Porthaven Post Acute

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 1 sampled residents (#11) reviewed for sexual abuse. This placed residents at risk for psychological harm. Findings include: The facility's Abuse policy, revised 1/2023, stated the facility and staff would protect residents from all types of abuse. The facility's Resident Sexual Consent policy dated 9/2022, stated a resident's consent to engage in sexual activity is not valid if a resident lacks the capacity to consent. Any forced sexual activity with a resident is considered sexual abuse. Resident 10 admitted to the facility 7/2024, with diagnoses including Alzheimer's disease. Resident 10's 8/2024 MDS indicated she/he was cognitively intact. Resident 10 was discharged home on 8/28/24. Resident 11 admitted to the facility 5/2024, with diagnoses including Factor X chromosome (a genetic disorder causing developmental and intellectual disability). Resident 11's Quarterly Minimum Data Set (MDS) indicated 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, interview, and record review it was determined the facility failed to follow infection control standards for 2 of 4 halls (East and Annex Halls), 1 of 1 dining room, and 2 of 4 sampled residents (#s 28 and 37) reviewed for dining and skin conditions. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. The Centers for Disease Control and Prevention website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use. The facility's 4/2019 Disinfection of Point-of-Care Devices/Instrument Policy & Procedure specified all point-of-care devices, including…

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 it was determined the facility failed to maintain a homelike environment for 3 of 4 halls reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 8/12/24 through 8/16/24 identified the following issues: -A light cover on the annex hall near room [ROOM NUMBER] was cracked with missing chunks of the lighting cover. -One hall light was out on the annex hall near room [ROOM NUMBER]. -Two lights were out in the dining room. -Dirty vent covers in rooms 155, 157, 158, the center hall outside the employee room and outside the RCM office near the west hall. -The east hall near the O2 storage closet had a torn/jagged baseboard to the left of the closet door. -The east hall near the emergency exit had broken pieces of plastic on both wall corners approximately 3 inches in length that were sharp/jagged. -A lower corner wall near the west hall and RCM office…

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 it was determined the facility failed to involve residents/representatives in the care planning process for 2 of 2 sampled residents (#s 4 and 41) reviewed for care planning and dementia. This placed residents at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including dementia. A review of Resident 4's medical record revealed the last care conference completed for Resident 4 was on 2/5/24. On 8/15/24 at 10:12 AM Staff 11 (SSD) stated Resident 4 had not had a care conference completed since 2/5/24. On 8/15/24 at 12:54 AM Staff 6 (LPN Resident Care Manager) and Staff 4 (LPN Resident Care Manager) stated care plan revisions and reviews are reviewed with the resident and/or representatives on a quarterly basis during the care conference. Staff 6 stated Resident 4 was overdue for a care conference. 2. Resident 41 was admitted to the facility in 1/2023 with diagnoses including acute respiratory failure. A 6/15/24 Quarterly MDS revealed Resident 41 had moderate cognitive decline. A review 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 interview and record review it was determined the facility failed to follow up on grievances for 1 of 1 resident (#309) reviewed for personal property. This placed residents at risk for unmet needs. Findings include: Resident 309 was admitted to the facility in 6/2020 with diagnoses including depression. On 7/8/24 a public complaint was received with allegations of missing personal property. On 8/12/24 at 5:25 PM Witness 1 (Complainant) stated Resident 309 was discharged from the facility in 4/2024 and was missing some personal belongings. Witness 1 stated she informed the facility via phone of the missing items but had not received a reply from the facility. On 8/13/24 at 9:41 AM Staff 4 (SSD) stated she never received a complaint or grievance related to missing personal items from Resident 309 or her/his representatives. An 8/14/24 review of the facility grievance binder revealed no evidence of a grievance from Resident 309 or her/his representatives. On 8/14/24 at 11:20 AM Staff 4 (LPN Resident Care Manager) stated she was Resident 309's care manager but had not received…

