Spring Creek Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. In addition, the attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 1 out of 33 sampled residents, a pharmacy recommendation was not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, malignant neoplasm of right female breast, dementia severe, delusional disorders, urinary tract infections, repeated falls, dysphagia, difficulty in walking, and unsteadiness on feet. Resident 62's medical record was reviewed on 1/28/25.…

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 and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 2 out of 33 sampled residents, four opened insulin injector pens were not labeled with open dates and they were in the medication cart available for resident use. Resident identifiers: 7 and 24. Findings included: On 1/30/25 at 1:54 PM, an observation was conducted of the third floor East hallway medication cart with Registered Nurse (RN) 7. There were four insulin injector pens in the medication cart that were not labeled with an open dated. RN 7 stated as soon as we get the insulin out of the fridge we would date the insulin with an open date. RN 7 stated that insulin was all ready labeled with the residents name. RN 7 stated the insulin was good for 28 days after opening. 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but were not…

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, 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 Coronavirus Disease 2019 (COVID-19). Specifically, the facility did not have an infection control tracking and trending program, a resident with pneumonia was walking in the hallway without a mask, a nurse touched the medications during administration, hand hygiene was not used during meal times, silverware that was used to close a meal tray cart door was then given to a resident for use, food items were transported through the hallways uncovered, and staff did not wear Personal Protective Equipment (PPE) appropriately when entering an isolation room. Resident identifiers: 6, 20, 35, 40, 52 and 64. Findings include: Infection Control tracking and trending On 1/11/23 at 12:30 PM, the facility was asked to provide 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 observation, interview and record review it was determined, for 10 of 38 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. Specifically, residents were called by nicknames, desserts were served in disposable cups, a sign was hung at the nurses station for residents, residents at the same table were not served at the same time and staff were talking loudly. Resident identifiers: 6, 18, 23, 31, 32, 43, 45, 52, 62 and 319. Findings include: 1. On 1/9/24 at 11:56 AM, an observation was made of residents in the dining room. The Assistant Director of Nursing (ADON) was observed to enter the dining room and stated [Resident 32's name], I got your lunch girl. On 1/9/24 at 11:57 AM, an observation was made of the Regional Nurse Consultant (RNC). The RNC called resident 6 My friend. On 1/9/24 at 12:00…

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 interview, it was determined that the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not employ a qualified dietary manager or a full time qualified dietitian that possesses one or more of the following credentials: Certified Dietary Manager, Registered Dietitian, Certified Food Service Manager, a Food Service Management Certificate, 2 or more years of experience in a nursing facility setting as a food service director and has completed a course of study in food safety and management, or an associates degree or higher with coursework in food service, hospitality, or restaurant management. Findings Include: On 1/8/24 at 7:05 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that she did not have her Certified Dietary Manager (CDM) certificate or equivalent certification. The DM stated that she was in a class to obtain her CDM and would obtain it by the end of the month. On 1/10/24 at 1:51 AM, 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.

Based on interview and record review, it was determined that the facility did not ensure that each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance. Specifically, multiple residents complained about the food during the initial pool interview process and multiple grievances were filed by residents about the quality of the food served by the facility. Resident identifiers: 1, 11, 13, 20, 23, 36, and 50. Finding include: 1. On 1/8/24 at 10:08 AM, an interview was conducted with Resident 1. Resident 1 complained of the quality of the food served by the facility. Resident 1 stated that the food served to her is only slightly warm. 2. On 1/8/24 at 8:51 AM, an interview was conducted with Resident 11. Resident 11 complained that breakfast that morning was served cold. Resident 11 also complained of small protein portions, small beverage portions, and the overall quality of the food. 3. On 1/8/24 at 8:56 AM, an interview was conducted with Resident 13. Resident 13 complained of the quality of the food served by 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 observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility served three residents beverages in plastic cups that were not clean and facility staff served residents hot chocolate without completing hand hygiene. Resident Identifiers: 38, 62, 7, 57, 319, and 61. Finding Include: On 1/9/24 at 11:50 AM, an observation was made of the Resident Advocate (RA) 1 and the Minimum Data Set Coordinator (MDSC). The RA 1 and MDSC pushed a three level cart that held juice on the top level, small plastic cups on the mid level and large plastic cups on the bottom level. All the small cups were observed to be clean. Three of the large cups on the bottom were observed to be dirty with a light brown sediment. On 1/9/24 at 11:59 AM, during drink service for lunch, RA 1 was observed to obtain a large cup from the bottom of the beverage cart. The cup was noted to have light brown…

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 record review and interview it was determined, for 5 of 38 sample residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, resident's influenza consent and declination records were not included in the medical record. Resident identifiers: 29, 34, 6, 1, and 21. Findings include: 1. Resident 29 was admitted the the facility on 8/29/22 with diagnoses which included multiple sclerosis, morbid obesity, muscle weakness, hemiplegia of the left side, lymphedema, major depressive disorder and neuromuscular dysfunction of bladder. Resident 29's medical record was reviewed 1/8/24 through 1/11/24. The Immunization section of the medical record documented resident 29 refused the Influenza vaccine. Resident 29's medical record did not have any documentation of an Influenza vaccination refusal. 2. Resident 34 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included…

