Troy Center For Rehabilitation And Nursing

Based on record review and interviews during a recertification and abbreviated survey (Case # NY00312707) from 2/05/2024 to 2/12/2024, the facility did not ensure the residents were free from significant medication errors for 1 (Resident #327) of 1 resident reviewed for medication reduction. Specifically, for Resident #327, medication reduction was not properly transcribed and administered as ordered in a timely manner. This is evidenced by: Resident #327 Resident #327 was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue); and was discharged from the facility prior to this survey. The Minimum Data Set (an assessment tool) dated 2/27/2023 documented the resident could understand and be understood by others and was cognitively intact. A document titled…

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 during a recertification and abbreviated survey (Case # NY00327311 and NY00315143) from 2/05/2024 to 2/12/2024, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was not sufficient staff to meet resident needs in activities of daily living; multiple residents stated there were long waits for call lights showers were not given, not gotten out of bed and dressed until late morning, long waits to return to bed, and not enough staff to provide care. This is evidenced by: The facility's staffing policy revised on 11/2023, documented staffing numbers and skills requirements of direct care staff were determined by the needs of the resident's care plan. The number of nursing staff on duty would be sufficient to ensure nursing care needs of each resident were met. The facility's Call Light…

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 during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on one (1) of 2 units. Specifically, the facility nurse call system did not function in resident room #s 5, 7, and 11 on the North Unit. This is evidenced by: During observations on 2/08/2024 at 9:33 AM, the call bell did not activate when tested in resident room # 5 for beds A and B. Additionally, room [ROOM NUMBER] was utilizing tap bells and did not have nurse cords to activate the nurse call system. room [ROOM NUMBER] was utilizing a tap bell and did not have a nurse call cord to activate the nurse call system. During an interview on 2/08/2024 at 9:37 AM, Resident #8 stated that they would press the nurse call cord if one were provided. Record review of [NAME] Center Repair Requisitions, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during recertification and abbreviated survey (Case #NY00322407) from 2/05/2024 to 2/12/2024, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were immediately reported to the State Agency for 1 (Resident #51) of 3 residents reviewed for abuse. Specifically, the facility did not report the allegations of abuse involving Resident #51 to the New York State Department of Health after becoming aware of the allegations on 8/09/2023 at 7:20 AM. This is evidenced by: Resident #51 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis with unspecified peripheral vascular disease, type II Diabetes, and vascular Dementia with other behavioral disturbances. The Minimum Data Set (an assessment tool) dated 12/10/2021 documented that the resident usually could be understood and understood others, and that the resident had severely impaired cognition for daily living decisions. The facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure the development of comprehensive person-centered care plans - that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs - as identified in the comprehensive assessment for 2 (Resident #s 14 and 327) of 27 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #327, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; and (2) for Resident #14, the facility did not ensure a comprehensive care plan was developed to address the resident's dental care. This is evidenced by: The Policy and Procedure titled Care Plans - Comprehensive, dated 10/2019, documented the facility would develop a comprehensive, resident centered care plan for each resident based on the individual needs/problems of each 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, record review and interviews during a recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 3 (Resident #s 2, 32 and 327) of 27 residents reviewed for Activities of Daily Living. Specifically, (A) Resident #'s 2 and 32 were not provided assistance with personal hygiene during morning care; (B) Resident #32 did not have a clean change of clothing and Resident # 2 was not provided sufficient extra-large incontinence briefs; (C) Resident #327 was not provided their weekly shower. This is evidenced by: The facility policy Activities of Daily Living Support effective 08/2016 and revised on 10/2019 documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #2 The resident was admitted to 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 conducted during an abbreviated survey (NY00294027), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #4) of 4 residents reviewed. Specifically, for Resident #4 who was care planned for floor mats next to bed when in bed, floor mats were not placed when the resident fell from the bed, resulting in a fall with fractures of the 8th and 9th right ribs. This was evidenced by: The facility policy Falls Management and Prevention, revised 01/2021, documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. Resident #4 was admitted to the facility with diagnoses including dementia, general muscle weakness, and compression fractures of the lumbar spine (when the bones of your spine collapse). The Minimum Data Set (an assessment tool) documented the resident had severely impaired cognition. The at risk for falls…

