Community Health Care Of Gore

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a significant change assessment was conducted after a resident was discharged from hospice services for 1 (#2) of 16 sampled residents reviewed for significant change assessments. The administrator identified 44 residents resided in the facility and three residents received hospice services. Findings: A facility policy titled facility's Comprehensive Assessment, revised 10/2023, read in part, Significant Change in Status Assessments (SCSA) - the SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and it's completion date depend on the date that the IDT determination was made that the resident had a significant change .a significant change is a major decline or improvement in a residence status. Resident #2 was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a level I PASARR was completed after a new mental health diagnosis for 1 (#3) of 5 sampled residents reviewed for PASARRs. The ADON identified 22 residents had a mental health diagnosis. Findings: Resident #3 was admitted on [DATE] with diagnoses which included cerebral infarction and dementia. Resident #3's electronic health record showed Resident #3 was diagnosed with bipolar disorder on 12/03/24. On 03/04/25 at 10:41 a.m., the MDS coordinator was asked about the level I PASARR completed for Resident #3 after a new diagnosis of bipolar on 12/03/24. The MDS coordinator stated there was not a PASARR completed after the new bipolar diagnosis and one should of been completed after the new diagnosis.

Based on record review and interview, the facility failed to perform a gradual dose reduction or document the rationale for not performing a gradual dose reduction of an antipsychotic medication for 1 (#27) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 22 residents with a mental health diagnoses. Findings: Resident #27 had diagnoses which included vascular dementia with other behavioral disturbance, aphasia following a stroke, major depressive disorder, and anxiety. A physician's order, dated 05/18/23, showed the resident was to receive Zyprexa (an antipsychotic medication) 5mg at bedtime for vascular dementia. A pharmacy recommendation, dated 05/07/24, showed the resident was on Zyprexa 5mg at bedtime and asked to consider a gradual dose reduction to Zyprexa 2.5mg at bedtime. The physician's response showed the resident had failed a prior gradual dose reduction. An annual assessment, dated 06/06/24, showed the resident was cognitively severely impaired (BIMS score 3), displayed no behaviors, and received and antipsychotic medication. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to offer dental services for 1 (#13) of 16 sampled residents reviewed for dental services offered. The administrator identified 44 residents resided in the center. Findings: On 03/03/25 at 3:30 p.m., Resident #13 was observed with broken and missing teeth. The facility's Dental Services policy and procedure, dated 12/06/23, read in part, [name of dental provider withheld] call our residents responsible party to agree they want services. This is part of a program with Medicaid. Resident #13 was admitted on [DATE], with diagnoses which included dysphagia following cerebral infarction and nocturnal enuresis. Resident #13's care plan, dated 01/25/24, showed Resident #13 required partial to moderate assistance X 1 staff with personal hygiene and oral care. Resident #13's care plan did not document they had broken or missing teeth or the need for dental services. Resident #13's annual assessment, dated 01/17/25, showed Resident #13's BIMS 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.

Based on observation and interview, the facility failed to maintain the ice machine in a sanitary manner. The dietary manager identified 44 residents who utilized ice from the kitchen. Findings: On 03/03/25 at 1:30 p.m., an observation of the ice machine was conducted with the dietary manager. There was a slimy black and brown substance in the crevices, along the edges, and around the pump of the water reservoir. On 03/03/25 at 1:30 p.m., the dietary manager stated there was something brownish black and slimy looking along the edges of the water reservoir. The dietary manager stated they cleaned the ice bin weekly, but did not know who cleaned the mechanical area of the ice machine. On 03/10/25 at 3:15 p.m., the administrator stated the ice machine should be on a regular cleaning schedule for the maintenance department to perform.

