Hudson Springs Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to provide timely assistance to residents who were dependent on staff for activities daily living with incontinence care. This affected one (Resident #25) of three residents reviewed for incontinence care. The facility census was 69. Findings include: Review of the medical record for Resident #25 revealed an admission date 05/18/24. Diagnoses included morbid obesity, major depression, anxiety, chronic pain, lymphedema, urinary retention, and chronic kidney disease stage III. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and was dependent on staff for toileting hygiene, was always incontinent of bowel, and had a indwelling catheter. Review of Resident #25's care plan revealed she had deficit in self-care performance related to morbid obesity and pulmonary disease. Interventions included Resident #25 was totally dependent on two staff for toilet use and…

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

Based on record review and interview, the facility failed to ensure respiratory treatments were administered and performed as ordered. This affected one (Resident #38) of three residents reviewed for respiratory care. The facility census was 74. Findings include: Review of the medical record for Resident #38 revealed an admission date of 11/29/24 with diagnoses including chronic respiratory failure with hypoxia, Rett's Syndrome (rare neurological genetic disorder that causes severe muscle movement disability), cerebral palsy (condition that affects movement and posture, epilepsy, tracheostomy status, ileostomy status and gastrostomy status. Review of the physician's orders for Resident #38 revealed he had an order dated 01/17/25 for a chest vest (used to help break the cycle of excess mucus, lung infections and lung damage) to be applied twice daily, every 12 hours, at 6:00 A.M. and 6:00 P.M. He also had an order for Albuterol Sulfate Inhalation Nebulization Solution 0.083% (medication that relaxes airway muscles and increases air flow to the lungs), 3 milliliters via trach every 12…

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, policy review, diet order list review, and interview, the facility failed to store food in a sanitary manner. This had the potential to affect all residents who received food from the kitchen except Residents #19, #28 and #73 who were ordered nothing by mouth. The census was 75. Findings include: Observation on 12/10/24 at 12:45 P.M. during tour of the kitchen with Dietary Manager (DM) #1 revealed there was an opened 32-ounce cardboard jug of liquid eggs without an opened date, a two-quart plastic container of what appeared to be sausage links without a label or date and a two-quart plastic container of what appeared to be hash browns without a label or date in the walk-in refrigerator. There was an opened plastic bag of shredded cheese without an opened date, three opened and varying sizes bags of parmesan cheese without an opened date, an opened bag of hot dogs without an opened date, a plastic gallon bag of what appeared to be sliced deli meat without a label or date, an opened bag of tortillas without an open date, a sandwich plastic bag of what appeared to…

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

Based on observation, staff interview and review of facility policy, the facility failed to ensure dietary staff performed hand hygiene prior to handling food and beverage items. This had the potential to affect all residents who received food from the kitchen. The facility identified two residents (#53 and #63) as receiving nothing from the kitchen. The facility census was 65. Findings include: Observation on 08/13/24 from 4:25 P.M. to 5:43 P.M. of the dinner tray line revealed at 5:11 P.M., Dietary Aide (DA) #439 took the 200-hall cart out of the kitchen. DA #439 did not perform hand hygiene upon return to the kitchen at 5:13 P.M. DA #439 proceeded to restock a snack cart. Continued observation revealed at 5:27 P.M., [NAME] #447 took the 300-hall cart out of the kitchen. [NAME] #447 returned to the kitchen at 5:29 P.M., did not wash her hands, and proceeded to place plated food and beverages onto trays and then placed the trays into a food cart. Interview on 08/13/24 at 5:39 P.M. with Dietary Manager #444 confirmed DA #439 and [NAME] #447 should have washed their hands upon entry…

