Signature Healthcare Of Putnam County

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 a care plan to include fall interventions after 2 falls for 1 resident (Resident #40) of 4 care plans reviewed for falls. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .facility will develop and implement a person centered care plan for each resident, that includes measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs .maintains a comprehensive care plan participate in the development of and reviewing and revising of the Comprehensive Care Plan . Review of the facility policy titled, Falls, revised 1/31/2025, revealed .A comprehensive Care Plan will be implemented based on the resident's risk for falls .interventions will be revised as applicable, with each new review . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Hypertension,…

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 timely implement interventions to reduce the risk of falls for 1 resident (Resident #43) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Falls, revised 1/31/2025, revealed .ensure the facility provides an environment that is as free from accident hazards, as possible over which the facility has control to prevent avoidable falls .based on the resident's risk for falls .interventions specific to each resident to attempt to reduce the risk . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Altered Mental Status, Muscle Weakness, Abnormal Walking and Mobility, and Mood Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment 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, facility documentation review, and interviews the facility failed to prevent loss or diversion of controlled medications (narcotics) for 1 resident (Resident #7) of 65 sampled residents reviewed for misappropriation of narcotics. The facility was cited as past non-compliance. Non-compliance began on [DATE] and ended on [DATE]. The facility is not required to submit a Plan of Correction for F-755. The findings include: Review of the facility's policy titled, Controlled Medications, dated [DATE], revealed .The facility will ensure Controlled Medications are handled, stored, disposed of, and recordkeeping is in place in accordance with federal, state, and other applicable laws and regulations .At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either licensed nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled…

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, observation, and interview, the facility failed to have sufficient staffing for 1 of 4 (500) halls. The findings include: Review of the undated facility documentation revealed the 500 hall had 11 assisted diners (residents who required assistance with meals). Review of the facility schedule dated 5/15/2023, revealed 2 Certified Nurse Aides (CNA) and 1 CNA scheduled from 12:00 PM to 6:00 PM. Observations on the 500 hall on 5/15/2023 at 12:08 PM, revealed the tray cart arrived to 500 hall. Observations at the 500 hall nurse's station on 5/15/2023 at 12:24 PM, revealed Resident #114 was seated in a wheel chair in front of the nurse's station. Observations in the 500 hall dining room on 5/15/2023 at 12:25 PM, revealed CNA #8 was assisting one resident with the lunch meal while another resident was seated in a wheelchair. Observations in the 500 hall dining room on 5/15/2023 at 12:51 PM, revealed Resident #114 was assisted with dining by a CNA. During an interview on 5/15/2023 at 12:37 PM, CNA #8 stated the 500 hall was her assigned hall. CNA #8 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, observation, and interview, the facility failed to serve food in a timely manner to 9 of 123 (Resident #9, #14, #15, #16, #39, #92, and #113) residents who ate food prepared by the facility. The findings include: Review of the undated meal times sheet revealed the serving times for meals for the dining rooms and the halls revealed breakfast was served to the main dining room (DR) at 7:00 AM, 100 hall 1st meal tray cart at 7:15 AM, hall 300/400 at 7:30 AM, hall 200 meal tray cart at 7:45 AM, 500 hall DR and hall at 8:00 AM, hall 100 2nd meal tray cart at 8:15 AM, and hall 200 2nd meal tray cart at 8:30 AM. Lunch was scheduled for the main DR at 11:30 AM, hall 100 1st meal tray cart at 11:45 AM, hall 300/400 at 12:00 PM, hall 200 1st meal tray cart at 12:15 PM, 500 hall DR 12:30 PM, hall 100 2nd meal tray cart at 12:45 PM and hall 200 2nd meal tray cart at 1:00 PM. Dinner was scheduled for the main DR at 5:00 PM, hall 100 1st meal tray cart at 5:15 PM, hall 300/400 at 5:30 PM,…

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

Based on facility policy review, observation, and interview, the facility failed to maintain appropriate temperatures (temps) for food served on a test tray dated 5/15/2023. The facility also failed to maintain appropriate temps for food on the steam table requiring re-heating and a delay in food service. The findings include: Review of the facility policy titled, Food: Preparation Policy 016, undated revealed .the Dining Service Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to techniques which minimize the amount of time that food items are exposed to temperatures greater that 41 degrees Fahrenheit (F) and/or less than 135 degrees F or per state regulation .all foods will be held at appropriate temperatures greater that 135 degrees F .for hot holding and less that 41 degrees F for cold food holding .temperatures .for foods will be recorded at the time of service . Observations in the kitchen on 5/15/2023 at 4:45 PM, revealed the Regional Food Service Manager (FSM) for the contracted food service…