Based on record review and interview, the facility failed to ensure staff who conducted Covid-19 testing received the appropriate training. The administrator identified 47 residents resided in the facility. Findings: On 11/13/24 at 8:45 a.m., the social services director stated they and the activities assistant sometimes performed Covid-19 testing on the residents at the facility. They stated they did not remember being given training on proper infection control techniques or specimen collection. On 11/13/24 at 8:53 a.m., LPN #2 stated various employees conducted outbreak testing, including unlicensed activities staff. On 11/13/24 at 10:25 a.m., the DON stated social services/activities staff were sometimes used for outbreak testing. They stated that was how it was when they took over the DON position. On 11/13/24 at 12:36 p.m., the activities assistant stated they routinely helped test the residents for Covid-19. They stated they were unsure if they had ever received training on infection control or specimen collection. On 11/14/24 at 10:00 a.m., the DON stated they were unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's representative and the physician were notified of a fall for one (#1) of three sampled residents reviewed for falls. The administrator identified 47 residents resided in the facility. Findings: A facility policy titled Community Healthcare of [NAME] Policy and Procedure, revised 12/16/22, read in part, Assess resident, contact medical director, DON, ADON, Admin and emergency family contact. Resident #1 had diagnoses which included a history of falling and dementia. A nurse note, dated 08/16/24 at 10:42 p.m., documented Resident #1 was on alert charting related to a non-injury fall. An Investigation Report Statement, dated 08/21/24, documented Resident #1 fell on [DATE] at around 6:33 p.m. The report further documented LPN #1 did not contact the physician or the family at the time of the incident. On 11/13/24 at 10:25 a.m., the DON stated when Resident #1 fell on [DATE] LPN #1 did not notify the family or the physician. On 11/14/24…

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 assess a resident after a fall for one (#1) of three sampled residents reviewed for falls. The administrator identifed 47 residents resided in the facility. Findings: A facility policy titled Community Healthcare of [NAME] Policy and Procedure, revised 12/16/22, read in part, Neuro checks for falls with head injury and unwitnessed falls with possible head injury .Assess resident, contact medical director, DON, ADON, Admin and emergency family contact .Obtain vital signs, assess residents' orientation, level of consciousness, pupil size and reaction to light. Resident #1 had diagnoses which included a history of falling and dementia. A nurse note, dated 08/16/24 at 10:42 p.m., documented Resident #1 was on alert charting related to a non-injury fall. An Investigation Report Statement, dated 08/21/24, documented Resident #1 fell on [DATE] at around 6:33 p.m. The report further documented LPN #1 did not complete an assessment on Resident #1 after 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 investigate an allegation of abuse for two (#1 and #3) of three residents reviewed for allegations of abuse. The DON identified nine residents with allegations of abuse in the past six months. Findings: A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program read in parts .All allegations are thoroughly investigated .The individual conducting the investigation as a minimum: .f. interviews the resident (as medically appropriate) or the resident's representative; .i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly . 1. Resident #1 had diagnoses which included dementia, anxiety, depression, and acute respiratory failure. A quarterly assessment, dated 04/23/24, documented the resident was severely impaired cognitively and was dependent for most ADLs. An incident report/state reportable, dated 06/10/24, documented an allegation of abuse 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, record review, and interview, the facility failed to follow the menus for the residents. The administrator identified 50 residents who resided in the facility and ate meals prepared by the kitchen. Findings: A dietary menu documented for the residents' meal they were to have a philly steak sandwich, potato wedges, coleslaw, and cheesecake for desert. On 06/26/24 a meal service was observed. At 1:00 p.m. the surveyor asked for a test tray. The DM stated they did not have any more coleslaw or coconut cake. The staff stated four residents had received a salad and ice cream in place of the coleslaw and coconut cake. On 06/26/24 at 1:35 p.m., the DM stated to their knowledge they had never served cheesecake. The DM stated the evening menu had been changed because the staff forgot the thaw the meat. The DM stated they had substituted menu items a lot recently.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DON identified 46 resident residing in the facility who receive meals from the kitchen. Findings: On 11/08/23 at 9:22 a.m., an initial tour of the kitchen was conducted. [NAME] #1 was observed wearing a ball cap. The cooks hair was not contained under the cap. On 11/08/23 at 9:27 a.m., the following items in the refrigerator were observed: a. shredded cheese in a sealed bag not in the original container was not labeled or dated, b. a container with what appeared to be gravy had no label or date, c. a container of fruit cocktail with the lid not properly sealed, dated 11/01, d. a container of Tapioca pudding, dated 10/28, e. a container of chili, dated 11/4, f. several cartons of thickened liquids in the refrigerator not dated when opened, g. catsup not in the original container labeled and dated 11/2, and h. ranch dressing not in the original container labeled and dated 11/4 were observed in pitchers 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents did not experience resident to resident abuse for two (#9 and #147) of two residents sampled for abuse. The facility failed to ensure Res #30 did not touch or kiss Res #9 and #147. The DON reported the facility had two allegations of abuse in the last three months. The administrator identified 47 residents who resided in the facility. Findings: A facility policy titled Abuse and Neglect- Clinical Protocol, revised March 2018, read in part, .3. Sexual abuse is defined .as non-consensual sexual contact of any type with a resident . A facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, read in part, .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical…

