Heritage Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy the facility failed to thoroughly investigate an incident of physical abuse involving Resident #37. This affected one resident (#37) of three residents reviewed for abuse. The facility census was 42. Findings include: Review of the medical record for Resident #37 revealed an admission date of 02/28/23 with diagnoses including Alzheimer's disease, anemia, muscle weakness, and dementia with psychotic disturbance. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and independent with eating, oral hygiene, toileting, dressing, and hygiene. Review of the care plan dated 11/28/23 revealed Resident #37 had the potential for mood swings and behavioral issues due to dementia and Alzheimer's disease. Interventions included non-pharmacological interventions such as a one-to-one attention, changing position or scenery, redirection or offering activities, providing a…

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

Based on record review and interview the facility failed to ensure eight hours of Registered Nurse (RN) coverage as required. This affected all 38 residents in the facility. Findings include: 1. Review of the facility's payroll based journal (PBJ) data and posted daily staffing sheets on 11/21/23 starting at 11:34 A.M. with Human Resource Manager (HRM) #255 revealed the following: • On 04/22/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 05/07/23, one RN was scheduled for eight hours on the daily staffing sheet but only 7.7 RN hours were recorded in the PBJ. • On 05/20/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 05/21/23, two RNs were scheduled for 15 hours on the daily staffing sheet but no RN hours were recorded in the PBJ. • On 06/03/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 06/04/23, no RN was scheduled on the daily staffing sheet and there were no RN hours recorded in the PBJ. • On 06/17/23, no RN…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented related to handwashing with medication pass, proper personal protective equipment (PPE) before entering a COVID-19 positive room, and did not fully develop and implement a comprehensive water management program to prevent Legionella. This had the potential to affect all residents. The facility census was 38. Findings include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 12/15/22. Diagnoses included congestive heart failure (CHF), morbid obesity, chronic obstructive pulmonary disease (COPD), and lymphedema. Review of the physician orders for November 2023 revealed active orders for contact and airborne precautions due to COVID 19 positive two times a day for 10 Days with a start date of 11/20/23. Observation on 11/20/23 at 9:56 A.M. of Resident #5's room door closed with signage on the door indicating contact and air borne precautions, and personal protective equipment (PPE) outside of the door that included, N95…

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

Based on observation, interview, and record review ,the facility failed to ensure a clean, sanitary, and well maintained environment in good repair. This affected five residents (#4, #30, #33, #34, and #38) of seven residents reviewed for physical environment. The facility census was 38. Findings include: 1. Observation on 11/20/23 at 10:21 A.M. of Resident #30's room revealed a hole in the wall behind the dresser that appeared to be the size of at least a baseball of what was able to be observed without moving the dresser. Interview at this time with Resident #30 revealed that hole had been there since she was admitted to the facility about two months ago. Observation on 11/20/23 at 10:26 A.M. of Resident #33's room revealed the windowsill in disrepair and lifted up. Also observed two holes in the bathroom door. Interview at this time with Resident #33 revealed it had been that way for a while. Observation on 11/20/23 at 10:33 A.M. of Resident #34's room revealed under the sink area was a large hole in the wall and also various dried brownish stains throughout this wall. Observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the do not resuscitate comfort care (DNRCC) order form was timely signed as required by the physician. This affected one resident (#33) of one resident reviewed for advance directives. The facility census was 38. Findings include: Review of the medical record for Resident #33 revealed an initial admission date of [DATE]. Diagnoses included chronic ischemic heart disease, atherosclerotic heart disease of native coronary artery without angina pectoris, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus with diabetic nephropathy, hyperlipidemia, peripheral vascular disease, coronary artery dissection, chronic obstructive pulmonary disease with (acute) exacerbation, muscle weakness, acquired absence of right leg below knee, chronic pain syndrome, and hypertension. Review of the physician orders for [DATE] revealed an active order for DNRCC- ARREST with a start date of [DATE]. Review of the care plan dated [DATE] for Resident #33…

