Noble Health Care Center

Based on record review and interview, the facility failed to maintain an antibiotic stewardship program and infection surveillance to monitor antibiotic use for residents from April 2024 through June 2024. The MDS coordinator identified 6 residents who were prescribed antibiotics. Findings: The facility's Antibiotic Stewardship Program policy, dated January 2022, read in part, . stewardship actions .prescription record keeping, dose, duration, route, and indication of every prescription MUST be documented in the medical record of every resident, regardless of prior prescriptions or documentation elsewhere .records will be reviewed monthly to assess compliance with this requirement as well as prescription appropriateness .site and type of infection .utilize the McGreer's Criteria .data will be compiled monthly .interpret monthly data .compile monthly information for the Quality Committee . During antibiotic stewardship and infection surveillance review, there was missing documentation of the McGreers criteria, symptoms, organism from culture from April to June 2024. On 08/08/24 at…

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 promote resident dignity by staff standing over residents while assisting them to eat. The administrator identified 81 residents resided in the building and 17 required assistance with eating. Findings: On 08/06/24 at 8:37 a.m., CMA #1 was observed standing while assisting two residents to eat at the dining table. CNA #1 was at the next table standing while assisting a resident to eat. There were eight empty dining chairs within a few feet of both staff that were standing. There was also another staff that was seated while feeding residents. On 08/06/24 at 9:26 a.m., CMA #1 stated they did not know about standing or sitting because they usually worked the night shift. On 08/06/24 at 9:29 a.m., CMA #1 stated they are supposed to sit down with the resident, but they were just trying to help the resident get the food on the spoon, so it wouldn't get scooped off the plate. They stated they did not mean any disrespect towards the resident. On 08/06/24 at 10:03 a.m., the DON stated the policy is to sit down eye level to feed…

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 were offered the choice to formulate an advanced directive for two (#7 and #40) of 24 sampled residents whose advance directive acknowledgements were reviewed. The administrator identified 81 residents resided in the facility. Findings: An Advanced Directives policy, reviewed April 22, 2024, read in part, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. 1. Resident #7 was re-admitted on [DATE] with diagnoses which included traumatic brain injury. 2. Resident #40 was admitted on [DATE] with diagnoses which included hemiplegia of left side and acute kidney failure. On 08/05/24 at 11:57 a.m., the DON stated that they are to ask each resident at admission, and they did not see that an advance directive was uploaded for either resident. On 08/07/24 at 1:20 p.m., the DON stated they were unable to locate the advance directives for Resident #7 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 ensure resident assessments were accurately coded on two of the MDS assessments completed for one (#7) of 19 sampled residents reviewed for accurate assessments. The Administrator identified 81 residents resided in the facility. Findings: Resident #7 had diagnoses which included traumatic brain injury, nephrolithiasis, and left upper extremity paralysis. A Resident Summary, dated 01/19/24, 01/20/24/01/21/24, and 01/22/24, all document resident #7 had an indwelling catheter. A Physician's order, dated 01/24/24, documented to change foley catheter as needed for clogged/dislodged/or clinically indicated. The quarterly MDS, dated [DATE], documented Resident #7 had no bowel or bladder appliances. The quarterly MDS, dated [DATE], documented Resident #7 had no bowel or bladder appliances. On 08/07/24 at 11:46 a.m. the MDS Coordinator stated the 01/23/24 and 04/24/24 quarterly MDS were both coded inaccurately because Resident #7 did have an indwelling catheter…

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 complete neurological checks per protocol after an unwitnessed fall for one (#71) of seven sampled residents reviewed for accidents. The administrator identified 82 residents resided in the facility. Findings: An INCIDENT/ACCIDENT REPORTING policy, reviewed 01/12/22, documented a neurological assessment flow sheet will be immediately initiated and maintained for each incident/accident involving an injury of any kind to the head or any unwitnessed fall. It documented monitoring is triggered to be completed for 72 hours. Res #71 admitted to the facility on [DATE] with diagnoses which included history of right femur fracture and spinal disc disorder. An incident report, dated 07/04/24, documented the resident had an unwitnessed fall resulting in a small bruise to the residents top right side of the head. The incident report documented neuro checks were started. A neuro check log for Res #71 dated 07/04/24 through 07/06/24, documented neuro checks were…

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 obtain a physician order for the placement of a foley catheter for one (#31) of three sampled residents reviewed for catheters. The administrator identified 82 residents resided in the facility. Findings: Res #31 readmitted to the facility on [DATE] with diagnoses which included sepsis. A progress note, dated 07/12/2024 at 6:24 p.m., documented a foley catheter was inserted per provider order. A review of physician orders from 07/11/24 to 08/06/24 did not document an order for placement of a foley catheter. On 08/06/24 at 12:15 p.m., Res #31 was observed seated in their wheelchair in the dining room. A foley catheter drainage bag was observed hanging from the wheelchair. On 08/07/24 at 9:46 a.m., the DON stated the nurse did not enter an order to place the foley before it was placed.

