Sandpiper Post Acute

Based on observation, interview, record review, and policy review, the facility failed to investigate the possible underlying issue for significant weight loss and assessed the resident before the use of a psychotropic drug for weight loss for one (Resident (R)51) of 10 sampled residents reviewed for nutritional status. This had the potential to cause further weight loss. Findings include: Review of the facility's policy titled, Weight Assessment and intervention revised 03/22 revealed, Weight Assessment .3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing.Evaluation, 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the facility's policy titled, Nutritional Assessment revised 10/17…

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, resident record, and facility policy, the facility failed to ensure residents receiving dialysis treatments, staff were using Enhanced Barrier Protection (EBP) when providing direct resident care for two of three residents (Resident (R) 113 and R412) reviewed for dialysis care. The facility failed to ensure physician orders were in place for dialysis treatment and accurate interventions were documented in the care plan. The deficient practice has the potential for the residents to not receive dialysis care in the facility. Findings included: Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident dated 09/19 revealed, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the care of grafts and fistulas. The resident's comprehensive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to ensure that one out of five residents (Resident (R) 145) out of a total sample of 33 residents reviewed for unnecessary medication use. Specifically, the facility failed to follow adequate monitoring of blood pressure parameters before the unnecessary administration of blood pressure medications, according to physician orders. This failure had the potential to increase the risk for serious adverse effects. Findings include: Review of the facility's policy titled, Administering Medications dated April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any time frame.1. Review of R145's admission Record found in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, localized hypertensive chronic kidney disease, and edema. Review…

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, interviews, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5% when two oral medications were not administered according to the physician's order for two (Residents (R)20 and R80) of seven residents observed during medication pass. This consisted of two medications errors in 30 opportunities for a 6.67% error rate. Findings included. Review of the facility's policy titled, Administering Oral Medications dated 2001 revealed, .Medications are administered in accordance with prescriber orders, including any required time frame .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) before giving the medication . 1. During a medication pass observation on 04/10/25 at 8:39 AM. Licensed Practical Nurse (LPN) 8removed a multivitamin (MVI) with iron tablet from a bottle in the top drawer of the medication and placed the medication into the medication cup. In addition, there was one…

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 interviews, document review, and review of the facility policy, the facility failed to ensure narcotic counts were initialed by the on-coming nurse (7:00AM to 7:00PM) and the off-going nurse (7:00PM to 7:00AM) at the change of shift to ensure the narcotic count was accurate for eight of eight medications carts reviewed. This failure had the potential for drug diversion. Findings included. Review of the facility's policy titled, Controlled Substances dated 2001 revealed, .Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count .The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services . 1. Review of the medication cart identified as 100 hall-cart 1 on 04/09/25 at 9:23 AM with Licensed Practical Nurse (LPN) 4 revealed on 04/07/25 the on-coming and off-going nurse did not identify how many narcotic cards were in the narcotic box at the end of the shift. In addition, on 04/08/25 the off-going nurse did 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, resident record, and facility policy, the facility failed to ensure residents receiving dialysis treatments had accurate documentation of care provided for the dialysis site for two of three residents (Resident (R) 113 and R412) reviewed for dialysis care. The deficient practice has the potential for the residents to not receive dialysis care in the facility. Findings include: 1. Review of R113's admission Record located in the EMR under the Profile tab revealed an admission date of 6/29/22 with medical diagnosis that included chronic kidney disease, stage three. Review of R113's physician orders under the Orders tab in the EMR documented an order dated 03/26/25 indicating, Resident has arteriovenous (AV) fistula (shunt) located on [right]chest wall. Monitor for presence of bruit (auscultation) and thrill (palpation of vibration) [every] shift. Notify MD [Medical Doctor] if unable to auscultate of palpate. Monitor [each] shift for bleeding. Drainage, excessive warmth, pain, redness, numbness in fingers, tenderness, or swelling. Check circulation…

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 facility policy, observation, and interview, the facility failed to protect residents private health information, for 3 of 8 residents. Specifically, a nurse did not secure the computer screen while administering medications. Findings include: Review of the facility's undated policy titled Protected Health Information (PHI), Uses and Disclosures of documented, The facility will make reasonable efforts to limit the use or disclosure of PHI to only the minimum necessary use to accomplish the intended purpose of the use, disclosure or request. During an observation on 01/28/25 at 5:16 PM, revealed a nurse's medication cart was left unattended, while the nurse was administering medications. Further observation revealed, the Electronic Medication Administration Record (EMAR) was still open on the computer screen, revealing multiple residents listed on the screen. During an interview on 01/28/25 at 5:18 PM, Licensed Practical Nurse (LPN)1 stated, You are interviewing me about my screen being open. I was gone for three minutes. I went to give morphine to a resident. The…

