Kingston Court Skilled Nursing And Rehabilitation

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of five residents reviewed (Resident 5). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). A review of Resident 5's clinical record revealed diagnoses that included muscle weakness and ileus (also known as paralytic ileus or pseudo-obstruction, is a condition where the intestines are blocked and stop working properly. It occurs when the muscles in the intestines stop squeezing to move food 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 policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident receives adequate supervision to prevent accidents for one of five residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). Staff may escort patients, if needed . A review of Resident 2's clinical record revealed diagnoses that included obstructive uropathy (a condition that occurs when urine is unable to drain normally through the urinary tract, resulting in a backup of urine and potential kidney damage) and chronic kidney disease (a condition where the kidneys…

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 facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of three residents reviewed (Residents 8 and 60). Findings include: Review of facility policy, titled Restorative Nursing, last revised on August 7, 2023, read, in part, Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. A licensed nurse must supervise the activities in the restorative nursing program. Purpose: to help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Implement the restorative nursing program according to the specifics on the care plan. Document daily on restorative nursing record in PointClickCare ADL Point of Care. Review of Resident 8's clinical record revealed diagnoses that…

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 facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards, and failed to maintain complete and accurate records related to dialysis communication for one of three residents reviewed for dialysis (Resident 93). Findings include: Review of facility policy, titled Procedure: Dialysis: Home Hemodialysis (HHD), last revised January 8, 2024, read, in part, At completion of HHD, Center staff will report and document: Vital signs; Documentation will include: Pre-HHD assessment and vital signs; Condition of AV access site or catheter insertion site with date and time of dressing change; Dialysis facility staff will report to Center staff upon completion of HHD. Review of Resident 93's clinical record revealed diagnoses that included dependence on renal dialysis (a treatment for kidney failure that filters your blood and removes toxins, waste, and excess fluids), hypertension (high blood pressure), 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 review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10); failed to provide annual training that included dementia management and resident abuse prevention for one of five nurse aide employee records reviewed (Employee 7); and failed to provide annual training that included abuse prevention for one of five nurse aide employee records reviewed (Employee 6). Findings Include: Review of personnel information revealed Employee 6's hire date was November 28, 2014; Employee 7's hire date was March 9, 2023; Employee 8's hire date was February 1, 2023; Employee 9's hire date was April 4, 2023; and Employee 10's hire date was December 10, 2022. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training…

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 review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 341). Findings include: Review of Resident 341's clinical record revealed the Resident was readmitted to the facility on [DATE], after a hospital stay and that their payor source was Medicare A. Skilled services ended on April 14, 2024, and Resident 341's payor source changed to Medicaid at that time, and Resident 341 remained in the facility. Resident 341 was issued a Notice of Medicare Non-Coverage (NOMNC- indicates when your coverage for care is set to end) on April 16, 2024. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, a form provides information that as of a specific date Medicare coverage ends and the specific amount 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 observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of three dining areas and four of 77 resident rooms observed (Resident 60, 71, 94, and 114). Findings include: Observation of Resident 60's room on August 26, 2024, at approximately 11:20 AM, revealed that the plastic molding was peeling away from the wall and hanging under the heating/ air conditioning unit. Observation of Resident 71's room on August 26, 2024, at approximately 11:00 AM, revealed that the plastic molding was missing from the wall at the head of their bed. Observation of Resident 114's room on August 26, 2024, at approximately 11:45 AM, revealed gouges in the wall near the head of their bed. Observation of Heritage Dining Room on August 26, 2024, at approximately 12:25 PM, revealed a stationary dining chair that had a missing piece of vinyl from the seating surface. During an interview with the Nursing Home Administrator (NHA) on August 29, 2024, at 10:48 AM, the NHA indicated the necessary repairs 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.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 30 residents reviewed (Residents 36 and 119). Findings include: Review of Resident 36's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 36's Annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of August 14, 2024, revealed in Section P. Restraints and Alarms that Resident 36 was coded as receiving a limb restraint when in bed on a daily basis. Review of Resident 36's current physician orders failed to reveal an order for a limb restraint. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to coordinate the resident assessment for one of four discharged residents reviewed (Resident 110). Findings include: Review of Resident 110's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and multiple sclerosis (disease of the central nervous system that damages the nerves, resulting in possible vision loss, pain, fatigue, loss of ability to speak, walk, and control motor movements). Review of Resident 110's clinical record revealed Resident 110 was admitted to the facility on [DATE]. Review of Resident 110's clinical record revealed that on May 31, 2024, Resident 110 left the facility against medical advice (AMA). Review of the history of Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents physical, cognitive and psychosocial needs) revealed that as of August 26, 2024, the facility did not complete a Discharge MDS. During a 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 facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 27 residents reviewed (Residents 6 and 94). Findings include: Review of facility policy, titled OPS214 Treatment: Refusal of, with a last revision date of March 1, 2022, revealed, in part: 1. If the patient refuses treatment, staff will determine what the patient is refusing and why. Staff will: 1.1 Try to address the patient's concern(s); 1.2 Consult his /her supervisor; 3. Notify physician of the refusal of the treatment; 4. Staff will 4.1 Determine and document what the patient is refusing; 4.2 Assess the reasons for the refusal; 4.3 Advise patient/HCDM [health care decision maker] of consequences of refusal; 4.4 Offer alternative treatments; and 6. Document discussions with the patient/HCDM, physician, and other involved persons. Review of Resident 6'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.

