Miami Nursing Center, LLC

Based on record review and interview, the facility failed to provide catheter care as ordered for 1 (#5) of 3 sampled residents reviewed for catheter care. The DON reported the census was 67. Findings: A physician's order, dated 01/30/25, showed staff were to cleanse the area around the suprapubic catheter and the catheter tubing with soap and warm water or normal saline every shift. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. A treatment administration record, dated 05/2025, showed for the first 17 days of May out of 51 opportunities to provide catheter care it was completed 31 times. The record showed the resident refused 16 times and there was no documentation of catheter care on the evening shift on 05/06/25, the night shift on 05/07/25, or the day shift on 05/10/25. On 05/20/25 at 10:45 a.m., Res #5 stated CNAs never performed catheter care on them. They also stated only one nurse…

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 accuracy of medical records for 1 (#5) of 3 sampled residents reviewed for catheter care. The DON reported the census was 67. Findings: A physician's order, dated 01/30/25, showed staff were to cleanse the area around the suprapubic catheter and the catheter tubing with soap and warm water or normal saline every shift. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. A Documentation Survey Report V2, dated 05/2025, showed CNA #1 documented they had performed catheter care on Res #5 on 05/05/25, 05/09/25, and 05/16/25. The report also showed CNA #6 had documented they had performed catheter care on Res #5 on 05/07/25, 05/08/25, 05/14/25, and 05/21/25. On 05/21/25 at 9:30 a.m., CNA #6 stated they did not go into Res #5's room. They also stated they did not perform catheter care on Res #5. CNA #6 stated they documented 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 provide written notice of a room change for 1 (#4) of 3 sampled residents reviewed for room changes. The DON reported the census was 67. Findings: An undated facility policy titled Policy and Procedure for Notification of Changes, read in part, The facility will also notify the resident, and if known, the resident's legal representative or interested family member within 48 hours when there is a change in room or roommate assignment. A resident list report, dated 10/16/24, showed Res #4 resided in room [ROOM NUMBER] bed A. A quarterly assessment, dated 03/15/25, showed Res #4 had a BIMS score (a test for cognitive function) of 0, which was indicative of severe impairment for daily decision making. A resident list report, dated 05/15/25, showed Res #4 resided in room [ROOM NUMBER] bed A. A review of Res #4's medical record did not show Res #4 or their representative had been notified in writing of the room change. On 05/20/25 at 2:25 p.m., the DON…

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 provide imaging services as ordered for 1 (#5) of 3 sampled residents reviewed for imaging services. The DON reported the census was 67. Findings: A physician's order, dated 12/29/24, showed Res #5 had a chest x-ray on 12/29/24. A nurse note, dated 12/29/24 at 7:33 p.m., showed Res #5 informed the nurse they were supposed to have a chest x-ray on 12/27/24 and they never got it. The note also showed the administrator was contacted and they confirmed Res #5 was supposed to have an x-ray on 12/27/24. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. On 05/20/25 at 10:45 a.m., Res #5 stated they were supposed to have a chest x-ray on 12/27/24 and they did not get it until 12/29/24. On 05/20/25 at 1:50 p.m., the DON stated Res #5 should have had an x-ray on 12/27/24, but the nurse did not put in the order. The DON also stated Res #5 did…

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 appropriate hand hygiene was performed during catheter care for one (#1) of three residents reviewed for catheter care. The DON identified five residents with catheters in the facility. Findings: An undated facility policy titled Procedure for Indwelling Urinary Catheters, read in part, .Catheter care will be provided periodically throughout the day .Staff will assist the resident to [their] room, provide privacy and provide care consistent with techniques that prevent cross contamination . Resident #1 had diagnoses which included quadriplegia and neuromuscular dysfunction of the bladder. On 10/17/24 at 10:32 a.m., catheter care was observed for Resident #1. CNA #1 was seen to don gloves, cleanse around the area of the catheter and without changing gloves or performing hand hygiene, then touched the resident's table and computer keyboard. LPN #1 was observed to don gloves, cleanse the area around the catheter with a 4x4, place the soiled 4x4 in the trash can, touch the side of the trash can with their gloved hand,…