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 during a recertification survey, the facility did not ensure each resident was treated with respect and dignity and each resident was cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 2 (North Unit and South Unit) of 2 units and 2 (Resident #s 50 and 32) of 4 residents reviewed for dignity. Specifically, in a Resident Council Meeting held on 10/22/2021, residents stated incontinence care was not provided timely, call bells were not answered timely, and staff were rude and lacked compassion. For Resident #50, staff used inappropriate language in their presence, and staff turned off their call bell without addressing their needs. For Resident #32, staff did not answer the call bell timely, and staff used inappropriate language in a demeaning manner after the resident had diarrhea and needed to be cleaned. This is evidenced by: A Resident Council Meeting was held on 10/22/2021 at 10:40 AM. There were 6…

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 reviews conducted during the Recertification Survey, the facility did not ensure the views of a resident group were promptly acted upon and the recommendations of such groups that concerned issues of resident care and life in the facility. Specifically, the facility did not ensure concerns voiced during Resident Council Meetings were promptly acted upon and did not ensure the Resident Council was provided with facility responses, actions, and rationale regarding their concerns. This is evidenced by: A review of Resident Council Minutes documented: -7/19/2021- documented a concern related to wandering residents and a question asking when podiatry would be coming. The minutes documented a resolution was returned by the department responsible for addressing the concerns, however the column on the Resident Council Minutes to document if the resident had been notified of the response was blank. -8/16/2021- documented concerns related to medication being left at bedside, a housekeeper not properly cleaning and a question asking if less residents can be in…

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 interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, door frames and baseboards were not clean and in good repair on 2 of 2 resident units. This is evidenced as follows. A selection of rooms were inspected on 10/26/2021 at 9:15 AM revealing that the paint on the door frames of resident rooms 1, 3, 6, 11, 12, 13, 17, 23, 24, 26, 31, 34, 37, 39, and 41 were heavily chipped, and the baseboards in resident rooms 6, 18, 36, and 37 were covered in a brownish debris. During an interview on 10/25/2021 at 1:00 PM, the Director of Maintenance and the Environmental Services Manager stated the facility would repaint the door frames and clean the baseboards in the resident rooms. During an interview on 10/27/2021 at 9:30 AM, the Administrator stated the facility would be audited, and all the chipped door frames would be repainted, and the baseboards repaired and cleaned. 10 NYCRR 483.10(i)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey and abbreviated survey (Case #NY00279792) the facility did not ensure baseline care plans were developed within 48 hours of a resident's admission and provided to the resident and their representative with a summary of the baseline care plan for 4 (Resident #s 22, 25, 67 and 175) of 17 residents reviewed. Specifically, for Resident #32, the facility did not ensure a baseline care plan was completed, for Resident #175, the facility did not ensure that the baseline care plan was fully completed and did not ensure the resident or representative were provided with the baseline care plan. For Resident #25 and #67, the facility did not ensure the baseline care plan was reviewed with, and a copy provided to, the resident and/or their representative. This is evidenced by: The Policy & Procedure titled Care Plans-Baseline and dated 1/2020 documented, a baseline plan of care to meet the residents immediate needs shall be developed for each…

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 recertification and abbreviated survey (Case #s NY00283415 and NY00285016) the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs for 8 (Resident #'s 14, 17, 27, 30, 32, 67, 74, and 225) of 33 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #14, the facility did not ensure the CCP for Activities of Daily Living (ADLs) addressed the resident's ambulation status; for Resident #17, did not ensure a care plan was developed to address the resident's bowel and bladder incontinence; for Resident #27 did not ensure a CCP was developed to address the diagnosis of anxiety; for Resident #30, did not ensure care plans were developed to address the resident's anxiety and depression, the use of anticoagulant medication…

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 during the recertification survey, the facility did not ensure a policy was developed for the Monthly Medication Regimen Review (MRR) that included timeframe's for the different steps in the process. Specifically, the facility did not ensure there were timeframe's established and documented in the policy for steps in the MRR process concerning actions the physician needed to take when an irregularity was identified. This is evidenced by: The Policy and Procedure (P&P) titled Medication Regimen Review (MRR) dated 3/2020, documented the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. If the identified irregularity represents a risk to a person ' s life, health, or safety, the Consultant Pharmacist contacts the physician immediately (within two hours) to report the information to the physician verbally, and documents the notification. If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been…

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 during the recertification survey, the facility did not ensure that it's medication error rate did not exceed 5% of greater for 3 (Resident #s 13, 29 and 62) of 4 residents reviewed for medication errors. Specifically, during an observed medication pass the facility did not adhere to provider orders during 8 of 26 total opportunities, resulting in a final medication error rate of 30.77%. This was evidenced by: The facility policy titled Medication Administration last revised 12/2019 documented medications must be administered in accordance with the orders, including any required timeframe. Vital signs, if necessary, must be checked/verified for each resident prior to administering medications. Medications must be administered within one hour of their prescribed time, unless otherwise specified. The individual administering the medication was to record in the resident's medical record the date and time the medication the medication was administered, and the dosage of the medication administered. Resident #13: During an observation…