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, and record review, the facility failed to provide necessary services to maintain personal hygiene and grooming for two residents (Resident #12 and #18) out of two residents reviewed for activities of daily living. The facility census was 38. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 06/09/23 with a diagnosis of non-Alzheimer's dementia and traumatic brain injury. Resident #18 was cognitively impaired and dependent on staff for hygiene and grooming. Review of the plan of care dated 09/07/23 for Resident #18 revealed assistance needed for activities of daily living (ADLs) related to cognitive impairment and dementia. Interventions included staff to assist as needed with daily hygiene and assist with showering resident per facility policy weekly. Interview on 11/20/23 at 1:11 P.M. with Resident #18's legal guardian revealed Resident #18's finger nails needed to be cleaned and trimmed. Observation of Resident #18's finger nails…

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, interview and facility policy review, the facility failed to have a comprehensive system in place for communication and collaboration with the dialysis facility. This affected one resident (Resident #97) of one resident reviewed for dialysis. The facility census was 38 residents. Findings include: Review of Resident #97's medical record revealed an admission date of 10/17/23 and diagnoses including type two diabetes, osteomyelitis, chronic kidney disease, dependence on renal dialysis, depression and glaucoma. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed it was still in progress. Review of Resident #97's physician's orders revealed an order dated 10/31/23 for Monday/Wednesday/Friday dialysis resident to be up front of [sister facility next door] for 5:30 A.M. pick up and an order dated 11/01/23 for dialysis at [facility name]. Review of Resident #97's October 2023 and November 2023 Medication Administration Records (MARs) and Treatment Administration…

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, interview and policy review, the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. The facility also failed to document a rationale for extending an as-needed (PRN) anti-anxiety medication. This affected two residents (Residents #21 and #24) out of five residents reviewed for unnecessary medications. The facility census was 38 residents. Findings Include: 1. Review of Resident #24's medical record revealed an admission date of 10/07/16 and diagnoses including depression, dementia, hypertension and COVID-19. Review of a plan of care dated 10/19/16 for Resident #24's potential for adverse side effects of psychotropic drug use - anti-depressant daily for depression revealed interventions of document side effects of medication: dry mouth, dizziness, drowsiness, constipation, extrapyramidal symptoms, seizures and notify physician of any changes; observe and document any…

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

Based on observation and interview the facility did not ensure a working call system was in place for Resident #17. This affected one resident (Resident #17) of one resident whose call light was not working. The facility census was 38. Findings include: Observation on 11/21/23 at 10:09 A.M. of a beeping noise. Interview at this time with the Administrator when asked about the call lights lighting up outside of the residents' rooms and she stated she did not know what the noise was. The Administrator then went to get Director for Maintenance (DOM) #256. Interview on 11/21/23 at 10:10 A.M. with DOM #256 revealed call lights lit up outside the residents' room and stated he could pull the call light in Resident #17's room. Observation at this time of DOM #256 pull the call light in Resident #17's room and it did not light up outside of the resident's room. DOM #256 verified the observation. Observation on 11/21/23 at 10:13 A.M. with DOM #256 of the call light board at the nurse's station revealed the light did not light on the call light board. At this time DOM #256 verified the…

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

Based on record review and interview, the facility failed to develop a care plan for antipsychotic use for Resident #34. This affected one (#34) of three residents reviewed. The census was 39. Findings include: Review of the open medical record for Resident #34 (Alleged Perpetrator) revealed an admission date of 09/09/22 and re-admission date of 10/30/23. Diagnoses included paranoid schizophrenia, altered mental status, hypertension, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of the annual Minimum Data Set (MDS) Assessment, dated 09/21/23, revealed Resident #34 had severely impaired cognition. The assessment indicated Resident #34 had physical and verbal behaviors directed toward others during the seven-day lookback period, which put others at significant risk of physical injury and significantly disrupted the care or living environment. The assessment indicated Resident #34's behaviors were worsening. Review of the physician's orders for November 2023 identified orders for Haloperidol (an antipsychotic medication) 10 milligrams (mg)…

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

Based on record review and interview, the facility failed to ensure orders for antipsychotic medications to be administered as needed (PRN) were limited to 14 days for Resident #34. This affected one (#34) of three residents reviewed. The census was 39. Findings include: Review of the open medical record for Resident #34 (Alleged Perpetrator) revealed an admission date of 09/09/22. Diagnoses included paranoid schizophrenia, altered mental status, hypertension, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of the annual Minimum Data Set (MDS) Assessment, dated 09/21/23, revealed Resident #34 had severely impaired cognition. The assessment indicated Resident #34 had physical and verbal behaviors directed toward others during the seven-day lookback period, which put others at significant risk of physical injury and significantly disrupted the care or living environment. The assessment indicated Resident #34's behaviors were worsening. Review of the progress note dated 09/28/23 at 1:28 P.M. revealed Resident #34 hit another resident in the face…