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 resident interview, observation, review of resident fund account records, staff interview and review of facility policy, the facility failed to ensure residents who had a financial account with the facility received quarterly statements as required. This affected five residents (#7, #31, #40, #48, and #57) of five residents reviewed for personal funds. The facility census was 65. Findings include: Interview on 08/12/24 at 11:14 A.M. with Resident #48 revealed she had a resident funds account at the facility. Resident #48 stated she had not received quarterly statements from the facility to show her account activity. Review of resident fund account records for five residents (#7, #31, #40, #48, and #57) revealed no evidence quarterly statements had been given over the past year to the resident and/or resident representative. Interview on 08/14/24 at 2:16 P.M. with Administrative Assistant (AA) #409 confirmed there was no evidence quarterly statements for Residents #7, #31, #40, #48, and #57 had been given to the resident and/or resident representative. AA #409 stated 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 review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report and staff interview, the facility failed to ensure MDS assessments were submitted in a timely manner. This affected 11 residents (#7, #9, #13, #15, #21 #23, #24, #33, #39, #41, and #48) of 23 residents reviewed for MDS submission. The facility census was 65. Findings include: Review of the iQIES MDS Final Validation Report submitted on 08/09/24 at 2:22 P.M. revealed each of the following resident's MDS assessments were submitted more that 14 days late: • Resident #7's quarterly MDS assessment dated [DATE] • Resident #9's quarterly MDS assessment dated [DATE] • Resident #13's quarterly MDS assessment dated [DATE] • Resident #15's comprehensive MDS assessment dated [DATE] • Resident #21's quarterly MDS assessment dated [DATE] • Resident #23's quarterly MDS assessment dated [DATE] • Resident #24's quarterly MDS assessment dated [DATE] • Resident #33's quarterly MDS assessment dated [DATE]…

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

Based on observation, resident interviews, staff interviews, review of staff schedules and punch detail, review of Resident Council meeting minutes and review of the facility assessment, the facility failed to have sufficient staff to meet the acuity needs of each resident. This affected two (#57 and #29) of two residents reviewed for staffing with the potential to affect all 41 residents residing on the 100 and 200 halls. The facility census was 65. Findings include 1. Interview on 08/14/24 at 9:20 A.M. with Registered Nurse Supervisor (RNS) #405 and State Tested Nursing Assistant (STNA) #424 revealed there was one aide for 19 residents on the 100 hall and one aide for 22 residents on the 200 hall. RNS #495 and STNA #424 stated a third, unidentified, aide was assigned to the 100/200 halls but had been sent out with a resident for an appointment. STNA #424 stated showers were not being completed as scheduled but did not provide any specific resident who had not received care. RNS #405 stated she had to deal with staffing for an hour before she could start her medication pass this…

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

Based on observation, staff interviews, review of the facility menu, review of the dietary spreadsheet and review of facility policy, the facility failed to ensure the spreadsheet was followed for residents on a mechanically altered diet. This affected eight (#5, #7, #13, #29, #32, #46, #59 and #76) of eight residents identified by the facility as being on a mechanically altered diet. The facility census was 65. Findings include: Review of the menu for dinner service on 08/13/24 revealed the meal consisted of baked fish, tartar sauce, boiled red potatoes with parsley, creamed spinach and strawberry trifle. Review of dietary spreadsheet for dinner service on 08/13/24 revealed mechanical soft diets were to receive two ounces of baked fish with one ounce of broth or sauce, one tablespoon of mayonnaise (instead of tartar sauce), boiled white potatoes (in place of boiled red potatoes with parsley), creamed spinach and strawberry trifle. Observations on 08/13/24 between 4:25 P.M. and 5:43 P.M. revealed all residents received the same food items of fish with no broth, red potatoes 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, resident interview and staff interview, the facility failed to ensure residents were not left in their rooms without visual or audio stimulation. This affected one resident (#62) of three residents reviewed for preferences. The facility census was 65. Findings include: Review of Resident #62's medical records revealed an admission date of 05/08/24. Diagnoses included stroke, muscle weakness and mobility abnormalities. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition and required partial assistance with personal hygiene and grooming. Observation on 08/12/24 at 10:18 A.M. revealed Resident #62 was in bed facing a blank wall. A television was observed on the opposite side of Resident #62's room that was not on. Interview with Resident #62 at time of observation revealed he was unable to turn to his left side to look at the television and stated he would at least like the television on to listen to. Concurrent interview with State Tested…

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 review of beneficiary notices and staff interview, the facility failed to ensure the appropriate beneficiary notices were provided at the end of Medicare services and failed to ensure beneficiary notices were provided timely. This affected three residents (#1, #47, and #169) of three residents reviewed for beneficiary notices. The facility census was 65. Findings include: 1. Review of the beneficiary notice list revealed Resident #1 discharged from Medicare services on 06/09/24 and remained in the facility. Review of the notices provided to Resident #1 revealed a Notice of Medicare Non-Coverage (NOMNC) was provided on 06/06/24. There was no evidence Resident #1 was provided the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). 2. Review of the beneficiary notice list revealed Resident #47 discharged from Medicare services on 07/05/24 and remained in the facility. Review of the notices provided to Resident #47 revealed a NOMNC was provided on 07/02/24. The was no evidence Resident #47 was…