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 allegations of abuse were reported to OSDH, the administrator, and the residents' representatives for two (#9 and #147) for alligations of abuse. The DON reported the facility had two allegations of abuse in the last three months. The administrator identified 47 residents who resided in the facility. Findings: A facility policy titledAbuse, Neglect, Exploitation and Misappropriation Prevetion Program, dated April 2021, read in part.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any alligation within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations . A facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, read in part, .3. Immediately is defined as: a. within two hours ofan alligation involving abuse or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to conduct a thorough investigation into an allegation of abuse for two (#9 and #147) of two residents reviewed for abuse. The DON reported the facility had two allegations of abuse in the last three months. The administrator identified 47 residents who resided in the facility. Findings: A facility policy titled Abuse and Neglect- Clinical Protocol, revised March 2018, read in part, .3. Sexual abuse is defined .as non-consensual sexual contact of any type with a resident . A facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevetion Program, revised April 2021, read in part.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegation within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations . A facility Abuse, Neglect, Exploitation or Misappropriation - Reporting…

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 obtain registry verification for one (CMA #1) of eight employee files reviewed for registry verification. The DON reported the facility had four CMAs. Findings: On [DATE] at 3:00 p.m., the employee file for CMA #1 was reviewed and documented the CMA's certification had expired [DATE]. On [DATE] at 3:23 p.m., the BOM stated CMA #1's certification expired on [DATE]. The BOM stated CMA #1 had up dated the class and sent off for the certification. The BOM was asked for proof the paper work for the certification was sent off. The BOM stated the CMA sent it in themselves and the facility did not have anything showing it had been done. The BOM stated since COVID they have had a grace period when a certification expired. On [DATE] at 3:54 p.m., the BOM stated the facility did not have any wavers for CNA or CMA to work with an expired certification. The [DATE] schedule documented the CMA worked 8 days without a current certification. On [DATE] at 8:58 a.m., 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 provide food that was palatable and at an appetizing temperature for the residents. The DON identified 46 resident residing in the facility who receive meals from the kitchen. Findings: 1. Res #2 had diagnoses which included diabetes mellitus, chronic kidney disease, and HTN. An annual assessment,dated 10/10/23, documented the resident was intact with cognition and required set up assistance with eating. On 11/09/23 at 1:42 p.m., Res #2 stated the food at the facility was not good. Res #2 stated it had gone down since the last DM retired. Res #2 stated they were served BBQ chicken and it could have been cooked more, potato salad, a green salad, and Texas toast. Res #2 stated she could get something different to eat but it still was not cooked well. Res #2 stated they were a diabetic and the kitchen served a lot of rice and noodles and they do not like and will not eat either of those. Res #2 stated yesterday she would call it juice from the vegetables was all over her plate under the other food. She 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 and interview, the facility failed to ensure infection control practices were followed during wound care for two (#23 and #9) of three sampled resident for pressure ulcers. The DON identified the facility had five residents with pressure ulcers who resided in the facility. Findings: A facility policy titled Wound Care, revised October 2010, read in part, .Use a disposable cloth (paper towel is adequate) to establish clean field on residents overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached .Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites .Pull gloves over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Discard disposable items into the designated container . 1. On 11/09/23 at 2:19 p.m., LPN #2 was observed to perform wound care for Res #23. The LPN had the supplies on a tray and entered the resident's room, placed the tray by the sink while they washed their hands. 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 record review, the facility failed to provide ABN notification for two (#9 and #41) of three residents who were reviewed for Medicare Part A services. The administrator identified 11 residents who were discharged from Medicare Part A with benefit days remaining in the past six months. Findings: Res #9 discharged from skilled services on 06/30/23 and stayed in the facility. The resident did not receive an ABN notice. Res #41 discharged from skilled services on 10/04/23 and stayed in the facility. The resident did not receive an ABN notice. On 11/09/23 at 11:44 a.m., the MDS coordinator stated an ABN notice form was not completed for the residents. They stated the form should have been completed for the residents.

