12:47 PM, Resident #12's bed had a Halo Safety Ring on both upper sides of the bed. Resident #12's physician order dated 10/13/2023, documented: May have Halo Safety Ring for bed mobility and maintain functional capabilities during perineal care. Resident #12's care plan intervention dated 10/13/2023, documented the resident would receive a cognitive assessment completed quarterly to determine safe and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 35 opportunities and two medication errors. The medication error rate was 5.71%. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications and mixed hyperlipidemia. Resident #3's physician's order documented Niacin Extended Release tablet 500 milligrams (mg) give two tablets by mouth one time a day related to hyperlipidemia, unspecified. On 05/22/2024 at 7:41 AM, during medication pass observation, a Licensed Practical Nurse (LPN) administered one tablet of Niacin 500 mg to Resident #3. On 05/22/2024 at 12:44 PM, the LPN confirmed Resident #3 was prescribed two tablets of Niacin 500 mg and the LPN administered one tablet of the medication. Resident #15 Resident #15 was admitted to the facility on [DATE],…

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 document review, the Quality Assessment Performance Improvement (QAPI) Committee failed to identify the lack of COVID-19 (COVID) booster vaccinations offered to residents with the potential to affect the entire facility census. Findings include: On 05/22/2024 at 2:35 PM, the Skilled Nursing Facility (SNF) Manager confirmed COVID vaccinations and boosters were not provided to the residents for 2023 and 2024, as the facility had not put anything in place for the resident vaccinations. On 05/23/2024 at 9:51 AM, the Infection Preventionist confirmed the IP was responsible for all resident vaccinations and the Infection Control Program. The IP verbalized the IP was not involved with COVID vaccinations for the residents. The IP had depended on the Director of Nursing (DON) and the SNF Manager to order the COVID vaccine and the DON and SNF Manager would arrange consent, administration, and documentation. The IP confirmed the IP did not follow up on COVID vaccinations to ensure the vaccine was ordered or if each resident was screened for eligibility to receive 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 observation, clinical record review, interview, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 1 of 12 sampled residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including peripheral vascular disease, unspecified, type II diabetes mellitus without complications, hereditary and idiopathic neuropathy, unspecified, and left lower extremity amputation. A physician's order for Resident #12 dated 04/22/2024, documented cleanse right second toe on right foot with wound cleanser. Apply medi (medical)-honey and cover with band aid every 48 hours for wound care. Resident #12's physician order dated 04/23/2024, documented apply pressure boot to resident's right foot every day and night shift for open sore on right second toe. A Nursing Progress Note dated 05/08/2024, documented Resident #12 had a small scabbed area on second toe which had been slow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure the alternatives were attempted, risks and benefits were explained, consents were obtained prior to installation of bedrails or grab bar (Halo ring) and mobility assessments were completed for 15 of 21 residents residing in the facility (Resident #1, #2, #3, #4, #5, #7, #9, #10, #12, #14, #15, #16, #17, #171, and #172). Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and falls. On 07/31/23, Resident #1's bed had a Halo ring on the left side. Resident #1's physician's order dated 04/19/22, documented may use Halo for bed mobility. Resident #1's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, an assessment for entrapment, a signed consent with risks and benefits, and alternatives were…

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 Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with psychotic disturbance, and major depressive disorder, recurrent, in remission, unspecified. Resident #4's clinical record documented the following psychotropic orders: -[DATE], Mirtazapine oral tablet 7.5 mg, give 7.5 mg by mouth at bedtime related to insomnia, unspecified. -[DATE], duloxetine hcl oral capsule delayed release sprinkle 30 mg, give 1 capsule by mouth one time a day related to major depressive disorder, recurrent, in remission, unspecified. Resident #4's care plan for the antidepressant medication, initiated on [DATE], included the following interventions: -Educate Resident #4 and guardian about risks, benefits, and the side effects and/or toxic symptoms of duloxetine. -Give antidepressant as ordered by physician. -Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary…