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 staff interview and review of personnel files, the facility failed to ensure Nurse Aide Registry (NAR) checks were completed on employees upon hire. This had the potential to affect all resident residing in the facility. The facility census was 65. Findings include: 1. Review of Dietary Manager (DM) #444's personnel file revealed a hire date of 02/01/24. Further review revealed no evidence a NAR check was completed. 2. Review of State Tested Nursing Assistant (STNA) #476's personnel file revealed a hire date of 07/30/24. Further review revealed no evidence a NAR check was completed. 3. Review of STNA # 478's personnel file revealed a hire date of 08/05/24. Further review revealed no evidence a NAR check was completed. Interview on 08/21/24 at 9:42 A.M. with Human Resources (HR) #403 revealed he had recently assumed the HR role. HR #403 stated he was unaware he was to check all employees against the NAR. HR #403 confirmed the facility had no evidence DM #444, STNA # 476 and STNA #478 had been checked on the NAR prior to employment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed. This affected three residents (#24, #52, and #66) of 23 residents reviewed for accuracy of assessments. The facility census was 65. Findings include: 1. Review of the closed medical record for Resident #66 revealed an admission date of 06/04/24 and a discharge date of 06/25/24. Diagnoses included Nontraumatic subacute subdural hemorrhage, dementia, hypertension, pelvic and spinal fracture, muscle weakness and abnormalities of gait and mobility. Review of the discharge return not anticipated MDS assessment, dated 06/25/24, revealed Resident #66 had intact cognition and had a planned discharge to a short term general hospital. Review of the discharge summary completed on 06/25/24 at 12:59 P.M. revealed Resident #66 discharged on to assisted living (AL), accompanied by his son. Interview on 08/14/24 at 8:29 A.M. with MDS Nurse #423 verified the discharge MDS assessment…

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 medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure care plans were updated timely and care conferences were held. This affected two residents (#44 and #7) of two residents reviewed for care planning. The facility census was 65. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 05/18/24. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/24 revealed Resident #44 had intact cognition, had delusions, rejected care four to six days of the look back period and received antidepressants during the seven day look back period. Review of the physician orders for August 2024 revealed orders for Alprazolam (anti-anxiety) oral tablet 0.5 milligrams (mg), Trazodone HCl (antidepressant) oral tablet 50 mg and Duloxetine HCl (antidepressant) oral capsule delayed…

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 medical record review, family interview, guardian interview, review of shower documentation and review of the facility policy and procedure, the facility failed to ensure showers were provided as scheduled for dependent residents. This affected two residents (#4 and #53) of seven residents reviewed for activities of daily living (ADLs). The facility census was 65. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 03/08/24. Diagnoses included encephalopathy, Alzheimer's disease, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had impaired cognition and was dependent on staff for showers and baths. Review of the care plan dated 08/08/24 revealed Resident #4 was at risk for self-care deficit for bathing, dressing, and feeding. Interventions included provide assistance with ADLs as needed. Review of shower sheet documentation revealed in June 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.

Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Intravenous (IV) dressings were changed per physician order and as needed. This affected one resident (#74) of one resident reviewed for IV dressings. The facility identified one resident with IV access. The facility census was 65. Findings include: Review of Resident #74's medical records revealed an admission date of 07/24/24. Diagnoses included osteomyelitis (bone infection) of the right ankle and foot and Methicillin Susceptible Staphylococcus Aureus (MRSA). Review of care plan dated 07/25/24 revealed Resident #74 was on IV medications related to osteomyelitis. Interventions included change IV dressing as ordered and indicated. Review of Resident #74's physician orders dated 08/06/24 revealed change IV dressing every seven days. Interview on 08/19/24 at 9:49 A.M. with Resident #74 revealed her IV dressing was to be changed every week and stated it was supposed to have been changed on 08/15/24. Resident #74 stated she has had IV lines 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 medical record review, staff interview, dialysis center staff interview and review of facility policy, the facility failed to ensure ongoing communication and collaboration with the dialysis center. This affected one (#24) of one resident identified by the facility as receiving dialysis. The facility census was 65. Findings include: Review of the medical record for Resident #24 revealed an admission date of 03/29/23. Diagnoses included end-stage renal disease (ESRD) and dependence on dialysis, cognitive communication deficit and hypertensive heart and chronic kidney disease without heart failure, with stage five chronic kidney disease, or end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/03/24, revealed Resident #24 was moderately cognitively impaired and exhibited disorganized behavior. Resident #24 was dependent on staff for toileting, showering and dressing and required substantial/maximal assistance from staff for mobility, including wheeling her manual…