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care and services consistent with professional standards of practice for one of five residents reviewed for respiratory care/oxygen services (Resident 58). Findings include: Review of facility policy, titled Respiratory Equipment/Supply Cleaning/Disinfection, last revised June 1, 2021, revealed Policy: Cleaning and disinfection of respiratory equipment is performed by a respiratory therapist, licensed nurse, or equipment technician. All respiratory equipment which cannot be immersed in water is cleaned with a disinfecting solution and allowed to dry. Disinfection is performed on all equipment on a scheduled basis and upon discontinuation from service and between patients. Purpose: To remove microorganisms from the surfaces of equipment. Review of Resident 58's clinical record revealed diagnoses that included obstructive sleep apnea (OSA- a sleep-related breathing disorder that causes repeated disruptions in breathing during…

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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide a record of the pharmacist's recommendation along with the physician's response for one of five residents reviewed for unnecessary medications (Resident 119), and failed to act upon a pharmacy recommendation appropriately or in a timely manner for one of five residents reviewed for unnecessary medications (Resident 46). Findings include: Review of the facility policy, titled Medication Regimen Review (MRR) and Reporting, last reviewed January 2024, read, in part, Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians, and the care planning team within 48 hours of MRR completion. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar…

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, facility policy, product information, and staff interviews, it was determined that the facility failed to store medication in accordance with professional principles for one of three medication storage rooms observed (Heritage Medication Storage Room). Findings Include: Review of facility provided policy, Medication Administration General Guidelines, effective [DATE], revealed, No expired medication will be administered to a resident. Observation of the Heritage Medication Storage Room on [DATE], at 9:15 AM, revealed one single-dose vial of Aranesp (medication used to treat low red blood cell count) 40mcg/1ml. The vial was open with the cap removed and no opened date on the vial. Review of Aranesp product information on [DATE], revealed that Aranesp is only available in single dose vials. Further review revealed once opened Aranesp should only be used one time. Throw the vial away after use even if there is medicine left in the vial. Interview with Employee 1 (Registered Nurse Supervisor)…

