Grandview Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to notify the Physician/Nurse Practitioner and family for 1 of 5 (Resident #1) residents reviewed for falls with injury. The findings include: 1. Review of the facility's policy titled, Notification of Change, dated 11/30/2017 and revised 3/28/2023 revealed, The purpose of this policy is to ensure the facility informs the resident, consistent with his or her authority, when there is a change requiring notification .The facility shall inform the resident, consult with the resident's physician, and/or notify the resident's family member .when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents a. resulting in injury . Review of the facility's policy titled, Accidents and Supervision, dated 11/1/2017 and revised 10/21/2021 revealed, .the resident environment remains as free of accident hazards as is possible: and each resident receives adequate supervision and assistive…

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, medical record review, and interview, the facility failed to revise the care plan for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Baseline Careplan, dated 11/2016 and revised 10/21/2022, revealed, The facility shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial…

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, medical record review, and interview, the facility failed to provide mouth care for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living (ADL), dated 3/9/2022 and revised 3/9/2023 revealed, .The facility shall, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services shall be provided for the following activities of daily living: 1.oral care .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right…

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, medical record review, and interview, the facility failed to provide wound care and administer medications as ordered for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, admission Orders, dated 11/30/2016 and revised 3/28/2023 revealed, To provide guidance on admission orders needed for the residents immediate care .At the time each resident is admitted , the facility shall have physician or other authorized individual orders for the resident's immediate care in accordance with law and regulation and professional practice acts, before care, treatment, and services are provided . Review of the facility's policy titled, Medication Reconciliation, dated 8/2018 and revised 11/23/2022, revealed, Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission…

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, medical record review, observation, and interview, the facility failed to maintain patient confidentiality related to 3 computer screens open with resident health information visualized with no staff attendance. The findings include: Review of the facility policy titled, Patient Confidentiality, dated 2/2021, revealed, .Confidentiality is defined as safeguarding the content of information .or other computer stored information from unauthorized disclosure without the consent of the resident and/or representative .all efforts will be made to protect the confidentiality/privacy of the resident and their health information .this includes medical records .the electronic record is equipped with security features that allow only those with a password to retrieve and review records . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Heart Failure, Pulmonary Hypertension, Respiratory Failure, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation review, medical record review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the care needs of 5 of 44 sampled residents (Resident #19, #27, #31, #34, #37, and #51) residing on 3 of 5 hallways having the potential to affect the entire facility related to receiving showers/baths, passing meal trays, and turning and repositioning residents every 2 hours. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, dated 11/2017 and revised 11/2018, revealed, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . Review of the facility's Full Time Equivalent Staffing sheet revealed there was only 1.9 nursing hours per patient per day (PPD) on 3/6/2022 and 3/16/2022, and the facility did not meet the state required nursing hours per…

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, observation, and interview, the facility failed to maintain water temperatures for a dish machine at or above 120 F [Fahrenheit] degrees and failed to clean and sanitize 1 of 3 refrigerators located in the nourishment rooms. The facility also failed to deliver food that was covered to residents for 2 of 2 meal observations. The findings include: Review of the facility's policy titled, Dietary: Cleaning dated 7/13/2022, revealed, .Cleaning surfaces, equipment or utensils involve the use of hot water and detergent which removes soil grease, food, and odors .Turn on machine, checking temperatures to assure proper wash and rinse temperature for your machine and cleaning chemicals .Wash and rinse temperatures will be observed and recorded at each meal service. This will be achieved while the dish machine is in operations .Low temperature machines should be between 120 F-140 F. With the low temperature machines, the sanitizer will also be checked and recorded using a PH [Potential of Hydrogen] strip. Any temperatures recorded outside the acceptable levels…