Based on observation, record review, and interview, the facility failed to supervise a resident while administering a breathing treatment for one (#49) of one sampled residents reviewed for respiratory treatments. The administrator identified 82 residents resided in the facility. Findings: Res #49 had diagnoses which included COPD. A physician order, dated 05/21/24, documented to administer budesonide 0.5 mg/2 mL suspension for nebulization twice per day for pneumonia. On 08/05/24 at 11:00 a.m., Res #49 was observed seated on the end of their bed holding a breathing treatment mask to their face. A nurse was not observed in the room or in the hall. The resident was observed turning off the treatment and setting the mask aside. On 08/05/24 at 11:06 a.m., Res #49 stated the nurse set up his breathing treatment and left. They stated the nurses never stay to monitor them during the treatment. On 08/05/24 at 11:08 a.m., LPN #2 stated the resident should be monitored during the breathing treatment unless they have been assessed to self administer medications. Res #49 did not have an…

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

Based on record review and interview, the facility failed to ensure psychotropic medications were monitored for target behaviors and side effects for one (#28) of five sampled residents reviewed for unnecessary medications. The DON identified 50 residents received psychotropic medications. Findings: Res #28 had diagnoses which included anxiety disorder. A physician order, dated 06/19/24, documented to administer mirtazapine 7.5 mg at bedtime for anxiety disorder. A physician order, dated 04/24/22, documented to administer buspirone 5 mg twice per day for anxiety disorder. A physician order, dated 02/28/24, documented to administer fluoxetine 40 mg in the morning for anxiety disorder. Behavior and side effect monitoring for 06/01/24 through 06/30/24 documented missing documentation for 25 of 60 opportunities. Behavior and side effect monitoring for 07/01/24 to 07/31/24 documented missing documentation for 25 of 62 opportunities. Behavior and side effect monitoring for 08/01/24 to 08/07/24 documented missed documentation for 11 of 14 opportunities. On 08/08/24 at 11:18 a.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 observation and interview, the facility failed to ensure: a. the kitchen was kept clean and maintained in good repair, b. food products were properly thawed, c. soiled/damp cloths were properly stored, and d. staff changed their gloves and/or washed their hands after touching parts of their body before handling food. The DM identified 71 residents received services from the kitchen. Findings: On 07/05/23 at 8:46 a.m., a tour of the kitchen was conducted and breakfast meal service was observed. The following observations were made: a. there was an accumulation of lint on the return vents, b. there was food splatter on the ceiling in the cook area, c. there were five soiled/damp cloths laying in and/or on the two compartment sink, d. there was a metal container of multiple packages of pre-cooked sliced turkey stored in standing water in the two compartment sink. The water was not running in the sink. The temperature of the standing water in the metal container was 73 degrees F, e. base board tiles were missing near the hot water heater closet and in the dish wash area, f.…

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 staff were seated while providing feeding assistance for one (#1) resident and failed to ensure staff did not refer to residents as feeders. The Resident Census and Conditions of Residents form, dated 07/05/23, documented five residents were dependent on staff for eating. Findings: 1. Res #1 had diagnoses which included non-Alzheimer's dementia and seizure disorder. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired and had limited range of motion on one upper extremity. On 07/05/23 at 9:09 a.m., CNA #3 was observed standing in front of Res #1 and feeding them the meal. On 07/05/23 at 9:47 a.m., CNA #3 stated they should not stand while feeding residents. On 07/06/23 at 11:20 a.m., the DON was asked how staff were instructed to provide eating assistance to residents. They stated staff should be at eye level with residents when providing assistance with eating. 2. On 07/05/23 at 8:47 a.m., RA #1…