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

Based on record review and interview, the facility failed to ensure Resident #33 and Resident #34's medical record was accurate and complete. This affected two residents (Resident #33 and Resident #34) of three residents reviewed for medical records. Findings include: 1. Review of the open medical record for Resident #34 revealed an admission date of 09/09/22 and re-admission date of 10/30/23. Diagnoses included paranoid schizophrenia, altered mental status, hypertension, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of the annual Minimum Data Set (MDS) Assessment, dated 09/21/23, revealed Resident #34 had severely impaired cognition. The assessment indicated Resident #34 had physical and verbal behaviors directed toward others during the seven-day lookback period, which put others at significant risk of physical injury and significantly disrupted the care or living environment. The assessment indicated Resident #34's behaviors were worsening. Review of the physician's orders for November 2023 identified orders for Haloperidol (an…

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

Based on interview and review of personnel files, the facility failed to have evidence State Tested Nurse Aides (STNA) had annual performance reviews for three STNA's (#315, #417 and #461). This had the potential to affect all 44 residents. Findings include: Review of the personnel records revealed STNA #315 who was hired on 04/21/10, STNA #417 who was hired on 12/05/17 and STNA #461 who was hired on 01/08/19 had no evidence performance reviews had been completed. Interview with Human Resource Director #444 on 07/20/21 at 2:00 P.M. verified the facility had no evidence of annual performance reviews.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of Centers for Disease Control (CDC) Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 04/27/21, the facility failed to provide adequate care and positioning of Resident #18's urinary catheter drainage tubing to prevent infection. This affected one resident (Resident #94) of three residents (Resident's #6, #8 and #94) reviewed for indwelling urinary catheter use; the facility failed to provide adequate care of Resident #94's oxygen tubing to prevent contamination. This affected one resident (Resident #94) of two residents (Resident's #5 and #94) reviewed for oxygen. In addition, the facility failed to use proper infection control procedures to obtain the temperature of food for one resident (Resident #13) and failed to ensure one resident (Resident #10) followed proper infection control protocols after returning from leave of absence. This had the potential to affect all 44 residents residing in the…

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

Based on interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received no less than 12 hours of in-service education to ensure continued competence per year. This affected three of three STNA's (#315, #417 and #461) with the potential to affect all 44 residents. Findings include: Review of personnel files for STNA's #315, #417 and #461 lacked in-service records. Review of in-services revealed no times to identify how many minutes/hours the in-service took to be able to calculate if the STNA's met the 12 hours required. Interview with Human Resource Director #444 on 07/20/21 at 2:00 P.M. verified the in-service records lacked indication of how long each in-service lasted. A spread sheet of in-services for 2021 was provided and one hour was given for each in-service. Further interview with the Human Resource Director #444 verified STNA #461 was not on the spread sheet at all.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of resident funds and policy, the facility failed to notify each resident that receives Medicaid benefits when the amount in the account reached $200.00 less than the resource limit and failed to disperse funds within 30 days of a resident's death. This affected ten residents (Resident's #9, #11, #22, #23, #24, #25, #29, #30, #38 and #39) of 32 resident accounts managed by the facility and one (Resident #47) of two (Resident's #47 and #48) residents that expired. The facility census was 44. Findings include: Review of the resident funds revealed ten residents (Resident's #9, #11, #22, #23, #24, #25, #29, #30, #38 and #39) of 32 accounts managed by the facility had a balance greater than $3,000.00. All these residents were Medicaid recipients. Review of the spend down notices revealed Resident #30 was sent a letter on [DATE] and Resident #22 was sent letters monthly since February 2021 indicating the failure to spend down monies could result in the loss of Medicaid benefits. Review of…

