Jan Frances Care Center

Based on observation, record review, and interview, the facility failed to ensure residents received showers as scheduled for two (#3 and #6) of six residents reviewed for activities of daily living. The ADON reported 32 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included non-traumatic brain dysfunction and metabolic encephalopathy. Resident #3's assessment, dated 02/20/24 documented cognition severly impaired and dependent on staff for bathing. Resident #3's shower sheets, provided by the Regional Director for February 2024, failed to document scheduled showers were performed for February 1st, 6th, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th, and 29th. Resident #3's shower sheets, provided by the Regional Director for March 2024, failed to document scheduled showers were performed for March 2nd, 5th, 7th, 9th, 16th, 19th, 21st and 23rd. Resident #3's care plan, dated 03/21/24, read in part, .Resident ADL functions: Assist x 1 staff with bathing . The facility's shower schedule, dated 03/26/24, documented resident #3's showers were scheduled on…

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

Based on observation, record review, and interview, the facility failed to maintain housekeeping services necessary to provide a clean, comfortable, and homelike environment. The Administrator reported 27 residents resided in the facility. Findings: The facility Housekeeping Service Policy, not dated, documented in part, .the facility shall be maintained in a clean, sanitary, orderly and attractive condition .daily room care shall be provided for each resident of the facility .deep cleaning of resident rooms will be performed on schedule .floors shall be maintained in clean and safe condition .housekeeping employees will be available to assist with spills and other accidents throughout the day . On 12/03/23 at 4:00 p.m., a tour of the facility was conducted. The floors in the lobby and all hallways were observed to be dirty with brownish-black spots observed in several areas, as well as trash and general debris on the floors. Resident rooms were observed to be cluttered with trash on the floors and cluttered bedside tables. No housekeeping staff was observed in the building. On…

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

Based on record review, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure: a. residents were not in common areas of the facility while wearing hospital gowns instead of appropriate clothing and foot coverings. b. grievances presented during resident council meetings were acted on or provide rationale as to why concerns could not be met. c. advanced directives (Do Not Resuscitate) were completed to include the required signatures. d. residents were free from neglect. e. resident assessments accurately reflected the resident status. f. a registered nurse reviewed, dated, signed, and transmitted the resident assessments to CMS when completed. g. baseline care plans were intimated and to provide a copy of the care plan to residents and/or their representatives. h. comprehensive care plans were developed which reflected the residents' current status. i. ensure…

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 employ the services of a qualified social worker on a full time basis. The Resident Census and Conditions of Residents form documented 53 resident resided in the facility. Findings: On 09/12/22 the corporate director provided a copy of the work schedules of all departments in the facility for review. The work schedules did not document a social worker. On 09/14/22 at 2:03 p.m., the SSD reported she was not a qualified social worker. The SSD stated she had been in the position since April of 2022. On 09/14/22 at 2:28 p.m., the administrator stated the facility had 138 licensed beds. The administrator stated the facility did not have a qualified social worker on staff. On 09/15/22 at 10:26 a.m., during the resident council meeting, residents in attendance reported they were not informed of physician appointments until shortly prior to the departure time. The residents stated they felt very rushed.

Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Resident Census and Conditions of Residents report documented 53 residents resided in the facility. Findings: Resident council minutes were reviewed for 12/01/21, 05/13/22, 06/23/22, and 08/18/22, which were all of the meeting minutes provided for review for the last 12 months. There was no documentation the residents' grievances had been acted upon. On 09/15/22 at 10:26 a.m., a resident council meeting was conducted in the activity room. Five residents attended the meeting. The ombudsman was present. No staff were present during the meeting. During the meeting, residents stated that they were not sure who the grievance official was but they thought it was the administrator. They stated none of the staff, including the administrator, ever responded to their concerns or gave a reason as to why the concerns were not addressed. On 09/15/22 at 12:00 p.m., the administrator was shown the grievances on 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 the facility failed to ensure a registered nurse (RN) coordinated, signed, and transmitted the resident assessments to CMS when completed for three (#2, #6, and #3) of three residents reviewed for assessments over 120 days. The Resident Census and Conditions of Residents form documented 53 residents who resided in the facility. Findings: 1. A quarterly assessment, dated 07/04/22, was reviewed as in progress for Res #2. The assessment administration page documented the MDS coordinator #1 signed the areas she completed. There was no RN signature for the assessment completion. 2. An annual assessment, dated 08/09/22, was reviewed as in process for Res #6. The assessment administration page documented the MDS coordinator #1 signed the areas she completed. There was no RN signature for the assessment completion. On 09/16/22 at 4:44 p.m., the MDS coordinator #1 stated the assessments were waiting on the signature from the corporate RN. MDS coordinator #1 stated the MDSs were completed just waiting on RN signature to transmit them. The MDS…