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 resident electronic medical records were kept confidential during medication pass. The Resident Census and Conditions of Residents form, dated 07/05/23, documented 72 residents resided in the facility. Findings: On 07/05/23 between 8:38 a.m. and 9:25 a.m., CMA #1 was observed passing medications in the dining room. CMA #1 administered 10 different resident's medications leaving the EMR on the laptop open and unattended with resident information visible. On 07/05/23 at 9:45 a.m., CMA #1 was asked how the facility ensured residents' electronic medical records were kept confidential while the medication cart was left unattended. They stated they were to pull the laptop screen down where it was not visible. CMA #1 was asked if they had pulled the laptop screen down. They stated, No, I get busy and forget. On 07/05/23 at 10:12 a.m., CMA #2 was observed passing medications on Hall 200 leaving the EMR on the laptop open and unattended with resident electronic medical records visible. On 07/05/23 at 10:29 a.m., CMA #2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a. change nebulizer tubing according to physician orders for one (#49) of two residents sampled for respiratory care and, b. date oxygen tubing according to physician orders for one (#59) of two residents sampled for respiratory care. The Resident Census and Conditions of Residents form, dated 07/05/23, documented eight residents received respiratory treatment. Findings: 1. Res #49 had diagnoses which included COPD. A quarterly MDS, dated [DATE], documented Res #49 was cognitively intact and was blind. A physician order, dated 04/18/23, documented to administer ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 ml nebulization solution three times per day for COPD. A physician order, dated 06/29/23, documented to change nebulizer tubing and respiratory bag every Sunday on night shift. On 07/05/23 at 11:03 a.m., Res #49 was observed in their room. They stated they had been receiving breathing treatments for a cough. A nebulizer machine was…

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

Based on observation, record review, and interview, the facility failed to ensure medications were administered according to physician orders for one (#20) of three residents sampled for medication pass. The Resident Census and Conditions of Residents form documented 72 residents resided in the facility. Findings: A facility policy, dated 01/2023, titled Nursing Care Center Pharmacy Policy and Procedure Manual Section 9.5 Sample Medication Administration Schedule, read in parts .medication frequency and administration are to be interpreted as follows daily medications to be administered between 8:00 a.m. to 9:00 a.m. unless specified otherwise by the prescriber . Res #20's physician order, dated 01/23/23, documented to administer multivitamin daily for vitamin deficiency 8:00 a.m. A physician order, dated 01/23/23, documented to administer polyethylene glycol 3350 17 grams in 8 ounces of liquid for constipation at 9:00 a.m. A physician order, dated 01/23/23, documented to administer sertraline 100 mg daily for depression at 9:00 a.m. A physician order, dated 01/23/23, 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 observation, record review, and interview, the facility failed to ensure medication error rate was less than 5%. A total of 27 opportunities were observed with 11 errors. Total medication error rate was 39.29%. The Resident Census and Conditions of Residents form documented 72 residents resided in the facility. Findings: Res #20's physician order, dated 01/23/23, documented to administer multivitamin daily for vitamin deficiency 8:00 a.m. A physician order, dated 01/23/23, documented to administer polyethylene glycol 3350 17 grams in 8 ounces of liquid for constipation at 9:00 a.m. A physician order, dated 01/23/23, documented to administer sertraline 100 mg daily for depression at 9:00 a.m. A physician order, dated 01/23/23, documented to administer cholecalciferol (vitamin D3) 125 mcg for vitamin D deficiency at 9:00 a.m. A physician order, dated 01/23/23, documented to administer docusate sodium 100 mg daily for constipation at 9:00 a.m. A physician order, dated 01/23/23, documented to administer duloxetine 60 mg daily for depression at 9:00 a.m. A physician order, dated…