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 personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 7 of 20 sampled employees (Employee #1, #6, #10, #11, #13, #14, and #16. Findings include: Employee #1 Employee #1 was hired as the Administrator on 06/15/22. Employee #1's personnel record lacked documented evidence of resident rights training. Employee #6 Employee #6 was hired as the Nutrition Services Supervisor on 11/28/21. Employee #6's personnel record documented lacked documented evidence resident rights training was completed since hiring date. Employee #10 Employee #10 was hired as a CNA on 06/01/23. Employee #10's personnel record lacked documented evidence resident rights training was completed. Employee #11 Employee #11 was hired as the CNA on 02/20/23. Employee #11's personnel record lacked documented evidence resident rights training was completed. Employee #13 Employee #13 was hired as a RN on 06/12/23. Employee #13's personnel record lacked documented evidence resident rights training had been completed. Employee #14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and document review, the facility failed to ensure a resident gave informed consent prior to administration of a psychotropic medication for 4 of 12 sampled residents (Resident #5, #6, #14 and #12). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified and major depressive disorder, recurrent severe without psych features. Resident #5's psychotropic physician orders included the following: -02/23/23 citalopram hydrobromide (brand name Celexa) Oral Tablet 20 milligrams (mg), give 20 mg by mouth one time a day related to major depressive disorder, recurrent severe without psychotic features. Resident #4's informed consent for Celexa, signed 10/10/22, lacked evidence the resident was informed on the indication for use. In a blank space intended for the diagnosis was the resident's first name. On 08/10/23 at 3:10 PM, the Minimum Data Set (MDS) Coordinator explained…

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, clinical record review, and document review the facility failed to honor a resident's choice to smoke for 1 of 12 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. A Unit Secretary Note dated 11/23/22, documented Resident #4 wanted to go out and smoke and was told by the resident's Public Guardian the resident could not smoke until 12/01/22 due to past actions. A Nursing Progress Note dated 12/17/22, documented the CNA had informed the Nurse of Resident #4's cigarette case and blanket being burned. No burns noted to resident's skin. The Director of Nursing was informed, and the cigarette breaks for the resident were discontinued for the time being. A Behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility was out of compliance due to late completion and/or transmission of Minimum Data Set (MDS) assessments, Care Area Assessments (CAA) and/or care plans for 8 of 12 months, starting July, 2022. Findings include: [DATE]: 10.00% of admission assessments were submitted late (1 of 10) 10.00% of admission care plans were completed late Sep 2022: 54.55% of assessments were transmitted late (6 of 11) [DATE]: 42.86% of assessments were transmitted late (3 of 7) 14.29% of comprehensive assessments were transmitted late (1 of 7) 14.29% of entry tracking records were transmitted late 14.29% of death in facility tracking records were submitted late [DATE]: 28.57% of assessments were transmitted late (4 of 14) 14.29% of entry tracking records were transmitted late (2 of 14) [DATE]: 47.06% of comprehensive assessments were transmitted late (8 of 17) 35.29% of assessments were transmitted late (6 of 17) 23.53% of care areas assessments were completed late (4 of 17) [DATE]:…

