North Auburn Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed. Nursing staff failed to: follow or clarify physicians orders when indicated, document for only those tasks completed, monitor residents for significant medication dose changes, follow up on appointment recommendations from outside providers, and to monitor residents for side effects for the treatment received at appointments in outside clinics. These failures placed residents at risk for medication errors, delay in treatment, adverse outcomes, and diminished quality of care. Findings included . <Failure to Follow/Clarify Physician Orders> <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS-an assessment tool) received regularly scheduled and as needed pain medication. Review of March 2025 Medication Administration Records (MARs)…

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 failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 12 (Residents 61, 22, 62, 54, & 31) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance including bathing, oral care, and nail care as required, left residents at risk for poor hygiene, soiled long nails, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly Minimum Data Set (MDS - an assessment tool) was assessed with a brain injury which caused the loss of muscle function and aphasia (a disorder that affects a person's ability to communicate), and was dependent on tube feeding (a method of delivering nutrients to individuals who cannot or will not eat or drink enough food to meet their nutritional needs). This MDS assessed the resident as dependant on staff for all care, including personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide risks and benefits of bed rail use prior to installation, ensure proper installation of bed rails, and provide ongoing maintenance of bed rails for 5 of 5 residents (Resident 7, 24, 28, 35, & 17) reviewed for bed rails and 2 supplemental residents (Residents 30 & 22) reviewed. These failures placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Safety Device Application, revised 04/07/2023, the facility would review safety devices with the resident and/or representative. The policy showed the facility would ensure proper installation as directed for the bed rails. <Resident 7> According to a 11/08/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 had no memory impairment. Review of Resident 7's health records showed a 06/10/2022 physician order for the bilateral bed rails. Resident 7's records showed an 11/13/2024…

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 failed to ensure 3 of 5 residents (Residents 52, 17, & 35) reviewed for unnecessary medications and 2 (Resident 36 & 54) supplemental residents were free from unnecessary psychotropic drugs related to the failure to: ensure clinical justification for dose increases, adequately monitor, and attempt Gradual Dose Reductions (GDR). These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings include: <Policy> According to a facility policy titled, Psychoactive Medication Management, revised 08/2024, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. The policy showed after the first year, a GDR must be attempted annually, unless clinically contraindicated. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 admission Minimum Data Set (MDS - an assessment tool) had multiple…

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 the facility failed to ensure a medication error rate of less than 5%. Failure to properly administer 5 of 25 medications for 3 of 4 residents (Residents 2, 30, & 19) observed during medication pass resulted in a medication error rate of 20%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications. Findings included . <Policy> According to the facility policy on ophthalmic (eye) drops, dated 11/15/2024, when administering multiple medications to the same eye, staff would wait 3-5 minutes between drops and staff would apply gentle pressure to the tear duct after administration or instruct the resident to close their eye. Waiting between eye drops was important to maximize their effectiveness and prevent potential side effects. It allows each drop to be absorbed by the eye before the next one is administered, preventing dilution and ensuring the medication stays in contact with the eye longer. Failure to follow Physician Ordered…

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 the facility failed to ensure food was served under sanitary conditions. Facility staff failed to: monitor and ensure adequate sanitation for the dishwasher and ensure staff reported when sanitation levels were inadequate. These failures placed residents at risk for food-borne illness. Findings included . Observation of the kitchen during rounds, on 04/17/2025 at 9:47 AM, showed Staff I (Dishwasher) running dishes from breakfast service through the dishwasher. Staff F (Dietary Manger) explained the facility used a low temperature dishwasher which required chemical sanitation (Chlorine used to kill viruses, bacteria, and other microorganisms to prevent foodborne illness) to clean dishes and kitchen utensils stating, I try to keep it (test strips which registered chlorine) at 200 Parts Per Million. During this observation, Staff F, tested the dishwasher for proper sanitizing solution. The chlorine test strip was dipped into the dishwasher water and was noted to be white, indicating an absence of chlorine. Staff F tested for adequate…

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 failed to obtain resident consent for vaccinations for 3 of 5 sampled residents (Residents 35, 7, & 24) and 1 supplemental resident (Resident 28) reviewed for vaccinations, obtain resident consent prior to administration of psychotropic medication for 2 of 5 residents (Resident 7 & 24) reviewed for unnecessary medications, and obtain consent prior to utilization of safety devices for 4 of 6 residents (Resident 7, 24, 28, & 35) reviewed for accident hazards. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options. Findings included . <Policy> According to a facility policy titled, Vaccinations for Residents P&P, revised 12/2022, did not discuss obtaining consent prior to vaccine administration and showed inquiries concerning the policy should be referred to the Staff A (Administrator) or Staff P (Infection Preventionist). According to a facility policy titled,…