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 interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility did not have infection control tracking and trending completed for the previous year. Findings include: On 1/11/23 at 12:30 PM, the facility was asked to provide the infection control tracking program for the facility. On 1/11/23 at around 2:00 PM, the Regional Nurse Consultant (RNC) reported the entire year of the infection control tracking program had been erased from their system and that there were no hard copies. The RNC stated she could not prove it but it was suspected a terminated employee had erased the files. The RNC stated they were working on getting a back up of the information to provide to the survey team. The RNC stated she had done the previous three months so she could go back in and recreate it, but she was unable to provide any other infection tracking for the facility. On 1/16/24 at 11:57 AM, the Administrator (ADM) provided 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 observation, interview and record review it was determined, for 2 of 38 sampled residents, the facility did not offer a therapeutic diet when there was a nutritional problem and the health care provider orders a therapeutic diet. Specifically, residents with physician's orders for liberalized renal diets were not provided the appropriate diet. Resident identifiers: 23 and 170. Findings include: 1. Resident 170 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, suicidal ideation's, type II diabetes mellitus, muscle weakness, lack of coordination, unsteadiness on feet, essential hypertension, bipolar II disorder, generalized anxiety disorder, legal blindness, major depressive disorder, anemia and morbid obesity. Resident 170's medical record was reviewed on 1/8/24 through 1/11/24. On 1/8/23 at 9:10 AM, an interview was conducted with resident 170. Resident 170 stated he did not get the food he was supposed to for his kidneys. Resident 170 stated they bring him…

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 and interview, the for 1 out of 38 sampled residents, the facility was not in accordance with currently accepted professional principles and included the Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Specifically, there was documentation of narcotics that were wasted with one nurse and a second nurse did not witness the waste. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included fracture of right femur, major depressive disorder and anxiety disorder. Resident 19's medical record was reviewed 1/8/24 through 1/11/24. On 10/31/23 a nurses progress note revealed resident 19 had a broken hip. Sent to the ER [emergency room] to be evaluated . Resident 19's Medication…

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 38 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, a resident's x-ray was not located in the medical record. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of the right femur, anxiety disorder, depression and chronic respiratory failure. Resident 19's medical record was reviewed 1/8/24 through 1/11/24. A progress note dated 10/30/23 at 3:48 PM revealed, resident 19 had spent the day in bed. is refusing al (sic) food and drinks. Still awaiting x ray to be taken . A progress note dated 10/30/23 at 4:14 PM revealed, x-ray here and preformed x ray. Results to be sent to hospice. An x-ray was not located in the resident 19's medical record. On 1/11/24 the Regional Nurse Consultant (RNC) provided a copy of an x-ray to resident 19's right femur.…

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 for 2 of 38 sampled residents, that the facility did not ensure that each resident receives and the facility provides food prepared in a form designed to meet individual needs. Specifically, residents were served food that they were unable to chew due to missing teeth, received double portions of all food served at a meal instead of double portions of protein, and were served diet textures inappropriate for their swallowing ability. Resident Identifiers: 64 and 23. Findings include: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included non traumatic intracerebral hemorrhage, transient cerebral ischemic attack, dehydration, history of falling, depression, unsteadiness on feet, generalized muscle weakness and lack of coordination. On 1/9/24 an observation was made of the lunch meal. Resident 64 was served the tray of resident 170 which was observed to be a bowl of salad with large lettuce pieces, mashed potatoes a roll and 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 38 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodates the resident allergies, intolerance's, and preferences Specifically, a resident reported that she could not digest dark chicken meat and had asked not to receive it. Resident identifier: 36. Findings include: Resident 36 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, pain, respiratory failure with hypoxia and hypertension. The medical record of resident 36 was reviewed 1/8/24 through 1/11/24. On 1/08/24 at 11:48 AM, an interview was conducted with resident 36. Resident 36 stated that she was having problems with the food and that she had told the staff multiple times about what she can an cannot eat, but they were not paying attention to what she would say. Resident 36 stated that she had explained to multiple staff that she could not eat dark poultry meat and that she could not…

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, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 38 sampled residents, the Resident Advocate (RA) was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 64. Findings include: Resident 64 was admitted to the facility on [DATE] with diagnoses which included non traumatic intracerebral hemorrhage, transient cerebral ischemic attack, dehydration, history of falling, depression, unsteadiness on feet, generalized muscle weakness and lack of coordination. The medical record of resident 64 was reviewed 1/8/24 through 1/11/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 64 required set up or clean up assistance with eating. In addition, the MDS assessment documented that resident 64 had a Brief Interview for Mental Status (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 interview and record review it was determined, for 1 of 38 sampled residents, that each resident did not receive adequate supervision to prevent accidents. Specifically, a resident's neurological assessments were not completed after sustaining falls. Resident identifier: 173. Findings include: Resident 173 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, chronic systolic heart failure, thoracic aortic ectasia, atrioventricular block, rheumatic tricuspid insufficiency and sick sinus syndrome. Resident 173's medical record was reviewed 1/9/24 through 1/11/24. Resident 173's incident reports were reviewed and revealed the following: 1. On 11/4/23 at 12:20 AM, resident 173's family member called the nurse into her room claiming resident 173 had slipped onto the bathroom floor after using the toilet. The Immediate Action Taken was resident 173 was placed in bed to rest by Certified Nursing Assistant (CNA) and nurse. Neurological assessment was initiated. 2. On 11/6/23…