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 it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalizations for 1 of 1 sampled resident (# 56) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 56 was admitted to the facility in 5/2024 with diagnoses including urinary tract infection and bacteremia (bacteria in blood). Resident 56's 5/23/24 Discharge MDS indicated the resident was discharged to an acute care hospital. A review of Resident 56's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 56 was discharged to a hospital. On 8/15/24 at 12:51 PM Staff 1 (Administrator) stated the facility did not notify the Ombudsman of discharged residents.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 3 residents (#s 4 and 56 ) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including epilepsy and dementia. A 1/31/24 Progress Note revealed Resident 4 experienced a change in condition which required increased medical attention and she/he was transferred to a hospital. A review of Resident 4's health record revealed no documentation to indicate a copy of the facility's bed hold policy was provided to Resident 4 when she/he experienced a change in condition and was transferred to a hospital. On 8/15/24 at 1:24 PM Staff 1 (Administrator) confirmed a bed hold policy was not provided to Resident 4 when she/he experienced a change in condition and was required to be transferred to a hospital. On 8/16/24 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, interview and record review it was determined the facility failed to accurately assess residents for oxygen therapy and wounds for 2 of 6 sampled residents (#s 22 and 37) reviewed for respiratory care and skin conditions. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 12/17/24 through 6/11/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 LPM (liters per minute) per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen to resident's through their noses) for signs of cyanosis (bluish or purple discoloration of the skin, lips and nail beds caused by lack of oxygen), symptoms of dyspnea (difficulty breathing) or shortness of breath. Resident 22's 6/11/24 through 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen…

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 it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 22 and 28) reviewed for respiratory care and unnecessary medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 to 4 LPM (liters per minute) continuously per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen through the nose). Resident 22's 5/14/24 (most current) Care Plan indicated the resident was to receive oxygen per NC at 2 LPM as needed to maintain oxygen saturation levels (a measurement of how well the lungs are working) between 88% and 92%. Observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM to 3:30 PM…

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 it was determined the facility failed to provided nail care services to 1 of 1 resident (# 24) reviewed for ADL care. This placed residents at risk of unmet care needs. Findings include: Resident 24 was admitted to the facility in 2/2020 with diagnoses including a stroke resulting in hemiplegia (partial or complete loss of function of one side of the body). Physician orders from 7/11/22 stated a licensed nurse was to check fingernails and toe nails once a week and trim as needed. A 6/5/24 Care Plan included Resident 24 requiring extensive assistance with ADL tasks including hygiene and grooming. Review of LN Care Records from 6/2024 through 8/2024 revealed nail care was marked as not needed on the following dates: - 6/3/24, - 6/24/24, - 7/1/24, - 7/8/24, - 7/15/24, - 7/22/24, - 7/29/24, - 8/5/24 and - 8/12/24. Review of LN Care Records from 6/2024 revealed Resident 24 refused nail trimming on the following dates: - 6/10/24 and - 6/17/24. On 8/13/24 at 12:35 PM Resident 24 stated her/his nails were too long, nail care had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to start antibiotic treatment timely or follow physician orders for 2 of 9 sampled residents (#s 4 and 28) reviewed for skin condition and unnecessary medications. This placed residents at risk for unmet needs. Finding include: 1. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure, diabetes with a foot ulcer and cellulitis (a bacterial skin infection) of the left lower limb. a. Resident 28's 5/20/24 Quarterly MDS revealed the resident was cognitively intact, had a total of two venous ulcers (leg ulcers caused by problems with blood flow in a person's leg veins) and arterial ulcers (a painful, deep sore or wound in the skin of the lower leg or foot) and received the application of nonsurgical dressings and ointments/medications other than to her/his feet. A 6/26/24 Progress Note indicated Resident 28 was observed to have three large greenish patches on her/his right lower extremity with a…

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

Based on interview and record review it was determined the facility failed to ensure necessary interventions were in place and followed to reduce the risk of falls and to thoroughly investigate the cause of a fall for 2 of 5 sampled residents (#s 37 and 360) reviewed for skin conditions and falls. This placed residents at risk for falls. Findings include: 1. Resident 37 was admitted to the facility in 7/2023 with diagnoses including diabetes, acquired absence of left foot, acquired absence of right toes and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Resident 37's 7/9/23 Morse Fall Scale indicated the resident was at high risk to fall. Resident 37's 3/7/24 At Risk For Falls Care Plan revealed the following: -The resident experienced impaired physical mobility as a result of the surgical amputation of her/his left foot. -The resident had a history of falls. -The resident's call light/personal items were to be within reach. -The resident was to wear nonskid footwear when transferring. -Staff were to remind the…