Based on record review and interview, the facility failed to ensure assessments were submitted to CMS within 14 days of completion for three (#14, 29, #38 ) of 18 residents whose assessments were reviewed. The administrator identified 47 residents resided in the facility. Findings: 1. A quarterly assessment for Res #14, dated 10/04/23, was completed in the EHR program and documented the assessment was accepted. An MDS 3.0 NH Final Validation Report for the resident documented the quarterly assessment, dated 10/04/23, was rejected. 2. A quarterly assessment for Res #29, dated 10/03/23, was completed in the EHR program and documented the assessment was accepted. An MDS 3.0 NH Final Validation Report'' for the resident documented the quarterly assessment, dated 10/03/23, was rejected. 3. A discharge return not anticipated assessment for resident #38, dated 07/22/23, was completed in the EHR program and documented Export Ready. On 11/14/23 at 10:36 a.m., the MDS coordinator stated they did not know why the assessment for Res #38 had not been exported. The coordinator 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 record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for one (#20) of 18 sampled residents reviewed for care plans. The administrator identified 47 residents resided in the facility. Findings: Res #20 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, CHF, and pneumonia. There was no documentation a baseline care plan was developed. On 11/14/23 at 12:20 p.m., the MDS coordinator stated stated the nurses were supposed to do the 48 hour care plan on admission and they did not do one for Res #20.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician, assess, and intervene timely for one (#20) of one sampled resident reviewed for hospitalization. The DON identified 19 residents were sent to the hospital in the past three months. Findings: Res #20 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, CHF, and pneumonia. An admission assessment, dated 10/24/23, documented the resident was severely impaired with cognition and was dependent on staff for ADLs. A nurse note, dated 11/06/23 at 4:00 a.m., documented at approximately 4:00 a.m., the nurse was notified the resident had no urine output in the urinary catheter bag. The note documented the resident was moaning and had facial grimacing with every movement, and after attempt to flush the urinary catheter and being unsuccessful, the nurse and co-nurse replaced the catheter. The resident appeared to have some relief. The resident had approximately 400 cc of output. The note…

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 the physician was notified and interventions in place for weight loss) (act and maintain acceptable parameters of nutritional status) for one (#28) of one sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: Res #28 was admitted on [DATE] and had diagnoses which included cerebral infarction, chronic obstructive pulmonary disease, right bundle branch block, cardiac pacemaker, and atherosclerotic heart disease. A annual assessment, dated 09/29/23, documented the resident was cognitively intact and required minimal assistance with ADLs. A physician order, dated 09/12/22, documented Res #28 was to have a house supplements TID. A vital sign record, dated 05/03/23, documented the resident weighed 123.0 lbs. A vital sign record, dated 09/05/23, documented the resident weighed 110.2 lbs. (10% weight loss in four months) A vital sign…

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 for the need and risk of using bed rails for one (#13) of one sampled resident reviewed for bed rail usage. The CMS 671 form documented 47 residents resided at the facility. Res #13 was diagnoses which included anxiety, atrial fibrillation, rheumatoid arthritis, and chronic obstructive pulmonary disease. On 05/26/23 a bed rail consent was signed. A quarterly assessment, dated 09/09/23, documented the resident's cognition was intact and independent to minimal assistance with all ADLs. On 11/08/23 at 3:49 p.m., an observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. The EHR was reviewed and revealed no documentation related to a bed rail assessment. On 11/13/23 at 12:35 p.m., MDS Coordinator #1 stated they could not find a bed rail assessment.