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 interview, the facility did not designate a registered nurse to serve as the director of nursing on a full time basis. Findings include: On 3/29/22 at 11:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked who was the current Director of Nursing (DON) at the facility, the ADON stated I'm the acting DON, but I'm an LPN (Licensed Practical Nurse). The ADON stated that there was a Registered Nurse (RN) who was going to be the DON, RN 1, but that she was still working the floor and hadn't started yet, but we are slowly bringing her up to speed. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. When asked who was designated as the facility DON, CRN 1 stated that it was RN 1, but she's just a license. CRN 1 stated that she had not done any training for RN 1 to serve as the DON, and RN 1 had not started as the DON. On 3/29/22 at 1:40 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the DON was RN 1 but it was a temporary position for her. The ADM stated that CRN…

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 record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility did not accurately assess the residents' needs, nor did they comply with their assessment. Findings include: On 3/28/22, the Administrator (ADM) was asked for a copy of the Facility Assessment (FA). The FA was not provided until 4/4/22. Review of the FA revealed that it had been updated on 3/29/22. On 4/4/22, the FA provided by the ADM was reviewed. 1. The FA indicated the following Specific Care or Practices for cares. These areas were determined not to be in compliance with federal regulations: a. Mental Health and Behavior: Manage the medical conditions…

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 4 of 51 sample residents, 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. Specifically, staff were observed entering rooms on Transmission Based Precautions (TBP) without wearing the required Personal Protective Equipment (PPE), observations were made during wound care of cross contamination and no hand hygiene was performed, residents were observed in the laundry room rummaging through the dirty linens bare handed, staff were observed to provide incontinence care and a brief change without the use of disposable gloves, medications were dispensed and handled with bare hands, laundry was washed without the use of detergents, wet linens were transported to the laundry mat for drying, and the facility did not maintain a system of surveillance and tracking…

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 interview and record review, the facility did not designate one or more individuals as the infection preventionist 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 for the months of February, March or April, 2022. There was no acting Director of Nursing (DON) in the building. The previous DON worked in the facility until January 2022. On 3/29/22 at 10:10 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that the former DON (DON 1) had been doing all the infection control, and did not have other staff assist with that. The ADON stated that she had a map in a little folder and was just starting coloring the building. The ADON stated that when the Corporate Resource Nurse (CRN) 1 was in the facility, CRN 1 asked the ADON for the book. The ADON stated that CRN 1 was hardly ever here and the ADON had met with CRN 1 at another facility where she was working. The ADON stated that she could call the CRN 1…

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 2. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, type II diabetes mellitus, obesity, peripheral vascular disease, primary hypertension, spinal stenosis, cervical disc degeneration, depression, and bilateral osteoarthritis of the knee. On 4/1/22 at 3:25 PM, resident 18 was interviewed. Resident 18 stated that he had fallen from a Hoyer lift while at the facility. Resident 18 stated that the higher capacity Hoyer was not able to go up and down so staff used a Hoyer that was rated 8 pounds above his weight, which was not sufficient for a safe transfer. On 4/13/22, resident 18's record review was completed. On 11/16/21 at 8:00 PM, an incident note revealed that resident 18 fell from the Hoyer lift while being transferred to bed. Pt (patient) fell on back and hit his head on the floor and his left arm on his electric wheelchair .Pt has c/o (complaints of) pain on left knee and leg, lower back and left arm . [Ambulance] was notified 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 interview and record review it was determined that the facility did not provide training to staff that educated on activities that constituted dementia managment, abuse, neglect exploitation and misappropriation of property, procedures for reporting abuse, and resident abuse prevention. Specifically, the facility did not provide dementia management training to facility staff. Resident identifiers: 4 and 14. Findings include: On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The facility ADM was asked to provide trainings provided to staff, including abuse prevention and dementia management. The ADM stated that she was aware of some abuse in the facility but had not done training until February, and again in April, 2022. The ADM did not provide any information with regard to dementia management. The ADM stated that this was the only training she had provided since beginning employment in September 2021. On 4/12/22 at 1:45 PM, an interview was conducted with Consultant Group Member (CGM) 2. CGM 2 stated that she could not locate any training provided to facility…

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 interview and record review it was determined that the facility did not provide training to staff that was sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Resident identifiers: 4 and 14. Findings include: On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The facility ADM was asked to provide trainings provided to staff, including abuse prevention and dementia management. The ADM stated that she was aware of some abuse in the facility but had not done training until February, and again in April, 2022. The ADM did not provide any information with regard to dementia management. The ADM stated that this was the only training she had provided since beginning employment in September 2021. On 4/12/22 at 1:45 PM, an interview was conducted with Consultant Group Member (CGM) 2. CGM 2 stated that she could not locate any training provided to facility staff regarding behavior response. CGM 2 provided the surveyors with a binder containing inservices provided to facility staff over the previous year. The only…

