Millard County Care and Rehabilitation

Based on observation, interview and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, a staff member tested positive for COVID-19 and was not excluded from working in the facility. Findings include: On 2/5/24 upon entering the facility, an interview was conducted with the Administrator. The Administrator stated the Maintenance Director tested positive for COVID-19 that morning. The Administrator stated he fixed the facility washing machine and then tested positive. The Administrator stated he was not feeling well and he was sent home. The Administrator stated the Maintenance Director did not feel good Friday and left early. The Administrator stated the Maintenance Director did not work Saturday or Sunday. On 2/6/24 at 10:05 AM, an observation was made of the Maintenance Director. The Maintenance Director was wearing a black surgical…

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

Based on observation, interview and record review, it was determined the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Findings include: The facility's Infection control documentation was requested. No Infection Control Surveillance Logs were available from the previous survey 5/5/22 to current. On 2/6/24 at 4:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had not had an IP since the previous survey. The DON stated she had not completed the IP training. The DON stated she was unable to fill the IP position because then it would take a nurse from patient care. The DON stated she did not have infection control tracking or trending. The DON stated she should have infection control tracking and trending for each month. [Cross refer to F880]

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 5 of 20 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist, and that any irregularities were reported to the physician and were acted upon. Specifically, monthly pharmacy reviews were not being conducted between July 2023 and January 2024. Resident identifiers: 14, 19, 20, 22 and 32. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of endocrine pancreas, type 2 diabetes, neoplasm related pain, anxiety disorder, nausea with vomiting, thrombocytopenia, and occlusion and stenosis of aortic artery. Resident 14's medical record was reviewed between 2/5/24 and 2/7/24. No pharmacy reviews were located in resident 14's medical record. 2. Resident 19 was admitted to the facility initially on 4/17/22 and then again on 11/17/23 with diagnoses that included fracture of coccyx, muscle weakness, displace…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 5 of 20 sampled residents, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR), and behavioral interventions, unless it was clinically contraindicated. Specifically, residents prescribed psychotropic drugs did not have a GDR attempted. In addition, documentation for contraindication for GDR's were not documented. Resident identifier: 14, 19, 20, 22 and 32. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypoxemia, pain in thoracic spine, unsteady on feet, wedge compression fracture, low back pain, pain in hip, heart failure, hypertension and osteoporosis. Resident 20's medical record was reviewed 2/5/24 through 2/7/24. Resident 20's physician's order dated 4/30/2020 revealed, Pristiq 100 milligrams (mg) to administer 1 tablet by mouth one time a day related to anxiety. Resident 20's physicians order dated 3/24/2020…