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

Based on interview and record review it was determined the facility failed to follow physician orders and provide correct humidity administration for 1 of 1 sampled resident (#17) reviewed for respiratory care. This placed residents at risk for improper humidity administration. Findings include: A Respiratory Treatment Policy and Procedure dated 6/22/22 stated: It is the policy of this center that residents receive respiratory treatments and monitoring per their physician orders, standards of practice and care plan. Resident 17 admitted to the facility in 3/2024 with diagnoses including respiratory failure which included a tracheostomy required to breathe and malnutrition. A 3/13/24 physician order for Resident 17 revealed the resident used humidity mist via her/his tracheostomy with a flow rate of eight liters per minute at all times. The 6/13/24 Quarterly MDS indicated Resident 17 was severely cognitively impaired. On 8/15/24 at 8:50 AM Staff 19 (LPN) observed Resident 17's humidity mist and confirmed it was set at four liters per minute. On 8/15/24 at 10:57 AM Staff 3 (Interim…

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 it was determined the facility failed to employ a Physical Therapist to provide therapy services to 1 of 1 resident (# 209) reviewed for therapy services. This placed residents at risk of a decline in function and/or a delayed recovery. Findings include: Resident 209 admitted to the facility on [DATE] with diagnoses including multiple left toe fractures. Hospital orders from 8/6/24 included instructions for Resident 209 to receive a PT evaluation and services. Review of therapy records on from 8/6/24 to 8/13/24 revealed Resident 209 had not been evaluated by PT and therefore had not received PT services to assist with her/his transfer safety and mobility. On 8/14/24 at 2:50 PM Staff 20 (Rehabilitation Director) stated the facility had not been able to have a consistent physical therapist who performed evaluations or provided therapy services. Staff 20 stated the frequency and duration of therapy services had to be reduced for all residents due to insufficient therapy staff.…

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 it was determined the facility failed to have a plan in place to coordinate care and document hospice services for 1 of 1 sampled resident (#359) reviewed for hospice. This placed residents at risk for lack of coordination of care. Findings include: Resident 359 admitted to the facility in 7/2024 with diagnoses including failure to thrive and acute kidney failure. Resident's 359's health record indicated the resident was admitted to hospice services on 8/6/24. There was no further documentation including contact information, physican's orders for hospice services, hospice care plan or hospice notes. On 8/13/24 at 2:01 PM Staff 11 (Social Services Director) stated resident 359 began hospice services on 8/6/24 and Staff 11 did not know when they came in to care for the resident. On 8/14/24 at 10:00 AM Staff 23 (CNA) stated she thought the resident received hospice services, but had not seen any hospice providers and had no communication with any hospice staff. On 8/15/24 at 10:17 AM Staff 5 (RNCM) acknowledged there was no hospice documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to have adequate staff available to meet resident care needs in a timely manner for 1 of 1 facility reviewed for staffing and call light response times. This placed residents at risk for delayed and unmet needs and lengthy call light response times. Findings include: On 5/9/24 the facility had a census of 63 residents. On 5/13/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 12 -Required one or two-person extensive or total assistance for bathing: 58 -Required one or two-person extensive or total assistance for toileting: 22 -Required one or two-person extensive or total assistance for dressing: 39 -Required suctioning due to a tracheostomy (an opening into the trachea from the outside due to obstructed breathing): 2 -Required tube feedings: 4 -Had behavioral healthcare needs: 8 Observations from 5/9/24 through 5/13/24 from the hours of 8:15 AM to 1:30 PM revealed the following concerns:…

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 it was determined the facility's quality assessment and performance improvement committee (QAPI) failed to systematically identify and correct deficiencies in the areas of reporting abuse, safe discharge and accident prevention. This placed residents at risk of abuse, accidents and injuries. Findings include: The facility's 1/4/2024 complaint survey identified the following: 1. The facility failed to report allegations of abuse timely. This deficient practice was also identified on the 2/2024 revisit survey. During an interview on 2/28/24 at 4:22 PM and 2/29/24 at 11:16 AM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional RN) acknowledged the QAPI system the facility had in place was not effective. Staff 3 shared audits she completed which did not systematically address the identified residents and areas the QAPI committee was to address in the facility's plan of correction. Additional information provided by the facility on 2/29/24 and 3/1/24 failed to demonstrate a root cause analysis, systems to identify, report, track,…