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 4. On 4/6/22 at 8:39 AM, resident 17 was observed in the lobby area of the facility with the receptionist. The receptionist stated that resident 17 was going to be leaving soon for an appointment. At 8:40 AM, CNA 18 came to the lobby area and was talking to the resident. The resident responded to CNA 18 in her primary language, which was not English. CNA 18 stated to the receptionist I don't know what the hell she's saying and proceeded to escort the resident out of the building. 5. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, paraplegia, traumatic brain injury (TBI), convulsions, chronic pain syndrome, muscle wasting and atrophy, dependence on wheelchair, and a history of falling. On 3/29/22 at 9:10 AM, an interview was conducted with resident 4. Resident 4 stated that last Friday on 3/25/22 at approximately 6:00 PM or 7:00 PM she overheard RN 3 talking about her. Resident 4 stated she overheard RN 3 say, that fucking bitch 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 interview, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident council had been formed and held. Resident identifier: 39. Findings include: On 3/29/22 at 11:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she was unaware if resident council meetings were being conducted. On 3/29/22 the resident council notes for the previous six months were requested from the Administrator (ADM). On 3/29/22 at 1:40 PM, the ADM stated that she had been employed at the facility since September 2021, and that no resident council meeting had been conducted since she had started her employment. The ADM stated that she had not made any plans to correct the issue. On 3/30/22 at 11:00 AM, a resident council meeting was conducted at the facility by the Activities Director (AD). During the meeting, the residents elected a resident council president. The six residents present at the meeting confirmed that the facility had not been conducting 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 interview and record review it was determined, for 5 of 51 sample residents, that the facility did not provide the residents the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have reasonable access to those funds. In addition, resident's were not provided their allocated 45 dollars each month. Resident identifiers: 31, 37, 38, 47 and 51. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, chronic obstructive pulmonary disease, type II diabetes mellitus, Post Traumatic Stress Disorder (PTSD), dementia, epilepsy, and essential hypertension. On 4/5/22 at 10:09 AM, resident 47 was interviewed. Resident 47 stated that she had not received money from the facility for six months and had not received any statement about her account or funds. Resident 47 stated that she needed her social security and was worried that she hadn't received money. On 4/13/22,…

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.

Based on interview, the facility did not ensure that 5 of 51 sample residents had their individual financial records available through quarterly statements and upon request. Resident identifiers: 31, 37, 38, 47 and 51. Findings include: 1. On 4/5/22 at 10:09 AM, resident 47 was interviewed. Resident 47 stated that she had not received money from the facility for six months and had not received any statement about her account or funds. Resident 47 stated that she needed her social security and was worried that she hadn't received money. 2. On 4/5/22 at 10:10 AM, resident 51 was interviewed. Resident 51 stated that he had not received any money since he was admitted to the facility. Resident 51 stated that he had not received any financial statements from the facility. Resident 51 stated that the only staff member he had asked about money was the Administrator (ADM). Resident 51 stated that he had not heard anything more about receiving money each month. 3. On 3/28/22 at 8:30 AM, resident 31 asked the Receptionist for his money. Resident 31 stated that it took too long for him to get…

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 2. On [DATE] at 11:30 AM, an observation was made of resident 21's wheelchair. The arms of the wheelchair were observed to be cracked and peeling, exposing the foam underneath. 3. On [DATE] at 2:06 PM, an interview was conducted with the laundry staff (LS). A Spanish speaking State Survey Agency (SSA) representative was obtained to assist in translating for the interview with the LS. The LS stated that the facility Administrator (ADM) gave her a department budget for housekeeping and laundry supplies of $800 per month. The LS stated that this was not enough money to purchase the required monthly supplies. The LS stated that she use to purchase buckets of detergent and Clorox for the washing machine and it cost $50 and lasted for 22 days. The LS stated that the ADM switched the system and now it utilized little detergent and Clorox bottles. The LS stated that the new system cost $200 and lasted 4 days. The LS stated that this impacted her overall monthly budget and she would sometimes go over budget or she would…

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 record review and interview it was determined, for 3 of 51 sample residents, that the facility did not ensure the prompt resolution of grievances. The facility did not ensure that grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Specifically, grievances were reported with no action taken by Administration to replace missing items or otherwise resolve the grievances. Resident identifiers: 6, 16, and 38. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included a history of cerebral infarction, cardiomyopathy, difficulty walking, depression, anxiety, and a history 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.

Based on interview and record review, the facility did not appropriately screen employees to ensure that they were free of legal findings regarding abuse, neglect, exploitation, misappropriation of property or mistreatment. Staff identifiers: Staff Members 1, 2, 3 and 4. Findings include: On 4/7/22, four employee files were reviewed and revealed the following: 1. Staff member (SM) 1 was hired on 10/6/21, however a background screening was not completed until 2/17/22. 2. SM 2 was hired on 12/1/19, however a background screening had not been completed as of 4/7/22. 3. SM 3 was hired on 1/11/20, however a background screening was not completed until 1/27/20. 4. SM 4 was hired on 1/13/22, however a background screening was not completed until 2/17/22. On 4/7/22 at 1:45 PM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that background screenings were supposed to be completed prior to the staff members working their first shift. The BOM was asked about the late or missing background screenings of SMs 1, 2, 3, and 4. The BOM confirmed that the background…

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 4 out of 51 sampled residents, that the facility did not ensure that any reasonable suspicion of a crime against any individual who was a resident of the facility was reported immediately to law enforcement, but not later than 2 hours after the suspicion was identified. Specifically, the police were not notified for two sexual abuse investigations. Resident identifiers: 4, 49, 51, and 111. Findings included: 1. Resident to Resident incident with Sexual Abuse allegation. A. Resident 111 was admitted to the facility on [DATE] with diagnoses of alcohol dependence with withdrawal, opioid dependence with withdrawal, opioid dependence with opioid-induced mood disorder, asthma, cirrhosis of the liver, bipolar disorder, stimulant abuse, liver cell carcinoma, convulsions, long QT syndrome, hypothyroidism, and traumatic brain injury (TBI). On 4/11/22 resident 111's medical records were reviewed. On 4/11/22, resident 111's clinical census documented that 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 interview and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 3 of 51 sample residents. Resident identifiers: 61, 111, and 112. Findings include: 1. Resident 112 was admitted to the facility on [DATE] with diagnoses that included local infection of the skin and subcutaneous tissue, diabetes mellitus, thrombocytopenia, gout, hypothyroidism, iron deficiency anemia, muscle weakness, and hypertension. Resident 112's medical record was reviewed between 3/23/22 and 4/13/22. No baseline care plan had been developed for resident 112. 2. Resident 111 was admitted to the facility on [DATE] with diagnoses of alcohol dependence with withdrawal, opioid dependence with withdrawal, opioid dependence with opioid-induced mood disorder, asthma, cirrhosis of the liver, bipolar disorder, stimulant abuse, liver cell…