Based on record review and interview, the facility failed to ensure a diagnosis for the use of a psychotropic medication for one #(39) of five sampled residents reviewed for unnecessary medications. The DON reported 34 resident in the facility who received psychotropic medications. Findings: Res #39 had diagnoses which included depression and anxiety. A physician order, dated 06/07/23, documented duloxetine (an antidepressant medication) 60 mg two times a day. No diagnosis was documented. A quarterly assessment, dated 09/16/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident scored a 17 in the mood section and had no behaviors. The assessment documented the resident received antidepressant medication. On 11/13/23 at 11:37 a.m., the MDS coordinator stated the DON would put in orders on admission and then if there were new orders the charge nurse would put in the orders. The MDS coordinator stated the duloxetine did not have a diagnoses for the medication. The DON or the ADON will review 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 follow a therapeutic diet and menu for the residents who received a pureed diet. The DM identified two residents resided in the facility who had a pureed diet. Findings: The menu, dated Monday week three, documented the puree diet for breakfast was oatmeal, sausage, scrambled egg, and white or wheat toast. On 11/13/23 at 6:36 a.m., [NAME] #1 was observed to puree biscuit with gravy and eggs for the two residents who receive puree meals. On 11/13/23 at 7:49 a.m., the residents were served puree meals which included biscuits and gravy, eggs, and a yogurt for breakfast. At that time the DM stated the residents were not served oatmeal but when they have cream of wheat they were served the hot cereal. On 11/13/23 at 9:39 a.m., the DM stated they don't serve the oatmeal to the puree meals because the oats don't puree well. They do get cream of wheat when they have it and they normally puree a meat like the sausage. The DM stated they did not know why the cook did not do that today. The DM stated the resident should…

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 inspect and maintain records for residents utilizing bed rails. The Resident Census and Conditions of Residents form, documented 47 residents resided at the facility. Findings: Res #13 had diagnoses which included anxiety, atrial fibrillation, rheumatoid arthritis, and chronic obstructive pulmonary disease. The resident record contained a bed rail consent, signed on 05/26/23. A quarterly MDS assessment, dated 09/09/23 documented the resident's cognition was intact and independent to minimal assistance with all ADLs. On 11/08/23 at 3:49 p.m., an observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. On 11/13/23 12:15 p.m., the maintenance man stated they would check the bed rails every so often but did not conduct regular checks on them and did not keep any documentation related to checking the rails.

Based on record review and interview, the facility failed to: a. complete neurological checks for two (#9 and #93) of two sampled residents reviewed for falls and b. notify a physician of abnormal blood sugars as ordered for one (#15) of five sampled residents reviewed for medications. Resident Census and Conditions of Residents report, dated 08/01/22, documented 45 residents resided in the facility. Findings: The facility's Fall policy, revised 09/2012, read in part, .Falls should also be identified as witnessed or unwitnessed events .Monitoring and Follow-Up .The staff .will follow up on .delayed complications such as .subdural hematoma have been ruled out or resolved .Frail elderly individuals are often at greater risk for serious adverse consequences of falls . 1. Resident #93 was admitted with diagnoses of dementia, muscle weakness, other abnormal gait and mobility, and history of falling. An Incident Note, dated 05/05/22 at 9:28 p.m., read in parts, .charge nurse was summoned to residents' room by family and resident was noted sitting on the floor on [their] buttocks by…

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 ensure lancets were disposed of properly for two (#31 and #34) of three sampled residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 08/01/22, documented 45 residents resided in the facility and 10 residents received insulin injections. Findings: The facility's Medical Waste policy, reviewed 05/2012, read in parts, .Medical waste may not be discarded with general trash .Everyone who generates or handles medical waste will be responsible for discarding it into appropriate receptacles . The facility's Blood Sampling-Capillary (Finger Sticks) policy, reviewed 09/2014, read in parts, .The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of blooborne diseases to residents and employee .Handle the lancet as a used needle .Discard lancet and platform into the sharps container . 1. Resident #31 had diagnosis of type two diabetes mellitus. A Physician order, dated 07/21/22, documented 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 record review and interview, the facility failed to ensure CNA competency evaluations were completed annually for three (CNA #4, 5 and #6) of three sampled staff records reviewed. Findings: A facility policy and procedure titled Policy On Nurse Aide Competency Evaluations, dated 05/01/04, read in part, .All certified nurse aides will receive an annual evaluation . On 08/04/22 at 10:48 a.m., The Administrator was asked to provide three CNA staff competencies. The Administrator reported CNA staff competencies had not been completed since 2020. The Administrator reported competencies should have been done annually.