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

Based on record reviews and interviews, the facility failed to ensure 3 of 3 certified nursing assistants (CNA)s received annual performance reviews. Findings include: On 04/18/24 at approximately 8:10 AM, the Regional Director revealed the facility does not have a policy specific to performance reviews for CNAs. Review of 3 CNA personnel files revealed, CNA5, CNA6, and CNA7's annual performance reviews were not completed by the facility in the past year. During an interview on 04/15/24 at 1:40 PM, the Regional Director of Clinical Services revealed that CNAs do not receive performance reviews. Instead, they are given a 2% raise if they have not received any disciplinary actions over the year. During an interview on 04/17/24 at 1:23 PM, the Administrator revealed performance reviews will be done annually moving forward. CNA performance levels will be evaluated once they reach their yearly marks, and Human Resources (HR) will notify them when year marks are approaching.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, manufacturer labeling and review of facility policy, the facility failed to ensure that medications were properly stored in 5 of 8 medication carts, 4 of 4 treatment carts and 2 of 4 medication rooms. Findings include: Review of the facility policy titled Storage of Medications revised on [DATE] states: Drugs and biologicals used in the facility are stored in locked compartments . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Unlocked medication carts are not left unattended. Review of the facility policy titled Security of Medication Cart revised on [DATE] states: The cart must be locked before the nurse enters the resident's room. Medication carts must be securely locked at all times when out of nurses' view. When the medication cart is not being used, it must be locked…

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 review of facility policy, the facility failed to ensure that kitchen staff wore beard/hair restraints while cooking, preparing, or assembling food. Furthermore, the facility failed to to properly store, label/date and discard expired foods for 1 of 1 kitchen. Findings include: Review of the facility policy titled, Food Preparation and Service revised on 11/2022, revealed, Policy Statement: Food and nutrition services employees, distribute and serve food in a manner that complies with safe food handling practices. Food and nutrition services staff wear hair restraints (hair net, beard restraint, etc.) so that hair does not contact food. Review of the facility policy titled, Staff Attire revised on 10/2023, revealed, Policy Statement: All employees wear approved attire for the performance of their duties. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the facility policy titled, Food Storage: Cold Foods revised on 04/2018, revealed, Policy Statement: All…

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 review of facility policy, the facility failed to provide dignity to Resident (R)129 prior to entering her room, for 1 of 2 residents reviewed for dignity. Findings include: Review of the facility policy titled Dignity last revised on 02/29/21, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth, and self-esteem. Residents' private space and property shall be respected at all times . staff will knock and request permission before entering residents' rooms. Review of R129's Face Sheet revealed R129 was admitted to the facility on [DATE], with the diagnoses including but not limited to: congestive heart failure, major depressive disorder, restless leg syndrome, and osteoarthritis. Review of R129's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/24, revealed R129 had a Brief Interview for Mental Status (BIMS) score of 15 out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to notify Resident (R)273's representative of a room change for 1 of 1 resident reviewed. Findings include: Review of the facility policy titled Room Change/Room Assignment revised on May 2017 stated, Documentation of a room change is documented in the facility record. Notice of a room change will include why the change is being made . all parties involved in the change/assignment and their representatives will be given notice of such change . Review of the facility policy titled Change in the Residents Condition or Status revised on February 2021 stated, A nurse will notify the residents representative when there is a need to change the residents room assignment. Review of R273's Face Sheet revealed R273 was admitted to the facility on [DATE] with diagnoses including but not limited to: fracture of right lower leg, left rib fracture, vertebral fracture, cognitive communication deficit, and alcohol abuse. Review of R273's South…