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: a. expired supplies and medications were disposed of, b. a medication label accurately documented the physician order for one (#20) of three sampled residents observed during medication pass, c. medications and vaccines were labeled with the date opened, d. non-medication food items were not stored in medication refrigerators, and e. temperature logs for medication refrigerators were completed. The Resident Census and Conditions of Residents form documented 72 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included anxiety. A physician order, dated 01/23/23, documented to administer lorazepam 0.5 mg one tab twice daily. On 07/06/23 at 11:10 a.m., CMA #2 was observed during medication pass preparing medications for Res #20. The directions on Res #20's card of lorazepam documented to administer the lorazepam 0.5 mg every eight hours. On 07/11/23 at 1:20 p.m., the DON was made aware of resident #20's lorazepam discrepancy order and what the card read. The DON stated she would put a change 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 record review and interview, the facility failed to ensure labs were collected as ordered by the physician for two (#38 and #42) of five sampled residents reviewed for lab services. Findings: 1. Res #42 had diagnoses which included recurrent major depressive disorder with severe psychotic symptoms. A physician order, dated 01/20/23, documented valproic acid every three months in February, May, August, and November. On 07/11/23 at 8:25 a.m., the DON was asked to locate valproic acid labs for February and May 2023. On 07/11/23 at 9:47 a.m., the DON stated the labs were not drawn. 2. Res #38 had diagnoses which included hypothyroidism and hypertension. A physician order, dated 03/25/21, documented to collect a thyroid cascade profile laboratory study every 12 months in January for hypothyroidism. A physician order, dated 03/25/21, documented to collect a vitamin K1 laboratory study every six months in January and July for hypertension. The laboratory results were not provided or documented in the resident record. On 07/11/23 at 9:59 a.m., the DON stated the thyroid cascade…

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 proper hand hygiene was performed during medication administration. The Resident Census and Conditions of Residents form documented 30 residents resided in the facility. Findings: An Infection Control Policy, dated 2020, read in part, .strategies for preventing and reducing healthcare associated infection will include .stringent hand hygiene .routine surveillance rounds including; the environment, hand hygiene practices .improving hand hygiene compliance with hand hygiene guidelines .monitoring of compliance with hand hygiene . On 07/05/23 between 8:38 a.m. and 9:25 a.m., CMA #1 was observed passing medications in the dining room. CMA #1 administered 10 different resident medications. No hand hygiene was observed during any of the medication administration. CMA #1 was observed to touch bare handed the trash can on multiple occasions, med cart keys, laptop, pill crusher, a resident's geri-chair, medication bottles and pills, and the medication cart drawers. On 07/06/22 at 11:24 a.m., CMA #2 was observed preparing and…

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

Based on record review, observation, and interview, the facility failed to ensure a resident did not self administer medications without a physician order for one (#59) of one sampled resident observed for self administration of medications. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 72 residents resided in the facility. Findings: Res #59 had diagnoses which included vitamin deficiency and constipation. A physician order, dated 04/18/23, documented alpha lipoic acid (antioxidant medication) 600 mg one capsule one time per day. A quarterly resident assessment, dated 04/26/23, documented the resident's cognition was intact. On 07/05/23 at 10:03 a.m., Res #59 was observed with a 120 capsule bottle of alpha lipoic acid and a 26.9 ounce bottle of Miralax (laxative medication) in their room. The resident stated a family had brought the Miralax, but they had not taken it. There was no documentation the resident had physician orders to self administer the medications stored in their room. On 07/05/23 at 10:30 a.m., LPN #1 was made aware 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfer/discharge for one (#19) of two residents sampled for hospitalization. The Resident Census and Conditions of Residents form, dated 07/05/23, documented 72 residents resided in the facility. Findings: A discharge return anticipated MDS, dated [DATE], documented Res #19 was discharged to an acute care facility. An entry record MDS, documented Res #19 returned to the facility on [DATE]. On 07/11/23 at 10:34 a.m., the administrator was asked how the ombudsman was notified of resident transfers, they stated the facility does not routinely notify the ombudsman of resident discharges. They stated they were unaware of the requirement to notify in the event of emergency discharge to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a new diagnosis of possible serious mental illness for a level II resident review for one (#64) of one residents sampled for PASARRs. The Resident Census and Conditions of Residents form, dated 07/05/23, documented 72 residents resided in the facility. Findings: Res #64 admitted to the facility on [DATE]. A nursing facility level of care assessment (PASARR level I), dated 07/29/22, documented the resident had no diagnosis of a serious mental illness. On 03/28/23, a diagnosis of bipolar disorder was added to Res #64's list of diagnoses. On 07/11/23 at 9:06 a.m., corporate RN #1 stated the resident was not referred for a level II resident review when the new diagnosis was added.