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 it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 1 was admitted to the facility in 12/2019 with diagnoses including stroke and dementia. Resident 2 was admitted to the facility in 3/2023 with diagnoses including anxiety and depression. A facility incident report dated 4/30/23 indicated at approximately 9:45 AM Resident 1 (who was on one-to-one staff supervision due to behavioral issues.) and Resident 2 started arguing with each other during a smoking break. Resident 2 told Resident 1 to shut up and used a racial slur. On 12/21/23 at 1:09 PM Staff 3 (CNA) stated on 4/30/23 she was assigned to monitor Resident 1 related to her/his behavior issues. Staff 3 stated while out in the smoking area Resident 1 was talking a lot and Resident 2 told Resident 1 to shut the [profanity] up. The argument escalated with the residents verbally and physically threatening each other and Resident 1 told Resident 2…

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 it was determined the facility failed to timely report allegations of abuse for 2 of 3 sampled residents (#s 6 and 7) reviewed for abuse reporting. This placed residents at risk for abuse. Findings include: 1. Resident 6 was admitted to the facility in 6/2020 with diagnoses including seizures and anxiety. A facility incident report dated 7/21/23 indicated on 7/21/23 an unnamed CNA reported Resident 6 was found wet, with a garbage bag underneath her/him during morning cares on 7/19/23. A Nursing Facility Reported Incident Form dated 7/21/23 indicated the incident was reported to the Sate Agency on 7/21/23. On 12/28/23 at 9:45 AM Staff 1 (Administrator) confirmed the incident was not reported to the State Agency in a timely manner. 2. Resident 7 was admitted to the facility in 10/2022 with diagnoses including obesity and anxiety. A facility incident report dated 7/26/23 indicated on 7/24/23 an unnamed CNA reported another unnamed CNA threw a gown at Resident 7. A Nursing Facility Reported Incident Form dated 7/26/23 indicated the incident 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 interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#13) reviewed for discharge. This placed residents at risk for accidents and lack of ADL care. Findings include: Resident 13 was admitted to the facility in 10/2023 with diagnoses including neck surgery and foot fracture. Resident 13's SNF Utilization Review Skilled dated 11/7/23 indicated the resident had upper body weakness, needed assistance with eating and the resident's upper body (strength and mobility) did not improve. The resident needed maximum assistance with dressing, toileting and bathing. The discharge plan indicated the resident still needed to work on upper body strength. Resident 13's Discharge Summary/Plan of Care dated 12/4/23 indicated the resident was discharging to her/his private residence and home health services would be arranged. Resident 13's Progress Notes dated 12/4/23 indicated the resident was discharged to her/his home with home health services set up. On 12/27/23 at 3:00 PM Witness 5 (Complainant) stated Resident 13 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 interview and record review it was determined the facility failed to ensure a resident was provided ADL care for 1 of 3 sampled residents (#4) reviewed for ADLs. This placed residents at risk for poor hygiene and pressure ulcers. Findings include: Resident 4 was admitted to the facility in 5/2023 with diagnoses including diabetes and anxiety. An undated facility Event Summary indicated overnight between 6/23/23 and 6/24/23 Resident 4 reported she/he was left in her/his wheelchair all night. Staff 4 (CNA) who was assigned to Resident 4 during the night shift stated she was not aware the resident was in her/his wheelchair all night. Staff 4 was terminated for neglect of Resident 4. On 12/27/23 at 10:34 AM Staff 1 (Administrator) confirmed the incident occurred according to the Event Summary.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 4 of 6 residents (#s 6, 14, 18 and 25) reviewed for staffing concerns. This placed residents at risk for delayed and unmet care needs. Findings include: 1. Resident 6 was admitted to the facility in 2022 with diagnoses including a knee fracture and obesity. Resident 6's 3/10/23 Quarterly MDS revealed the resident was cognitively intact. Resident 6's 12/1/22 Self Care Performance ADL Care Plan indicated the resident required extensive assistance with one to two person assistance for bed mobility, dressing, toileting, transfers and personal hygiene. Resident 6's 4/18/23 through 5/2/23 iAlert (call light tracking records) indicated the following delayed response times: Call light times between 20 minutes and 30 minutes: 17 Call light times between 31 minutes and 45 minutes: 7 Call light times between 46 minutes and one hour: 8 Call light times over one hour: 3 Resident 6's call light times were delayed 26% of the time.…