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 during the recertification survey and abbreviated survey (Case #s NY00279792 and NY00280289), the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 4 (Resident #'s 17, 67, 175 and #177) of 19 residents reviewed. Specifically, for Resident #17, the facility did not ensure Certified Nurse Aide (CNA) documentation for Bladder/Bowel incontinence was complete, for Resident #67, the facility did not ensure documentation in the resident record accurately reflected the provision of wound care or when oxygen was administered, for Resident #67, the facility did not ensure daily CNA documentation of Activities of Daily Living (ADL) care was complete and accurate. Additionally, for Resident #'s 175 and 177, the facility did not ensure that the resident's records documented when oxygen was administered. Resident #17: Resident #17 was admitted to the facility with the…

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

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 1 (Resident #67) of 1 resident reviewed. Specifically, for Resident #67, the facility did not ensure a physician's order for the prescribed flow rate for oxygen administration was followed. This is evidenced by: Resident #67: The resident was admitted to the facility with the diagnoses of congestive heart failure (CHF), atrial fibrillation and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 9/14/2021, documented the resident was cognitively intact, could understand others and could make self understood. A physician's (MD) order dated 10/21/2021, documented the resident was to receive oxygen as needed via nasal cannula to be administered at two liters per minute to keep oxygen saturations at or above ninety percent. During observations Resident #67 received Oxygen via nasal cannula: 10/22/2021 at 8:31 AM at three liters per minute;…

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 interviews during the recertification survey, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #17) of 3 residents reviewed for laboratory services. Specifically, for Resident #17, the facility did not ensure a physician ordered urinalysis (UA- a test of the urine used to detect and manage a wide range of disorders, such as urinary tract infections) and Culture and Sensitivity (CS- a laboratory test to detect and identify bacteria and yeast in the urine, which may be causing a urinary tract infection) dated 9/19/2021 was obtained. This was evidenced by: Resident #17: Resident #17 was admitted to the facility with the diagnoses of seizures, stroke, and hydrocephalus. The Minimum Data Set (MDS - an assessment tool) dated 7/30/2021 documented the resident had moderately impaired cognition, could understand others and could make themself understood. The facility's Policy and Procedure for Physician Orders was requested on 10/25/2021 and was not provided to the New York State Department 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 observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Resident #'s 12, 23, 52, 54, 58, 59, 63, 66, and #67) of 18 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #12, the facility did not ensure that the CCP for Psychotropic Medications and Behaviors included person centered interventions; for Resident #23, the CCP for Cognitive Loss and Mood did not include resident centered interventions; for Resident #52, the facility did not ensure the CCP for Psychotropic Medication Use addressed the use of an antidepressant medication (Trazodone), the CCP for Alteration in Psychosocial Well-Being included goals or interventions and did not…

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, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure that the minimum staffing levels for Certified Nursing Assistants (CNA) was met on 14 out of 14 calendar days from 1/25/20 to 2/7/20; that each resident received care for their incontinence during the night shift and specifically, for Resident #4, that the resident received incontinence care from 7:00 PM on 2/5/20 to 10:30 AM on 2/6/20; Additionally, the facility did not ensure meals were served timely in 4 out of 4 designated dining areas on 2/6/20 and 2/10/20; and that care and services provided by the Certified Nurse Aides (CNAs) was documented daily. This was evidenced by: Finding #1: The facility did not ensure that the minimum staffing…

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 during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies, intolerances, and preferences, and appealing options of similar nutritive value to residents who choose not to eat food that was initially served or who requested a different meal choice for 2 (Resident #54 and #227) of 3 resident's reviewed for nutrition. Specifically, for Resident #54, the facility did not ensure the resident's food preferences were printed on the resident's meal ticket and did not ensure the resident was offered an option of similar nutritive value when he/she declined the main meal provided; for Resident # 227, the resident's food preferences provided at meals were not consistent with the resident's printed meal tickets. This is evidenced by: The Policy and Procedure titled Honoring Preferences, Making Substitutions, last revised 1/2019, documented food preferences were obtained as part of the admission process by the Director of Food and Nutrition or…