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: a. provide for the residents' dignity for three (#55, #4, and #50) of three residents observed for full visual privacy and for two (#50 and #26) of two residents observed with signage to always keep the residents' door open; and, b. provide enough dishware to allow for meals to be served without use of disposable containers and/or cutlery. The DON identified 73 residents in the facility. Findings: 1. Resident #55 had diagnoses which included dysphagia. On 07/15/24 at 10:28 a.m., there was no privacy curtain observed to provide privacy for the middle bed of a three-bed bedroom. On 07/15/24 at 10:30 a.m., stated they had episodes of incontinence. The resident stated the staff closed the door but there was no curtain to provide full visual privacy from the two roommates. On 07/17/24 at 3:30 p.m., CNA #6 stated the staff pulled the door closed and pulled the curtains around bed A and bed C but did not have a curtain to pull for B bed to provide full visual privacy for the resident. - Resident #4 had diagnoses which included…

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 residents were not charged separately for services paid for by Medicare/Medicaid for one (Resident #174) of four residents who were charged room and board during covered periods of stay and for four (#8, #44, #55, and #174) of four residents charged for administrative supplies and whose monies were managed in the Resident Trust. The BOM identified 38 residents with funds in the Resident Trust. Findings: Resident #174 had diagnoses which included depression. On 07/19/24 at 10:30 a.m., the Trust Transaction History for Resident #174 was reviewed and compared to the facility's monthly billing statements from admission to 07/19/24 with BOM and Administrator #2. The transaction history and facility statements documented the following: February 2024 facility statement documented a charge of $2015.00 for Medicaid pending stay from 01/19/24 to 01/31/24 which left a balance due of $2015.00; Resident #174 trust transactions with posting dates of January thru February 2024: - 01/22/24 balance of $95.47 in trust account; -…

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 skin assessments were conducted for two (#42 and #3) and failed to ensure orders for intravenous care were obtained upon return from the hospital for one (#8) of three sampled residents who were reviewed for quality of care. The DON identified 73 residents who resided in the facility and one resident with intravenous access. Findings: The undated Procedure for Care of the Central Venous Catheter policy, read in parts, .Specific flush orders are obtained from the physician .DRESSING CHANGE Frequency .24 post insertion or on admission, at least weekly . 1. Resident #42 had diagnoses which included hypertension. The Order Recap Report, dated 07/03/24 through 07/31/24, read in part, .Skin assessment to be completed within 24 hours of admission and then at least every 7 days thereafter .Order Date 07/03/24 . The Admit/Readmit Screener, dated 07/03/24, documented the resident had right antecubital bruising. The Care Plan, dated 07/03/24,…

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.

Based on record review and interview, the facility failed to provide routine catheter care for one (Resident #2) of one resident whose records were reviewed for catheter care. The DON identified three residents with catheters in the facility. Findings: Resident #2 had diagnoses which included quadriplegia and neurogenic bladder. On 07/16/24 at 3:07 p.m., Resident #2 stated only one nurse consistently provided catheter care and when that nurse was off, they did not receive catheter care. On 07/19/24 at 3:08 p.m., CNA #7 stated they did not provide catheter care for Resident #2. They stated it was the nurse who provided catheter care. On 07/19/24 at 3:22 p.m., CNA #6 stated they did not provide catheter care for Resident #2. They stated it was the nurse who provided catheter care. On 07/19/24 at 3:30 p.m., LPN #1 stated catheter care was assigned to the certified nurse aides. On 07/22/24 at 11:28 a.m., LPN #5 stated catheter care was assigned to the nurse aides. On 07/22/24 at 3:35 p.m., LPN #3 stated they provided catheter care each shift they worked but had no place to document it.…