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

Based on interview, review of the medical record and review of beneficiary notices, the facility failed to inform residents/representatives orally and in writing of changes in services. This affected two residents (Resident's #23 and #27) of three residents (Resident's #23, #27 and #46) reviewed for Notices of Medicare Non-Coverage (NOMNC). The facility census was 44. Findings include: Review of the medical record revealed Resident #23 was discontinued from skilled therapy but would remain in the facility. There was no NOMNC or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) provided to the resident/representative. Review of the NOMNC indicated Resident #27 was discontinued from skilled services on 06/03/21. The NOMNC did not have the provider contact information, the skilled service(s) the resident was cut from and lacked the Quality Improvement Organization name and toll-free number to appeal. Also, the signature portion of the form was signed by the administrator on 06/01/21 indicating he went over the cut via phone. There was no documented evidence…

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, interview and policy review, the facility failed to maintain Resident #94's dignity by not providing a urinary catheter drainage bag cover and Resident #41 for not providing preferred colostomy supplies. This affected two residents (Residents #94 and #41) of three residents reviewed. The facility census was 44. Findings include: 1. Observation of Resident #94 on 07/13/21 at 12:30 P.M. revealed the resident in her room, lying down in bed. The resident had two visitors at her bedside. Resident #94's urinary catheter drainage bag was attached to the bedside and approximately one-third full of urine. The urinary drainage bag was uncovered without a privacy bag. Observation of Resident #94 on 07/13/21 at 12:43 P.M. with certified nurse assistant (CNA) #484 revealed resident had a urinary catheter drainage bag that was not covered with a privacy bag. CNA #484 indicated she had only been working at the facility for two weeks and had not been taught about covering the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide Resident #24 with nail care and feed him according to speech therapy recommendations for safe swallowing. This affected one (Resident #24) of seven (Resident's #8, #14, #21, #24, #41, #42 and #144) reviewed for activities of daily living. The facility census was 44. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including aphasia, dysphagia, schizoaffective disorder, dementia, heart failure, cardiac pacemaker, impulse disorder, atrial fibrillation, reflux, chronic pulmonary edema, major depressive disorder, hypertension, hyperlipidemia, atherosclerotic heart disease, epilepsy, and cerebral infarction. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he was moderately cognitively impaired, displayed no behaviors and required the total dependence of one staff for eating and the total dependence of two plus staff 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 observation, record review, interview and policy review, the facility failed to ensure skin assessments and documentation accurately reflected the status of resident's non-pressure wounds and pressure wounds. This affected two (Resident's #8 and #42) of three (Resident's #8, #25 and #42) reviewed for pressure wounds. The facility census was 44. Findings include: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, hypertension, type two diabetes mellitus, moderate protein-calorie malnutrition, depression, and anxiety. A Braden Scale for Predicting Pressure Ulcer Risk was conducted on [DATE] indicated Resident #42 was at low risk for skin impairment. Review of the progress note dated [DATE] indicated Resident #42 arrived at the facility with skin dry and intact. Review of the entry Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #42 was severely cognitively impaired with a BIMS (brief interview for mental status) score…

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, interview and record review, the facility failed to provide an ordered treatment for Resident #24 to increase range of motion/mobility or prevent further decrease in range of motion/mobility. This affected one resident reviewed for range of motion/positioning of 44 residents in the facility. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including aphasia, dysphagia, schizoaffective disorder, dementia, heart failure, cardiac pacemaker, impulse disorder, atrial fibrillation, reflux, chronic pulmonary edema, major depressive disorder, hypertension, hyperlipidemia, atherosclerotic heart disease, epilepsy, and cerebral infarction. Review of the physician orders dated 05/03/21 revealed the resident was to wear a left resting hand splint daily for three hours. The nursing staff was to don the splint at breakfast time and doff the splint at lunch time with intermittent skin checks. Review of the Minimum Data Set (MDS) 3.0…

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 and interview, the facility failed to ensure Resident #6 was provided with timely incontinence care. This affected one resident (Resident #6) of four residents (Resident's #6, #195, #15 and #8) reviewed for incontinence care and one resident (Resident #6) of four residents (Resident's #8, #6, #94 and #42) reviewed for catheter (sterile tube inserted into the bladder to drain urine) care. The facility census was 44. Findings include: Review of Resident #6's medical records revealed an admission date of 03/01/21 with diagnosis including muscle weakness, lupus, and blindness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance with toileting and personal care. Interventions included provide incontinence care as needed. Review of the physician orders for June 2021 revealed the resident was to receive catheter care every shift and as needed and irrigation of the catheter with normal saline as…