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 clinical record review, interview, and document review the facility failed to ensure a care plan was developed related to 1) wound care for a resident with pressure ulcers for 1 of 12 sampled residents (Resident #17), 2) the use and monitoring of high-risk medications for 1 of 12 sampled residents (Resident #4), 3) the administration of psychotropic medications to include specific behaviors associated with the administration for 4 of 11 residents (Resident #4, #12, #3, and #6) reviewed for unnecessary medications, and 4) a resident requiring pain management for 1 of 12 sampled residents (Resident #10). Findings include: Pressure Ulcers Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including moderate protein-calorie malnutrition, multiple sclerosis, and pressure ulcer of sacral region, stage I. Resident #17's physician order for Vitamin C documented the following: -4/21/23, Vitamin C 500 milligrams (mg), give 500 mg by mouth two times a day to aid in wound healing for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, clinical record review, and document review, the facility failed to ensure a comprehensive care plan for smoking included revisions or updates upon readmission and included documentation of the smoking assessment with evaluation of cognitive ability, judgement, manual dexterity, and mobility for 2 of 12 sampled residents (Resident #6 and #4), a comprehensive care plan for smoking was revised to include an update for an imposed smoking restriction for 1 of 12 sampled residents (Resident #4), and a comprehensive care plan was updated to include interventions for residents' nutrition status for 1 of 12 residents (Resident #5). Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, unspecified, uncomplicated, and personal history of nicotine dependence. On 07/31/23 at 2:01 PM, Resident #6 verbalized the resident was able to smoke when the resident wanted to, and staff did not supervise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations, clinical record review and document review, the facility failed to ensure a resident received supervision and assistance to prevent a resident from burning a blanket and cigarette case on the resident's person for 1 of 12 sampled residents (Resident #4), and ensure a smoking resident had a smoking assessment completed quarterly for safety and the assessment determined safety interventions resulting from information gathered on the assessment for 2 of 12 sampled residents (Resident #4 and #6). Findings include: Supervision and Assistance and Smoking Assessment Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. A Certified Nursing Assistant (CNA) Progress Note dated 10/18/22, documented Resident #4 was found…

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, clinical record review, and document review, the facility failed to provide a therapeutic diet for an edentulous resident for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, vitamin deficiency, unspecified, and type two diabetes mellitus without complications. On 07/31/23 at 12:27 PM, Resident #5's lunch tray contained a whole pork chop. The resident verbalized the resident did not have any teeth and would not be able to eat the whole pork chop but was going to try. The resident did not recall if staff normally cut up meat, however the resident would prefer the meat to be cut up. Resident #5's tray card documented regular, soft texture: smothered pork cutlet with onions, rice pilaf, green beans, wheat dinner roll, and ice cream. On 07/31/23 at 12:30 PM, a Licensed Practical Nurse (LPN) verbalized a soft diet would contain chopped or ground meat. The LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, clinical record review and document review, the facility failed to ensure a resident's pain was managed with care planned interventions, pain was evaluated per a physician order, and appropriate administration of pain medication for 1 of 12 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility 09/01/21, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications. On 07/31/23 at 12:24 PM, Resident #10 verbalized having had pain in the resident's right hand. The resident had requested Voltaren gel for the resident's right hand. The resident requested to end the interview due to the pain. A Registered Nurse entered the resident's room and applied the Voltaren gel to the resident's right hand. On 07/31/23 at 2:07 PM, the resident verbalized having extreme pain in the right hand and was awaiting an X-ray. The resident was repeatedly pressing the call bell. The nursing progress note, dated…

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

Based on interview and document review the facility failed to ensure the facility had a full-time Director of Nursing (DON). Findings include: On 07/31/23 at 11:03 AM, the Administrator verbalized the facility did not have a DON, however the facility had a Licensed Practical Nurse (LPN) functioning as the Skilled Nursing Facility (SNF) Manager. On 08/03/23 at 1:28 PM, the Human Resources Director verbalized the facility did not have a DON and the DON position was vacant. The Facility Assessment Tool, revised 07/19/23, documented to ensure sufficient staff to meet the needs of the residents at any given time one Skilled Nursing Manager, License Practical Nurse (LPN), was to be full-time on days.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and clinical record review, the facility failed to ensure a physician responded to a pharmacist recommendation to add an end date to a psychotropic as needed (PRN) physician's order for 1 of 11 residents receiving psychotropic medications (Resident #12) Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavior/psychosis/mood/anxiety, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, and insomnia, unspecified. Resident #12's psychotropic physician orders documented the following: -07/24/23 Lorazepam Oral Concentrate 1 milligram (mg)/0.5 milliliter (ml) (Lorazepam), give 0.5 ml by mouth every six hours as needed for anxiety. Resident #12's Medication Regimen Review note, dated 07/31/23, completed by the pharmacist, documented consideration to add duration to PRN lorazepam had been made to the psychotropic medication review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, clinical record review and document review, the facility failed to ensure a resident did not receive an unnecessary pain medication when a nurse administered Voltaren gel for a different location of pain than indicated in a physician order for 1 of 12 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility 09/01/21, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications. On 07/31/23 at 12:24 PM, Resident #10 verbalized having had pain in the resident's right hand. The resident had requested Voltaren gel for the resident's right hand. The resident requested to end the interview due to the pain. The Registered Nurse entered the resident's room and applied the Voltaren gel to the resident's right hand. The nursing progress note, dated 07/31/23, documented the resident complained of right hand pain. The Supervisor assessed the resident. The area of concern was noted to right hand thumb where…