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, observation, and record review, the facility did not develop and implement a comprehensive person-centered care plan for 10 of 51 sample residents, that includes 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 developed or implemented with regard to pain, wound care, nutrition, social work, catheters, and mental health needs. Resident identifiers: 14, 17, 29, 31, 32, 41, 46, 53, 57, and 61. Findings include: 1. Resident 32 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, mild protein calorie malnutrition, cerebral infarction, major depressive disorder, dementia without behavior disturbances, alcohol abuse, epilepsy, and paranoid schizophrenia. Resident 32's medical record was reviewed between 3/23/22 and 4/13/22. Resident 32's weights were documented as follows: a. 12/9/21 - 127.9 pounds (lbs) b. 1/7/22 -…

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, the facility did not develop and implement an effective discharge planning process for 5 of 51 sample residents that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Resident identifiers: 6, 21, 35, 38, and 51. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included lupus, peripheral vascular disease, opioid dependence, chronic obstructive pulmonary disease, lymphedema, morbid obesity, asthma, and anxiety disorder. On 3/30/22 at 12:00 PM, an interview was conducted with resident 6. Resident 6 stated that he can take care of myself and I don't want to be here. There's no social worker here and I just want to leave. Resident 6 stated that he wanted to be discharged to an assisted living facility (ALF) but no one is helping. Resident 6's medical record was reviewed…

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 3 of 51 sample residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, residents were not provided showers according to their schedules. Resident identifiers: 16, 29, and 41. Findings Include: 1. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses which included type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, acute myocardial infarction, unspecified dementia, anxiety disorder, and low back pain. On 4/6/22 at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that he does not remember the last time he had a shower or bed bath. Resident 29 stated that it must have been at least a week ago. Resident 29 stated that the staff were not offering showers or bed baths to him. Resident 29's medical record…

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 4 of 51 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents had medications scheduled for administration that were unavailable from the pharmacy. Resident identifiers: 17, 43, 112, and 212. Findings included: 1. Resident 17 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of congestive heart failure, type 2 diabetes mellitus, chronic respiratory failure, neuropathy, retinopathy, major depressive disorder, end stage renal disease, dependence on renal dialysis, calcaneal spur, right below knee amputation, anxiety disorder, hypertension, and non-pressure chronic ulcer left foot. On 4/2/22 at 11:26 AM, an observation was made of resident 17 at the nurse's station on the 2nd floor with a visitor. The visitor was heard informing Registered Nurse (RN) 4 that he was taking resident 17 home over the weekend and that…

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 store medications in a proper manner. Specifically, for 4 out of 51 sampled residents, medications were left in residents rooms without nurse verification that resident had taken medications, and medications were improperly labeled. Resident identifiers: 16, 43, 51, and 53. Findings included: 1. Resident 16 was admitted to the facility on [DATE], with diagnoses that include COVID-19, pneumonia, type 2 diabetes, asthma, benign prostatic hyperplasia, anxiety, depression, idiopathic neuropathy and failure to thrive. On 3/26/22 at 10:00 PM, it was observed that a cup of medications was left at resident 16's bedside. Resident 16 was immediately interviewed. Resident 16 stated that the nurse brought them by about 30 minutes ago and he didn't take them because he wanted to take them with food. Resident 16 stated that this happened all the time, meaning 3 to 4 times a week. On 4/5/22 at 11:04 AM a follow-up interview was conducted…

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 observations and interviews it was determined that, for 11 of 51 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of food, appearance of the food, and the temperature of the food. Resident identifiers: 4, 7, 11, 15, 16, 18, 31, 33, 43, 51, and 111. Findings include: 1. On 3/30/22 at 10:40 AM an interview with resident 16 was conducted. Resident 16 stated that the food was always cold. Resident 16 stated that he did not think the food was good enough to eat, and instead he will order peanut butter and jelly sandwiches. During this interview the resident stated that the food was horrible. Resident 16 stated I wouldn't feed this food to my dog. Resident 16 also stated that the food was always cold. On 4/4/22 at 1:28 PM, resident 16 stated that today the food was at least warm but not very good. 2. On 3/30/22 at 11:10 AM an interview 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 interview and record review, the facility did not ensure that medical records were complete and accurate for 10 of 51 sample residents. Specifically, physicians orders were not correctly added to residents' electronic medical records, outside provider records were not correctly added to residents' electronic medical records, private health information was not secured, and medications were not documented accurately. Resident identifiers: 1, 8, 17, 18, 40, 41, 46, 49, 112, and 212. Findings include: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included sepsis, chronic osteomyelitis, chronic obstructive pulmonary disease, type 2 diabetes mellitus, muscle weakness, and cellulitis. On 4/6/22 at 11:25 AM an interview with resident 41 was conducted. Resident 41 stated that he was aware that a doctor put in an order for wound care to his stomach on 3/15/22. Resident 41 stated that he believes the order was to be completed daily. Resident 41 stated that no staff member has came in…