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 residents who received psychotropic medications were monitored for behaviors and side effects for three (#3, 44, and #28) of five residents who were reviewed for unnecessary medications. The DON identified 22 residents who received antipsychotic medications and 53 residents who received psychotropic medications. Findings: The undated, Monitoring of Extra Pyramidal Side Effects policy, read in parts, .Monitoring of EPS symptoms will be conducted through a universal procedure known as Abnormal Involuntary Movement Scale (AIMS) testing .a minimum of quarterly . 1. Resident #3 had diagnoses which included schizophrenia. The Care Plan, dated 04/29/24, documented to monitor for anxiety, tearfulness, and agitation every shift. The Behavior Monthly Flow Sheet dated May 2024, documented behaviors were monitored 50 out of 93 opportunities. The specific behaviors to monitor for were not indicated on the flow sheet. The Behavior Monthly Flow Sheet dated June 2024, documented behaviors were monitored 32 out of 90 opportunities.…

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. medications were secured for one (North hall) of three medication/treatment carts observed; b. medications were dated when opened for three (North hall, North hall main, and the treatment cart); and c. medications were not expired for one of one medication rooms observed. The DON identified five medication/treatment carts in the facility. Findings: The Quality Control of the Glucometer policy, dated 03/22/12, read in part, .containers of test strips will be dated with the month, day and year when opened . The undated, Cleaning and Maintenance of Nebulizers, Oxygen Supplies and Metered Dose Inhalers policy, read in parts, .Staff will date the box of metered dose inhalers or the inhaler itself .when they are opened . The undated, Insulin Administration policy, read in part, .All insulin should be dated when opened . 1. On 07/16/24 at 4:09 p.m., a bottle of Miralax powder was observed on top of the North hall medication cart 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 and interview, the facility failed to maintain a surety bond in an amount to cover the facility trust. The business office manager identified 38 residents in the facility trust. The surety bond, dated 10/07/22, documented the bond to cover the balance of the trust was in the amount of $90,000.00. The April 2024 bank statement documented the daily balance on 04/03/24 was $91,136.92 and on 04/09/24 the daily balance was $91,773.92. The May 2024 bank statement documented the daily balance on 05/03/24 was $92,755.93 and on 05/10/24 the daily balance was $92,739.71. The June 2024 bank statement documented the daily balance on 06/03/24 was $97,106.92 and on 06/10/24 the daily balance was $95,842.14. On 07/19/24 at 9:38 a.m., the administrator stated they thought the trust was around $70,000.00 and did not realize the trust had such a high balance. The administrator stated they would have the bond raised to cover the higher balance.

Based on observation and interview, the facility failed to provide a privacy curtain to allow for full visual privacy for two (#4 and #55) of two residents whose rooms were observed for a privacy curtains. The DON identified 73 residents resided in the facility. On 07/19/24 at 2:26 p.m., there was privacy curtain present for resident #4. On 07/19/24 at 2:30 p.m., the resident stated there had never been a curtain, and they would like to have one for visual privacy from their two roommates. On 07/19/24 at 2:44 p.m., CNA # 2 stated if resident #4 received incontinent care they pulled both curtains around the two roommates and shut the door. The CNA stated there was not a curtain to pull to provide full visual privacy for Resident #4. 2. Resident #55 had diagnoses which included dysphagia. On 07/15/24 at 10:30 a.m., Resident #55 stated they had episodes of incontinence. The resident stated the staff closed the door but there was no curtain to pull for the resident to have full visual privacy from the two roommates. On 07/17/24 at 3:30 p.m., CNA #6 stated to provide the resident 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.

Based on observation, record review, and interview, the facility failed to ensure the care plan was revised for one (#8) of 16 sampled residents whose care plans were reviewed. The DON identified 73 residents who resided in the facility. Findings: Resident #8 had diagnoses which included atrial fibrillation. The Admit/Readmit Screener, dated 07/09/24, documented the resident had returned from a hospital stay and had a midline placed in the left arm. The Care Plan updated 07/11/24, documented the resident had returned from the hospital with an order for an intravenous antibiotic. The care plan did not document the resident had intravenous access. On 07/16/24 at 1:20 p.m., Resident #8 was observed to have a PICC line to their left upper arm. On 07/22/24 at 2:15 p.m., the MDS coordinator stated care plans were updated quarterly, with a significant change, when new orders were received, and upon readmission from the hospital. They stated the care plan for Resident #8 had not been updated to reflect the PICC line. On 07/22/24 at 3:13 p.m., the DON stated they did not have a system in…