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, the facility failed to develop a comprehensive care plan which reflected the residents' current status for four, (#14, 51, 56, and #60) of 20 residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 53 residents who resided in the facility. Findings: 1. Res #51 had diagnoses which included chronic congestive heart failure, diabetes mellitus, and severe protein calorie malnutrition. An admission assessment, dated 05/28/22, documented Res #51 was severely impaired in cognition, required supervision to limited assistance with ADLs, and did not walk. On 06/22/22 a discharge return not anticipated assessment was completed. Res #51's clinical records were found to not document a comprehensive care plan. On 09/16/22 at 1:16 p.m., the MDS coordinator confirmed she had not developed a comprehensive care plan for Res #51. 2. An admission assessment for Res #56, dated 09/03/22, documented the resident was intact in cognition…

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, the facility failed to ensure residents' care plans were reviewed and updated and failed to ensure the resident and/or representative participation in the care plan process for three (#8, 24, and #34) of twenty residents whose records were reviewed for care planning. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: 1. Res #8 had diagnoses which included COVID-19, urinary tract infection, and schizophrenia. An admission assessment, dated 05/22/22, documented Res #8 was severely impaired in cognition and required supervision to limited assistance with ADLs and had not fallen. Nurse notes, dated 08/01/22, documented Res #8 complained of rib pain after a self reported fall in the dining room. The notes documented the staff were unaware the resident had fallen. The notes documented an X-ray was obtained for Res #8. The notes documented the residents ribs were negative for fracture. The notes documented the primary care provider and family were notified. The notes 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 observation, record review, and interview, the facility failed to ensure a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infections for three (#8, 45, and #56) of three residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents form documented six residents with indwelling or external catheters. Findings: A facility policy titled Catheter Care, Urinary, revised in 2010, read in parts, .2. Maintain an accurate record of the resident's daily output, per facility policy and procedure .The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given . 1. Resident #8 was admitted with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms and urinary tract infection. A care plan, dated 05/10/22, documented the resident had the potential for urinary complications related to having a suprapubic catheter. It documented a goal of the resident would not have signs and/or symptoms 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 observation, record review, and interview, the facility failed to ensure respiratory orders were followed for one (#5) of one resident sampled for respiratory care. The Resident Census and Conditions of Residents form documented eight residents who received respiratory treatments. Findings: Res #5 had diagnoses which included acute respiratory disease. A care plan, dated 01/20/22, documented Res #5 has episodes of shortness of breath and was at risk for respiratory distress/failure for COVID -19. The care plan did not document what liter O2 was to be administered. The care plan documented to apply O2 as ordered and encourage the resident to take slow deep breaths. Physician orders dated, 02/13/22, documented O2 at 2 liters via nasal cannula continuous to maintain O2 sat of 90%, record O2 sat every shift, and to document, date, and change the O2 tubing weekly on Sunday night shift. A review of the resident's TAR for July 2022, had six days where the resident's oxygen sat was not documented. There were two times the oxygen tubing was not documented as changed for July. 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 observation, record review, and interview, the facility failed to assess and monitor for pain every shift according to the plan of care for one (#40) of one resident reviewed for pain. The Resident Census and Conditions of Residents form documented 53 residents who resided in the facility. Findings: Res #40 had diagnoses which included chronic pain. Physician orders, dated 08/05/22, documented acetaminophen 325 mg give two every eight hours PRN mild pain or fever, Lyrica 100 mg one every day, and tramadol 50 mg give one every eight hours PRN for pain. A five day assessment, dated 08/09/22, documented the resident was intact with cognition, required extensive assistance with ADLs, and had pain he rated at a 10 which make it hard to sleep. The assessment documented the resident did not receive copious during the assessment period. A care plan, last reviewed 08/17/22. documented the resident had chronic pain, to administer medications as ordered, and to monitor and record any complaints of pain, location, frequency, effect on function, intensity, alleviating factors, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to perform ongoing assessment and oversight of the resident after dialysis treatments for one (#49) of one resident sampled for dialysis. The Resident Census and Conditions of Residents form documented two residents resided in the facility who required dialysis. Findings: Resident #49 had diagnoses which included end stage renal disease, peripheral vascular disease, hypertension, diabetes, and noncompliance with renal dialysis. A physician order, dated 08/16/22, documented the resident was to receive dialysis treatments Monday, Wednesday, and Friday at 6:40 a.m. A dialysis communication form, dated 08/17/22, documented no information under Resident Specific Post-Dialysis Information (completed by facility upon return). The document had spaces to record vital signs, pain, status of access graft/catheter upon return, if bruit/thrill present, if resident returned with any orders, if the resident was offered a meal upon return, medications…