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 clinical record review, facility document review, and staff interviews, it was determined that the facility failed to document education regarding the influenza vaccination at the time of refusal for two of five residents reviewed for immunizations (Residents 46 and 85). Findings include: Review of facility influenza vaccination tracking revealed that Residents 46 and 85 had refused the 2023/2024 influenza vaccine. Review of available information revealed that the facility was unable to provide documentation that the facility provided education of the benefits and potential risks of not accepting the 2023/2024 influenza vaccination to Residents (or Resident Representative) 46 and 86. During an interview with the facility's Infection Preventionist on August 29, 2024, at approximately 1:00 PM, it was revealed that the facility could not locate documentation that education was provided to Resident 46. Further, it was revealed that the facility employee that documented Resident 85's influenza vaccination refusal was not aware that the Resident and/or Resident Representative 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 review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 5 residents reviewed (Residents 1, 3, and 4). Findings include: Review of facility policy, Central Vascular Access Device Dressing Change policy, revised August 1, 2021, read, in part, upon admission, if a resident has a transparent dressing, and the dressing is clean and dated it may be changed in 7 days from the date on the dressing and completed at least weekly thereafter; if the dressing is a gauze dressing it is to be changed upon admission and at least every two days thereafter. Assessment of the vascular cite is completed upon admission and during dressing changes, prior to and after intermittent infusions. Assessment for signs and symptoms of infusion related complications should also be completed. Length of external catheter should be obtained upon admission, during dressing changes, if…

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 document review and staff and other interviews, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident by failing to employ a qualified Social Worker to deliver medically related social services to all its residents for one of one employee record review (Employee 1). Findings Include: Review of the facility's Job Description titled Social Services Specialist 1, revised November 17, 2020, described the position as non-exempt and Bachelor's Degree in Social Work or Human Services required. The Job Description continued, Special Educational and Vocational Requirements: * Must possess any certifications/licensure's as required by State of employment to practice in long term care. * 1-3 years of supervised social work experience in health care setting working directly with individuals preferred. * Additional certification such as Geriatric Case Management, Hospice and Palliative Care,…

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 document review, interviews with staff, and other interviews, it was determined that the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for one of one staff person's credentials reviewed (Employee 1). Findings Include: Review of the facility's Job Description, titled Social Services Specialist 1, revised November 17, 2020, described the position as non-exempt and Bachelor's Degree in Social Work or Human Services required. The Job Description continued, Special Educational and Vocational Requirements: * Must possess any certifications/licensure's as required by State of employment to practice in long term care. * 1-3 years of supervised social work experience in health care setting working directly with individuals preferred. * Additional certification such as Geriatric Case Management, Hospice and Palliative Care, Gerontology, Clinical Social Work, Health Care, Nephrology, Mental Health and/or Substance Use preferred. Review of Employee 1's personnel file revealed a signed Job Description dated December 27, 2023, by…

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

Based on policy review, observation, resident and staff interviews, clinical record review, and other document review, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing care to all residents in accordance with the resident care plans to attain and maintain the highest practicable physicial, mental, and psychosocial well-being of each resident for two of seven residents reviewed (Residents 1 and 7), two Grievance Forms reviewed (December 18 and 21, 2023), and review of two months of Resident Council Meeting Minutes (December 2023-January 2024). Findings Include: Review of the facility's policy, titled Resident Rights Under Federal Law, recently revised February 1, 2023, defines its purpose is To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/ her self-esteem and self-worth. Also, To incorporate the resident's goals, preferences, and choices into care. Review of the facility's Resident Council Meeting minutes dated December 5, 2023,…

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 document review and resident and staff interviews, it was determined that the facility failed to ensure each resident the right to manage his or her financial affairs for three of four residents reviewed for personal funds (Residents 66, 121, and 126). Findings Include: Review of Resident 66's clinical record revealed diagnoses that included Diabetes Mellitus Type II (A chronic condition that affects the way the body processes blood sugar [glucose]) and anemia (condition in which the blood doesn't have enough healthy red blood cells). Review of Resident 66's Quarterly Minimum Data Set (MDS - a tool used to assess all care areas specific to the resident), dated September 15, 2023, revealed under Section C- Cognitive Patterns, the Brief Interview for Mental Status (BIMS). Review of the BIMS revealed Resident 66 scored 15/15. This score denotes an intact cognitive status. Review of the facility provided document, titled Medical Source Opinion of Patient's Capability to Manage Benefits provided by 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 clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflects the resident status for four of 35 residents reviewed (Residents 44, 48, 70, and 135). Findings Include: Review of Resident 44's clinical record on October 17, 2023, at approximately 10:30 AM, revealed diagnoses including central cord syndrome (injury to the spine that results in decreased nerve function for motor and sensory function of the body), and Guillain-Barre syndrome (neurological disorder caused by the immune system attacking the peripheral nervous system that results possible weakness, paralysis, and sensory deficit). Review of Resident 44's admission Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial need), with an assessment reference date of September 3, 2023, revealed that section N0410. Medications Received, subsection D was coded to reflect that Resident 44 had received a hypnotic…