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 it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 3 of 3 sampled residents (#s 1, 44 and 99) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Records reviewed for Residents 1, 44 and 99 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 5/3/23 at 10:02 AM Staff 19 (Regional Director of Operations) stated advance directives were typically sent with the resident from the hospital and placed in their medical record. Staff 19 stated it was his expectation staff asked for advance directives prior to admission and offered one within the first 72 hours of admission. On 5/3/23 at 11:32 AM Staff 1 (Administrator) stated she had not educated social services on going over advance directives prior to admission or offering one within 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 interview and record review it was determined the facility failed to provide a Notice of Medicare Non-coverage for 2 of 3 sampled residents (#s 102 and 103) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 102 was admitted to the facility on [DATE] with diagnoses including influenza and heart attack. Resident 102's Clinical Census (reviewed on 5/5/23) indicated the resident's last covered day of Medicare Part A services (skilled services including therapy) was 1/21/23. On 5/4/23 at 9:26 AM Staff 1 (Administrator) was asked to provide documentation demonstrating Resident 102 was provided a Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal. On 5/4/23 at 11:20 Staff 19 (Regional Director of Operations) stated Resident 102 was not provided with a NOMNC prior to discharge, but a notice should have been provided. 2. Resident 103 was admitted 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 interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 1 sampled resident (#248) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 21 was admitted to the facility in 2019 with diagnoses including dementia with behavior disturbance. Resident 21's 3/16/22 Care Plan included monitoring for behaviors including verbal and physical aggression. Resident 248 was admitted to the facility in 1/2023 with diagnoses including anxiety disorder. Resident 248's 2/2023 cognitive assessment concluded normal cognitive function. Review of a 3/6/23 Facility Incident Report indicated Resident 21 was attempting to get hot chocolate from the kitchen and was asked to wait. Resident 21 observed Resident 248 laughing with staff members and assumed Resident 248 was laughing at her/him. Resident 21 approached and verbally threatened to strike Resident 248. Staff 13 (CNA) intervened and removed Resident 248 from the altercation. A Progress Note dated 3/7/23 at 8:35 AM…