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 during a recertification survey, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure a nourishing bedtime snack was provided when there was a greater than 14-hour time span between the evening meal and breakfast. This was evidenced by: The Policy and Procedure titled Nourishments- Supplements- Snacks, last revised 3/2019, documented residents may request a snack at any time, however nursing personnel would offer at least a bedtime snack to residents. A review of the document titled, Meal Service Times and Location dated 1/2020, documented the meal times were approximate to when the trays/meals would arrive in the designated dining areas: Breakfast: Cart 1: 8:00 AM Liberty Cafe Cart 2: 8:10 AM Activities Room Cart 3:…

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 interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition and shall protect the integrity of the contents so food is not exposed to adulteration or potential contaminants, paper towels must be supplied at handwashing stations, and non-food surfaces are to be kept clean. Specifically, cans of food were dented, paper towels were missing from the handwashing station, and the shelves and walls in the walk-in cooler were not clean. This is evidenced as follows. The main kitchen was inspected on 02/06/2020 at 8:45 AM. One can of sweet potatoes and one can of cranberry sauce found in the common stock had dents on the hermetic seals. The kitchen handwashing station was missing paper towels, and the storage racks and walls in the walk-in cooler were covered with a moldlike substance not clean. The Food Service Director in an interview on 02/06/2020 at 9:15 AM, stated that he will remove the dented cans in…

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 during a recertification survey the facility did not ensure Medical Records were maintained in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible and systematically organized for 6 (Resident #'s 4, 7, 23, 54, 66, and #227) of 18 residents reviewed. Specifically, for Resident #'s 4 & 23 the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care; for Resident #7, who received dialysis, the facility did not ensure the resident's fistula (a connection located under the skin and used during dialysis to access the bloodstream) site was monitored daily per the physician's order for signs and symptoms of infection/inflammation/bleeding and for the presence of bruits/thrills; for Resident #54, the facility did not ensure the resident's percentage of food consumed was documented daily; for Resident #66, the resident's ADLs including bathing,…

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 recertification survey, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, for one (Resident #63) of one resident reviewed for a dressing change, the facility did not ensure gloves were changed when contaminated, handwashing was performed between glove changes and supplies were not removed from the resident's room during a dressing change to an unstageable pressure ulcer of the right heel; the facility did not ensure face masks were properly worn by two employees while in resident areas. Additionally, for one (Resident #1) of six residents reviewed for medication administration, the facility did not ensure the resident was not provided with medications staff had handled with bare hands and for one (Resident #57) of three residents reviewed for urinary catheter care, the facility did not ensure the indwelling catheter…

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 staff interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #66) of 1 resident reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #66, the facility did not ensure the directions documented on the care card ensured the resident, who could not carry out activities of daily living independently, had her hair washed weekly to maintain good personal hygiene. This is evidenced by: Resident #66: The resident was admitted to the facility with the diagnoses of necrotizing fasciitis, diabetes and heart failure. The Minimum Data Set (MDS - an assessment tool) dated 1/10/20, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled, Bed Bath last revised, 7/2019, documented the facility promoted cleanliness, provided comfort and observed the condition of the resident's skin, through the…

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

Based on observation, record review and interviews during the recertification survey the facility did not ensure the director of nursing served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing served as a charge nurse when there were 77 residents residing on 2 units (North Unit and South Unit). This was evidenced by: Upon entrance to the facility on 2/6/20 at 8:30 AM, there were 77 residents residing on 2 units (North Unit and South Unit). During the Survey Entrance Conference on 02/06/20 at 08:41 AM, the facility Assistant Administrator stated that Registered Nurse #2 was the Director of Nursing (DON) for the facility and the Registered Nurse Manager (RNM) for the North Unit. During an interview on 02/10/20 at 12:24 PM, Registered Nurse #2 stated that she was both the RNM and the DON since November 2019. During an interview on 02/10/20 at 12:45 PM, the Administrator stated Registered Nurse #2 was both the DON and RNM. The Administrator was not aware that the regulation stated that a DON could not…

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, interviews and record reviews during a recertification survey, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principals for 1 (Resident #1) of 6 residents reviewed for medication administration. Specifically, for Resident #1, the facility did not ensure that the resident's narcotic record for pregabalin (Lyrica) (a controlled substance used for pain) documented the current physicians order. This is evidenced by: A policy titled Medication-Narcotic Management with a last revised date of 4/2019 documented that the information required on the bound narcotic book included resident name, the name of the medication, and the directions for administration. A policy titled Medication Administration with a last revised date of 12/2019 documented: Medications shall be administered as prescribed and the individual administering the medication must check the label three times to verify the right medication, right dosage, right time and right method (route) of administration before…

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.