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, record review, and review of facility policy, the facility failed to prevent a resident-to-resident altercation. Furthermore, the facility neglected to provide care for R58 for 3 of 5 residents reviewed for abuse/neglect. Findings include: Review of the facility policy titled Abuse and Neglect last revised on 03/31/28, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The nurse will assess the individual and document findings. Assessment data will include injury assessment; pain assessment; current behaviors; patient's age and sex; all current medications; all active diagnoses; and behavior over last 24 hours. The physician and staff will help identify risk factors within the facility, for example, significant numbers of residents with unmanaged problematic behaviors. Review of R160's Face Sheet revealed R160 was admitted to the facility on [DATE], with diagnoses 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 interview, record review, and review of facility policy the facility failed to report a resident-to-resident altercation and an allegation of neglect to the state agency in a timely manner as required by federal regulation, for 3 of 5 residents reviewed for abuse/neglect. Findings include: Review of the facility policy titled Abuse and Neglect last revised on 03/31/28, revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. All aged violations of involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported to the facility Administrator, or his/her designee, to the following persons or agencies: the state licensing/certification agency responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to provide Resident (R)60 with Activities of Daily Living (ADL) care, for 1 of 4 residents reviewed for ADLs. Finding include: Review of the facility policy titled ADLs, Supporting last revised on 03/31/18 revealed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, muscle weakness, rheumatoid, dementia with behaviors, anxiety disorder due to known…

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

Based on observation, record review, interviews, and review of the facility's policy, the facility failed to properly position the catheter bag for Residents (R)163, for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled Catheter Care, Urinary revised on August 2022, revealed, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complication, including urinary tract infections. Infection control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Review of R163's admission Record revealed the facility admitted the resident on 04/11/24 with diagnoses including but not limited to: retention of urine, presence of urogenital implants, and edema. Review of the Order Summary Report' for the month of April 2024, revealed an order, dated 04/01/24, for foley catheter: 16 french 10 cc bulb, and change as needed. Review of R163's Care plan revised on 04/01/24, revealed the resident was at risk for complication with urinary system related to indwelling catheter. Interventions initiated on 03/30/24 revealed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to assess and provide pain medication as prescribed to Resident (R)60 in a timely manner, for 1 of 5 residents reviewed for pain. Findings include: Review of the facility policy titled Pain- Clinical Protocol last revised on 10/31/22 revealed, The Physician and staff will identify individuals who have pain or who are at risk for having pain. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Staff will provide elements of a comforting environment and appropriate physical and complementary interventions; for example local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Resident (R)3 with a dinner meal tray for 1 of 8 residents reviewed for food. Findings include: Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses including but not limited to: absence of kidney, muscle weakness, epilepsy, and end stage renal disease. Review of R3's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/24 revealed R3 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that she is cognitively intact. Review of R3's Physician Orders for April 2024 revealed the following order, Regular, Large Portion diet, Regular texture, thin liquids consistency. During an interview on 04/16/24 at 8:40 AM, R3 revealed they did not receive their dinner tray on 04/15/24, when they returned back to the hospital. R3 stated that she got back from the hospital around 4:30 PM or 5:00 PM and does not understand why staff did not bring her a tray…

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 the facility policy, record review, and interviews, the facility failed to report an incident involving death to the State Agency (SA) within two (2) hours. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, with a revision date of [DATE] revealed Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Section 3 indicates, Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury . The SA received a call on [DATE] at 3:47 PM from the [NAME] County Coroner's Office indicating they had received an anonymous tip that a resident had expired after being found caught…

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

Based on observation, interview, and record review, the facility failed to follow preplanned menus and make food substitutions that were equal in nutritional value for 153 of 163 residents in the facility. Findings include: Review of the Week 3 Spring Menu 2023 revealed, the menu included meat or entrée, a vegetable, carbohydrate, and dessert. The alternate menu revealed residents could receive peanut butter and jelly, egg salad, chicken salad, and pimento cheese. Residents may also request chicken noodle soup. During an observation in the kitchen, with the cook (C)10, the Dietary Manager (DM) and the Assistant Dietary Manager (ADM), on 05/18/23 from 12:15 PM through 1:03 PM revealed, lunch included spaghetti with meat sauce, steamed mixed vegetables, garlic bread and a brownie. The DM stated that residents who were allergic to tomatoes, would receive spaghetti with no meat or sauce, steamed vegetables, garlic bread and baked chicken. The DM further stated residents who required mechanical soft meals would receive ground beef and rice. The puree meal was pureed ground beef 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 observation and interview, the facility failed to dispose of garbage and refuse properly in 2 of 2 dumpster. Findings include: During the kitchen tour on 05/17/23 at 6:59 AM with the Assistant Dietary Manager (ADM), two dumpsters were observed in the back of the facility. There were no lids on the dumpsters and refuse was sticking out of the top of one dumpster. Further observation revealed, wood lying on the ground and carts that had dried paint on them. During an interview with the Maintenance Director (MD) on 05/18/23 at 10:57 AM, the MD stated there had been a lot of construction going on with the building, so that was why the wood, and paint and other items were by the trash dumpster. The MD stated he would call the company when the trash was getting full, and they would pick it up. He stated there was no scheduled pick up for trash, it would only occur when he contacted the trash company.

