Ferncliff Nursing Home Co Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, conducted during an abbreviated survey (NY00355382 and NY00362103), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 3 residents (Resident #1 and #3) reviewed. Specifically, on 9/3/2024 Resident reported they were bumped by the elevator door [NAME] exiting and reported pain 3 out of 10 to their right hip. 2) On 9/30/2024 while exiting the core elevator on the 4th floor, the elevator door closed hitting Resident #1's right hip causing pain and discomfort. 2) On 11/25/2024, Resident #3 was found inside of the facility housekeeping closet on the 4th floor. Facility investigation revealed the housekeeping door was unsecure due to the striker plate being broken. Resident #3 who had a history of wandering behaviors, was able to gain entry to the unit 4A utility closet due to a screw being loose on the striker plate which prevented the door from closing and locking as expected. Findings include: The facility's policy on Accidents 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 observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 6 residents (Residents #432, #218, #48, and #54,) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, (1) Resident #432 acquired a stage 4 sacral pressure ulcer at facility and treatments were not completed as ordered. (2) Resident #218 was observed 4 times without a pillow under their right elbow and their right elbow stage 4 pressure ulcer had re-opened, (3) Resident #48 was admitted with moisture associated skin damage to the right sacrum which developed into an deep tissue injury and an unstageable wound, and (4) Resident #54's sacral pressure ulcer increased in size during a time period when 3 of 10 topical wound dressing treatments were not documented as administered. Findings include: The facility's policy, 'Pressure injury care and prevention' last reviewed 12/23…

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

Based on interviews and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of the residents. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing, 3) a review of one month of facility staffing revealed the facility did not ensure that the minimum staffing levels for certified nurse aides was met on the night shift. Findings include: Review of the facility staffing from 2/13/24-3/13/24 revealed: - on 2/13/24, 7 CNA slots were unstaffed on the night shift, - on 2/15/24, 3 CNA slots were unstaffed on the night shift, - on 2/19/24, 2 CNA slots were unstaffed on the night shift, - on 2/23/24, 2 CNA slots were unstaffed on the night shift, - on 2/27/24, 1 CNA slot was unstaffed on the night shift, - on 2/29/24 1 CNA…

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 conducted during the Recertification Survey completed from 3/13/24 through 3/29/24, the facility did not ensure each resident received drinks, including health shakes and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 17 (Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278) of 36 residents reviewed. Specifically, Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278 did not receive coffee or tea, and health shakes as per meal ticket. Findings include: The undated facility policy titled Resident Meal Service, documented beverages were to be provided as listed on ticket or per resident preference. On 03/13/24 from 12:21 PM-01:05 PM, during the dining room lunch observation, Residents #1, 11, 84, 177, 237, 250, 258, and 278's meal tickets all documented 6 ounces of a hot beverage (tea, coffee, and decaffeinated tea or coffee). None of the residents received the hot beverages listed on their meal tickets…

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 conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1. Portable food storage bins used for storing bulk dry foods were not maintained in a sanitary condition, 2. A cooling log was not used to monitor cooling of potentially hazardous cooked food (poultry), 3. Storage racks used to store cleaned and sanitized food preparation equipment were not maintained in a sanitary condition and the floor under the storage racks was not maintained in a sanitary condition, 4. Eight (8) food transport trucks used for transport of foods to the resident units were not maintained in a sanitary condition, and 6. A formica countertop located directly in front of 1 of 8 kitchenette hot food holding areas was in poor repair and presented a risk for food contamination and potential injury to residents. The findings are: During a follow up tour of the main kitchen on 3/19/2024…

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 observations, interviews, and record review conducted during the recertification and abbreviated surveys (NY00334054) from 3/13/24 to 3/29/24, it was determined that the facility did not ensure an effective pest control program was maintained to ensure the facility was free of pests and rodents. Specifically, facility staff and residents reported mice sightings. Additionally, there were multiple observations of mice droppings in resident rooms. Findings include: During an interview on 3/13/24 at 4:15 PM Resident #206 stated that there were black mouse traps on the unit and in their room, pointing to their radiator. The trap killed about three mice within the past few weeks. During an observation on 03/14/24 at 09:54 AM in Resident #206 room, small black mouse droppings were noted on the floor around the black mouse trap at the base of the radiator. During an observation on 03/14/24 at 12:47 PM while in Resident # 93's room, a mat against the radiator was pulled back, and a black box mouse trap with…