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 document review the facility failed to ensure the facility had a full-time Director of Nursing (DON), resulting in a lack of clinical oversight for safe bedrail implementation, and psychotropic medications. Findings include: Full-time DON On 07/31/23 at 11:03 AM, the Administrator verbalized the facility did not have a DON, however the facility had a Licensed Practical Nurse (LPN) functioning as the Skilled Nursing Facility (SNF) Manager. The Administrator explained the SNF Manager was in a nursing program and would become a Registered Nurse in May of 2024. On 08/01/23 at 9:36 AM, a Registered Nurse (RN) verbalized the SNF Manager was the charge nurse. On 08/03/23 at 1:28 PM, the Human Resources Director verbalized the facility did not have a DON and the DON position was vacant. On 08/09/23 at 3:59 PM, an RN verbalized the SNF Manager was the Charge Nurse and the RN took clinical direction from the SNF Manager. On 08/09/23 at 4:20 PM, the Assistant Director of Nursing (ADON)/RN verbalized the Charge Nurse supervised the care of residents and ensured policies…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the last revised Facility Assessment reflected an open Director of Nursing (DON) position. Findings include: The Facility assessment dated [DATE], did not include the open DON position on the facility's staffing plan. On 08/10/23 at 11:27 AM, the Administrator confirmed the Facility Assessment's staffing plan did not include the open DON position. The Administrator confirmed the Facility Assessment staffing plan should indicate all open positions.

Based on interview and document review, the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) Committee identified areas of concern related to use of widespread implementation of bedside rails and unnecessary psychotropic medications and implemented Performance Improvement Projects (PIPs) to reduce the risk of Substandard Quality of Care (Cross-reference tags F700 and F758). Findings include: The facility's Quality Assessment Performance Improvement (QAPI) Plan, undated, documented the QAPI plan addressed clinical care by monitoring existing quality indicator and quality monitor results, internal monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, and adverse events. The QAPI committee was to prioritize topics for PIPs based on the current needs of the residents and the organization. Priority would be given to areas defined as high risk to residents and staff, high prevalence, or high-volume areas, and areas problem prone. Potential topics for PIPs were identified through a prioritization process by the QAPI…

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

Based on observation, interview and document review, the facility failed to ensure signage regarding COVID-19 (COVID) was present at the facility's point of entry and at the internal and external entrance doors of the Long-Term Care (LTC) Unit. Findings include: On 07/31/23, 08/01/23, 08/02/23, 08/03/23, 08/09/23, and 08/10/23, the dates of the facility's annual recertification survey, signage related to COVID was not posted at or near the facility's point of entry, the internal LTC Unit entrance, and the LTC Unit external entrance door. On 08/03/23 at 10:42 AM, the Infection Preventionist (IP) explained the IP was not aware signage related to COVID was needed when the facility was not experiencing an outbreak. The IP verbalized the facility did not have signage related to COVID at the facility's point of entry, at the internal entrance double doors leading to the LTC unit, or at the external entrance door of the LTC unit. The IP explained visitors were verbally educated on self-monitoring for signs and symptoms of COVID, but this occurred after the visitor entered the facility. 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.