Beacon Ridge

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety and dishes were sanitized prior to use. The DON identified 57 residents resided in the facility and received services from the kitchen. Findings: An initial tour of the kitchen was conducted on 11/18/24 at 10:39 a.m. The following observations were made: a. an open bottle of nectar thickened water with lemon, dated open on 11/07/24. The label on the container documented to discard after 10 days of opening; b. an open bottle of nectar thickened orange juice, dated open 11/03/24. The label on the container documented to discard after 10 days of opening; c. an open bottle of honey thickened orange juice, not dated when opened; d. an open bottle of honey thickened milk, dated open on 11/07/24. The label on the container documented to discard after four days of opening; e. an open bottle of honey thickened orange juice, not dated when opened; and d. the walk in freezer door was observed with ice accumulation on the outside of the seal to the…

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

Based on record review and interview, the facility failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The DON identified 57 residents who resided in the facility. Findings: A Legionella Water Management policy, revised September 2022, read in part, As part of the infection control prevention and control program, our facility has a water management program, which is overseen by the water management team .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .The water management program includes the following elements: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that could lead to Legionella growth, specific measures…

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 conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four (#3, 5, 14, and #44) of four sampled residents reviewed for accident hazards. The DON identified 13 residents whose beds were equipped with a bed rail of any type. Findings: An undated Proper Use of Bed Rails policy, read in parts, If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails .The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible and ensuring that the bed's dimensions are appropriate for the resident .Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair .The maintenance director, or designee, is responsible for adhering to a routine maintenance and…

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

Based on record review and interview, the facility failed to report an allegation of abuse to OSDH within two hours. The DON identified 57 residents resided in the facility. Findings: A facility Abuse, Neglect, and Exploitation policy, dated 2024, documented the facility was to report all allegations of abuse immediately, but no longer than two hours after the allegation was made. A facility reported incident, dated 10/16/24, documented an allegation of abuse regarding LPN #3. The incident report was not sent to OSDH until 10/17/24. On 11/19/24 at 11:58 a.m., the MDS coordinator stated the incident report should have been sent to OSDH within two hours, but was not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete comprehensive MDS assessments within the required time frame for two (#15 and #109) of five sampled residents reviewed for MDS assessment completion. The DON identified 57 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, documented a significant change MDS must be completed no later than the 14th calendar day after determination a significant change had occurred. The manual also documented an admission assessment must be completed no later than the 14th day of the resident's admission. 1. Res #15 had a significant change assessment with an ARD of 10/16/24, reflective of the determination date a significant change had occurred. The MDS was not completed and signed until 11/18/24. 2. Res #109 was admitted to the facility on [DATE]. A comprehensive MDS was not completed until 11/18/24. On 11/19/24 at 9:30 a.m., the MDS coordinator 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a baseline care plan within 48 hours of admission for one (#109) of five sampled residents reviewed for MDS completion. The DON identified 57 residents resided in the facility. Findings: Res #109 was admitted to the facility on [DATE]. On 11/18/24 there was no active care plan documented in the resident's chart. On 11/19/24 at 9:30 a.m., the MDS coordinator stated baseline care plans should be completed within 48 hours of admission. They stated the facility had been without a MDS coordinator for about five months. They stated they were aware there were some issues with care plans.

Based on observation, record review, and interview, the facility failed to review/revise a care plan for one (#17) of 15 sampled residents reviewed for care plans. The DON identified 57 residents resided in the facility. Findings: Res #17 was admitted to the facility with diagnoses which included chronic kidney disease, HTN, and chronic pain syndrome. A significant change assessment, dated 09/15/24, documented the resident was frequently incontinent of bladder and required partial to moderate assist with transfers. The assessment did not document the resident had an uindwelling catheter. A physician's order, dated 10/15/24, documented Hoyer lift with all transfers. On 11/18/24 at 11:40 a.m., Resident #17 was observed resting in bed with their eyes open. A catheter was observed draining to gravity at bedside. The resident's record was reviewed and the care plan had not been revised to document transfers with a lift or the catheter. On 11/20/24 at 12:03 p.m., the corporate nurse stated the care plan should have been revised to contain transfers with the lift and the catheter.