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

Based on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure residents had a right to a dignified existence in an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident #133 was observed on multiple occasions, not shaved with a large amount of facial hair, and hair on the head was disheveled. The findings are: Resident # 133 was admitted to the facility with diagnoses including Alzheimer's disease, diabetes mellitus, and history of traumatic brain injury. The 02/17/24 Quarterly Minimum Data Set ( an assessment tool ) documented Resident #133 had severely impaired cognition, required partial assistance with personal hygiene, and had no behavioral symptoms and no rejection of care. The comprehensive care plan titled impaired activities of daily living, dated 1/18/22, documented Resident #133 would remain clean, neat, dressed appropriately for the season and free of body odor. Interventions included Resident #133 would be provided privacy, and dignity…

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 staff interviews during the recertification survey from 3/13/24 to 3/29/24, the facility did not maintain a homelike environment for 4 of 8 rooms observed on unit 5B. Specifically, for Residents #154, #210, #135 and #131, observations were made of ripped and peeled protective padding in bathrooms, particles of food and other debris on the floor, dirty adult briefs on the floor, and a toilet paper dispenser with fecal remains dried on over a period of 6 days. Findings include: On 3/13/24 at 11:16 AM, Resident #210's bathroom, located on unit 5B, was observed with an adult brief soiled with urine and feces lying on the floor. Feces were observed on the toilet and the toilet paper dispenser. A soiled gown was observed on the floor. A heavy urine odor was noted in the room. The resident's bed headboard was observed with protective padding that was ripped, peeling and damaged. On 3/13/23 at 3:33 PM, Resident #210's bathroom was observed with the soiled adult brief still on the floor. The feces were still on the toilet and the toilet paper dispenser and a soiled…

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 review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 5 residents (Residents #114, 161, 216 and 258), reviewed for abuse, had the right to be free from abuse. Specifically, Resident #258 was observed on multiple occasions exhibiting physical and verbal aggression towards other residents including Residents #114, #161 and #216, and the facility did not ensure interventions were implemented to prevent abuse. Findings include: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and Procedure dated 1/11/20 and last revised on 8/28/23 documented to protect residents' and ensure freedom from abuse, mistreatment, neglect, misappropriation of property, exploitation corporal punishment and involuntary seclusion. The facility takes all witnessed and/or suspicion of resident/patient abuse, mistreatment, neglect, misappropriation of funds and/or exploitation by anyone including facility staff, other residents, consultants, volunteers, staff of other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record review and interviews, during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents and for 2 of 6 reviewed for pressure ulcers. Specifically, (1) Resident #97 had suicide attempts on 11/23/22 and 11/29/22 and the Care Plan was not updated to reflect the second suicide attempt and was not revised with new interventions to prevent reoccurrence; (2) Resident #432 had a Stage IV pressure ulcer on the sacrum and their Care Plan was not revised with new interventions to reflect resident's current wheelchair being used, and (3) Resident #218 had a Stage IV pressure injury to the right elbow, and the Care Plan was not revised to include Resident #218's noncompliance with having pillows placed underneath their right elbow for offloading, and the Care Plan was not reviewed to determine 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, interview and record review conducted during a recertification survey from 3/13/2024-3/29/2024, the facility did not ensure residents received the necessary services to maintain good grooming and personal care for 1 of 5 residents (Resident #152) reviewed for activities of daily living. Specifically, Resident #152 was observed with untrimmed fingernails and visible scratch marks to scalp. Findings include: Resident # 152 admitted with diagnoses that include hypertension, dementia, and Huntington disease. The Quarterly Minimum Data Set (a resident assessment tool) dated 1/28/24 documented the resident was severely impaired and was dependent with eating, oral care, hygiene, toileting, shower, bath, and personal hygiene. The care plan dated 1/7/22 titled Skin integrity at risk for skin breakdown or pressure ulcer related to right hand contracture as evidence by right hand contracture, Resident #152 frequently scratched scalp. Interventions included to apply white glove as tolerated and 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, record review, and interviews conducted during the recertification and abbreviated surveys (NY00332770) from 3/13/24 to 3/29/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #382), reviewed for change of condition. Specifically, Resident #382 did not receive antibiotic Flagyl / Gentamicin topical treatment dressings as recommended by the wound care consultant physician; the resident was admitted to the hospital with a malodorous (bad smelling) wound and was started on antibiotics for wound cellulitis (infection of the skin). Findings include: The facility policy, 'Surgical Wounds', effective 5/2010 and reviewed 3/22/24 documented that all licensed nurses are responsible for assessing/observing the status of wounds, determining the effectiveness of the current treatment dressing, and to report and document any untoward findings to the health care provider. Resident #382 was admitted…