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

Based on observation and interview it was determined that the facility failed to store all drugs and biologicals in locked compartments. Specifically, two refrigerators that contained medications were unlocked. Findings include: On 2/6/24 at 2:05 PM, an observation was made of the north side nursing station medication refrigerator. The medication refrigerator was unlocked and contained insulin medications. On 2/6/24 at 2:22 PM, an observation was made of the south side nursing station medication refrigerator. The medication refrigerator was unlocked and contained insulin medications. On 2/6/24 at 2:22 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the medication refrigerator contained insulin and suppository medications. RN 1 further stated the south side medication refrigerator did not have a lock on it. On 2/6/24 at 2:35 PM, an interview was conducted with RN 2. RN 2 stated the medication refrigerator always needed to be locked. RN 2 stated the refrigerator contained insulin, eye drops, and suppository medications. On 2/6/24 at 4:35 PM, an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not notify the resident's physician when there was a signigicant change in the resident's physical, mental or psychosical status or when there was a need to alter treatment significantly. Specifically, a resident developed a new wound and the physicain was not notified. In addition, the resident did not have physician's orders to treat the wound. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, moderate protein-calorie malnutrition, open wound left foot, major depressive disorder and cutaneous abscess of left lower limb. On 2/5/24 at 1:52 PM, an interview was conducted with resident 21. Resident 21 stated she thought she had sores on her body. Resident 21 stated she did not have pain from her sores. Resident 21 stated her sores were kept covered with dressings. On 2/5/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not provide or obtain routine dental services. Specifically, a resident stated her dentures did not fit and needed to be adjusted. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis, subluxation of left shoulder, heart failure, insomnia, cerebral infarction due to unspecified occlusion or stenosis of cerebral artery, muscle weakness, and type 2 diabetes mellitus. On 2/5/24 at 2:51 PM, an interview was conducted with resident 34. Resident 34 stated she needed her dentures realigned. Resident 34 stated she was not sure if she had enough money. Resident 34 stated she was able to wear her top dentures and her food was cut up for her to be able to eat it. Resident 34's medical record was reviewed 2/5/24 through 2/7/24. An annual Minimum Data Set (MDS) dated [DATE] revealed no dental issues. 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 interview and record review, for 1 of 20 sampled residents, it was determined the facility did not develop and implement a baseline care plan that included the instructions needed to provide effective and person centered care of the resident that met professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, the resident's care plan was developed 5 days after the resident was admitted to the facility. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of coccyx, muscle weakness, displaced fracture of left humerous, encephalopathy, chronic kidney disease, type 2 diabetes, major depressive disorder and dementia. Resident 19's medical records were reviewed between 2/5/23 and 2/7/23. A review of resident 19's careplan revealed focus areas initiated on 11/22/23 included: a. The resident had an ADL (activities of daily living) performance deficit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that, for 5 of 20 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 9, 14, 21, 22, and 34. Findings include: 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mental disorder, polyosteoarthritis, type 2 diabetes mellitus, sensorineural hearing loss, paralytic syndrome, chronic pain, hypoxemia, lagophthalmos left eye, hallucinations, and malignant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for 2 of 20 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident who had a change in her diet order was not assessed as having a change in condition, and a resident who developed pneumonia and the flu did not have his change in condition documented until it was necessary to send him to the hospital. Resident identifiers: 22 and 32. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, psychophysiologic insomnia, mood disorder with depressive features, and anxiety disorder. On 2/5/24 at 12:10 PM, an observation was made of resident 22 in the dining room for the lunch meal. Resident 22 received a pureed diet in a divided plate and a cup of jello. Resident 22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medications did not have a diagnoses. Resident identifier: 20. Findings included: Resident 20 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypoxemia, pain in thoracic spine, unsteady on feet, wedge compression fracture, low back pain, pain in hip, heart failure, hypertension and osteoporosis. Resident 20's medical record was reviewed 2/5/24 through 2/7/24. Resident 20's physician's orders dated 3/24/2020 revealed Eliquis 2.5 milligrams (mg) twice daily for displaced intertrochanteric fracture of unspecified femur, sequela. A physician's order 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 interview and record review, for 1 of 20 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, a resident had laboratory services completed without a physician's order. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypoxemia, pain in thoracic spine, unsteady on feet, wedge compression fracture, low back pain, pain in hip, heart failure, hypertension and osteoporosis. Resident 20's medical record was reviewed 2/5/24 through 2/7/24. Resident 20's last physician's orders for laboratory services was on 9/20/22 for a Comprehensive Metabolic Panel (CMP) with a diagnosis of protein malnutrition. Laboratory values in resident 20's medical record were the following: 1. 4/12/23: Urine analysis 2. 3/17/23: Urine analysis 3. 3/17/23: Urine Culture 4. 3/16/23 B-Type Natriuretic Peptide, Complete Blood Count (CBC) with Auto Diff, CMP, C-reactive protein (CRP),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review. it was determined for 1 of 20 sampled residents, that the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of testing laboratory. Specifically, the lab results for 3 urinary cultures and sensitivities were not obtained or filed in the resident's medical record. