Spring Gate Rehab & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide information to the residents regarding their right to formulate an advance directive for 10 of 32 (Residents #34, #57, #71, #72, #73, #79, #92, #104, #140, and #498) residents reviewed for advance directives. The findings include: 1. Review of the facility policy titled, End of Life dated 12/29/2023, revealed .the facility .will inform and educate the resident and or the residents' family about decisions for end-of-life .advance directives will be documented in the medical record . 2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Tracheostomy, and Hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #34 was cognitively intact. There was no documentation in the medical record if Resident #34 had an Advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to notify the resident representative in advance of a change in room for 1 of 1 (Resident #305) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Change of Room or Roommate dated 10/30/2023, revealed .Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible .The Social Service designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate . 2. Review of the medical record revealed Resident #305 was admitted to the facility on [DATE], with a readmit date of 10/4/2024, with diagnoses including Ventricular Tachycardia, Myoclonus, Cognitive Communication, Seizures, Severe Protein- Calorie Malnutrition, and Severe Hypoxic Ischemic Encephalopathy. Review of the census in the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, Facility Reported Incident (FRI) review, and interview the facility failed to report allegations of abuse and neglect related to injury of unknown origin within 2 hours for 1 of 3 (Resident #248) sampled residents. The Findings include: 1.Review of the facility policy titled Abuse, Neglect and Exploitation revised 1/10/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .establish policies and procedures to investigate any such allegations: and include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures .and resident abuse prevention .the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, facility investigation review and interview, the facility failed to thoroughly investigate an allegation of abuse and failed to report to the government agency the results of the facility investigation within 5 working days for 4 of 13 residents (Resident #58, #248, #298, #300) reviewed for abuse incidents. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . Possible indicators of abuse include .resident, staff or family report of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 4 of 47 (Resident #6, #41, #84, and #105) MDSs reviewed. The findings include: 1.Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Osteoarthritis, Acute Upper Respiratory Disease, and Muscle Weakness. Review of the quarterly MDS dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was completed with a dash, indicating the BIMS score was not assessed. The facility failed to ensure the BIMS was assessed and completed for the quarterly MDS dated [DATE]. 2. Review of the medical record revealed Resident # 41 was admitted to the facility on [DATE], with diagnoses including Dementia, Cerebral Infarction, Hemiplegia and Hemiparesis, and Muscle Weakness. Review of the annual MDS dated [DATE] revealed the BIMs was completed with a dash, indicating the BIMS…

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 Level 1 Pre-admission Screening and Resident Review (PASRR) form, policy review, medical record review, and interview, the facility failed to resubmit a PASRR after the resident had the addition of a new mental health diagnosis for 1 of 6 sampled residents (Resident #56) reviewed for PASRRs. The findings include: 1. Review of the facility policy titled PASARR-Pre-admission Screen and Resident Review dated 10/30/2023, revealed .All residents are required to have a level I PASRR screen prior to or upon admission to the facility. When indicated on the level I screen that a level II screen is required, the facility will complete notification to the State's PASRR program notice for the level II screen .if a resident is admitted with a level diagnosis .review is required upon change in the resident's condition . 2.Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Respiratory Failure, Paraplegia, and Cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to conduct quarterly care conference meetings for 1 of 1 (Resident #20) sampled resident reviewed. The findings include: 1.Review of the facility policy titled Comprehensive Care Plans revised 6/30/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives .The comprehensive care plan will be prepared by an interdisciplinary team, that includes but is not limited to .the resident and the residents representative .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . 2.Review of medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Fracture of Right Femur, Dysphagia, and 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 policy review, medical record review, observation, and interview, the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for personal grooming for 1 of 4 residents (Resident #80) reviewed for ADLs. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADLs), revised 12/28/2022, revealed .The facility takes measures to minimize the loss of residents functional abilities, including activities of daily living .including the ability to bathe, dress, and groom .resident who is unable to carry out activities of daily living receives the necessary services to maintain . grooming and personal and oral hygiene .the facility maintains individual objectives of the care plan through periodic review and evaluation . 2. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Muscle Weakness, 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 policy review, medical record review, observations, and interview, the facility failed to follow Physician orders related to blood glucose monitoring, missed medication doses, physician orders for parameters for the use of an anti-hypertensive medication (a medication given for high blood pressure) and failed to obtain vital signs before administering anti-hypertensive medication for 3 of 3 sampled residents (Resident #12, #68, and #73) reviewed for medication administration. The findings include: 1. Review of the facility's policy titled, Physician/Practitioner Orders-Consulting revised 3/20/2024, revealed . The attending physician shall authenticate orders for the care and treatment of assigned residents . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Hypertension, Diabetes, End Stage Renal Disease, Hyperkalemia and Atrial Fibrillation. Review of the Physician Orders dated 4/23/2024, revealed .May obtain blood glucose as needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to follow its policy for changing oxygen tubing and failed to follow the prescribed physician order for oxygen administration for 1 of 1 (Resident #68) sampled residents reviewed for respiratory care. The findings include: 1.Review of the facility policy titled, Oxygen Administration revised 10/26/2023, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences . Oxygen is administered under orders of a physician . Change oxygen tubing and mask/ cannula weekly and as needed if it becomes soiled or contaminated . 2.Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including Diabetes, Heart Failure, Hypertension, and Stage 4 Pressure Ulcer. Review of the Physician's Order dated 7/12/2024, revealed .Oxygen: RUN @ [at] 1L [liter]…