Based on observation, record review, and interview, the facility failed to update the care plan with fall interventions for one (#1) of one resident sampled for falls. The Resident Census and Conditions of Residents form, dated 07/05/23, documented 72 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included dementia, repeated falls, senile degeneration of the brain, and seizures. A care plan, revised 04/12/23, documented the resident was at risk for falls related to balance, impaired cognition, and right upper extremity weakness. A quarterly assessment, dated 04/29/23, documented the resident had severe cognitive impairment and required extensive assist with all of their ADLs. The assessment documented the resident had two or more falls with no injury and two or more falls with minor injury since the last assessment. A fall report, dated 06/08/23, documented the resident had an unwitnessed fall with minor injury. The fall report documented an intervention of reclining wheelchair back. A fall report, dated 06/10/23, documented the resident had a witnessed…

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 bathed as scheduled for one (#125) of one sampled resident reviewed for bathing. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 72 residents resided in the facility. Findings: Res #125 had diagnoses which included type two diabetes mellitus and diabetic nephropathy. The June 2023 bathing record documented the resident was bathed one out of two opportunities during the week of 06/11/23 through 06/17/23. A comprehensive resident assessment, dated 06/29/23, documented the resident's cognition was intact and required physical help in part of bathing with one person physical assist. A physician order, dated 06/29/23, documented bathe every Wednesday and Saturday on day shift. On 07/05/23 at 10:51 a.m., Res #125 was asked if they were bathed according schedule or their preference. They stated they were supposed to be bathed twice a week and they were not. On 07/06/23 at 10:56 a.m., CNA #2 was asked how often the resident was bathed. They stated the aides were provided…

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 timely physician response to monthly pharmacy medication regimen reviews for one (#38) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/05/23, documented 72 residents resided in the facility. Findings: The facility's policy titled Medication Regimen Review and Reporting, dated January 2023, documented in part .Recommendations shall be acted upon within 30 calendar days . Res #38 had diagnoses which included schizoaffective disorder, bipolar disorder, and anxiety. A physician order, dated 11/24/20, documented to administer oxcarbazepine 150 mg tablet at bedtime for bipolar disorder. A physician order, dated 04/21/22, documented to administer quetiapine 300 mg tablet by mouth at bedtime for schizoaffective disorder. A physician order, dated 10/09/22, documented to administer Lunesta 1 mg tablet by mouth at bedtime for anxiety. A MRR, dated 03/09/23, documented a request for a gradual dose reduction of oxcarbazepine, quetiapine, and Lunesta. A MRR,…

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 interviews, the facility failed to act upon grievances presented to staff during resident council meetings. The Resident Census and Conditions of Residents report, dated 11/30/21, documented 95 residents resided in the facility. Findings: Resident council meeting minutes, dated 09/03/21, documented the residents felt the resident council meetings were pointless because things were not being taken care of. Resident council meetings minutes were reviewed for 09/03/21, 10/01/21, and 11/05/21. There was no documentation the residents' grievances had been acted upon. On 12/02/21 at 10:02 a.m., a confidential group meeting was conducted with four cognitive residents. They were asked if the facility acted upon their grievances and/or recommendations presented during their resident council meetings. They stated their concerns during their meetings were not being addressed. They stated there was no communication and they paid too much money to not have their issues addressed. At 1:21 p.m., the AD was asked what the process was for acting upon residents' grievances…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide bathing services for six (#47, 77, 85, 145, 146, and #196) of nine sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report documented 95 residents who resided at the facility. Findings: 1. Resident (Res) #77 was admitted to the facility on [DATE] with diagnoses which included glaucoma and a recent fracture to his leg. An admission assessment, dated 11/07/21, documented the resident was cognitively intact and required extensive assistance with ADLs including bathing. On 11/30/21 at 11:02 a.m., the resident stated he had only two showers since he had been at the facility. The resident's medical record was reviewed. There was no documentation of bathing in the record. On 12/06/21 at 4:24 p.m., the DON stated she could not find any documentation of showers being given. 2. Res #85 was admitted to the facility on [DATE]. An admission assessment, dated 11/16/21, documented the resident was cognitively intact 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, interview, and record review, the facility failed to provide a safe environment for two (#12 and #196) of two residents reviewed for accident hazards. The Resident Census and Conditions of Residents report documented 95 residents who resided at the facility. Findings: 1. Resident (Res) #196 was admitted to the facility on [DATE] and discharged on 05/26/20. A significant change assessment, dated 05/17/20, documented the resident was severely cognitively impaired and required extensive assistance with ADLs. On 12/08/21 at 10:12 a.m., the resident's room video camera footage for 05/12/20 at 4:29 p.m. was viewed. The camera had filmed two CNAs changing the resident's shirt and then having the resident lean forward lifting off the wheelchair slightly to pull her pants up. When the resident was sitting back down the wheelchair moved and the CNAs, one on each side, held her and put her back in the chair. The wheelchair brakes were not locked and the CNAs were not using a gait belt while having 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 supplements as ordered for one (#12) of two sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report documented 12 residents with unplanned weight loss/gain. Findings: Resident (Res) #12 had diagnoses to include unspecified dysphagia, GERD, and vitamin deficiency. A significant change assessment, dated, 08/28/21, documented the resident's cognition was moderately impaired and he required supervision with setup help only. It documented he was 69 inches in height and weighed 135 pounds. It documented he had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. A physician order, dated 09/22/21, documented the resident was to receive a house shake thickened to nectar consistency three times a day with meals. A nutrition note, dated 12/01/21, documented, the resident's weight had been stable since the last RD note on 09/22/21. The note documented the resident took 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.