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

Based on observation, record review, and interview, the facility failed to ensure interventions were in place to prevent unnecessary weight loss for one (#33) of one resident reviewed for weight loss. The DON identified 73 residents resided in the facility. Findings: Resident #33 had diagnoses which included dementia. An undated policy titled, Nutrition Policy read in part, .The resident will be assessed for weight gain or loss. Significant gain or loss will be reported to the resident's physician for possible diet adjustment. If the resident eats 50% or less of two consecutive meals, a nutritional supplement will be provided . A care plan dated 05/02/24 documented Resident #33 had a nutritional problem or the potential to have a nutritional problem, would maintain adequate nutritional status as evidenced by maintaining weight within 5% of current weight with no signs or symptoms of malnutrition, and would consume at least 50% of the three daily meals through the review date. On 05/02/24, the resident's electronic medical record documented the resident's weight was 132.2 lbs. 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 and interview, the facility failed to ensure a resident was assessed after dialysis treatments for one (#64) of one resident reviewed for pre/post dialysis assessments. The DON reported four residents in the facility received dialysis treatments. Findings: Resident #64 had diagnoses which included end stage renal failure. A comprehensive assessment, dated 06/17/24, documented Resident 64 was cognitively intact. On 07/16/24 at 11:19 a.m., Resident #64 stated the nurse usually checked their blood pressure and temperature before they went to dialysis but when they returned from dialysis, they did not see the nurse unless the resident asked for something from them. The resident stated recently their port was infected and they had to take antibiotics. Resident #64 stated the laboratory test finding documented they had a blood infection. The resident's electronic medical record was reviewed for Resident #64. The electronic medical record did not document a post dialysis assessment to include vital signs, weight, or fistula/port assessment for the following dates:…

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, it was determined the facility failed to ensure the physician was notified of significant weight loss for one (#33) of one sampled resident who was reviewed for nutrition. Findings: On 05/02/24, the resident's electronic medical record documented the resident's weight was 132.2 lbs. On 07/03/24, the electronic medical record documented the resident's weight was 116.8 lbs, a significant weight loss of 11.65% weight loss in two months. 07/18/24 at 1:00 p.m., the Resident's electronic medical resident documented the resident ate less than 50% of one of more of their daily meals on 07/11/24, 07/12/24, 07/14/24, 07/16/24, 07/17/24, 07/18/24 On 07/18/24 at 2:32 p.m., LPN #5 stated if a resident eats less than 50% of a meal the CNA was to go to the kitchen and get a house shake to offer the resident. The LPN stated they were to document the supplement in with the activities of daily living. On 07/18/24 at 2:52 p.m. the Resident's electronic medical record did not document a house shake being offered in the last 30 days. On 07/19/24 at 10:39 a.m., CMA…

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 post the required staffing information. The DON identified 73 residents resided in the facility. Findings: On 07/17/24, 07/18/24, 07/19/24, and 07/22/24 a staffing schedule was observed on the nurses station. The schedule did not document the census or the nursing hours. On 07/22/24 at 5:50 p.m., the administrator stated they posted a copy of the schedule but it did not have the nursing hours or the resident census on it.

Based on record review and interview, the facility failed to ensure medications were administered per physician orders for one (#42) of seven sampled residents who were reviewed for unnecessary medications. The DON identified 73 residents who resided in the facility. Findings: Resident #42 had diagnoses which included transient ischemic attack (mini stroke). The Discharge Summary from the hospital, dated 07/01/24, read in parts, .CONTINUE taking these medications .clopridogrel 75 MG tablet TAKE 1 TABLET BY MOUTH EVERY DAY . The Order Recap Report, dated 07/03/24 through 07/31/24, did not document Resident #42 had been started on clopridogrel upon admission to the facility. The admission assessment, dated 07/10/24, documented the resident was cognitively intact for daily decision making. On 07/15/24 at 9:51 a.m., Resident #42 stated they were supposed to take clopridogrel for a history of strokes but they had not received it while a resident at the facility. On 07/17/24 at 6:26 p.m., the DON stated admission orders for the facility were obtained from the hospital discharge orders.…