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 ensure posted staffing information was accurate and current for 5 of 15 days (9/23/2024, 9/25/2024, 10/1/2024, 10/15/2024 and 10/16/2024) during the survey. The findings include: 1. Review of the facility policy titled, Nurse Staffing Posting Information dated 3/4/2024, revealed .The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information .The current date .The facility will post/update the Nurse Staffing Sheet at the beginning of each shift . 2. Observations in the front lobby on 9/23/2024 at 3:21 PM, revealed the posted Direct Care Staffing Hours was dated 9/20/2024. Observations in the front lobby on 9/23/2024 at 5:25 PM, revealed the posted Direct Care Staffing Hours was dated 9/24/2024. Observations in the front lobby on 9/25/2024 at 7:36 AM, revealed the posted Direct Care Staffing Hours was dated 9/24/2024. Observations in the front lobby on 10/1/2024 at 2:42 PM, revealed the posted Direct Care Staffing Hours was dated 9/30/2024. Observations in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured for 2 of 2 sampled residents (Residents #49 and #70) when medications were found unattended and unsecured in the resident rooms, and when opened and undated medications were stored in 2 of 13 medication storage areas (100 Hall Medication Room). The findings include: 1. Review of the facility policy titled, Medication Storage reviewed and revised on 1/30/2024, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored according to manufacturer's recommendations and sufficient to ensure proper .segregation and security .all drugs and biologicals are stored in locked compartments .medication carts, cabinets, drawers .medication rooms .During a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart . 2. Review of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 of 1 sampled resident (Resident #39) reviewed for dental services. The findings include: 1. Review of the facility policy titled, Dental Services Policy dated 11/28/2017, revealed .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .Social Services personnel will be responsible for assisting the resident .family in making dental appointments . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Dependence on Ventilator, Diabetes, and Congestive Heart Failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 with a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #40 was cognitively intact and had no dental problems…