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, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the spread of infection related to: staff failed to provide tracheostomy care in a sterile technique for 1 of 3 sampled residents (Resident #61); provide catheter care in a sanitary manner for 1 of 10 sampled residents (Resident #37) who required an urinary catheter; ensure oxygen tubing was not on the floor for 5 of 36 sampled residents (Resident #18, Resident #30, Resident #32, Resident #61, and Resident #72), and clean nebulizer mask for 1 of 36 sampled residents (Resident #32) who received respiratory treatments, and ensure urinary drainage bag was not laying in the floor for 2 of 10 sampled residents (Resident #64 and Resident #274) who required an urinary catheter. The facility also failed to prevent the spread of infection related to: staff not sanitizing hands between resident contact while passing meal trays during the supper…

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, observation, and interview, the facility failed to promote a homelike environment for 5 of 5 residents observed, in the dining room, during the breakfast meal on 3/28/2022. The findings include: Review of the facility's policy titled, Resident Rights and Resident Responsibilities, dated 1/2022, revealed, .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . Observation in the 100 Hall dining room on 3/28/2022 at 7:30 AM, revealed 3 residents sitting in the dining room eating breakfast. Continued observation revealed the meal plates were on meal trays. Observations in the 100 Hall dining room on 3/28/2022 at 7:56 AM and 7:59 AM, revealed Certified Nurse Aide (CNA) #3 assisted 2 residents to the dining room, set up their meal trays and left the plate on the tray. During an interview on 3/28/2022 at 7:40 AM, Registered Nurse (RN) #1 confirmed meal plates were on the meal trays for the 3 residents sitting in the dining room. 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 facility policy review, medical record review, observation, and interview, the facility failed to ensure orders were complete for 8 of 10 sampled residents (Resident #11, #23, #27, #35, #37, #55, #61, and #274) who had an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter, dated 1/1/2016 and revised on 3/30/2022, revealed, .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder and Chronic Pain. Review of the Annual Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to label and date the oxygen tubing for 18 of 36 sampled residents (Resident #4, Resident #8, Resident #10, Resident #11, Resident #12, Resident #18, Resident #30, Resident #32, Resident #34, Resident #35, Resident #45, Resident #51, Resident #54, Resident #61, Resident #64, Resident #72, Resident #273 and Resident #274) reviewed with oxygen therapy and properly store 3 of 36 sampled residents (Resident #18, Resident #30, and Resident #32) with respiratory treatments, the facility also failed to have complete physician orders for 1 of 36 sampled residents (Resident #54) who received respiratory treatments. The findings include: Review of the facility policy titled, Oxygen Concentrator and Oxygen Storage, dated 12/21, revealed .TO administer oxygen for the treatment of certain diseases or conditions in a safe manner .Cannulas and mask should be changed weekly .Change tubing weekly and as needed; document in…

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

Based on facility policy review, facility documentation review, observations, and interviews, the facility failed to have the Daily Nurse Staffing form posted on 3/27/2022, and failed to ensure the Daily Nurse Staffing forms were completed and retained for 132 days from 9/1/2020 through 3/27/2022. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, dated 11/2017 and revised 11/2018, revealed, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and to make staffing information readily available .The nurse staffing information will be posted on a daily basis . Review of the Daily Nurse Staffing forms dated 9/1/2020 through 3/27/2022, revealed there were no forms for 80 days and there were incomplete forms for 52 days. Observation at the 100/200/300 Hall's Nurses' Station on 3/27/2022 at 3:30 PM, revealed the Daily Nurse Staffing form was dated 3/12/2022. During an interview on 3/27/2022 at 6:02 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure dignity for 1 of 8 sampled residents (Resident #22) who required assistance with meals, and failed to ensure dignity for 2 of 10 sampled residents (Resident #23 and Resident #325) who required an indwelling catheter. The findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity Policy, dated 11/30/2017, revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Dementia with Lewy Bodies and Dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 required extensive assistance with one person assist with eating. Observation in Resident #22's room on 3/30/2022 at 8:12 AM, revealed Certified Nurse Aide (CNA) #1 was standing…