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of coccyx, muscle weakness, displace fracture of left humerus, encephalopathy, chronic kidney disease, type 2 diabetes, major depressive disorder and dementia. Resident 19's medical records were reviewed between 2/5/23 and 2/7/23. On 12/6/23 at 4:45 PM, a nursing progress note revealed, .She has been c/o [complaining of] lower back and pelvic pain, burning on urination. Staff reported that her urine looks cloudy and there is possible the presence of blood in the urine .At 1230…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 20 sampled residents, that the facility did not file in the resident's clinical record the signed and dated reports of radiological and other diagnostic services. Specifically, a resident's chest x-ray result was not filed in the medical record. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included type 2 diabetes, major depressive disorder, macular degeneration, dementia, anxiety disorder, insomnia, pneumonia, and influenza A with respiratory manifestations. Resident 32's medical records were reviewed from 2/5/24 to 2/7/24. A physician's progress noted dated 11/29/23 revealed, DX [diagnosis]: Pneumonia. Patient with acute onset shortness of breath decreased oxygen today. Patient reports congestion. Borderline low oxygen 88 on my examination though noted to be 86. Blood pressure was stable today. Ordered CBC [complete blood count] CMP [complete metabolic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not provide or obtain routine dental services. Specifically, a resident stated her dentures did not fit and needed to be adjusted. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis, subluxation of left shoulder, heart failure, insomnia, cerebral infarction due to unspecified occlusion or stenosis of cerebral artery, muscle weakness, and type 2 diabetes mellitus. On 2/5/24 at 2:51 PM, an interview was conducted with resident 34. Resident 34 stated she needed her dentures realigned. Resident 34 stated she was not sure if she had enough money. Resident 34 stated she was able to wear her top dentures and her food had to be cut up for her to be able to eat it. Resident 34's medical record was reviewed 2/5/24 through 2/7/24. An annual Minimum Data Set (MDS) dated [DATE] revealed no dental issues. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined for 2 of 20 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, residents were provided puree diets when their prescribed diet was mechanical soft or regular. Resident identifiers: 9 and 22. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, psychophysiologic insomnia, mood disorder with depressive features, and anxiety disorder. On 2/5/24 at 12:10 PM, an observation was made of resident 22 in the dining room for the lunch meal. Resident 22 received a pureed diet in a divided plate and a cup of jello. Resident 22 had water and juice to drink with her meal. A Certified Nursing Assistant (CNA) was sitting between resident 22 and another resident and was assisting resident 22. Resident 22 was unable to feed herself. Resident 22's medical record was reviewed between 2/5/24 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 interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident with a referral for cataracts to be evaluated was not completed. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, mood disorder and macular degeneration. Resident 38's medical record was reviewed 2/6/24. A nursing progress note dated 6/8/23 at 4:45 PM revealed, Resident supervised with her care this morning. She c/o [complained of] R [right] eye pain and itching, eye is red from her rubbing it. She does have a history of macular degeneration. Prior to coming here, she had been getting an injection in her eye. She was given PRN [as needed] Tylenol and reported that it had helped some. I suggested that we talk with her family about getting an eye appointment here for her and possibly treatment with medication. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 20 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to providing services in the facility and to the timeliness of those services. Specifically, the facility did not obtain from the hospice provider the most recent hospice plan of care, physician re-certification of terminal illness, and all communication visit notes were not maintained in the resident's medical record. Resident identifier: 14. Findings include: Resident 14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of endocrine pancreas, type 2 diabetes, neoplasm related pain, anxiety disorder, nausea with vomiting, thrombocytopenia, and occlusion and stenosis of aortic artery. Resident 14's medical records were reviewed between 2/5/24 and 2/7/24. Resident 14's care plan revealed, The resident has a terminal prognosis r/t [related to] cancer. The goal was The resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not provide the right for residents to choose medical treatment. Specifically, for 4 out of 37 sampled residents, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not completely filled out. Resident identifiers: 2, 41, 202 and 23. Findings include: 1. Resident 2 was admitted to the facility on [DATE], with a diagnoses that included: heart failure, Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, anxiety, polyneuropathy, cerebral infarction and dysphasia. On [DATE] a review of resident 2's medical record was conducted. During this review, it was discovered that resident 2's POLST was not completely filled out in Section D. 2. Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnoses that included: hepatic failure, hypotension, bacteremia, esophageal varicies, type 2 diabetes, hypomagnesia and anemia. On [DATE] a review of resident 41's 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 3. Resident 252 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, iron deficiency anemia, muscle weakness, repeated falls, rheumatoid arthritis without rheumatoid factor, epilepsy, major depressive disorder, and anxiety. Resident 252's medical record was reviewed on 5/5/22. A review of resident 252's care plan revealed the care plan to be incomplete. Resident 252's care plan was initiated on 4/25/22 with the next review date scheduled for 5/6/22. Resident 252's care plan had a focus area initiated on 4/26/22 which stated, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, musculoskeletal impairment, weakness. This focus area had one goal, initiated on 4/26/22, which stated, The resident will improve current level of function in ADL ability through the review date. This focus area and goal had six incomplete interventions, initiated on 4/26/22, which read: a. BED MOBILITY: The resident requires (SPECIFY what…