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 a sanitary kitchen environment, maintain a sanitary dish machine, and store foods according to professional standards of practice. The DON identified 71 residents who ate meals prepared in the kitchen. An invoice, dated 06/12/24, documented the ice machine was cleaned and the water filter replaced by a contracted company. On 07/15/24 at 7:50 a.m., the following observations were made in the kitchen: - four flies buzzing about and landing on food preparation tables, cookware, and dishware. - two ceiling vents positioned over food preparation tables were covered with a layer grease, dust, and debris. - an open one gallon bottle of apple juice in the refrigerator with no open date; - an open 20 ounce bottle of Pepsi and a 20 ounce bottle of Coke in the refrigerator with no open dates or names; - an open storage bag with sliced luncheon meat in the refrigerator with no open date; - an open storage bag with four left over meat and cheese omelettes in the refrigerator with no prepared date; - an open…

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: a. Maintain an infection control program for enhanced barrier precautions by donning gowns prior to catheter care or wound care for two (#8 and #2) of two resident who received catheter care and/or wound care; and b. ensure catheter tubing and dignity bags were maintained in a manner to prevent cross contamination for one (#8) of two sampled residents reviewed for urinary catheters. The DON identified three residents with indwelling urinary catheters. The undated Policy and Procedure for Transmission-Based Precautions, read in parts, .The expanded use of PPE and refer to the use of gown and gloves during the high-contact care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDRO) to or from staff hands or clothing or indirectly transferred from resident/client during high contact activities. Use Enhanced Barrier Precautions when providing care to any resident/client with an indwelling medical device such as an indwelling urinary catheter, central line, feeding tube,…

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 the physical environment was maintained in good repair. The Nursing Manager identified 73 residents resided in the facility. Findings: APolicy Regarding Triage of Maintance and Repairs undated, read in part, .It is the policy of this facility to maintain the physical plant in a safe and homelike environment .staff to maintain the facility in good repair, and clean and orderly environment . On 04/02/24 at 8:45 a.m., a yellow wet floor sign and a blue bucket were observed to be on the floor in the middle of the dining area near the serving window. The bucket contained approximately one half cup of water. On 04/02/24 at 9:03 a.m., Maintenance #1 stated he guessed the bucket was there so people won't slip and fall. They stated it looked like the water was coming from the ceiling. On 04/02/24 at 9:07 a.m., the CDM stated the roof leaks when it rains. On 04/02/24 at 10:21 a.m., the Maintenance Supervisor stated the roof had last been repaired in September 2023.