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 maintenance documentation, observation, and interview, the facility failed to provide proper storage dating of foods. The facility also failed to provide proper sanitation of equipment after use and maintenance of equipment in the kitchen. The facility further failed to provide appropriately dated foods and sanitized equipment in 1 of 3 (500 hall) nutrition rooms. The findings include: Review of the facility policy titled, Food Storage: Cold Foods Policy 019 revealed .all time/temperature control for .foods, frozen and refrigerated will be appropriately stored .foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . Review of the facility policy titled, Ice policy 021, undated, revealed .the Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned, and sanitized quarterly and as needed or according to manufacturer guidelines .the exterior of the ice machine will be cleaned weekly .ice bins will…

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 serve silverware for 1 of 2 carts on the 500 hall during a meal. The findings include: Review of the facility policy titled, Resident Rights reviewed 4/17/2023 revealed .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with access to persons and services inside and outside the facility . Observations on the 500 hall on 5/15/2023 at 5:38 PM, revealed the first tray cart on the floor had 18 trays. Two of the trays on the cart had silverware, and the other 16 trays did not. Continued observation revealed Certified Nurse Aide (CNA) #9 had to go upstairs to the kitchen and retrieve silverware for the other trays on the cart. During an interview on 5/15/2023 at 6:34 PM, the Regional Food Service Manager (FSM) stated the staff had pulled the silverware off the trays because the cart was for residents eating in the dining room. The FSM thought the 500 hall…

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, observation, and interview, the facility failed to provide a homelike environment for 2 of 5 (100 and 500) halls. The findings include: Review of the facility policy titled, Resident Rights reviewed by the facility on 4/17/2023 revealed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the undated facility policy titled, Housekeeping In-Service revealed .Spot clean walls: Vertical surface are not completely wiped down daily-but must be spot cleaned daily. Walls -especially by trash cans and light switches and door handles -will need special attention .Clean and sanitize sink and tub: The sink includes: the sink fixtures, pipes, under the sink, mirror and light above the mirror . Observations on the 500 halls on 5/15/2023 at 10:27 AM, revealed two vents located at the nurse's station and one vent located in front of the nutrition room were covered with black debris. Observations in room [ROOM…

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 comprehensive care plan for 1 of 47 (Resident #22) sampled residents. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 7/19/2018, revealed, .Care plans are ongoing and revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes on the residents' status . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Unspecified Protein-Calorie Malnutrition, Unspecified Dementia, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle Weakness (generalized), and Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Comprehensive Care Plan dated 4/26/2023 for 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 assess and treat impaired skin integrity for 1 of 1 (Resident #4) sampled residents observed during the initial tour. The findings include: Review of the facility policy titled, Skin Integrity Policy reviewed by the facility 7/11/2022 revealed, .A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing .The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified .In addition, to ongoing observations of skin integrity, nursing stakeholders shall observe the skin for areas of impairment with bathing, daily dressing, and peri care notify and notify the nurse if an area is identified . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] 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 medical record review, observation and interview, the facility failed to supervise intrusive wandering for 1 of 6 (Resident #41) sampled residents and failed to provide supervision for transport of 1 of 1 (Resident #60) sampled residents. The findings include: Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Altered Mental Status, and Alzheimer's Disease. Review of the nursing progress notes dated 2/22/2023, revealed Resident #41 was found one evening lying in the floor of another resident's room, appearing to be asleep with her knees slightly bent without distress. Review of the nursing progress notes dated 2/25/2023, revealed Resident #41 was ambulating ad lib (without previous preparation) into another resident's room per normal, and was restless with anxiety and fidgeting. Review of the nursing progress notes dated 3/8/2023, revealed Resident #41 continued to have intrusive wandering with repetitive opening…

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 safe handling, cleaning, and storage of breathing treatment and CPAP/BiPap (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) equipment for 1 of 4 (Resident #44) sampled residents and failed to properly date and store oxygen equipment for 2 of 4 (Residents #66 and #77) sampled residents observed with oxygen therapy. The findings include: Review of the facility policy titled .Departmental (Respiratory Therapy) - Prevention of Infection Revised November 2011 .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among resident and staff .Infection Control Considerations Related to Oxygen Administration .Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water)Change the oxygen cannulae and tubing every seven (7) days, or as needed .Infection Control Considerations Related 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 facility policy review, medical record review, observation, and interview, the facility failed to develop and implement a baseline care plan for the care and maintenance of a peripherally inserted central catheter (PICC) for 1 resident (Resident #250) of 1 residents reviewed for PICC lines of 30 residents reviewed. The findings included: Review of the facility policy Baseline Plan of Care, not dated, revealed .development and implementation of the Baseline plan of care will start at admission and within the first 48 hours .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .goals based on admission orders .physician orders . Medical record review revealed Resident #250 was admitted to the facility on [DATE] with diagnoses of Osteomyelitis (bone infection) Requiring Antibiotic Intravenous (IV) Therapy. Medical record review of the Nursing admission assessment dated [DATE] revealed Resident #250 was admitted to the facility with a PICC line…

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.