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 observations, record review, policy review, and resident and staff interviews, it was determined the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for five of 35 residents reviewed (Residents 15, 71, 97, 99, and 122). Findings Include: Review of the facility's policy, titled OPS416 Person-Centered Care Plan, last revised April 2023, revealed that the care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Review of Resident 15's clinical record reveals diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 15's current physician orders revealed an order for a hand splint to bilateral hands…

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 review of facility policy and procedure, review of product user manuals, observations, record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of five of 35 residents reviewed (Resident 20, 71, 102, 110, and 391). Findings include: Review of facility procedure, Bi-Level Positive Airway Pressure (BIPAP- non-invasive ventilation or breathing support administered through a face or nasal mask in which air usually with added oxygen is given under positive pressure )/Continuous Positive Airway Pressure (CPAP- respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing), revision date July 15, 202, read, in part, if oxygen is ordered for patient, connect one end of the oxygen tubing to the oxygen enrichment adapter and the other end to the oxygen source. Cleaning the system: clean reservoir daily, clean the unit…

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, review of facility policy, product packaging review, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen and for two of three nourishment pantries. Findings include: Review of facility policy, titled Food Brought In For Residents, dated May 2023, read, in part, food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. Review of facility policy, titled Dry Food Storage, dated May 1, 2023, read, in part, open packages should contain a used by date, all shelved/storage racks should be 18 inches below the sprinkler head, foods removed from initial packaging should be dated with the received date, bulk items should be clearly marked with the product name and date opened. Observation in the preparation area 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 observation, policy review, and staff interviews, it was determined that the facility failed to prepare and administer medications to residents in a manner that promoted infection control practices for one of three residents observed for medication administration (Resident 75); and failed to implement their Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: Review of facility policy, titled Medication Administration: Oral, last reviewed April 2023, revealed the policy did not address handling medications with a bare hand nor how to handle a dropped medicine tablet. Review of the facility Water Management Program, indicated that the plan was last reviewed in June 2023, but failed to identify members of the Water Management Plan Committee. During medication administration observations on October 18, 2023, at approximately 9:36 AM, Employee 14 was observed preparing to administer medication to Resident 75. During 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 policy review, resident clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure an effective compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and in promoting quality of care for three of four residents reviewed for personal funds and the application for resident Social Security benefits (Residents 66, 121, and 126). Findings include: Review of the facility's policy, titled Compliance and Ethics Program, Doing the Right Thing dated October 2022, read under Standard of Conduct Corporation [company] is committed to the delivery of high quality healthcare services. To achieve that goal it is the policy of Corporation to conduct all business affairs with the highest level of integrity. Corporation requires that every employee strictly complies with all applicable laws and regulations.…