Based on record review, observations, and interview, the facility failed to: a. wear appropriate PPE when providing care to two Covid-19 positive residents (#6 and #9) of five sampled residents and b. ensure a glucometer was cleaned between three (#13, 31, and #34) of three sampled residents reviewed for infection control. Findings: The facility's Blood Sampling-Capillary (Finger Sticks) policy, revised 09/2014, read in parts, .The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . 1. On 08/02/22 at 9:29 a.m., upon entrance into the Covid-19 positive unit, CNA #1 was observed in a Covid-19 positive room with resident #6 and #9, without a gown, face shield or gloves on. On 08/02/22 at 9:30 a.m., CNA #1 reported they should have had gloves, gown and face shield on while in the residents' room. On 08/03/22 at 1:41 p.m., the DON reported full PPE should had been…

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

Based on record review, observation, and interview, the facility failed to ensure residents were provided privacy during administration of FSBS and insulin for one (#13) of three sampled residents reviewed for privacy. The Resident Census and Conditions of Residents report, dated 08/01/22, documented 45 residents resided in the facility and 10 residents received insulin injections. Findings: Resident #13 was admitted with diagnosis of type two diabetes mellitus. Resident #13's Physician order, dated 04/11/22, documented CBGs were to be performed before meals and at bedtime. Resident #13's admission assessment, dated 04/24/22, documented the resident had moderately impaired cognition for daily decision making. Resident #13's Physician order, dated 07/19/22, documented the resident was to receive 25 units of Lantus (insulin) every morning. Resident #13's quarterly assessment, dated 07/25/22, documented the resident had moderately impaired cognition. On 08/03/22 at 6:40 a.m., LPN #3 was observed to bring Resident #13 out of the dining room and obtained FSBS in the hallway. On 08/03/22…

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 baseline care plans were completed for one (#93) of one sampled resident reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 08/01/22, documented 45 residents resided in the facility. Findings: Resident #93 was admitted [DATE]. There was no baseline care plan documented for the resident. On 08/03/22 at 10:10 a.m., the MDS coordinator was asked when were care plans completed after admission. They stated 14 days after admission. They were asked when care plan were completed prior to 14 days. They stated they sometimes started the care plan early. MDS coordinator was asked if they completed the baseline care plan. They stated the nurses complete the interim care plan. They were asked to locate this care plan for Resident #93. They stated they didn't see one and the resident should have had one.

Based on record review, observation, and interview, the facility failed to revise a care plan for one (#15) of 14 sampled residents reviewed for care plans. The Resident Census and Condition of Residents report, dated 08/01/22, documented a census of 45. Findings: Res #15 was admitted to the facility with diagnoses which included dementia and schizophrenia. A wandering risk assessment, dated 04/21/22, documented Res #15 was high risk for wandering. An admission assessment, dated 05/04/22, documented Res #15 was moderately impaired with cognition and wandered four to six days of the seven day look back period. A care plan, dated 05/19/22, documented in part, .is an elopement risk/wanderer r/t Dementia and anxiety A progress note, dated 06/29/22 at 8:44 p.m., documented, Res #15 was exit seeking this shift but was easily redirected to their room. A progress note, dated 07/01/22 at 5:16 p.m., read in part, .Resident pushed past a woman that was leaving the front entrance of the facility. Resident ran to the left of the facility towards 400 hall into the field. Another nurse saw [Res…

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 provide a suction machine at bedside for one (#39) of one sampled resident reviewed for tracheostomy. The Resident Census and Condition of Residents report, dated 08/01/22, documented one resident with a tracheostomy. Findings: A facility policy and procedure titled Tracheostomy Care, revised August 2013, read in part, .A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at bedside at all times Res #39 was admitted to the facility with diagnoses which included morbid obesity, acute respiratory failure, tracheostomy status, and dysphagia. A quarterly assessment, dated 07/07/22, documented Res #39 was cognitively intact and required extensive assistance with activities of daily living. A care plan, dated 07/07/22, read in part, .Suction as necessary . On 08/02/22 at 3:00 p.m., Res #39 was observed in their bed watching television. Res #39 stated they did not have a suction machine in their room. There was no observation of a suction machine in Res #39's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure the resident's progress note was completed with correct time and details of an incident for one (#93) of two sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 08/01/22, documented 45 residents resided in the facility. Findings: Resident #93 was admitted with dementia. Resident #93's discharge assessment, dated 05/08/22, documented the resident had severely impaired daily decision making. An Incident Note, dated 05/31/22 at 3:30 a.m., read in parts, .Resident up and ambulating about unit staff monitoring and resident attempted to sit in hall and fell in the floor . This note was completed by the DON. On 08/02/22 at 4:07 p.m., the DON and the activity assistant and stated they remembered this incident. They stated Resident #93 went to sit on the floor and the activity assistant and restorative aide lowered the resident to the floor. The DON stated it is documented the resident…

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