Based on interviews, during the facility's resident council meeting, the facility failed to ensure that 9 Residents (R)8, R12, R41, R52, R65, R71, R117, R114, and R123 out of 163 residents received mail delivery on Saturdays. Findings include: During a resident council meeting on 05/18/23 at 11:00 AM with nine residents (R)8, R12, R41, R52, R65, R71, R117, R114, and R123 in attendance, revealed residents do not always receive mail on the weekends. The residents stated they did not receive mail this past Saturday (05/13/23). The residents further stated the activities staff were responsible for delivering the residents' mail. During an interview on 05/19/23 at 9:05 AM with the Activities Director (AD) revealed, the activities staff were responsible for delivering the residents' mail, however on the weekends, if the activities staff are not working then it is the responsibility of the front desk receptionist to deliver the mail. During an interview on 05/19/23 at 9:10 AM with Certified Nursing Assistant (CNA)16, who works as the front desk receptionist, revealed the weekend front desk…

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, observations, record review and staff interviews, the facility failed to ensure one Resident (R)90 of a total of 36 residents reviewed in the sample was appropriately assessed for self-administration of medication. Specifically, R90 had a bottle of Tums Chewable Antacid Medication at his bedside and there was no assessment or care plan related to the resident's self-administration of this medication. In addition, R90 did not have a physician's order for the medication. Findings include: Review of the facility's policy titled Self-Administration of Medications dated 02/2021 read, in pertinent part, Residents have the right to self-administer medications if the inter-disciplinary team has determined that it is clinically appropriate and safe for the resident to do so; and As part of the evaluation comprehensive assessment, the inter-disciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administration of medication is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a notice including the reason the services were ending or what the options were prior to the discontinuation of therapy services. This had the potential to affect 1 of 3 Residents (R58) who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review. Findings include: Review of R58's Face Sheet located in the electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. R58 was receiving Medicare benefits and she was discontinued from skilled therapy services on 01/10/23. R58 had not exhausted her Medicare benefit days. However, the facility failed to notify her representative regarding the expiration of benefits prior to the expiration date. R58's benefits ended on 01/10/23 and her representative was notified on 01/13/23, three days later. Review of R58'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 record review, interview, and facility policy review, the facility failed to ensure 3 of 4 Resident (R)5, 119, and 414, reviewed for hospital transfers out of a total sample of 36 residents, contained documentation that the resident and/or the resident representative and ombudsman were provided a written notice of transfer when the residents were transferred to the hospital. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency dated 08/2018 revealed, Policy: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) . Policy Interpretation and Implementation: . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .e. Notify the representative (sponsor) or other family member. Further review of the policy reveals the facility policy fails to address providing written notification to the resident, resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and staff interviews, the facility failed to ensure the accuracy of a Level 1 PASARR (Pre-admission Screening and Resident Review) in order to potentially generate a Level 2 PASARR assessment for 1 Resident (R) R145, who had a diagnosis of major mental illness with significant behavioral disturbances, of four residents reviewed for PASSAR. There were 36 residents reviewed in the sample. The findings include: During an interview with the facility's Social Services Director (SSD) on 05/18/23 at 12:55 PM, she stated the facility did not have a specific policy for PASARR evaluations, but rather the facility relied upon the South Carolina Department of Health and Human Services (SCDHHS) for guidance related to PASARR. The SSD further stated, per the SCDHHS, a Level 1 screening was expected to be accurate and referral for a Level 2 PASARR was expected to be timely and based upon accurate information gathered within the Level 1 PASARR Screening. She indicated Level 1…