Based on observation, record review, and interview, the facilty failed to obtain a physician's order for a catheter for one (#17) of one sampled resident reviewed for catheters. The DON identified 57 residents resided in the facility. Findings: Res #17 admitted to the facility with diagnoses which included chronic kidney disease, HTN, and chronic pain syndrome. On 11/18/24 at 11:40 a.m., resident #17 was observed resting in bed with their eyes open. A catheter was observed draining to gravity at bedside. The resident's record was reviewed and did not contain a physician's order for a catheter. The resident's care plan was reviewed and did not document the resident's catheter. On 11/20/24 at 12:03 p.m., the corporate nurse stated a physician's order should have been obtained and the care plan for the catheter should have been developed.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 30 opportunities were observed with two errors. The total medication error rate was 6.67% related to incorrect doses of medication given to one (#55) of four sampled residents observed during the medication pass. The ADON identified 57 residents resided in the facility. Findings: An undated Medication Errors policy, read in part, The facility must ensure that it is free of medication error rates of 5% or greater. A physician's order for Resident #55 documented they were to receive fludrocortisone (steroid) 0.1mg tab - 0.5mg (5 tabs) by mouth daily and vitamin D3 25mg by mouth daily. A notation on the label of the blister pack for Resident #55's fludrocortisone 0.1mg tab read in part, give 5 tablets by mouth daily. The label on the blister pack for Resident #55's vitamin D3 read in part, vitamin D3 1,000 IU. On 11/20/24 at 10:24 a.m., CMA #1 was observed while administering medications to Resident #55. Medications administered by CMA #1 to Resident #55…

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 QAA committee met at least quarterly. The DON identified 57 residents resided in the facility. Findings: The QAA committee meetings were reviewed. The last QAA meeting documented was February of 2024. A QAA form, dated 08/22/24, documented a meeting was not completed in August 2024 due to the lack of a DON and staff. On 11/21/24 at 9:25 a.m., the interim administrator stated QAA meetings should have been completed quarterly. On 11/21/24 at 9:41 a.m., the interim administrator stated documentation of quarterly QAA meetings could not be located.

Based on interview and record review, the facility failed to conduct and document a facility-wide assessment. The BOM identified 56 residents resided in the facility Findings: On 01/24/24 at 8:03 a.m., the BOM was asked for a copy of the facility assessment. They stated they were unsure what a facility assessment was but would ask the stand-in administrator. On 01/24/24 at 12:03 a.m., the stand-in administrator presented their emergency preparedness book. They were informed it was not a facility assessment. They stated they would continue to look for the it. On 01/25/24 at 9:25 a.m., the stand-in administrator presented their emergency preparedness book stating this was their facility assessment. They were informed of the components required for a facility assessment. They stated they had never heard of a facility assessment and had never seen one in any of their buildings. On 01/25/24 at 10:00 a.m., the stand-in administrator stated they were unable to locate a facility assessment.

Based on observation, interview, and record review, the facility failed to: a. implement their infection control program to prevent potential spreading of influenza; b. ensure OSDH was notified when residents and/or facility staff had a positive influenza test result; and c. implement a surveillance plan for identifying, tracking, monitoring and/or reporting signs/symptoms of influenza for six (#1, 4, 5, 6, 7, and #9) of seven residents sampled for infection control. The BOM identified 56 residents resided in the facility Findings: A facility policy titled, Infection Prevention and Control Program, revised October 2018, documented, .7. Surveillance .b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks .monitoring employee infection, monitoring adherence to infection prevention and control practices .10. Outbreak Management a. Outbreak management is a process that consists of . (3) preventing the spread to other residents .11. Prevention of Infection a. (4) communicating the importance of standard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed related to the resident's dental status for one (#10) of three sampled residents whose care plans were reviewed. The administrator identified 52 residents who resided in the facility. Findings: Res #10 was admitted to the facility on [DATE] with diagnoses which included diabetes, dental caries, and hypertension. An admission assessment, dated 04/18/23, documented the resident's dental status was obvious or likely cavity or broken natural teeth. There was no comprehensive care plan developed or implemented for Res #10's dental status and to include their upper and lower teeth extractions. On 01/09/23 at 1:17 p.m., the DON stated a comprehensive care plan related to the resident's dental status had not been completed but should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident records were complete for one (#10) of three residents whose records were reviewed. The administrator identified 52 residents resided in the facility. Findings: Res #10 was admitted to the facility on [DATE] with diagnoses which included diabetes, dental caries, and hypertension, right shoulder pain, and atrial fibrillation. An admission assessment, dated 04/18/23, documented Res #10's cognition was intact and was dependent on staff for most ADLs. A physician's progress note, dated 07/24/23, documented Res #10 attended an appointment with an orthopedic physician. There was no documentation found in the resident's record they had attended the appointment or when the resident returned to the facility. There also was no nursing documentation of the resident's condition upon return to the facility or if any physician orders were put in place. A physician's progress note, dated 10/11/23, documented Res #10 attended an appointment with 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 residents had access to monies held in their trust account at all times for two (#14 and #206) of two sampled residents for access to their trust funds. The Resident Census and Condition of the Residents report, dated 09/08/23, documented 55 residents resided in the facility. The BOM identified 39 residents in the trust account. Findings: The Management of Residents' Personal Fund, policy, revised 03/2021, read in part, .Should our facility be appointed the residents' representative payee, and directly receives monthly benefits which the resident is entitled , such funds are managed in accordance with established policies and federal/state requirements . The BOM could not provide any financial statement's on resident held trust accounts prior to 07/01/23. On 09/05/23 at 1:59 p.m., Resident #206 stated they did not have access to their funds held in the trust account from January 2023 through August 2023. On 09/06/23 at 6:07 a.m., Resident #14 was asked about how their personal funds were managed. They stated from…