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 review and interviews conducted during the recertification survey from 3/13/24-3/29/24, the facility did not ensure for 2 (Residents #74 and #218) of 7 residents reviewed for positioning and limited mobility, that appropriate treatment and services were provided to improve and/or prevent a further decrease in range of motion. Specifically, Resident #74 was observed on multiple occasions not wearing a resting hand splint to the left hand as ordered and Resident #218 was observed with a right hand contracture and on multiple occasions, no adaptive devices were observed in place to prevent a further decrease in range of motion. The findings include: 1) Resident #74 was admitted to the facility with diagnoses including Alzheimer's disease, non-traumatic brain dysfunction, and hemiplegia and hemiparesis following a cerebrovascular infarction affecting the left dominant side. The 12/11/2023 Quarterly Minimum Data Set (an assessment tool) documented the resident had moderately impaired cognition, required setup with eating, and required extensive assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 2 of 4 residents (Residents #97 and #168) reviewed for accidents. Specifically, (1) Resident #97's supervision was not maintained after an attempted suicide resulting in another attempt 6 days later, and (2) Resident #168 sustained two falls on 5/6/23, the second of which resulted in Resident #168 fracturing their tibia (lower leg) and femur (upper leg). The findings are: The facility policy titled Occurrence Reporting and Investigation Policy and Procedure dated 11/28/2017 documented an occurrence report is initiated so that the facility obtains information relevant to each occurrence and allegation as well as to obtain information for analysis of the cause of the event in order to prevent…

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 during the post survey revisit (PSR) from 5/30/24 to 6/3/24, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 6 residents reviewed for pressure ulcers (Resident #500). Specifically, there was no documented evidence that Resident #500 received a 5/22/24 physician ordered fentanyl patch until 5/26/24. Additionally, there was no documented evidence of pain monitoring on 5/30/24 after Resident #500 received physician ordered as needed pain medication for a complaint of 8/10 pain and/or prior to the nurse performing a wound dressing change. Findings include: Resident #500 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain), pressure ulcer of the sacral region Stage 3, and urinary tract infection. The Nursing admission Assessment, dated 5/22/24, completed by Registered Nurse #22, documented occasional…

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 review and staff interview conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. This was observed during dining observation for 3 of 15 residents reviewed for nutrition (Resident #135, #229, and #236). Specifically, Resident #135 was observed dropping food when trying to scoop an item from a regular plate. Resident #229 was observed on three occasions eating without the use of an adaptive bowl and cup as indicated in the meal tray ticket and ordered by occupation therapy. Resident #236 was observed on three occasions being fed without the use of the adaptive maroon spoon, as documented on their meal ticket. Findings include: 1. Resident # 135 was admitted with diagnoses that included dementia, Huntington's Disease, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (an assessment tool) dated 2/24/24 documented the resident had modified independence in cognition and the resident required set up or clean up…

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 interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infection was maintained for 4 of 5 residents (Residents #12, # 70, #93, #210) reviewed for infection control and prevention practices. Specifically, for Resident #12, during a wound care observation, the nurse did not wash their hands and don clean gloves after cleansing a pressure ulcer and before applying treatments The findings include: Review of the facility's policy entitled Infection Prevention and Control Manual last reviewed March 5, 2024. The facility policy stated they review infection control surveillance reports and statistics to implement corrective actions through monitoring aseptic techniques and procedures utilized within the facility. The facility hand hygiene/hand washing protocol stated the facility considers, hand hygiene the primary means to prevent the spread of infections. All staff are expected to perform…

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 conducted during the abbreviated survey (NY00319337), the facility did not ensure residents right to be free from abuse, mistreatment, neglect, and exploitation for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, (1) Resident #2 who had a previous incident on 04/19/2023 of touching Resident #3's upper thigh through clothing had no appropriate care plan review conducted, and no new interventions placed post incident (2) Resident # 2 was witnessed walking up to Resident #1, and using both hands, rubbed and fondled Resident #1's breasts through clothing on 7/02/2023 after chapel. Resident #2 was not adequately supervised. The findings are: The Facility Policy on Resident Abuse Reporting and Investigation Protocol created 01/11/2010, last revised 06/27/2019 documented that the facility leadership will assess the needs of the residents in the facility to be able to identify concerns to prevent potential abuse. The interdisciplinary team will identify the vulnerabilities and interventions on the resident's care plan. The facility will…