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

Based on interview, record review, and review of facility policy, the facility failed to develop a care plan with interventions for 1 Resident (R)160, with a diagnosis of post-traumatic stress disorder (PTSD) from a sample of 36 residents. This has the potential for the staff to not provide appropriate and compassionate care specific to this resident's trauma needs. Findings include: Review of the facility's policy titled Trauma Informed Care dated March 2022 revealed, As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Review of R160's undated Diagnoses sheet located in the electronic medical records (EMR) tab titled Medical Diagnosis revealed, the resident has a diagnosis that included PTSD. Review of R160's Onsite Behavioral Health Comprehensive Exam dated 5/12/23, located in the EMR, under the tab Practitioner Notes documented the resident was diagnosed with PTSD but has not exhibited any signs or symptoms of flashback…

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, interviews, record review and review of facility policy, the facility failed to provide oral and personal hygiene care for 2 Residents (R)83 and R159, that are dependent on staff for all areas of care, from a sample of 36 residents. Specifically, R83 was identified as incontinent of bowel and bladder, and R159 was observed with dry and cracked lips. Finding include: Review of the facility policy titled Activities of Daily Living (ADLs) with a revision date of March 2018 documents, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. During an observation on 05/19/23 at 1:50 PM revealed, R83 receiving incontinent care from Licensed Practice Nurse (LPN)13. R83 was observed to have reddened areas to her sacrum and buttocks, bruising to the groin area (in the process of healing), and her labia area was reddened. The resident had been incontinent of her bowels. Review of R83's Diagnoses sheet located in the electronic medical record…

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 interviews and record review, the facility failed to ensure medication was available per order for one Resident (R)37 of 36 total residents reviewed in the sample. R37 returned from the hospital with orders for antibiotic medication related to his diagnosis of a urinary tract infection (UTI) and the medication was not available for administration for four days after the resident's return. The findings include: Review of R37's admission Record dated 05/19/23 located in the Electronic Medical Record (EMR) under the Admissions Tab, indicated R37 was admitted to the facility on [DATE] with diagnoses including but not limited to; multiple sclerosis (MS), disorder of the brain, and history of urinary tract infections (UTIs). Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/23 located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R37 is cognitively intact. Review of R37's Order Summary Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, interviews and record review, the facility failed to ensure 1 of 1 Resident (R)12 reviewed for smoking was appropriately assessed for safe smoking. Specifically, R12 was not routinely assessed to ensure safe smoking practices or the need for assistance with smoking. Findings include: Review of the facility's undated policy titled Smoking Policy read, in pertinent part, This facility has established and maintains safe smoking practices; and Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes; pipe; etc.) c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation;) and A resident's ability to smoke safely is re-evaluated quarterly, upon significant change, (physical or cognitive) and as determined by the staff; and Any resident with smoking privileges…

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 the facility policy, observation, interview, and record review, the facility failed to provide proper positioning of 1 of 1 Resident (R)159's urinary drainage bag, from a sample of 36 residents. Specifically, R159's urinary drainage bag was observed laying flat on the floor. This has the potential for the resident to develop reoccurring urinary tract infection (UTI). Finding include: Review of the facility's policy titled, Suprapubic Catheter Care with a revision date of October 2010, revealed, General Guidelines include the following . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. During an observation on 05/17/23 at 9:01 AM revealed R159 lying in a low bed with the head of the bed (HOB) elevated 30 degrees. R159 had a catheter connected to a urinary drainage bag with a privacy covering. There was yellow urine with sediment in the tubing. The drainage bag was lying flat on the floor. During an observation on 05/18/23 at 9:43 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.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were seven errors observed out of 37 opportunities, resulting in an 18% error rate. This had the potential to place 1 Resident (R)81 at risk of not receiving the full benefit of their medication therapy. Findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration revised on 01/01/22, read in pertinent part, 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. Review of R81's Order Summary Report located in the Electronic Medical Record (EMR) under the Report tab, revealed Buspirone HCl Tablet 7.5 MG (milligrams), Give 1 tablet by mouth two times a day for Anxiety -Start Date- 11/23/22; Baclofen Tablet…

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, interviews, record review and review of facility policy, the facility failed to adhere to guidance for 1 of 1 Resident (R)214) on Contact Isolation Precautions from a sample of 36 residents. This has the potential to spread this organism throughout the facility. Findings include: Review of the facility policy titled Isolation Categories of Transmission Based Precautions with revision date of November 2022 direct staff as follow: If possible, place the resident in a private room. Staff and visitors wear gloves when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.…

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.