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 medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure residents with a history of trauma were appropriately assessed to identify triggers to potentially minimize re-traumatization. This affected one resident (#48) of one resident reviewed for post-traumatic stress disorder (PTSD). The facility census was 65. Findings include: Review of medical record for Resident #48 revealed an admission date of [DATE]. Diagnoses included postconcussional syndrome, bipolar disorder, acute respiratory failure with hypoxia, acute kidney failure, type two diabetes and anxiety disorder. Review of modification of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #48 was cognitively intact and had not exhibited any signs or symptoms of delirium, psychosis, or rejection of care. Resident #48 was either was independent or required setup/clean up assistance with activities of daily living (ADLs). Review of a Trauma…

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 medical record review and staff interview, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed (PRN) anti-anxiety medication. The facility further failed to document the effectiveness of PRN medication use or the rationale for extended use past 14 days for the PRN anti-anxiety medication. This affected one resident (#44) of five residents reviewed for unnecessary medications. The facility census was 65. Findings include: Review of the medical record for Resident #44 revealed an admission date of 05/18/24. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/24, revealed Resident #44 had intact cognition, had delusions, rejected care four to six days of the look back period and received antidepressants during the seven day look back period. Review of the physician orders revealed orders 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, staff interview, Power of Attorney (POA) interview and medical record review, the facility failed to ensure residents were free of significant medication errors. This affected two residents (#17 and #28) of five residents reviewed for medication errors. The facility census was 65. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 06/13/24. Diagnoses included seizures and muscle weakness. Review of Minimum Data Set (MDS) assessment, dated 06/20/24, revealed Resident #28 had intact cognition. Review of Resident #28's care plan, dated 06/21/24, revealed the resident was at risk for seizures. Interventions included administer medications as ordered. Review of the physician orders revealed Resident #28 was ordered Depakote (anti-seizure medication) 250 milligrams (mg) once a day and Depakote 500 mg once a day for a total of 750 mg in the morning, once a day. Review of progress note, dated 08/13/24 timed 10:45 A.M. and authored by the Director of Nursing (DON), revealed the nurse reported that Resident #28 received 1250 mg 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 resident interview, observation, review of the dietary meal ticket, staff interview and medical record review, the facility failed to ensure resident food preferences were honored. This affected one resident (#74) of two residents reviewed for food preferences. The facility census was 65. Findings include: Review of the medical record for Resident #74 revealed an admission date of 07/24/24. Diagnoses included acute osteomyelitis (bone infection) of the right ankle and foot, methicillin susceptible staphylococcus aureus (MRSA) infection, non-pressure chronic ulcer of right lower leg with fat layer exposed, hypertension, hyperlipidemia and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 07/30/24, revealed Resident #74 had intact cognition and was independent with eating. Interview on 08/12/24 at 2:20 P.M. with Resident #74 revealed during her first week of admission, she spoke with the dietitian, the former Director of Nursing (DON) and Dietary Manager (DM) #444 regarding her diabetic diet and food preferences. Resident #74 stated she asked 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, staff interview, family interview, medical record review and review of facility policy, the facility failed to ensure appropriate personal protective equipment (PPE) was donned prior to providing care to a resident on Enhanced Barrier Precautions (EBP) and further failed to ensure contact precautions were implemented timely for a resident identified with a transmissable infection. This affected two resident (#4 and #74) of two residents reviewed for infection control. The facility census was 65. Findings include: 1. Review of Resident #74's medical records revealed an admission date of 07/24/24. Diagnoses included osteomyelitis (bone infection) of the right ankle and foot and Methicllin Susceptible Staphylococcus Aureus (MRSA). Review of the care plan dated 07/25/24 revealed Resident #74 required enhanced barrier precautions (EBP) related to risk for infections related to indwelling medical device and a wound. Interventions included to don appropriate personal protective equipment (PPE)…