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 is was determined the facility failed to ensure a resident's care plan reflected the needs of the resident for 1 of 2 sampled residents (#99) reviewed for ADLs. This placed residents at risk for pain and injury. Findings include: Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis and [NAME]-Danlos syndrome (a disorder which can cause overly flexible joints which can cause pain and dislocations). A review of Resident 99's Care Plan initiated on 4/19/23 revealed no instructions for staff to handle the resident carefully to prevent joint pain or dislocation. On 5/2/23 at 9:29 AM Resident 99 stated during care staff caused a subluxation (partial dislocation) of her/his left shoulder which caused severe pain. A 4/25/23 incident investigation indicated while Resident 99 was being turned in bed, the resident's arm dropped and caused pain to the resident's left shoulder. The investigation concluded the resident's disease process caused the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide bed baths for 2 of 2 sampled residents (#s 6 and 99) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. On 5/2/23 at 9:31 AM Resident 99 stated she/he had not received a bed bath since she/he was admitted to the facility on [DATE] because the facility had to order hypoallergenic soap. Resident 99's bathing record from 4/20/23 through 5/1/23 indicated the resident received bed baths on 4/24/23, 4/27/23 and 4/29/23. On 5/3/23 at 11:36 AM Staff 13 (CNA) confirmed Resident 99 was not receiving bed baths because the facility did not have the special soap for Resident 99 and were just wiping the resident down with water. On 5/3/23 at 12:19 PM Staff 1 (Administrator) stated she ordered the special soap for Resident 99 and it was delivered the last week of 4/2023. The soap was called Vanicream. 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 interview and record review it was determined the facility failed to ensure physician orders were followed for 2 of 6 sampled residents (#s 23 and 43) reviewed for unnecessary medications and amputation healing. This placed residents at risk for adverse medication consequences and inadequate amputation healing. Findings include: 1. Resident 23 was admitted to the facility in 2/2020 with diagnoses including heart failure, high blood pressure and arteriosclerotic heart disease (thickening and hardening of the heart arteries). A 10/31/22 physician order indicated Resident 23 was prescribed clonidine transdermal patch for hypertensive heart disease with heart failure (heart damage due to chronic high blood pressure), to be applied every Monday and the old patch removed. A review of Resident 23's 4/2023 MAR indicated the clonidine patch was not applied and the old patch was not removed on Monday, 4/10/23. A review of Resident 23's 4/2023 Progress Notes revealed no documentation regarding the resident's missed clonidine patch and no evidence Resident 23's medical provider 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, interview and record review it was determined the facility failed to provide necessary services for pressure ulcer care for 1 of 1 sampled resident (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 7 was admitted to the facility in 2019 and was diagnosed with a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on her/his coccyx (tailbone) in 1/2022. Resident 7's 1/2023 Care Plan included instructions for pressure ulcer healing for her/his coccyx including repositioning Resident 7 at least every two hours. On 5/1/23 at 2:52 PM Resident 7 said, [she/he] would be lying if [she/he] said I was repositioned every two hours. On 5/2/23 at 10:21 AM Resident 7 stated she/he had not been repositioned since she/he had received breakfast around 8:00 AM that morning. Observations of Resident 7 were made on 5/3/23 from 10:15 AM through 12:27 PM. No positioning change assistance was provided during the observation period. At 12:27 PM, Resident 7 stated she/he had not…

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

Based on observation, interview and record review it was determined the facility failed to provide foot care for 1 of 2 sampled residents (#6) reviewed for ADLs. This placed residents at risk for increased foot problems. Findings include: Resident 6 was admitted to the facility in 12/2022 with diagnoses including a knee fracture and obesity. Resident 6's 3/10/23 Quarterly MDS indicated the resident had intact cognition and required extensive assistance with one person physical assistance for personal hygiene. On 5/1/23 at 3:38 PM and 5/3/23 at 8:58 AM Resident 6 was observed with long, yellow and very thick toenails on both feet. Resident 6 stated her/his toenails were starting to get long before she/he was admitted to the facility and the toenails grew a lot since her/his admission. Resident 6 stated she/he asked a nurse to trim her/his toenails a long time ago but they said they did not have the right type of clippers. Resident 6 stated nothing had been done about her/his long toenails. A review of Resident 6's health record did not include evidence the resident received toenail…

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 it was determined the facility failed to provide brace/splint devices to prevent further decrease in range of motion for 2 of 2 sampled residents (#s 14 and 27) reviewed for ROM. This placed residents at risk for worsening contractures. Findings include: 1. Resident 14 was admitted to the facility in 2018 with diagnoses including stroke and left sided flaccid hemiplegia (severe or complete loss of motor function on one side of the body). Resident 14's 1/26/23 Annual MDS indicated the resident had upper and lower extremity impairment on one side and there were 0 days with brace/splint assistance. Resident 14's current Care Plan instructed staff to apply the resident's brace twice daily for four hours and remove for four hours in between. Resident 14's 4/1/23 through 4/30/23 Brace Donning log indicated the following: -Staff documented Resident 14 wore her/his brace for 3-15 minutes on 11 days. -Staff documented Resident 14 refused her/his brace on 13 days. -Staff documented not applicable on 15 days. Observations on 5/1/23 at 11:45 AM,…

