Hardin County Nh

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after the addition of a new mental illness diagnosis for 2 of 2 (Resident #17 and #21) sampled residents reviewed for PASRR. The findings include: 1. Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), dated 10/1/2024, revealed .PASRR requires that.all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness.A negative Level I screen permits admission to proceed and ends the PASARR [PASRR] process unless a possible serious mental disorder . arises later.An individual is considered to have a serious mental illness.Diagnosis.anxiety disorder.psychotic disorder; or another mental disorder that may lead to a chronic disability.If a significant change in status assessment (SCSA) occurs for an individual known or suspected to have a mental illness.a referral to the State Mental Health.for a possible…

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 staff were administering medications per Physician's Orders for 1 of 5 (Resident #5) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Administration of Drugs, dated 12/2008, revealed .give medications per physician's orders. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Presence of Artificial Larynx, Hemiplegia (paralysis affecting one side of the body), Depression, Anxiety and Fractured Fibula. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #5 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Review of the Physician's Order dated 12/30/2025, revealed .Nystatin [used to treat yeast infections] External Powder 100000 UNIT/GM [gram].Apply to perineal [area between the genitals and…

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

Based on review of facility policy, Quarterly Payroll Based Journal (PBJ) review and interview, the facility failed to report PBJ for Quarter 1 of 2024 (October 1, 2024- December 31, 2024). The findings include: 1. Review of the undated facility policy titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal), revealed, .Direct-care staffing and census information will be reported electronically to CMS though the Payroll-Based Journal System (PBJ) system . 2. Review of the Quarterly Payroll Based Journal (PBJ) dated 10/1/2024 - 12/31/2024, revealed, .Failed to Submit Data for the Quarter . During an interview on 1/23/2025 at 3:38 PM, the Administrator confirmed the facility failed to submit the PBJ data, by the required deadline, for the first quarter of 2024.

Based on facility policy, observations, and interviews, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions when 1 of 6 (Dietary [NAME] B) dietary staff failed to sanitize the thermometer after each use, and when the facility failed to ensure the deep fryer and the cooking stove eyes were clean. The facility had a census of 39 with 39 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, Food Preparation Area, dated 5/2013, .Our facility will maintain a clean, sanitary, and safe food preparation area . 1. Observation in the Kitchen on 1/21/2025 at 4:09 PM and 1/23/2025 at 8:28 AM, revealed the deep fryer had dark brown cooking grease with brown crumbs floating on top of the cooking oil and the cooking stove eyes had black build up. 2. Observation in the Kitchen on 1/22/2025 at 10:52 AM, revealed Dietary [NAME] B took the temperature of the broccoli, placed the thermometer into the roast beef and failed to clean the thermometer prior to taking the temperature of the roast…

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 care plan conference with the resident and/or family representative for 1 of 12 (Resident #28) sampled residents reviewed for care plan conferences. The findings include: 1. Review of the facility policy titled, Care Plan Meeting dated 12/2024, revealed .A Care Plan meeting is conducted to demonstrate to the resident, family, and resident representative that the organization is dedicated to the provision of person-centered care to achieve the resident's highest practicable well-being and outcomes of the resident's ongoing health and safety concerns .MDS Coordinator or designee will set the appointment date and time with the resident, family/representative .The Interdisciplinary Team (IDT) will introduce themselves and explain their roles on the care team. The IDT will obtain additional pertinent information regarding the resident's clinical status, prior living conditions, and the presence of family/local support 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.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 5 of 11 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #6, and Licensed Practical Nurse (LPN) #5) failed to knock and/or announce themselves before entering a resident's room during dining, stood to assist with dining, and failed to use courtesy titles when addressing residents. The findings include: 1. Review of the facility's policy titled, Dignity, dated 7/2018, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Staff will knock and request permission before entering residents' rooms .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs .Staff shall promote dignity and assist person served as needed by .sitting…

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 update and revise the Care Plan for Physical Restraints, Smoking Safety Screen, and Wandering Risk Assessments for 1 of 1 sampled resident (Resident #8) reviewed. The findings include: 1. Review of the facility's policy titled Care Plan, dated 5/2013, revealed .An individual care plan for activity is developed and maintained for each resident . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Cognitive Communication Deficit, Chronic Obstructive Pulmonary Disease, Tobacco Use, Dementia with Behavioral Disturbance, Depression and Legal Blindness. Review of the most current Wandering Risk Assessment revealed the last assessment was done on 8/17/2023. There was no documentation the Wandering Risk Assessment was conducted after 8/17/2023 and quarterly. Review of the quarterly MDS dated [DATE], revealed Resident #8 had a BIMS score 13…

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 medications were properly stored and labeled when expired medications were observed in 1 of 1(Hall 1 Medication Cart) medication storage areas. The findings include: 1. Review of the facility's policy titled Storage of Medications, revised 5/2013 revealed .Drugs and biologicals shall be stored in a safe and orderly manner .No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this facility . 2. Observation at Hall 1 Medication Cart on 2/8/2024 at 3:39 PM, revealed 2 opened bottles of Latanoprost Ophthalmic Solution 0.005% (percent) (eyedrops). One of the bottles of Latanoprost Ophthalmic Solution 0.005% had an opened date of 12/26/2023 and a discard by 2/6/2024 date, the other bottle of Latanoprost Ophthalmic Solution 0.005% had an opened date of 12/25/2023 and no use by date on the bottle. During an interview on 2/8/2024 at 3:46 PM, Licensed Practical Nurse (LPN) #1 was asked how long are eyedrops good for use after they have been opened. LPN #1 stated, .30 days .…

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.