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, the facility failed to monitor blood pressure before administering medications for one (#45) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents report documented 53 residents resided in the facility. Findings: Resident #45 was admitted with diagnoses which included congestive heart failure, hypertension, and end-stage renal disease. A care plan, dated 02/25/19, documented to administer medications as ordered and to evaluate, record, and report effectiveness and adverse side effects of medications. A physician's order, dated 01/20/22, documented to administer carvedilol 12.5 mg orally twice a day and isosorbide mononitrate 30 mg orally once a day for a diagnosis of hypertension. Both orders documented to hold the medication if the systolic blood pressure was less than 100 and/or the diastolic blood pressure was less than 60. The July 2022 MAR documented carvedilol 12.5 mg was administered on 07/15/22, 07/16/22, and 07/17/22 without documentation of a blood pressure reading.…

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, the facility failed to monitor for behaviors and side effects related to psychotropic medications for five (#3, 5, 25, 34, and #40) of five residents reviewed for unnecessary psychotropic medications. The Resident Census and Conditions of Residents report documented 38 residents received psychotropic medications. Findings: 1. Resident #25 was admitted with diagnoses which included hydrocephalus, pseudobulbar affect, generalized anxiety disorder, visual hallucinations, and, psychotic disorder with delusions due to known physiological condition. An admission assessment, dated 04/12/22, documented the resident had disorganized thinking that changes in severity and behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). A physician's order, dated 06/13/22, documented to observe resident closely for significant side effects…

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, the facility failed to ensure a medication error rate below five percent for two (#14 and #42) of five residents observed during medication pass. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: An undated facility policy, titled Documentation of Medication Administration read in part, .Administration of medication must be documented immediately after (never before) it is given . An undated facility policy, titled Medication Errors and Drug Reactions read in part, .Report all medication errors and drug reactions immediately to the attending physician, Director of Nursing Service and Administrator . An undated facility policy, titled Self-Administration of Drugs read in parts, .the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications .In addition to general evaluation of decision-making capacity,…

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 failed to ensure expired supplies and medications were disposed of. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: On 09/16/22 at 8:19 a.m., a tour of the medication room was conducted. The following expired medications and supplies were observed in the medication room: - one opened 100 unit/1 ml insulin needle without safety mechanism - two opened exactamed 5 ml oral syringes - one Medtronic quick-set expired 06/2010 - one quarter full bottle of rubbing alcohol expired 05/2016 - one 22 g/1 inch BD angiocath IV catheter expired 10/2019 - one 18 g/1.16 inch BD insyte autoguard BC winged IV catheter expired 09/30/2020 - one silicone latex covered Foley catheter 24 fr 30 ml expired 10/12/2021 - one Dynarex IV administration set expired 01/27/2022 - one opened bottle Nutricia Pro-stat sugar free complete 30 fl oz bottle expired 03/03/2022 - one open tube of Zim's max freeze pro formula cold therapy cooling gel expired 06/2022 - one Medical Action Industries central line…