2. Res #6 had diagnoses which chronic respiratory failure with hypoxia, chronic diastolic heart failure, dependence on supplemental oxygen and COPD. A physician order, dated 03/21/20, documented the resident was to receive oxygen 2 lpm via NC. A breathing patterns care plan, last reviewed 08/24/21, documented to administer oxygen as ordered. On 11/30/21 at 11:48 a.m., the resident was observed with a portable O2 tank in place on the back of her W/C. The gauge on the portable O2 tank was observed to be full and the dial was set on zero. At 1:00 p.m., the DON was shown the resident's portable O2 tank. She was asked if the resident was supposed to be on continuous O2. She stated she was, but was not sure what the order was for. She was asked if the dial was set at zero. She stated it was. Based on observation, interview and record review, the facility failed to provide oxygen in residents' portable oxygen tanks and/or failed to turn on the oxygen for two (#6 and #24) of three residents sampled for respiratory care. The Resident Census and Conditions of Residents report documented 14…

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 administered pain medications as ordered for three (#5, 24, and #146) of three residents reviewed for pain management. The Resident Census and Conditions of Residents identified 64 residents on a pain management program. Findings: 1. Resident (Res) #146 had diagnoses which arthritis, acute embolism and thrombosis of other specified veins, pain, diabetic neuropathy, pneumonia, and angina pectoris. Physician orders, dated 10/18/21, documented the resident was to receive gabapentin (nerve pain medication) 600 mg four times per day. Physician orders, dated 10/21/21, documented the resident was to receive morphine ER (extended release pain medication) 15 mg q 12 hrs. The eMAR, dated 10/18/21 - 11/09/21, documented the resident was to receive gabapentin 600 mg one tablet four times per day at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 8:00 p.m. During this time period the eMAR documented the resident received the medication a total of 21 out of 84 opportunities from 1 hr and 15 min to 2 hrs and 8 min before or after…

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

Based on observation, interview, and record review, the facility failed to provide a sufficient number of staff on a 24-hour basis to meet the needs of the residents. The Resident Census and Conditions of Residents report documented 95 residents resided in the facility. Findings: 1. On 11/30/21 at 11:02 a.m., Resident (Res) #77 stated he had only two showers since he had been at the facility. He said sometimes you have to wait a long time for call lights to be answered. The resident's medical record was reviewed. There was no documentation of bathing in the record. 2. On 11/30/21 at 12:49 p.m., Res #85 stated his medications were late. He stated sometimes they come in to give evening medications after he has gone to sleep for the night. He said it has been as late as 2:00 p.m. On 12/01/21 at 8:57 a.m., Res #85 stated he did not get a shower for two weeks after he arrived. He stated he did not know where the shower room was until he asked someone and they showed him where it was. He stated he had to have supervision because of his recent falls. The resident's medical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to have medications available and/or administer medications as ordered for five (#52, 84, 85, 145, and #146) of ten sampled residents reviewed for pharmacy services. The Resident Census and Conditions of Residents identified 95 residents who resided in the facility. Findings: 1. Resident (Res) #145 had diagnoses which included type 2 diabetes mellitus. Physician orders, dated 09/25/19, documented the resident was to receive Basaglar KwikPen (Insulin) 35 U SQ q 12 hrs. Physician orders, dated 09/28/19, documented the resident was to receive NovoLog Flexpen (INSULIN) 10 U SQ before meals. Hold if FSBS <100 and inject as directed per sliding scale before meals. The November 2020 eMAR documented the resident was to receive Basglar KwikPen 35 Units SQ q 12 hrs at 8:00 a.m. and 8:00 p.m. During this time period the eMAR documented the resident received the medication a total of 11 out of 62 opportunities from one hr and 17 min to 10 hrs and 56…