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 610 Based on record review and interviews conducted on a recent recertification survey, the facility did not ensure that a full investigation was conducted for one of three residents (R #189) reviewed for medication errors. Specifically, there was no documented evidence that a full investigation into a medication timing error involving psychotropic and benzodiazepine medications was performed, or that vital information was communicated to the physician. The findings are: The facility policy titled Medication Errors and dated July 2012 documents it is the policy of the facility that residents are to remain free from medication errors. The Licensed Nurse who identifies the error conducts an immediate evaluation and notifies the Nursing Supervisor. The Nursing Supervisor assesses the resident, initiates the investigation of the medication error and directs notification of appropriate staff (Attending Physician, Director of Nursing and Pharmacist are notified) Poison Control is to be contacted if necessary. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a recent recertification survey, the facility did not ensure the comprehensive person-centered care plan was revised for 1 of 2 Residents (Resident # 252) reviewed for vision and hearing. Specifically, (1) Resident #252 Hearing Impairment Care Plan was not revised to reflect the resident's recent complaint of changes in hearing loss, (2) orders for audiology consultation for hearing aids; and (3) to determine if the interventions remained appropriate. The findings are: Resident # 252 is an [AGE] year-old who was admitted to facility on 12/5/2012. Diagnoses included Major Depression, Generalized Muscle Weakness, and Hearing Loss. According to the 9/2/2020 Annual Minimum Data Set (MDS; a resident assessment and screening tool), the resident had intact cognition, required extensive assistance with activities of daily living (ADLs), and had minimal difficulty hearing in some environment. This MDS stated the resident had no hearing aid. A subsequent…

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 conducted during a recent recertification survey, the facility did not ensure that a resident receive proper treatment and assistive device to meet the resident's hearing needs. Specifically, 1of 2 residents (Resident #252) reviewed for vision/hearing complained to the facility staff about hearing difficulties and was not provided the audiology consultation or hearing aids ordered by the physician. The findings are: Resident #252 is an [AGE] year-old who was admitted to facility on12/5/2012. Diagnoses included Major Depression, Generalized Muscle Weakness, and Hearing Loss. According to the 9/2/2020 Annual Minimum Data Set (MDS; a resident assessment and screening tool), the resident had intact cognition, required extensive assistance with activities of daily living (ADLs), and had minimal difficulty hearing in some environment. This MDS stated the resident had no hearing aid. A subsequent Quarterly assessment dated [DATE] also stated the resident had minimal…

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

Based on interviews and record review during a recertification survey the facility failed to ensure adequate supervision and effective use of the facility's monitoring program to prevent elopement was provided for 1 of 1 resident (Resident #81). Specifically, Resident #81 entered an elevator on the 3rd floor and was found by staff on the 4th floor. The findings are: The facility occurrence report indicates on 4.6.21 the resident stated she was leaving, her boss said she could go. The resident, who resides on Unit 3A was found in the core elevator at 1:50pm on the 4th floor unit A. Staff on the 4th floor responded to the alarm and found the resident sitting her wheelchair in the elevator. The therapy aide who got on the elevator notified the 3rd floor unit manager that she was taking the resident outside for a few minutes. Upon returning to the unit 3A the Unit Manager assessed the resident and determined she was not harmed. The facility policy regarding Wander Guard dated 8.5.2005 and revised most recently on 1.14.2015 was reviewed and indicated for residents who are determined 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 interviews and record reviews during a recent recertification survey, the facility did not ensure that one (Resident # 189 ) of three residents reviewed for medication administration was free from significant medication error. Specifically, the nurse did not administer medications at the physican prescribed time placing the resident at risk for dangerous drug interaction/reactions. The findings are: The facility policy dated May 1, 2009 documented Medications and Treatments shall be administered in a timely manner that is safe, timely, and reduces the incidence of error as much as humanly possible. Medications may be administered one hour before and one hour after the scheduled ordered time. The facility policy titled Medication Errors and dated July 2012 documents it is the policy of the facility that residents are to remain free from medication errors. The Licensed Nurse who identifies the error conducts an immediate evaluation and notifies the Nursing Supervisor. The Nursing Supervisor assesses 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.