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 NOMNC and SNF ABN were provided for a facility initiated discharge from Medicare Part A services with days remaining for two (#256 and #23) of three sampled residents reviewed for beneficiary notices. The Entrance Conference Worksheet, undated, documented three residents discharged from Medication Part A services with days remaining in the last six months. Findings: An Advance Beneficiary Notice of Non-Coverage, policy, undated, read in part, .The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case .healthcare providers .must complete the ABN as described below in order to transfer potential financial liability to the beneficiary, and deliver the notice prior to providing the items or services that are the subject of the notice . A SNF Beneficiary Protection Notification Review report, documented Resident #256 started Medicare Part A skilled services on 03/29/23 and the last covered day was 04/14/23. It 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 ensure a comprehensive care plan was completed for two (#19 and #255) of 15 sampled residents reviewed for comprehensive care plan. The Resident Census and Conditions of Residents report, dated 09/08/23, identified 55 residents resided in the facility. Findings: A Care Planning policy, revised date, March 2022, read in part .the comprehensive, person-centered care plan is developed within seven (7) days of completion of the required MDS assessment (Admission, Annual or Significant Change in Status), no more that 21 days after admission . 1. Resident #19 had been admitted to the facility on [DATE] with diagnosis which included dementia, and atrial fibrillation. A Care Plan, dated, 07/13/23 documented one focus regarding personal choices. There were no other focus areas documented on the care plan. On 09/06/23 at 11:25 a.m., MDS coordinator #1 was asked what the policy was on implementing a comprehensive care plan. They stated I am not sure. The MDS…

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

Based on record review and interview, the facility failed to ensure a resident was provided an involuntary notice of discharge that met the federal requirements for one (#256) of one sampled resident reviewed for involuntary discharge. The Resident Census and Conditions of Residents report, dated 09/08/23, identified 55 residents resided in the facility. Findings: Resident #256 had diagnoses which included paranoid schizophrenia, depression, and dementia. A Nurse Progress Note dated, 8/11/23, read in part, .resident was indeed unresponsive, EMSA arrived, resident transferred to [hospital] . A Hospital Physician Discharge Note, dated 08/15/23, read in part, .on arrival to our facility the resident was otherwise medically stable however prior nursing home refused to accept to patient back stating that the resident was discharged that day due to nonpayment and because of chronic medical issues they cannot take care of . There was no documentation that a 30 day involuntary discharge notice had been given to Resident #256 or family. On 09/07/23 at 8:15 a.m., the Administrator was asked…

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 allowed to return to the facility after they were hospitalized for one (#256) of two sampled residents reviewed for discharges. The Resident Census and Conditions of Residents report, dated 09/08/23, identified 55 residents resided in the facility. Findings: A admission Agreement document, undated, read in parts, .either party may terminate this agreement by giving a 30 day notice . Resident #256 had diagnoses which included dementia, schizophrenia, depression. A Nurses Progress Note, dated 08/11/23, documented to transfer the resident to the hospital. On 09/07/23 at 8:15 a.m., the Administrator was asked what the policy was for readmission to the facility after a hospital stay. She stated the facility tries to accommodate date every residents needs. She was asked if Resident #256 wanted to come back to the facility. She stated Yes, and he was refused because the facility could not take care of resident.

Based on record review and interview, the facility failed to ensure a care plan was revised to reflect fall interventions for one (#16) of 15 sampled residents reviewed for care plans. The Residents Census and Conditions of Residents report, dated 09/08/23, documented 55 residents resided in the facility. Findings: Resident #16 had diagnoses which included dementia and displaced intertrochanteric fracture of right femur. A Nurse Progress Note, dated 04/05/23, read in part, .resident outside for .smoke break observed by staff tripping over leg of chair fell onto right knee and right side resident got right back up and said I'm okay .Assess outside area when [Resident] goes out for smoke break to make sure chairs are not to close together assist resident with pulling out chair or move chair for [Resident] assist with seating to ensure safety . A Nurse Progress Note, dated 05/22/23, read in part, .Resident just got a pop out of the vending machine turned to walk away lost balance fell onto left hip . A Care Plan, revised on 05/23/23, did not document any interventions for the falls…