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

Based on interview and record review it was determined that the facility did not test residents and facility staff based on the identification of any individual identified as diagnosed with COVID-19 in the facility. Specifically, staff members who were not fully vaccinated were not tested as required. Findings include: A facility policy/procedure for COVID-19 Vaccine Mandate dated 2/7/22 was reviewed. The policy stated .It is the policy of this facility to ensure that staff physically enter the facility are fully vaccinated for COVID-19 unless an individual meets exclusion criterion Any individual that performs their duties at any site of care or has the potential to have contact with anyone at the site of care, must be fully vaccinated Facility Actions: The facility will implement actions to ensure all staff meet this requirement, including providing education to health care providers and contractors about the vaccination mandate and the importance of obtaining the COVID-19 vaccination Facility actions when exemption is accepted - If an individual qualifies for a medical 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.

Based on interview and record review it was determined, for 5 out of 5 staff members sampled, that the facility did not ensure that that each staff member was provided education regarding the benefits and risks and potential side effects associated with the vaccine before offering the COVID-19 vaccine. Specifically, the facility did not maintain documentation that staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine and that staff were offered the COVID-19 vaccine unless medically contraindicated or the staff member had already been immunized. Staff Identifier: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings include: On 9/15/21 the facility employee vaccination records for COVID-19 were reviewed. The vaccination records documented that Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 had refused the COVID-19 vaccination. No documentation was found of when the vaccine was offered or if the vaccine was contraindicated. No documentation was found that the staff were provided education regarding the benefits and potential…

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 follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures. Findings include: On 2/23/22, the Administrator provided a list of staff who were fully vaccinated for COVID-19 or had an exemption. Registered Nurse (RN) 2 was listed to have a medical exemption. Certified Nursing Assistant (CNA) 3 had a religious exemption. On 2/23/22, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 2:45 PM, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 5:45 AM, an observation was made of CNA 3. CNA 3 was observed to be wearing a surgical mask with eye protection. The facility COVID-19 Vaccine Policies and Procedures with no date revealed, .The purpose of this policy and procedure is to outline the community…

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 an means for contacting nursing staff that was reliable and easily to use. Specifically, for 1 out of 51 sampled residents, multiple call lights were not working, and an emergency call light in a bathroom was not accessible. Resident identifier: 43. Findings include: 1. Resident 43 was admitted to the facility on [DATE], with a diagnosis that included alcohol dependence, peripheral neuropathy, hyperlipidemia, anxiety, depression, muscle weakness, lack of coordination, club foot and insomnia. On 3/23/22 at 9:00 AM, an interview with resident 43 was conducted. During this interview, resident 43 stated that his call light was not working. Resident 43 stated that the pull string for the emergency call light in his bathroom was not there, and therefore the call light was unusable. On 3/23/22 at 9:15 an observation was made to confirm that the call light in resident 43's room was not working. At that time it was also…

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 did not provide a safe, functional, sanitary, and comfortable environment for residents. Specifically, the emergency water tanks had not been maintained or disinfected since August 2020. Findings include: On 4/7/22 at 2:06 PM, an interview was conducted with the laundry staff (LS) in the facility laundry area. A Spanish speaking State Survey Agency (SSA) representative assisted in translating for the interview with the LS. The LS stated that she had worked at the facility for 8 years. An observation was made of the door to the mechanical room inside the laundry area. Located inside the mechanical room was a double stacked emergency water storage tank system. The tanks were blue in color and constructed of plastic. Each tank had a spigot on it and below the spigots were notable hard water deposits. The LS stated that the maintenance staff was supposed to change out the water in the storage tanks, but that it had not been done in about 5 years. The LS stated that the maintenance staff signed off that the water in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not accommodate the residents needs or preferences. Specifically, for 2 out of 51 sample residents, residents were not provided the correct size briefs or provide for communication barriers for non-English speaking residents. Resident identifiers: 16 and 28. Findings include: 1. Resident 16 was admitted to the facility on [DATE], with diagnoses that included COVID-19, pneumonia, type 2 diabetes, asthma, benign prostatic hyperpiesia, anxiety, depression, idiopathic neuropathy and failure to thrive. On [DATE] at 10:53 AM, it was observed that staff were attending to resident 16's needs with a brief change. After the brief change, resident 16 was interviewed, and the resident stated that he would get up out of bed if they had the correct size briefs for him to wear. Resident 16 stated that he wore size 5-6 XL briefs, and the facility only provided 2 XL to save money. Resident 16 stated that facility staff would use two 2XL briefs,…

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 and interview it was determined, for 2 of 51 sample residents, that the facility did not ensure that the resident had the right to and the facility promoted and facilitated the resident self-determination through support of the resident choice. Specifically, a resident was not able to access the facility gym due to the elevator's continued disrepair and the facility did not assist a resident with arranging transportation to the Department of Motor Vehicles (DMV) to obtain a drivers license. Resident identifiers: 11 and 38. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, osteoarthritis, acquired clubfoot of the right and left foot, hyperlipidemia, hypertension, myalgia, and repeated falls. On 1/8/22, a Quarterly Minimum Data Set (MDS) Assessment documented that resident 11's Brief Interview for Mental Status (BIMS) score was a 15, which indicated cognitively intact. The assessment documented that resident 11 was 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, it was determined that the facility failed to formulate an advance directive for 1 of 51 sampled residents. Specifically, a resident did not have an advance directive available for facility staff to access. Resident identifier: 41. Findings include: Resident 41 was admitted to the facility on [DATE] with diagnoses that included sepsis due to methicillin susceptible staphylococcus aureus, chronic osteomyelitis, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, acute respiratory failure with hypoxia, type 2 diabetes mellitus, and acute kidney disease. On 3/29/22 at 8:25 AM, resident 41's electronic medical record (EMR) was reviewed. Resident 41's EMR did not include an advance directive. On 4/5/22 at 1:12 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that there was no advance directive binder or resource at the nurses' station and if an advance directive was not in the resident's EMR, that the facility's Medical Records Director…