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 observations, facility policy review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 35 residents reviewed and one of four shower rooms observed (Residents 8, 20, 27, 68, 71, and 110). Findings include: Review of facility policy, titled Cleaning: Resident/Patient Areas, with a last review date of April 2023, indicated the following: 3. Cleaning is accomplished using the Seven-Step Cleaning Procedure which includes the following cleaning procedures: 3.1 High Dusting; 3.2 Spot cleaning and surface sanitizing; 3.3 Bathroom cleaning; 3.4 Waste collection; 3.5 Floor dust mopping, floor wet mopping; and 3.7 Room inspection- visually inspect room after completing all tasks and correct any issues before leaving the room. Observation of Resident 8's bathroom on October 16, 2023, at 10:18 AM, revealed the presence of a dried brown substance on the floor and down the side of the toilet. Observation of Resident 8's bathroom on October 17, 2023, at 9:36 AM, continued to reveal the presence 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to identify and monitor a device as a restraint for one of 35 residents reviewed (Resident 71). Findings include: During a review of facility policy, titled Procedure: Use Of Restraints, revised June 1, 2021, revealed the interdisciplinary team will review restraint use monthly for three months and then quarterly and with significant change in condition or in accordance with state regulations. Review of Resident 71's clinical record included diagnoses that included stroke, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), left leg above the knee amputation, right leg partial foot amputation, and obstructive sleep apnea (intermittent airflow blockage during sleep). Observation 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 facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to verify the standing of professional license prior to hire for one of five personnel files reviewed (Employee 13). Findings Include: Review of facility policy, titled OPS300 Abuse Prohibition, with a revision date of October 24, 2022, revealed, 3. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. Review of personnel file for Employee 13 (Licensed Practical Nurse [LPN]) revealed license verification with the Licensing board was completed October 17, 2023; indicating license verification was not completed prior to Employee 13's date of hire on September 12, 2023. Further review of Employee 13's timecard revealed hours worked September 12, 2023, from 9:00 AM to 3:30 PM, labeled…

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 clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of 35 residents reviewed (Resident 23). Findings include: Review of facility policy, titled Bed Hold Policy Notice & Authorization, last reviewed April 2023, failed to include that residents are to receive a bed-hold notice upon transfer. Review of Resident 23's clinical record revealed diagnoses that included type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin) and hypertension (high blood pressure). Review of a nursing progress note in Resident 23's clinical record dated August 20, 2023, at 1:46 PM, revealed that Resident 23 left for Well Span [NAME] Hospital and has subsequently been admitted to the hospital. An interview with the Director of Nursing (DON) on October 18, 2023, at 2:21 PM, revealed that they 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for one of 35 residents reviewed (Resident 8). Findings include: Review of facility policy, titled Person Centered Care Plan, with a last review date of April 2023, revealed 7. Care plans will be: 7.2 (in part) reviewed and revised by the interdisciplinary team .as needed to reflect the response to care and changing needs and goals. Review of Resident 8's clinical record revealed diagnoses that included muscle wasting, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), benign prostatic hyperplasia (age associated prostate gland enlargement that can cause difficulty with urinating), and chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump 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 clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 68). Findings Include: Review of Resident 68's clinical record included diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), congestive heart failure (CHF - the heart doesn't pump blood as it should), hypertension (high blood pressure), and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of Resident 68's October 2023 physician orders included to check blood pressure and heart rate and to call Physician if systolic blood pressure (SBP-the top number when documenting blood pressure-measures the force the heart exerts on the walls of the arteries each time it beats, normal is less than 120 millimeters 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 facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living (ADL) for one of 35 resident s reviewed (Resident 71). Findings include: Review of facility policy, titled Activities Of Daily Living, revision May 1, 2023, read, in part, a resident who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain food grooming. ADLs are provided in accordance with accepted standards of practice, the care plan, and resident's choices and preferences. Review of Resident 71's clinical record included diagnoses that included stroke, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow 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 facility policy, review of the clinical record, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 35 residents reviewed (Residents 71). Findings include: Review of Resident 71's clinical record included diagnoses that included stroke, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), left leg above the knee amputation, right leg partial foot amputation, and obstructive sleep apnea (intermittent airflow blockage during sleep). Observation on October 17, 2023, at 11:03 AM, revealed Resident 71's left hand was contracted; it was tightly closed in a fist. Interview with Resident 71 on October 17, 2023, at 11:03…

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 clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure the resident environment is free from accident hazards for two of 35 residents reviewed (Resident 8 and 23). Findings Include: Review of Resident 8's clinical record revealed diagnoses that included muscle wasting, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), benign prostatic hyperplasia (age associated prostate gland enlargement that can cause difficulty with urinating), and chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 8's clinical record progress notes revealed that they had experienced a fall on August 5, 2023, at 8:30 AM. The progress note indicated that Resident 8 was found on the floor in their room, and that they had transferred their self out of bed into their wheelchair, and then…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure residents requiring dialysis services receive such services consistent with professional standards of practice for one of two residents reviewed for dialysis services (Resident 122). Findings Include: Review of Resident 122's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident 122's physician orders revealed an order dated July 12, 2023, that read, Dialysis Tuesday, Thursday and Saturday @ 11:00 AM. Dialysis is defined as the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. Review of the facility's policy, titled Dialysis Guidelines, reviewed April 2023, read, in part, Both the center…