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 observations and interviews, it was determined that the facility did not ensure that standard precautions and hand hygiene procedures were followed by staff in direct resident contact to prevent the spread of infection. Specifically, staff members did not perform hand hygiene before and after providing resident care, did not perform hand hygiene between resident encounters, and did not disinfect the weight bench before and after each resident use. Findings included: On 05/02/22 at 1:14 PM, Certified Nursing Assistant (CNA) 2 was observed assisting a resident to her room. It was observed that CNA 2 did not perform hand hygiene upon entering the resident's room or before providing care to the resident. It was observed that another staff member entered the same room and assisted CNA 2 to transfer the resident without performing hand hygiene before or after the encounter. On 05/03/22 at 12:45 PM, it was observed that CNA 2 and another staff member weighed the resident in room [ROOM NUMBER] with the weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined for 1 of 37 sampled residents, the facility did not conduct a periodic comprehensive, accurate, standardized, and reproducible Minimum Data Set (MDS) assessment of each resident's functional capacity. Specifically, an annual MDS assessment was not completed timely. Resident identifier: 35. Findings include: Resident 35 was admitted on [DATE] with diagnoses that included morbid obesity with alveolar hypoventilation, chronic kidney disease, type 2 diabetes with diabetic neuropathy, lymphedema, hypoxemia, mood disorder with depressive features, obstructive sleep apnea, acute chronic diastolic heart failure and Charcot's joint-left ankle and foot. Resident 35's medical record was reviewed on 5/4/22. Resident 35's annual MDS assessment had a target date of 4/15/22. An observation was made that the annual MDS assessment on resident 35 was In Progress and the MDS viewer was flagged stating the annual assessment was 14 days overdue. On 5/5/22 at 9:30 AM, 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 interview and record review the facility did not use the quarterly review instrument once every three months for 1 of 37 sampled residents. Specifically, a Quarterly Minimum Data Set (MDS) assessment was not completed and submitted in a timely manner. Resident Identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hypokalemia, dementia, psychotic disorders with delusions and hallucinations, benign prostatic hyperplasia, heart failure, amnesia, edema, insomnia, restless leg syndrome, hypertension, and gout. On 5/5/22 resident 23's electronic medical record (EMR) was reviewed. Resident 23's Quarterly MDS assessment had a target Assessment Reference Date (ARD) of 4/1/22. Resident 23's EMR indicated that the Quarterly assessment was In Progress and the MDS viewer was flagged stating the Quarterly Assessment was 20 days overdue. [Note: A Quarterly MDS assessment dated [DATE] was the last submitted and accepted MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility did not develop and implement a baseline care plan for each resident that included the instruction needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Specifically, a baseline care plan was not completed for a newly admitted resident, which left facility staff without the needed instruction to provide the resident with effective, person-centered care. Resident identifier: 252. Finding included: Resident 252 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, iron deficiency anemia, muscle weakness, repeated falls, rheumatoid arthritis without rheumatoid factor, epilepsy, major depressive disorder, and anxiety. Resident 252's medical record was reviewed on 5/5/22. The record review revealed that a baseline care plan was not completed or implemented for resident 252. Records showed that an admission assessment was completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not provide treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 37 sampled residents, the facility did not provide baseline monitoring of a resident's blood sugars. Resident identifier: 202. Findings include: Resident 202 was admitted to the facility on [DATE], with a diagnosis that included: hemiplegia, heart failure, cerebral infarction, type 2 diabetes, hyperlipidemia, and chronic kidney disease. On 5/3/22 a review of resident 202's medical record was completed. Physician orders dated 4/22/22 stated continue to recheck blood sugar if BS (blood sugar) is below 70 or above 430 every hour until within these parameters. There were no physician orders to establish a baseline blood sugar. No blood sugar data was available during resident 202's stay. On 5/4/22 at 11:45 AM an interview was conducted with Registered Nurse (RN) 1, During this interview, RN 1 stated that she should have…

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

Based on observation, interview, and record review it was determined that the facility did not maintain acceptable parameters of nutrition status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, there was 1 of 37 sampled residents that lost weight and nutritional interventions recommended were not implemented timely. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility initially on 6/5/17, had subsequent admissions on 10/4/2018 and 10/20/2019, and most recent readmission was on 4/13/22. Diagnoses upon admission included pneumonia, respiratory failure, severe sepsis, gastroesophageal reflux disease, anxiety disorder, systolic congestive heart failure, and mild cognitive impairment. On 5/2/22 at 2:55 PM an interview was conducted with resident 9. Resident 9 stated that she had not been included in decisions that were made about her care. Resident 9 also stated she was unsure if she had lost weight recently. Resident 9 was observed in her room, dressed…

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.