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 medical record review, staff interview and review of the facility policy, the facility failed to ensure influenza and pneumococcal vaccinations were offered to all residents. This affected one resident (#4) of five residents reviewed for immunizations. The facility census was 65. Findings include: Review of the medical record for Resident #4 revealed an admission date of 03/08/24. Diagnoses included encephalopathy, Alzheimer's disease and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the quarterly MDS assessment, dated 07/29/24, revealed Resident #4 had impaired cognition, had no behaviors, and was dependent on staff for toileting hygiene. Further review of the medical record revealed no evidence Resident #4 was offered or received influenza or pneumococcal vaccinations. Interview on 08/20/24 at 3:42 P.M. with the interim Director of Nursing (DON) verified the facility had no evidence Resident #4 was offered or received influenza or pneumococcal vaccinations. Review of the facility policy titled Pneumococcal Vaccine, revised October 2019,…

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, interview, and review of the Local Health Department (LHD) information, the facility failed to ensure proper screening and monitoring of infections were in place to prevent development and transmission of Carbapenem Resistant Acinetobacter Baumanii (CRAB). This affected one resident (#47) of how four residents reviewed for infection control and had the potential to affect all 72 residents residing in the facility. Findings include: Review of the infection control log for May 2023, June 2023, and July 2023 revealed one case of Carbapenemase Producing Organisms (CPO). On 06/16/23 Resident #47 was noted to have CPO. Review of the medical record for Resident #47 revealed an admission date of 03/16/18 with diagnoses including sacral spina bifida without hydrocephalus, anxiety disorder, major depressive disorder, paraplegia, insomnia, anemia, neuromuscular dysfunction of bladder, history of coronavirus disease (COVID-19), pressure ulcer of right buttock, stage IV (full thickness tissue loss with exposed bone, tendon, or muscle), colostomy, and type II diabetes…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure medications were administered timely according to physician orders. This affected one resident (#75) out of three residents reviewed for medication administration. The facility census was 72. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date of 06/28/23 and a discharge date of 07/05/23. Diagnoses included seizures, bipolar disorder, asthma, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), acute pyelonephritis, anxiety disorder, old myocardial infarction, history of transient ischemic attack (TIA), and tobacco use. Review of Resident #75's physician orders revealed an order for Atorvastatin 40 milligram (mg) (statin to treat high cholesterol) once a day at 7:00 P.M. to 11:00 P.M., Diphenoxylate-Atropine tablet 2.5 - 0.025 mg (medication to treat diarrhea) give two tablets four times 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 Resident #75 was free from significant medication errors when the resident did not receive seizure medications. This affected one resident (#75) out of three residents reviewed for medication administration. The facility census was 72. Findings included: Review of the closed medical record for Resident #75 revealed an admission date of 06/28/23 and a discharge date of 07/05/23. Diagnoses included seizures, bipolar disorder, asthma urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), acute pyelonephritis, anxiety disorder, old myocardial infarction, history of transient ischemic attack (TIA), and tobacco use. Review of Resident #75's physician orders revealed an order for Carbamazepine extended release (ER) tablet 200 milligram (mg) to be given twice a day for seizures and Levetiracetam 205 mg to be given two times a day for seizures. Review of Resident #75's medication administration records (MAR) for June 2023 revealed Carbamazepine ER tablet 200 mg and…

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

Based on record review of the facility medication storage policy, the manufacturer's instructions for use for insulin, interviews and observations the facility failed to ensure medications were appropriately labeled and dated once opened. This affected nine residents (Residents #14, #21, #27, #47, #48, #49, #55, #256 and #257) on two of two medication carts observed in the facility. The facility census was 59. Findings included: Observation on 04/20/22 at 4:02 P.M. of the 300-hall medication storage cart revealed one Humalog (insulin ) pen for Resident #55 was opened without a date on it of when it was opened and there was no expiration date per manufacturer's guidelines on it. An Aprida (insulin) pen for Resident #256 was opened and without a date it was opened and without an expiration date per manufacturer's guidelines on it. One bottle of Dorzolamide HCL opthalmic solution and Timolol Maleate ophthalmic solution for Resident #257 were both open and without a date of when those were opened and without a use by date. At the time of the observation, LPN #520 confirmed the findings…

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.