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 1. Based on observation and interview it was determined the facility failed to ensure residents' environment was free from hazards for 1 of 1 facilities randomly observed. This placed residents at risk for injury and blood borne infection. Findings include: a. A random observation on 5/1/23 at 11:14 AM revealed several unused syringes on top of a medication cart by room [ROOM NUMBER]. The syringes were unsecured and unmonitored by staff. On 5/1/23 at 11:18 AM Staff 1 (Administrator) verified the syringes were unsecured. b. A random observation on 5/2/23 at 9:21 AM revealed a large sharps container on a cart by room [ROOM NUMBER]. The sharps container did not have a lid on the top and numerous used sharps and syringes were in the container. The container was not being monitored by staff. On 5/2/23 at 10:29 AM Staff 20 (former Administrator) verified the sharps container did not have a lid and had used sharps including syringes. 2. Based on observation, interview and record review it was determined the facility…

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 it was determined the facility failed to conduct post dialysis assessments of resident's condition for 1 of 1 sampled resident (#31) reviewed for dialysis. This placed residents at risk for potential unmet care needs upon return from dialysis. Findings include: Resident 31 was re-admitted to the facility in 12/2022 with diagnosis including end stage renal disease and diabetes with other diabetic kidney complications. Resident 31's Care Plan identified she/he needed dialysis due to end stage renal disease, which was scheduled every Monday, Wednesday and Friday. Interventions included to monitor and report any problems with the resident's access site to the physician or dialysis nurse. The facility's Dialysis Transfer Form included a Post Dialysis Nursing Assessment to be completed by the facility upon the residents return from dialysis. The Post Dialysis Nursing Assessment included the following sections: Lung sounds, access site, bruit, thrill, signs/symptoms of post dialysis complications, temperature, pulse, rate, BP and did 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 interview and record review it was determined the facility failed to ensure resident records were accurate for 2 of 3 sampled residents (#s 43 and 99) reviewed for bathing and skin conditions. This placed residents at risk for poor hygiene and improper amputation healing. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. On 5/2/23 at 9:31 AM Resident 99 stated she/he had not received a bed bath since she/he was admitted to the facility on [DATE] because the facility had to order hypoallergenic soap. Resident 99's bathing record from 4/20/23 through 5/1/23 indicated the resident received bed baths on 4/24/23, 4/27/23 and 4/29/23. On 5/3/23 at 11:36 AM Staff 13 (CNA) confirmed Resident 99 was not receiving bed baths because they did not have the special soap for Resident 99 and were just wiping the resident down with water. Refer to F677 example 1. 2. Resident 43 was admitted to the facility in 2023 with diagnoses including a left leg above the knee…

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 it was determined the facility failed to maintain respiratory care equipment in a sanitary manner and perform wound care in a sterile manner for 2 of 2 sampled residents (#s 29 and 99) reviewed for respiratory care. This placed residents at risk for infection. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. A physician order dated 4/20/23 indicated staff were to change Resident 99's disposable inner cannula (The smaller inner tube which inserted into the larger outer tube of a tracheostomy (an independent airway created by a surgical incision in the neck into the windpipe)) every day. Resident 99's 5/2023 TAR included replacement of the inner cannula and tracheostomy care every day and PRN. On 5/3/23 at 9:42 AM Staff 17 (RN) was observed as she performed tracheostomy care for Resident 99. Resident 99 had a vertical tracheotomy (the incision which created the tracheostomy) which extended slightly below the outer cannula and a bandage was in place over the incision. Staff 17 obtained a new…

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 it was determined the facility failed to ensure residents' call lights were functional for 1 of 1 sampled resident (#27) reviewed for call light functioning concerns. This placed residents at risk for delayed assistance. Findings include: Resident 27 was admitted to the facility in 2020 with diagnoses including a stroke. On 5/1/23 at 3:00 PM, 5/2/23 at 8:30 AM and 9:29 AM and 5/3/23 at 8:19 AM Resident 27 turned on her/his call light which was observed to not be activated on the call light monitors located in the hallways and at the nursing station. On 5/1/23 at 3:00 PM Resident 27 stated her/his call light did not work and had not been working for a while. On 5/3/23 at 8:20 AM Resident 27 turned on her/his call light and Staff 11 (CNA) confirmed the resident's call light did not activate. Staff 11 pulled the call light cord from the device and re-inserted it and the call light still did not activate. On 5/3/23 at 10:40 AM Staff 16 (Maintenance Director) confirmed Resident 27's call light was not working. Staff 16 stated he completed…

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.