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 clinical record review, policy review, and staff interview, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication irregularity for one of 35 residents reviewed (Resident 23). Findings include: Review of the facility's policy, titled Medication Regimen Review Policy, last reviewed April 2023, indicated that the facility should encourage the physician/prescriber or other responsible parties receiving the Medication Regimen Review (MRR) and the Director of Nursing (DON) to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. Review of Resident 23's clinical record revealed diagnoses that included type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin) and hypertension (high blood…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 48). Findings include: Review of Resident 48's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension (high blood pressure). Review of Resident 48's physician's orders revealed an order for Ativan oral tablet one milligram (lorazepam), give one tablet by mouth every eight hours as needed for anxiety for 14 days, dated October 4, 2023. Review of Resident 48's physician order history revealed that the Ativan (lorazepam) had been…

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

Based on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on four medication errors out of 28 opportunities, which equated to an error rate of 14.29 percent. Findings include: Review of facility policy, titled Medication Administration: Oral, last reviewed April, 2023, revealed that when preparing medications for administration, staff should, Verify medication order on Medication Administration Record (MAR) with medication label for correct patient, drug, dose, route and time .If [there are] discrepancies, notify physician/advanced practice provider (APP) and/or pharmacy as indicated . During medication administration observations on October 18, 2023, at approximately 9:16 AM, Employee 18 was observed preparing and administering medications to Resident 109. Review of Resident 109's clinical record on October 18, 2023, at approximately 10:30 AM, revealed Resident 109 was ordered Ocuvite-Lutein (multiple vitamins with minerals)…

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 observations, facility policy review, and staff interview, it was determined that the facility failed to ensure medications were stored in a secure manner for one of three medication carts observed. Findings include: Review of facility policy, titled Storage and Expiration Dating of Medication, last revised August 7, 2023, revealed subsection 3.3 stated, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. During medication administration observations on October 18, 2023, it was revealed that Employee 14 was utilizing the 300 hall medication cart while preparing and administering medications to residents on the 300 hall. During observations at approximately 9:30 AM, it was observed that on top of the 300 hall medication cart were four multi-dose medication containers, one containing aspirin 81 milligrams (mg - metric unit of measure), one iron sulfate tablet, one vitamin B12 tablet, and one vitamin D3 tablet. During…

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained/processed timely as ordered by the physician for one of 35 residents reviewed (Resident 102). Findings include: Review of Resident 102's clinical record revealed diagnoses that included enterocolitis (inflammation of the digestive tract due to clostridium difficile [c-diff - a bacteria]) and malignant neoplasm of lung (cancer of the lung). Review of Resident 102's physician orders revealed an order to check a stool sample for clostridium difficile, dated October 12, 2023. Review of Resident 102's progress notes revealed a note dated October 14, 2023, at 2:56 AM, that indicated Attempted to find the results of the stool sample collected on 10/12/23. The stool was found in the refrigerator. It was not picked up by the lab. It is now too old and was disposed of. Will collect a new sample. Further review of Resident 102's progress notes revealed a note dated October 15, 2023, at 11:39 AM, that indicated, in part, the lab just called for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview and staff interviews, and policy review, it was determined that the facility failed to ensure four of seven residents reviewed were provided care and services regarding hygiene and bathing (Residents 1, 2, 3, and 4). Findings include: Review of the facility's Activities of Daily Living (ADLs) (daily self-care activities) policy, titled NSG200 Activities of Daily Living, last reviewed and revised on May 1, 2023, under the Practice Standards section, indicated that a patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident 1's clinical record also revealed…

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.