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 the person designated to serve as the DM had a current certification. The Resident Census and Conditions of Residents form documented 53 residents who resided in the facility with two resident who received tube feedings. Findings: The Association of Nutrition & Foodservice Professionals website documented CDM CFPP credential read in part, .you will also need to maintain it by completing and reporting continuing education as well as paying the annual certification fee .Certificants must comply with all recertification requirements to maintain use of the credential . On 09/15/22 at 10:10 a.m. the DM was asked if he was current with his dietary manager training. The DM stated he did not have a current certificate of training. He stated he let it lapse. On 09/16/22 at 11:25 a.m., the DM presented a certificate for certified Dietary Manager, dated 10/11/14. On 09/19/22 at 11:23 a.m., during a meeting with the administrator and the corporate director, the corporate director stated she was unaware of the requirement 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 and interview, the facility failed to provide food which was palatable and at a safe and appetizing temperature. The Resident Census and Conditions of Residents form identified 53 residents who resided in the facility. The corporate director, documented the facility did not have any residents who were NPO. Findings: 1. On 09/12/22 at 5:02 p.m., corn dogs were observed on the steam table. The corn dogs were observed to have been burnt and split open. On 09/12/22 at 5:13 p.m., an observation was made of 13 meals in disposable boxes which were sitting on an open cart in the hall way. The other meals were observed in a hot box on the hall. On 09/12/22 at 5:34 p.m., three meals were observed to have been brought out of the kitchen on an open cart and placed in the hall. One cover on one of the meals was observed to have not been on properly and the macaroni and cheese was not covered. On 09/12/22 at 5:37 p.m., hospitality aide #1 was observed to place the tray in the warmer. On 09/13/22 at 10:26 a.m., Res #23 stated the food was not good. She stated it was never hot…

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 food was prepared, stored, and distributed in a sanitary manner. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. The corporate director documented all residents receive food from the kitchen. Findings: 1. On 09/12/22 at 5:13 p.m., CNA #4 was observed while delivering meals to resident rooms. CNA #4 was observed to use the bed controller to sit the head of the bed up, then returned to cart for another meal, placed a drink on the meal tray, and delivered the meal to another resident room. The CNA was observe to serve meals to five resident rooms without performing hand hygiene. At 5:18 p.m. CNA #4 was observed to shut a resident door, returned to the food cart, pour a cup of coffee, pulled up his pants, and then delivered another meal without performing hygiene. At 5:23 p.m., CNA #4 was observed to use his right hand and push a resident in a wheel chair while he delivered a meal tray to separate…

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 residents' medical records were complete, readily accessible, and systematically organized for three, (#8, 56, and #152) of 20 residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 53 resident resided in the facility. Findings: 1. Resident #152 admitted to the facility on [DATE] with diagnoses including interstitial pulmonary disease, acute respiratory failure with hypercapnia, COPD, atherosclerotic heart disease, history of TIA and cerebral infarction, acute kidney failure, hydronephrosis with renal and ureteral calculus obstruction, muscle weakness, and dementia. An LTC -admission Assessment/Observation Documentation form, dated 08/22/22, had no resident observations or assessments documented. A MAR, dated 08/01/22 to 08/21/22, documented diclofenac 1% topical, apply two grams to affected area four times daily. There were no documented administrations of this medication. A respiratory flowsheet,…

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, the facility failed to ensure residents were not in common areas of the facility while wearing hospital gowns instead of appropriate clothing and foot coverings for one (#31) of one residents reviewed for dignity. The Residents Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: An undated facility policy, titled Loss of Personal Items Policy, read in parts, .In the event an item [sic] is lost or misplaced, the staff or president will report the loss to the administrator immediately .A complete survey of the facility will be make [sic] to locate the item if misplaced .In the even the item is not found and the resident so requests, the loss will be reported to the local police department . Resident #31 had diagnoses which included cerebral infarction, hemiplegia/hemiparesis affecting left non-dominant side, depression, and chronic pain. An admission MDS, dated [DATE], documented the resident was cognitively intact,…