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 failed to inform a Medicaid-eligible resident in writing periodically during the resident's stay, of services available in the facility, and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the Notice of Medicare Non-Coverage (NOMNC) form, which documents notification from the facility to the resident could not be found for 1 of 51 sampled residents. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, moderate protein-calorie malnutrition, major depressive disorder, dementia, and anxiety disorder. On 4/5/22, resident 21's medical record was reviewed. Resident 21's electronic medical record (EMR) did not include a NOMNC form. On 4/5/22, an interview was conducted with the facility's Medical Records Director (MRD). The MRD stated she could not find 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 out of 51 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider and included: contact information of the practitioner responsible for the care of the resident; resident representative; advance directive information; all special instructions for ongoing care; comprehensive care plan; and any other documentation to ensure a safe and effective transition of care. Specifically, a resident was transferred to the hospital and no documentation could be found in the resident's medical record that information was communicated to the receiving provider for the transition of care. Resident identifier 40. Finding include: Resident 40 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, malignant neoplasm, Klinefelter…

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 record review and interview it was determined, for 2 out of 51 sample residents, that the facility did not ensure that the Preadmission Screening for individuals with a mental disorder was performed by a person or entity other than the State mental health authority, prior to admission; and that because of the physical and mental condition of the individual, the individual required the level of services provided by the nursing facility; and whether the individual required specialized services. Specifically, two residents admitted with a mental health disorder did not have a Preadmission Screening Resident Review (PASRR) Level II recommended or completed. Resident identifiers: 14 and 111. Findings include: 1. Resident 111 was admitted to the facility on [DATE] with diagnoses of alcohol dependence with withdrawal, opioid dependence with withdrawal, opioid dependence with opioid-induced mood disorder, asthma, cirrhosis of the liver, bipolar disorder, stimulant abuse, liver cell carcinoma, convulsions, long…

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, the facility did not ensure that 2 out of 51 sample residents received the appropriate treatment and assistive devices to maintain vision. Specifically, one resident was missing glasses and another resident's glasses had been broken by a Certified Nursing Assistant (CNA) without being repaired or replaced. Resident identifiers: 18 and 51. Findings include: 1. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, diabetes mellitus type II, peripheral vascular disease, primary hypertension, history of myocardial infarction, depression, spinal stenosis, cervical disc degeneration, and bilateral osteoarthritis of the knee. On 3/29/22 at 11:00 AM, resident 18 was interviewed. Resident 18 stated that he needed assistance getting bifocals. Resident 18 stated that the previous Resident Advocate (RA) had been working on it, but the RA no longer worked at the facility. Resident 18 stated that he did…

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, observation and record review, the facility did not ensure for 1 of 51 sample residents, that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE], with diagnosis that included COVID-19, pneumonia, type 2 diabetes, asthma, benign prostatic hyperplasia, anxiety, depression, idiopathic neuropathy and failure to thrive. On 3/26/22 at 10:28 AM an interview was conducted with resident 16. During this interview, resident 16 stated that he is bed bound and unable to get up and go to the bathroom. Resident 16 stated that he does not have any bed sores that he knew of. Resident 16 stated that on average he waits 30-45 minutes for staff to answer the call light to assist with brief changes, and that he has waited 3-4 hours at times. Resident 16 stated that he usually has to wait 3-4 hours 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, and interview it was determined the facility did not ensure oxygen delivery systems were in good working condition. Specifically, for 1 out of 51 sampled residents, resident did not have water in humidifier, and the oxygen concentrator was too close to the walls to work as designed. Resident identifier: 16. Findings included: Resident 16 was admitted to the facility on [DATE], with a diagnosis that included COVID-19, pneumonia, type 2 diabetes, asthma, benign prostatic hyperplasia, anxiety, depression, idiopathic neuropathy and failure to thrive. On 3/26/22 a record review was completed for resident 16. According to nurses notes dated 2/15/22 it stated Note Text: resident had a small bloody nose, that he was very concerned about. Says before his previous strokes he had bloody noses. Their was a few quarter sized spots on his sheet he wanted to show me. stated just before it started bleeding he had dislodged a chunk of something like a clot or booger. oxygen water was checked and refilled by…

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 51 sample residents that the facility did not ensure that residents who required dialysis receive such services, consistent with professional standards of practice. Specifically, a resident receiving dialysis did not always receive the needed dialysis, there was no contract with the dialysis company, and communication did not always occur between dialysis staff and the facility . Resident identifier 41. Findings include: Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, end stage renal disease, essential hypertension, long-term use of insulin, latent tuberculosis, and chronic hepatitis. On 3/27/22 at 2:30 PM, resident 1 was interviewed. Resident 1 stated that he had problems with dialysis in the past, but it was OK for him now. On 4/13/22, resident 1's medical record review was completed. Dialysis communication forms revealed the following: a. On 11/22/21, and 12/10/21, resident refused treatment…