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

Based on observation, interview, and record review, the facility failed to provide food that accommodates residents' preferences for seven (#12,14, 33, 47, 61, 70, and #79) seven residents sampled for food preferences. The Resident Census and Conditions of Residents identified 95 residents who resided in the facility. Findings: 1. Resident (Res) #61 had diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris and diabetes mellitus. A physician order, dated 10/18/21, documented the resident was to receive a reduced concentrated sweets/no added salt/thin liquid/regular consistency diet. An admission assessment, dated 10/27/21, documented the resident's cognition was intact and she required supervision with setup help only with eating. On 12/01/21 at 8:47 a.m., the resident was observed in her room and just received her breakfast tray. She was asked if she received what she ordered. She stated she did not, but she would eat what they sent her. The resident's meal ticket indicated she was to have received two cranberry juices, a large…

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

Based on observation, interview, and record review, the facility failed to provide meals in a timely manner. The Resident Census and Conditions of Residents identified 95 residents who resided in the facility. Findings: 1. A meal service procedure sheet, undated, documented lunch service was to begin at 11:30 a.m. It documented hall carts were supposed to go out of the kitchen at 11:30 a.m., 12:00 p.m., and 12:30 p.m. On 11/30/21 at 12:12 p.m., the first food tray was served out of the kitchen for the lunch service. At 12:14 p.m., resident (Res) #11, #34, and #50 were observed at an assisted dining table in the dining room waiting to receive their meals. At 12:44 p.m., the corporate IP was heard telling the staff in the kitchen to give her resident #50's food and she would feed him. She was then observed taking the resident's food tray to him and assisted him with his meal. At 12:49 a.m., Res #34 received his food tray. At 12:50 p.m., Res #11 received her food tray. At 12:51 p.m., CNA #2 was observed assisting Res #11 and #34 with their meals. At 1:16 p.m., Res #91 could be heard…

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 kitchen in good repair and clean. The RD identified 94 residents received services from the kitchen. Findings: On 11/30/21 at 8:05 a.m., a tour of the kitchen was conducted. The following observations were made: a. ceiling lights were burned out, b. dead cockroaches were on the floor and in the light shields in the dish wash area, c. base boards were loose from the wall in the dish wash area and around the hand sink, d. an accumulation of black and white residue was on the floor in the dish wash area, e. an accumulation of white residue was on the dish machine in the dish wash area, f. there was a hole in the wall around the piping below the three compartment sink in the dish wash area, g. an accumulation of dried food splatter was on the base of the Ninja mixer, h. there was dried food splatter on the wall in the prep area, i. an accumulation of grease was on the metal rack next to the fryer, j. an accumulation of dried food debris was on the bulk bin of dried oatmeal in the cook area, k. an accumulation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a dependent resident was not transported and left at his home alone for one (#245) of two residents sampled for abuse and neglect. The Resident Census and Conditions of Residents report documented 95 residents who resided at the facility. Findings: Resident (Res) #245 was admitted to the facility on [DATE] and was discharged home on [DATE]. The resident was [AGE] years old and had diagnoses which included COPD, DM, heart failure, HTN, chronic kidney disease, weakness, and pain. A Baseline Care Plan, dated 05/17/21, documented the resident's discharge goal was to be discharged home and live with family. The care plan documented the resident's concern about the home environment was he was unable to care for himself. The assessment documented the primary caregiver was his son. The assessment documented the resident did not have the potential to discharge/return to the community. The assessment documented the resident was at the facility 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 interview and record review, the facility failed to notify OSDH within two hours of an allegation of abuse for two (#13 and #79) of three resident sampled for abuse. The Resident Census and Conditions of Residents report documented 95 residents who resided at the facility. Findings: The facility's abuse policy read in parts .report such allegation to the State Regulatory Agency .not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The initial Incident Report Form, with an incident date of 10/27/21, documented at approximately 6:30 on 12/27/21, Resident (Res) #13 gave Res #79 a cupcake and sat it on her table. The report documented Res #79 told Res #13 that she did not want the cupcake and gave it back to her. Res #13 picked up the cupcake and threw it at Res #79 and began yelling. Res #13 then wheeled herself towards Res #79 and grabbed Res #79 by both arms. The residents were separated and redirected. The report documented red marks were noted to both of Res #79 arms. The report…

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.