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, medical record review, observation, and interview, the facility failed to ensure call lights were in reach for 2 of 44 sampled Residents (Resident #64 and #326) reviewed. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Response, dated 6/11/2021, revealed, .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .to allow Residents to call for assistance .with each interaction in the Resident's room or bathroom, staff will ensure the call light is within reach of Resident and secured, as needed . Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #64 required extensive assistance of 2 staff for be mobility, toileting, and personal hygiene. Review of the Care Plan Report dated 3/15/2022-Present…

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, medical record review, observations, and interview, the facility failed to implement interventions on care plan for 1 of 44 sampled residents (Resident #10). The Findings include: Review of the facility's policy titled, Comprehensive Careplan, dated 3/25/2021, revealed, .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .comprehensive care plan will include measurable objectives .the objectives will be utilized to monitor the resident's progress .alternative intervention will be documented . Review of the medical record revealed Resident #10 was admitted on [DATE] with a diagnosis which included Hypertensive Heart Disease, Hyperlipidemia, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 required extensive assist with Activities of Daily Living (ADLs). Review of the Care Plan dated 5/10/2021-Present revealed a plan of care developed to address falls with…

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 the facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings and failed to invite resident #67 to any IDT Care Plan meetings for 1 of 44 sampled residents (Resident #67). The Findings include: Review of the facility policy titled, Comprehensive Careplan, dated 3/25/2021, revealed, .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .our resident person-centered plan of care includes the Comprehensive care plan and the Resident care needs .Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set [MDS] assessment .other factors identified by the interdisciplinary team or in accordance with 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 facility documentation review, medical record review, observations, and interviews, the facility failed to ensure 1 of 79 sampled residents (Resident #19) had clean and groomed fingernails. The facility also failed to ensure 4 of 44 sampled residents (Resident #27, #34, #37, and #51) received their showers and baths as scheduled. The findings include: Review of facility documentation dated 5/28/2014, titled, CNA [Certified Nurse Aide] Assignment Sheet, revealed, .Routine patient care - nail care . Review of an undated facility documentation titled, Shower Days For Facility, revealed, .A [person in bed A] bed showers are scheduled/offered on Monday, Wednesday, and Friday. B [person in bed B] bed showers are scheduled/offered on Tuesday, Thursday, and Saturday . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Dementia. Observation and interview in Resident #19's room on 3/27/2022 at 3:38 PM, revealed 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 facility policy review, medical record review, observations, and interviews, the facility failed to follow physician orders for 4 of 44 sampled residents (Resident #11, #18, #27, and #61) reviewed. The findings include: Review of the facility policy titled, Physician Verbal Order Policy, dated 5/30/2021, revealed, .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered healthcare specialist who are legally authorized to do so .follow through with orders by making appropriate contact or notification (e.g. lab or pharmacy) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea. Review of Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Continued review of the MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent a pressure ulcer from worsening for 1 of 10 sampled residents (Resident #18) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management, revised 10/15/2021, revealed, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate .Licensed nurses will conduct a full body assessment on all residents upon admission/re-admission and weekly .Weekly assessments will be signed off using the skin audit order weekly…

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 the facility documentation, facility policy review, medical record review, and interview, the facility failed to prevent an accident for 1 of 14 sampled residents (Resident #34) who required a mechanical lift for transfers. The findings include: Review of the facility's documentation titled, Statement of Inservice Training for Employees, dated 8/21/2020, revealed 15 signatures of staff and the following areas of instructions were covered, 506 - A [Resident #34's room]: Staff to be mindful of positioning equipment when using lift/shower chair and transferring patients. Review of the facility's policy titled, Safe Resident Handling and Transferring, dated 8/2021, revealed, .it is the policy of this facility to provide safe handling and transferring for residents who need assistance . Review of the facility's policy titled, Accidents and Supervision, dated 10/21/2021, revealed, .resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure orders were complete for 2 of 2 sampled residents (Resident #35 and #55) who had a colostomy. The findings include: Review of the facility's policy titled, Ostomy Care Policy, dated 5/1/2021, revealed, .it is the policy of this facility to ensure that residents who require colostomy .receive care consistent with professional standards of practice .a licensed nurse will determine the actual type of ostomy through physical assessment, medical record review, and collaboration with the attending physician .ostomy appliance will be provided by licensed nurses under the orders of the attending physician .the products required for changing ostomy devices will be noted on the resident's eTar [electronic treatment authorization request] . Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included Colostomy Status. Review of the Quarterly Minimum Data Set (MDS)…