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 did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurses, Certified Nurse aides, and resident census. The facility must post the nurse staffing data daily at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the wrong nurse staffing posted at the facility was posted for the wrong date or not at all. Findings include: On Friday, 3/25/22, the facility had the 3/24/22 nurse staffing posted next to the Receptionist's Desk on Level 1. On Saturday, 3/26/22, the facility still had the 3/24/22 nurse staffing posted next to 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 interview and record review it was determined for 1 of 51 sample residents, that each resident was not free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, on resident received a blood pressure medication when their blood pressure was low, and a resident received medication without required monitoring. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses that included a history of cerebral infarction, cardiomyopathy, difficulty walking, depression, anxiety, and a history of falls. On 3/28/22 at 12:06 PM, resident 38 was interviewed. Resident 38 stated that he thought he received the wrong medications occasionally. On 4/13/22, resident 38's medical record review was completed. Resident 38's physician…

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 ensure that 2 of 51 sample residents were free of significant medication errors. Specifically, residents were not provided inhalers, antibiotics or insulin as ordered. Resident identifiers: 31 and 112. Findings include: 1. Resident 112 was admitted to the facility on [DATE] with diagnoses that included local infection of the skin and subcutaneous tissue, diabetes mellitus, thrombocytopenia, gout, hypothyroidism, iron deficiency anemia, muscle weakness, and hypertension. Resident 112's medical record was reviewed between 3/23/22 and 4/13/22. Resident 112's nursing progress notes were reviewed. Per the nursing notes, resident 112 was admitted at 7:00 PM. Resident 112's February 2022 Medication Administration Record (MAR) was reviewed. Per the MAR, the following significant medications were not administered per physician orders on 2/25/22 when resident 112 was admitted : a. Insulin Glargine 55 units at bedtime b. Lisinopril 40 milligrams (mg) at bedtime c.…

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 and it was determined that, for 2 of 51 sample residents, that the facility did not provide or obtain laboratory services when ordered by the physician. Specifically, prothrombin time (PT)/international normalized ratio (INR) blood draws and a basic metabolic panel (BMP) were not completed as ordered by the physician. Resident identifiers: 2 and 61. Findings include: 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anemia, sepsis, cellulitis, a stage 3 pressure ulcer of the sacral region, type II diabetes, chronic kidney disease, hypoxemia, hyperkalemia, and fluid overload. On 4/13/22, resident 61's medical record review was completed. On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a follow up BMP (basic metabolic panel) completed in 1 week with a noted date of 1/12/22. Resident 61 had a white blood cell count of 11,300, with high…

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 51 sample residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Resident identifier 17. Findings include: Resident 17 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of congestive heart failure, type 2 diabetes mellitus, chronic respiratory failure, neuropathy, retinopathy, major depressive disorder, end stage renal disease, dependence on renal dialysis, calcaneal spur, right below knee amputation, anxiety disorder, hypertension, and non-pressure chronic ulcer left foot. On 4/2/22 resident 17's medical records were reviewed. On 7/15/21 at 6:50 AM, the nurse documented that they were informed in report that the Nurse Practitioner (NP) gave new orders for a Complete Blood Count (CBC), a Basic Metabolic Panel (BMP), a Erythrocyte Sedimentation Rate (ESR), and a 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 medical record review it was determined, for 1 of 51 sample resident, that the facility did not file in the resident's clinical record, a signed and dated report of radiological services. Specifically, one resident who had a fall from a Hoyer lift did not have the Computerized Tomography (CT) and X-ray reports from the hospital in the medical record. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, diabetes mellitus type II, peripheral vascular disease, primary hypertension, history of myocardial infarction, depression, spinal stenosis, cervical disc degeneration, and bilateral osteoarthritis of the knee. On 4/4/22 at 10:09 AM, resident 18 was interviewed. Resident 18 reported that he had fallen while in the Hoyer lift. Resident 18 stated that there were two Hoyer lifts, and one was not working, so staff used a different Hoyer. Resident 18 stated that he thought 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 interview and record review, the facility did not provide the required specialized rehabilitation services as ordered by a physician. Specifically, a physician-ordered speech therapy evaluation was not completed. Resident identifier: 30. Findings include: Resident 30 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, diabetes mellitus, chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, major depressive disorder and anxiety disorder. Resident 30's medical record was reviewed between 3/23/22 and 4/13/22. Review of resident 30's physician's orders revealed that on 10/7/21, resident 30's physician wrote an order for a speech therapy evaluation to be completed. No evidence could be located in resident 30's medical record to indicate that the speech therapy evaluation had been completed. On 4/13/22, Consultant Group Member 2 confirmed that the speech therapy evaluation had not been completed for resident 30 as ordered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving a prophylactic antibiotic without justification, not all antibiotics were administered when ordered, and infection control tracking and trending was not completed. Resident identifier: 30. Findings Include: 1. Infection control documentation was requested. The antibiotic documentation revealed that antibiotic stewardship was completed in January, 2022. No Infection Control Surveillance Logs were available for the months of February, March or April, 2022. No antibiotic reviews were completed by the pharmacy in 2022. There was no acting Director of Nursing (DON) in the building. The previous DON worked in the facility until January 2022. On 3/30/33 at 10:50 AM, employee 5 (E5) was interviewed. E5 stated that…

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.