Based on record review and interview, the facility failed to implement a comprehensive care plan for one (#1) of five residents reviewed for care plans. The DON identified 73 residents resided in the facility. Findings: A Policy and Procedure regarding Resident Care Plan, revised 03/27/17, read in part, .the facility will establish and implement .care plan that will .provide effective and person-centered care of the resident and meets current standards of practice for quality care . A Care Plan, dated 02/16/24, documented, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Resident #1 had diagnosis which included stage three pressure wounds. No documentation of wound care being provided was documented prior to to 03/17/24. On 04/03/24 at 8:53 a.m., LPN #2 stated the effectiveness of wound care was documented in the wound assessment. On 04/04/24 at 9:50 a.m., the DON stated they could not find any documented wound observations prior to 03/17/24. 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 observation, record review, and interview, the facility failed to: a. provide pressure ulcer care as ordered by the physician, b. complete weekly wound observations and measurements and, c. document refusals in the nursing notes. The Nursing Manager identified 73 residents resided in the facility. Findings: A Policy and Procedure for the Prevention and Treatment of Pressure Ulcers, revised on 08/28/08, read in part, .For individuals who enter the facility with a pressure ulcer, or whose clinical condition demonstrates the development of a pressure ulcer was unavoidable post admission, the facility will strive to provide care and services necessary to promote healing, prevent infection and the development of new ulcers from developing .For individuals identified with risk factors, the facility will develop interventions necessary in an effort to prevent the development of pressure ulcers .The resident has a right to refuse treatment. This shall be documented in the resident's clinical record .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 and interview, the facility failed to ensure the call light system was functioning in one of six occupied resident rooms reviewed for call light functionality. The administrator reported the census was 65. Findings: An undated facility policy, titled Policy and Procedure on Resident Call System, read in part, Resident calls from every bed, toilet and bathing facility, must register at the nurses station . On 11/20/23 at 8:40 a.m., Maintenance #1 pushed the call button in room [ROOM NUMBER] and the light did not activate. On 11/20/23 at 9:01 a.m., the maintenance supervisor stated they did not routinely test the call light system to ensure they were functioning properly. They also stated they were unsure a resident with diminished cognition would alert the staff if a call light was not functioning properly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain safe water temperatures on the main hall for two (room [ROOM NUMBER] and room [ROOM NUMBER]) of nine rooms reviewed for safe water temperatures. The maintenance supervisor identified 27 residents who resided on the main hall. Findings: 1. Resident #18 had diagnoses which included schizoaffective disorder, bipolar type. Review of the water temperature logs, dated [DATE] through [DATE], did not reveal the water temperature had been monitored for room [ROOM NUMBER]. The Care Plan, updated [DATE], documented the resident was able to toilet themselves independently and required set up and staff assistance as needed for personal hygiene/oral care. The quarterly assessment, dated [DATE], documented the resident was cognitively intact for daily decision making and was independent with personal hygiene and toileting. On [DATE] at 4:24 p.m., Resident #18 exited the bathroom in room [ROOM NUMBER] and LPN #3 washed their hands. LPN #3 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 the ice machine was clean and sanitary. The DON identified 60 residents who received ice from the kitchen. Findings: An invoice, dated 03/14/23, documented the ice machine was last provided planned maintenance on 03/09/23. The invoice read in part, .The technician arrived and performed planned maintenance. He disassembled ice machine, cleaned the ice machine with descaler, sanitized and replaced the water filter. The unit is functioning properly . On 06/20/23 at 10:15 a.m., the ice machine was observed to have pink, yellow, and brown gel-like substances in the top of the ice machine, where the ice was made. The maintenance supervisor was asked what the substance was. They wiped the area with their finger, collecting the substance onto their finger, and stated they did not know. They stated it looked like the service company needed to come out again and clean the machine. The maintenance supervisor was asked how often the ice machine was cleaned. They stated every two or three months. On 06/21/23 at 12:44 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure advance directives were periodically reviewed for changes for one (#1) of three sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents form identified 63 residents who resided in the facility. Findings: Resident #1 had diagnoses which included schizoaffective disorder bipolar type. The resident's face sheet in the electronic clinical record documented the resident was admitted on [DATE] and was a full code. An Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt form, dated 10/26/20, documented the resident/resident's guardian acknowledged they had been informed of the right to formulate an advanced directive. Review of the clinical record did not reveal any other acknowledgements of the right to formulate or change the resident's advanced directive. On 06/22/23 at 12:37 p.m., the MDS coordinator and DON was asked what was discussed during care plan meetings. The MDS coordinator…

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 provide a notice of transfer to one (#25) of three resident reviewed for discharges. The Resident Census and Conditions of Residents form identified 63 residents who resided in the facility. An incident note, dated 04/14/23 at 9:07 p.m., documented the resident #25 had been transferred to a hospital following a fall. On 06/21/23 at 1:58 p.m., the administrator was asked if resident #25 or their family had been given a written notice of transfer for the resident's hospitalization which began on 04/14/23. The administrator replied no written notice was given but the family had been contacted over the telephone.

Based on record review and interview, the facility had not provided a bed hold policy to one (#25) of three residents reviewed for discharges. The Resident Census and Conditions of Residents form identified 63 residents who resided in the facility. An incident note, dated 04/14/23 at 9:07 p.m., documented resident #25 had been transferred to a hospital following a fall. On 06/21/23 at 1:58 p.m., the administrator was asked if resident #25 or the family had been provided a copy of the bed hold policy on or after 04/14/23 when they were transferred to a hospital. The administrator replied the resident nor the family had be given the policy for that hospitalization.