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 record review, the facility failed to ensure the physician/prescriber acted upon pharmacy identified irregularities for Resident #6. This affected one of six residents (Resident's #5, #6, #14, #27, #42 and #96) reviewed for unnecessary medications. The facility census was 44. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including anemia, legally blind, diabetes with neuropathy, adjustment disorder, rheumatoid arthritis, hypertension, systemic lupus, heart failure, atherosclerotic heart disease, major depressive disorder, and the presence of a cardiac defibrillator. Review of the pharmacy recommendation dated 07/13/21 indicated Duloxetine (a selective serotonin and norepinephrine reuptake inhibitors (SNRI) was on backorder and asked if it would be appropriate to change it to Cymbalta (a drug in the same class). On 07/19/21 the Director of Nursing (DON) #402 marked no changes and signed the form in the area…

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 policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 46 out of 46 residents who ate meals from the facility's kitchen. Findings include: Observations during the initial tour of the kitchen on 03/25/19 from 9:06 A.M. to 9:45 A.M. with interim Dietary Manager (DM) #100 revealed the milk cooler had dried milk and food residue on the bottom, food residue and splatter on plate warmer, food crumbs on shelf underneath the prep table and the floor was dirty especially around corners of the baseboards where small piles of dirt and a dried tomato peel was found near the walk-in refrigerator door. Interview with DM #100 on 03/25/19 at 9:45 A.M. verified the kitchen sanitation issues. Review of Sanitation policy (undated) revealed that all work surfaces will be cleaned and sanitized.

Based on observation, interview, policy review, and record review, the facility failed to dispose of garbage properly. This had the potential to affect all 46 residents residing in the facility. Findings include: Observation was conducted on 3/25/19 at 2:48 P.M. with Interim Dietary Manager #100 of the dumpster area located outside the delivery door to the kitchen revealed two dumpsters. The area around both dumpsters had debris around them with dirty gloves, a mattress with a slash in it and used styrofoam cups. Interview and verification were conducted on 3/25/19 at 2:48 P.M. with Interim Dietary Manager #100, she walked out to the dumpster with this surveyor and verified the debris that was around the dumpster area. Review of the facility policy entitled Environment dated May 2014 revealed that the Food Services Director will insure that all trash is properly disposed in external receptacles and that the area is free of debris.

Based on interview, observation, and policy review the facility failed to maintain comfortable temperatures throughout the facility. This affected one of 46 residents interviewed regarding ambient temperatures and comfort levels (Resident #4). Findings include: Interview on 3/25/19 at 10:30 A.M. with Resident #4 revealed that he was cold and wanted a blanket. Observations at the time of the interview revealed that Resident #4 was fully dressed lying in bed with a jacket covering him up. At the time of the observation, Activity Assistant #101 and State Tested Nurse Aide (STNA) #102 verified the room was cold and that rooms did not have individual thermostats to adjust temperatures. Staff got a blanket for Resident #4. Observations of ambient temperatures taken with a laser thermometer provided by the Maintenance Director #103 on 03/26/19 at 9:35 A.M. revealed the room was 58 degrees Fahrenheit (F) towards the exterior wall where Resident #4's bed was positioned. The temperature against the interior wall revealed a temperature of 63 degrees F. A review of the facility policy 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.

Based on observation and staff interview the facility failed to ensure medications were secured when left unattended. This had the potential to affect the nine residents (Residents#7, #13, #14, #18, #29, #33, #37, #142, and #144) who resided on the secured dementia unit who were both cognitively impaired and independently mobile. Findings include: On 03/27/19 at 9:44 A.M. the surveyor was walking toward the front hall of the secured dementia memory support unit and observed a medication cart unlocked and unattended near the nurses station. The director of nursing (DON) #104 entered the facility secured dementia memory support unit and verified that the cart was unlocked. All residents who resided on the unit were cognitively impaired. Residents#7, #13, #14, #18, #29, #33, #37, #142, and #144 were cognitively impaired and independently mobile. The above was verified with the DON at the time of observation.