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's referral for an outside appointment was completed timely for one (#17) of two residents reviewed for social services. The Residents Census and Condition of Residents report, dated 09/08/23, documented 55 residents resided in the facility. Findings: A Referral Policy, undated, read in part, .Our facility policy strives to act promptly on resident referrals to outside doctors/specialists. Once a referral is received the following takes place .The information is then given to our Social Service Director to schedule an appointment. This needs to be completed within 48 hours of receiving the information . Resident #17 had diagnoses which included glaucoma. A Quarterly Assessment, dated 06/08/23, documented Resident #17's cognition was intact. A Physician's Order, dated 08/24/23, documented, .Referral to see an optometrist . On 09/05/23 at 10:04 a.m., Resident #17 stated they had a problem with their left eye. They stated they had received two different eye drops, but their eye continued to be puffy and…

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

Based on record review and interview, the facility failed to ensure side effect monitoring was in place for a resident who was prescribed anticoagulants for one (#54) of five residents sampled for medication review. The Resident Census and Condition of the Residents report, dated 09/08/23, documented 55 residents resided in the facility. The DON identified six residents were prescribed anticoagulants. Findings: A High Risk Medications-Anticoagulants policy, undated, read in part, .The residents plan of care shall alert staff to monitor for adverse consequences. Risk associated with anticoagulant include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit or blood pressure c. Thromboembolism . Resident # 54 had diagnoses which included cerebral infarction, unspecified psychosis, and morbid obesity. A Physician order, dated 01/02/23, read in part, . Apixaban Tablet 5 MG Give 5 mg by mouth two times a day for Anti-coagulant . A Quarterly Assessment, dated 03/28/23, documented Resident #54's cognition was moderately…

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 dental services were provided to one (#40) of one sampled residents reviewed for dental services. The Resident Census and Condition of Residents report, dated 09/08/23, documented 55 residents resided in the facility. Findings: An Emergency Dental Care policy, undated, read in part, .dental care is available .Social services shall contact the consultant dentist to set up the appointment ( should social services not be available, the charge nurse shall contact the consultant dentist . Resident #40 had diagnoses which included depressive disorder, polyosteoarthritis, type 2 diabetes, and panic disorder. A Comprehensive Assessment, dated 04/23/23, documented the resident's cognition was mildly impaired. A Physician Order, dated 05/12/23, read in parts, .Ibuprofen Oral Tablet 600 MG .Give 600 mg by mouth every 6 hours for tooth pain . A Physician's Order, dated 06/27/23, read in part, .refer to dentist for possible gum/tooth infection . The MAR, dated 06/01/23 through 08/01/23, documented Resident #40 received Ibuprofen…

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 required staff in-service for dementia training was conducted annually for nurse assistants. The DON identified 24 residents with dementia resided in the facility. Findings: A Dementia protocol, revised November 2018, read in part .nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually . The facility in-service records were reviewed. There was no documented in-service for dementia training with nurse assistants since 04/22/22. On 09/07/23 at 10:53 a.m., the ADON was asked for the in-service logs for the facility. They stated there were no in-services since 11/28/22 and have not had one since. On 09/07/23 at 10:57 a.m., the DON was asked when in-service for nursing staff regarding dementia training had been conducted. She stated, I have not done any of the in-services.

Based on interview and record review, the facility failed to ensure skills competency evaluations were conducted: a. annually for three certified nurse aides (#1, 2, and #3) of five personnel files reviewed. b. upon hire for three certified nurse aides (#4, 5, and #6) of three personnel files reviewed. The Administrator reported a census of 52 residents. Findings: A policy and procedure, labeled Competency Evaluation, dated 01/01/21, documented in parts .Policy: It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents .Initial competency is evaluated during the orientation process .subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment .or/or job performance evaluations .checklists are used to document training and competency evaluations .employee competency forms are maintained .in the employee's personnel file . 1. CNA #1 was hired on 11/09/20. A review of the employee's personnel file did not document an annual…

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 quarterly assessment was conducted every three months for two residents (#1 and #2) of two reviewed for timely submission of resident assessments. The Administrator reported a census of 52 residents. Findings: 1. Resident (Res) #1 was admitted to the facility on [DATE] and had diagnoses which included chronic obstructive pulmonary disease, schizoeffective disorder bipolar type, and anxiety. A review of the Res's MDS assessment (a resident assessment tool used to identify resident care needs) documented the last quarterly MDS assessment was dated 08/20/21. The resident records did not document a November 2021 quarterly assessment. 2. Res #2 was admitted to the facility on [DATE] and had diagnoses which included kidney failure, diabetes mellitus, and depression. A review of the Res's MDS documented the last quarterly MDS assessment was dated 09/27/21. The resident records did not document a December 2021 quarterly assessment. On 02/08/22 at 8:29…

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.