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 advanced directives (Do Not Resuscitate) were completed to include the required signatures for one (#7) of one sampled resident who was reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 53 residents who resided in the facility. Findings: Res #7 had diagnoses which included cognitive communication deficit. A quarterly assessment, dated 08/13/22, documented the resident was moderately impaired with cognition and required limited assistance with most activities of daily living. Review of the medical record for Res #7 documented their code status as Do Not Resuscitate. The DNR form contained a printed name in the signature of POA and beside the printed name was documented gave verbal agree over phone and a phone number. The DNR was dated 04/07/20 and signed by two witnesses. The medical record did not contain any POA paperwork for Res #7. On 09/15/22 at 9:20 a.m. the BOM stated Res #7 had a POA who was supposed to bring in the POA paperwork to the facility. The BOM stated…

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, the facility failed to ensure resident assessments accurately reflected the resident status for one (#56) of 20 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: Res #56 had diagnoses which included diabetes mellitus. A physician order, dated 08/31/22, documented the facility was to administer Levemir (a long acting insulin) 60 units SQ twice daily. A physician order, dated 08/31/22, documented the facility was to administer Novolog (a short acting insulin) 25 units, SQ before meals. An MDS admission assessment, dated 09/03/22, documented Res #56 was intact in cognition and required limited to total assistance with ADLs. The assessment documented Res #56 had a diagnosis of diabetes mellitus. The assessment documented no insulin was administered during the assessment period. On 09/13/22 at 2:54 p.m., Res #56 was observed in her room sitting at the bedside. She stated she had to go the hospital recently due to the facility giving…

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, the facility failed to initiate a baseline care plan and provide a copy of the care plan to one (#60) of 20 residents whose records were reviewed. The new resident Roster/Sample Matrix documented seven residents were admitted in the previous 30 days. Findings: Res #60 had diagnoses which included orthopedic aftercare, pathological fracture, diabetes mellitus, and chronic kidney disease. A review of Res #60's admission orders documented the facility was to administer 14 different medications, three separate treatments, a diet order, and an order for physical therapy, occupational therapy, and speech therapy. On 09/14/22 at 9:12 a.m., Res #60 was observed sitting in a wheelchair in her room. Res #60 stated she did not receive a baseline care plan. She stated she was put in bed and left. On 09/15/22 at 12:47 p.m., the MDS coordinator reviewed Res #60's clinical records and stated the records did not document a baseline care plan was completed. The MDS coordinator stated when a resident was admitted and the initial assessment was done,…

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, the facility failed to ensure a resident's fall was investigated and steps to prevent recurrence of falls were initiated for one (#8) of one resident sampled for falls. The Corporate Director of Operations reported 41 residents fell in the previous six months. Findings: Res #8 had diagnoses which included COVID-19, urinary tract infection, and schizophrenia. An admission assessment, dated 05/22/22, documented Res #8 was severely impaired in cognition and required supervision to limited assistance with ADLs and had not fallen. Nurse notes, dated 08/01/22, documented Res #8 complained of rib pain after a self reported fall in the dining room. The notes documented the staff were unaware the resident had fallen. The notes documented an X-ray was obtained for Res #8. The notes documented the resident's ribs were negative for fracture. The notes documented the primary care provider and family were notified. The notes did not document steps to prevent recurrence of falls. A care plan, last reviewed on 08/28/22, documented Res #8 had…

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, the facility failed to ensure a resident's nutritional preference was accommodated and provide substitutions for food dislikes for one (#23) of four residents reviewed for food. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. The corporate director documented all residents receive food from the kitchen. Findings: Res #23 had diagnoses which included paraplegia, hypoglycemia, cognitive communication defect, GERD, and other specified disorders of teeth and supporting structures. A 5-day MDS assessment, dated 07/06/22, documented the resident was cognitively intact. On 09/16/22 at 11:13 a.m., Res #23 stated the facility did not bring other sides if she did not want what was served. She stated her dietary card documented she did eat fish but when she had told the staff in the past she did not want fish they did not provide her with a substitution. She stated she kept food in her personal freezer and would have to wait for staff to finish with everyone else before they would assist…

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.