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 that the binding arbitration agreement signed by residents or resident's legal representative was understood for 1 of 3 residents (Resident #140) reviewed for arbitration agreement. The findings include: 1.Review of the facility policy titled Binding Arbitration Agreements revised on 11/1/2022, revealed .The facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission .Arbitration is a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments .Policy Explanation and Compliance Guidelines: .When explaining the arbitration agreement, the facility shall: .explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, facility investigation, medical record review, and interview, the facility failed to follow up and honor a resident's right to request a room change for 1 of 6 residents (Resident #118) sampled for resident rights. The findings include: 1. Review of the facility's undated policy titled, Residents Rights, revealed, .As a company we place a top priority on preserving resident rights, ensuring their rights are not violated . Review of the facility's policy titled, Change of Room or Roommate, dated 10/30/2023, revealed .It is the policy of the facility to conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or resident representative .Requests for changes in room or roommate should be communicated to the Social Service Designee . 2. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE], with diagnoses including Non-Traumatic Intercranial Hemorrhage, Need Assistance with Personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, daily working schedule review, Labor Details review, employee screening logs review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when 1 of 1 staff member(Respiratory Therapist (RT) #1 and #2) failed to follow infection control guidelines during tracheostomy care for 2 of 3 sampled residents (Resident #102 and #39) reviewed with tracheostomies, when 1 of 1 staff member (Registered Nurse (RN) #1) failed to don (putting a garment on) Personal Protective Equipment (PPE) before entering a residents room in droplet precautions for 1 of 4 sampled residents (Resident #106) reviewed in droplet precautions, and the facility failed to properly prevent and contain COVID-19 when 4 of 174 staff members (Housekeeper #1, Physical Therapist #1, Occupational Therapist #1, and Speech Language Pathologist #1) failed to complete the COVID-19 screening logs on 13 of 20 days (9/4/2021, 9/5/2021, 9/6/2021,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 sampled resident (Resident #34) reviewed for self-administration of medication. The findings include: Review of the facility's policy titled, Nebulizer Therapy, dated 10/30/2020 revealed .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique .Care of Resident .Observe resident during the procedure for any change in condition . Review of the facility's policy titled Medication - Resident Self Administration of, dated 10/30/2020, revealed .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .The care plan must reflect resident self-administration . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure residents were invited to participate in care planning for 1 of 22 sampled residents (Resident #87) reviewed for participation in care planning. The findings include: Review of the facility's policy titled, Patient/Family Initial Care Conference, dated 9/3/2020, revealed .Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan .The resident and his/her family .are invited to attend and participate in the resident's assessment and care planning conference .Give seven (7) day advance notice of the care planning conference to the resident . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Cerebral Infarction, and Parkinson's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #87 was cognitively intact. 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 policy review, medical record review, and interview, the facility failed to administer the prescribed medication for 1 of 6 sampled residents (Resident #80) reviewed for Physician's Orders and medication administration. The findings include: Review of the facility's policy titled, .Medication Administration, revised 10/30/2020, revealed .Medications are administered as ordered by the physician and in accordance with professional standards of practice .sign MAR [medication administration record] after administered . Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses of Methicillin Resistant Staphylococcus Aureas Infection, Extradural and Subdural Abscess, Diabetes, and Crohn's Disease. Review of the Physician's Orders dated 9/2/2021 - 10/3/2021, revealed the following orders for Resident #80: Cubicin Solution Reconstituted 500 MG [milligrams] (daptomycin) Use 1000 mg intravenously at bedtime for spinal epidural abscess until 10/03/2021. Review of 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 medical record review, observation, and interview, the facility failed to accurately assess a pressure injury for 2 of 5 sampled residents (Resident #68 and #112) reviewed for pressure injuries. The findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 10/30/2020, revealed .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment . Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Spina Bifida, Morbid Obesity, and Stage 3 Pressure Ulcer. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, and the resident was coded for Stage 3 pressure ulcers. Review of Resident #68's Wound Evaluation notes revealed the following measurements for the Ischial Tuberosity stage 3 sacral wound:…

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

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when dishware was washed inappropriately, wet nesting of dishware, and 2 (Dietary Aide #1 and #2) kitchen staff were observed in the kitchen without hair and beard restraints. The facility's failure had the potential to affect 170 of the 175 residents receiving a meal tray from the kitchen. The findings include: 1. The facility's Dining Services Policy and Procedure Manual revised 9/2017 documented, .All dishware will be air dried and properly stored . The facility's Dining Services Policy and Procedure Manual revised 9/2017 documented, .All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . 2. Observations in the Kitchen on 9/30/19 at 9:15 AM, revealed a tray rack with multiple plate lids sitting inside of each other. The rack of plate lids had gone through the wash cycle and were wet. Interview with the Kitchen Manager on 9/30/19 at 9:20 AM, in the Kitchen, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the comprehensive care plan intervention of 2 person transfers via mechanical lift were implemented for 1 of 38 (Resident #6) sampled residents reviewed. The findings included: The facility's Care Plans-Comprehensive policy revised on 1/28/11 documented, .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels . Medical record review revealed Resident #6 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Polymyalgia Rheumatic, Osteoarthritis, and Diabetes. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure an environment was free of accident hazards for 2 of 5 (Resident #6 and #149) sampled residents reviewed for falls. The findings included: 1. The facility's Mechanical Lift policy revised 8/2016 revealed, The purpose of this procedure is to help lift residents using a manual lifting device .Two (2) nursing assistants will be required to perform any mechanical lift procedure . 2. Medical record review revealed Resident #6 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Polymyalgia Rheumatica, Osteoarthritis, and Diabetes. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or more staff assist. The quarterly Minimum Data Set, dated [DATE] documented Resident #6 was assessed with a Brief Interview for Mental Status (BIMS) of 8 out of 15 indicating a moderate deficit and requiring extensive assistance of 2 persons with transfers. An Incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 13 (500 Hall Medication Cart) medication storage areas. The findings include: 1. The facility's Medication Storage policy dated 9/18 documented, .Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorizes access . 2. Observations in the 500 Hall outside of the Secured Unit Dining Room on 9/30/19 at 4:24 PM, revealed an unlocked and unattended medication cart. Observations in the 500 Hall outside of room [ROOM NUMBER] on 9/30/19 at 4:30 PM, revealed an unlocked and unattended medication cart. Interview with the Director of Nursing (DON) on 10/2/19 at 4:23 PM, in the DON Office, the DON was asked if a medication cart should be left unlocked and unattended. The DON stated, No.