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

Based on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for the 18 months reviewed. 9/1/2020 through 3/27/2022. The findings include: Review of the Daily Staffing (Nursing) sheets revealed there were 5 days (10/26/2021, 12/24/2020, 11/29/2020, 11/28/2020, and 11/27/2020) there was not a Registered Nurse on duty for 8 consecutive hours as required. During an interview on 3/30/2022 at 9:10 AM, the Assistant Director of Nursing, also known as the Staffing Coordinator, confirmed the facility did not have 8 consecutive hours of Registered Nurse coverage on 10/26/2021, 12/24/2020, 11/29/2020, 11/28/2020, and 11/27/2020.

Based on review of facility policy, review of facility cleaning and sanitizing equipment schedule, observation, and interview the facility failed to remove expired food in 1 of 3 nourishment rooms; failed to date and label resident food in 3 of 3 nourishment rooms; failed to separate staff and resident food in 3 of 3 nourishment rooms; and failed to maintain clean, sanitary, and safe equipment in 3 of 3 nourishment rooms potentially affecting 98 residents. The findings include: Review of the facility policy Food Storage, revised 11/2017 revealed .foods are stored in appropriate containers .covered, labeled, and dated .used within .3 days .all stored items should have an expiration date . Review of the facility policy Food Brought in by Family/Visitor revised 1/2019 revealed .all food items that are prepared by the family or visitor must be labeled with name, content and date .prepared food must be consumed by the resident within 3 days .if not consumed within 3 days, food will be discarded by the facility staff . Review of the facility policy Housekeeping-Routine Cleaning and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and interview the facility failed to follow standards of infection control for storage of resident care equipment and supplies in 3 of 3 nourishment rooms. The findings include: Review of the facility policy Infection Prevention and Control Program revised 5/2019 revealed .all reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment . Review of the facility cleaning and sanitizing equipment schedule policy, Cleaning and Sanitizing of Equipment, dated 8/30/12, revealed .water pitchers must be brought to the kitchen to be cleaned . Observation and interview with the Dietary Manager (DM) on 6/12/19 from 9:00 AM to 9:20 AM, in the Southside Nourishment Room, under the double working sink, revealed the following: 17 water pitchers; 17 detached lids with reusable straws labeled with resident names; 4 bedpans; 1 container…

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, medical record review, observation, and interview, the facility failed to implement a care plan intervention for 2 residents (#36, #49) of 22 sampled residents. The findings include: Review of the facility policy Comprehensive Care Plans, last revised 11/2016, revealed .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Osteoarthritis, Dementia Without Behavioral Disturbance, Difficulty Walking, Cortical Blindness, Anxiety, and Fracture Upper End of Right Humerus. Medical record review of an admission Minimum Data Set (MDS) dated [DATE] revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen as ordered by the physician for 1 resident (#49) of 9 residents reviewed for oxygen therapy of 22 sampled residents. The findings include: Review of the facility's Oxygen Concentrator policy revised 11/2017 revealed .Oxygen should be administered only under orders of the attending physician .Obtain physician's order for the rate of flow and route of administration .Turn the unit on to the desired flow rate . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Anxiety. Medical record review of Resident #49's care plan dated 9/2018 revealed the resident was care planned for being at risk for shortness of breath related to having a tracheostomy [tube placed in windpipe to help you breath] and diagnoses of 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.