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, the facility failed to have a system in place which ensured grievances were thoroughly investigated and resolved in response to residents' concerns for two (Residents 52 &17) of three residents reviewed for grievances. Failure to ensure accurate resident inventories detracted from staff's ability to thoroughly investigate reported complaints of missing items and failure to follow up with residents about the grievances placed residents at risk of feeling frustration and diminished quality of life. Findings included . <Policy> According to the 02/2024 Grievances Policy, employee responsibilities in the grievance process included: (1) initiating the Resident Grievance Report for all concerns brought forth by residents, and (2) immediately providing the completed report to the Grievance Officer or designee. The policy showed the Grievance Officer or designee would follow-up with the resident/resident representative about the grievance to ascertain satisfaction with the resolution of the reported concern. <Resident 52> According 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, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information and provide required written notices at the time of transfer/discharge to the residents and/or their representatives for 3 (Residents 54, 31, & 7) of 4 residents reviewed for hospitalization. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights. Findings included . <Resident 54> According to the 09/02/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 54 was discharged to the hospital with their return anticipated. Review of Resident 54's medical records did not show documentation indicating the LTCO was notified of the resident's hospital transfers for the 09/02/2024 discharge as…

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 failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours for 3 (Resident 54, 31, & 7) of 4 residents reviewed for hospitalization. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> According to a facility policy titled, Bed Hold Notification Notice of Bed Hold Policy and Return, dated 09/2022, the facility would provide written notice to the resident/representative when a resident was transferred to a hospital with the residents bed hold rights and the centers bed hold policy. <Resident 54> According to the 09/02/2024 and 01/27/2025 Discharge Minimum Data Set (MDS - an assessment tool), Resident 54 was discharged to the hospital twice with their return anticipated. Review of Resident 54's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge including documenting the reason for leaving or explaining the risks of discharging for 1 of 1 (Resident 67) resident who chose to leave the facility Against Medical Advice (AMA). This failure placed the resident at increased risk of hospital readmission and diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Against Medical Advice Discharge, revised 05/2023, the facility would complete an AMA form, read the information with the resident, and carefully explain the information before witnessing the resident sign the form before the resident left the facility AMA. The facility would treat the situation similarly to a refusal of care, discuss the reasons for leaving AMA with the resident/their representative. Staff were to document the risks of discharging AMA, the resident's reason for leaving AMA, the condition of the resident at discharge, the transportation method used, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change MDS, the resident was cognitively intact and required care related to fractures and other multiple traumas. Resident 30 was assessed with multiple skin issues including pressure ulcers, functional limitations in range of motion to both lower extremities, and was dependant on staff for toileting, bathing, and dressing the lower extremities. Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty, reddish debris on the medial (inside) left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here. During observations on 04/18/2025 at 10:19 AM, Staff B (Director of Nursing) confirmed the resident had brownish rust colored discharge to both the left and right great toes and the resident appeared to have, ingrown toenails. Staff B…

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 failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident 30) of 2 residents reviewed for vision services. Failure to ensure Resident 30 received assistance in obtaining vision devices placed this resident at risk for decline in Activities of Daily Living (ADLs) related to vision. Findings included . <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 admission Minimum Data Set (an assessment tool) had adequate vision and did not require the use of corrective lenses. Observation on 04/14/2025 at 1:20 PM showed Resident 30 lying in bed, a pair of eyeglasses were noted on the overbed table. In an interview at this time, Resident 30 indicated they needed an eye exam stating, I put in for an eye exam a few months ago, but it didn't happen, nobody's gotten back to me. In an interview on 04/16/2025 at 8:19 AM, Resident 30 stated. I can't read…

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 the facility failed to ensure 2 of 3 sampled residents (Residents 6 & 7) reviewed for Pressure Ulcers (PUs), received appropriate pressure reducing measures and repositioning on a consistent basis. This failure placed all residents at risk for PU development, and a diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Safety Device Application, revised 04/07/2023, showed the facility would apply the safety device as directed. The policy showed staff would follow the safety device Care Plan (CP) and interventions. According to a facility policy titled, Wound Prevention and Treatment, revised 02/03/2023, the facility would reduce the occurrence of pressure over bony prominence to minimize injury, manage risk factors, and provide preventive interventions. The policy showed the staff would ensure residents received continuous preventative interventions to promote healing and prevent skin issues. <Resident 6> According to a 01/04/2025 Annual Minimum Data Set (MDS - an assessment tool)…

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 failed to provide necessary foot care and treatment in accordance with professional standards, including provision of nail care and Podiatry Services. Deficient practice was identified for 3 (Residents 30, 17, & 23) of four residents reviewed for nail care. Failure to provide timely toenail care placed the residents at risk for negative health outcomes. Findings included . <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change Minimum Data Set (MDS - an assessment tool) the resident was cognitively intact and had multiple diagnoses including diabetes. Resident 30 was assessed with functional limitations in range of motion to both lower extremities and was dependant on staff for dressing the lower extremities. Record review showed no evidence Resident 30 received Podiatry services since admission. Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with 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.

Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 1 of 1 resident (Residents 62) reviewed for smoking. These failures left the resident at risk for injury and a diminished quality of life. Findings included . <Facility Policy> Record review of the facility policy titled, Smoking, revised 06/2023, showed the facility would screen all residents for smoking via the nursing admission evaluation. Residents who wished to continue smoking would have smoking reflected in their care plan. The policy showed the facility would store all smoking materials in a locked storage cabinet in the resident's room, at the nurse's station, or another designated location in the facility. <Resident 62> According to the 01/03/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 62 had clear speech, their memory was intact, and they understood others during communication. The MDS showed Resident 62 required one person assistance with transfers, toileting, and bed mobility. The MDS showed Resident 62…

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 failed to ensure indwelling urinary catheters (device that drains urine from the bladder to an external bag) had a valid medical justification for the use of or a plan for discontinuation for one (Resident 36) of two residents reviewed for catheter use. These failures placed residents at risk for urinary tract infections and decline of normal bladder function. Findings included . According to the facility policy on indwelling catheters dated 12/2024, all residents with an indwelling catheter required a medical justification for the initiation and continuing need for catheter use. A comprehensive assessment included underlying factors supporting medical justification, determination of which factors could be reversed and development of a plan for appropriate indications for continuing use of an indwelling catheter beyond 14 days which may include: urinary retention that could not be treated or corrected medically or surgically, and characterized 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 observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident 17) reviewed for nutrition and staff offered and provided hydration services to 2 of 2 residents (Resident 7 & 35) reviewed for hydration. Failure to ensure consistent, timely weights, and act on the Registered Dietician (RD) recommendations, including reweighs, placed the residents at risk for delayed identification of interventions, and continued weight loss. Failure to offer and provide hydration services to residents placed all residents at risk for dehydration and decreased quality of life. Findings included . <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 07/31/2024 admission Minimum Data Set (MDS - an assessment tool) the resident had diagnoses which included a brain injury causing the loss of muscle function, either complete or partial, in part of the body, and diabetes (unstable blood sugar…

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 failed to ensure drugs and biologicals were stored in accordance with current accepted professional standards in 2 of 2 medication carts and 1 medication room reviewed. Additionally, the facility failed to ensure medications were stored in a secure manner for 1 (Resident 52) of 1 residents with medications at bedside. These failures placed residents at risk to receive expired and/or improperly administered medications and biologicals. Findings included . <MEDICATION CART A> Observation of Medication Cart A on [DATE] at 7:44 AM revealed a topical skin treatment that suppresses the immune system for Resident 22 which was discontinued on [DATE] and a topical cream used to treat fungal or yeast infections for which there was no current order. In an interview at this time, Staff S (Registered Nurse) indicated the resident no longer received either of the treatments stating, they should be discarded. A topical treatment to decrease inflammation was noted…

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 failed to maintain complete and accurate records for 10 (Residents 17, 52, 61, 40, 47, 6, 7, 36, 62, & 35) of 20 current sampled residents reviewed and 15 supplemental residents (9, 2, 51, 19, 27, 32, 4, 5, 18, 15, 29, 49, 24, 33, & 21) reviewed. The facility failed to ensure: physician orders were clear/accurate, assessment documents accurately reflected resident condition, behaviors were monitored, personal inventories were accurate/updated/available, informed consents were signed/dated, and resident inventory lists were complete. Failure to ensure clinical records were complete and accurate placed residents at risk of not having their needs met. Findings included . <Podiatry Consults> <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS - an assessment tool) was assessed as cognitively intact with multiple medically complex diagnoses, including diabetes. Record review showed a Podiatry…

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 failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: ensure staff performed hand hygiene before and after resident care for 3 of 3 staff observed, ensure proper labeling and containment of resident's personal care items observed in 2 resident rooms, administer medications while maintaining infection control measures, and wear facility required face masks appropriately to prevent the spread of infection. These failures placed residents at risk for the development of infectious diseases and living in an unclean environment. Findings included . <Facility Policy> According to the facility's October 2023 revised Handwashing/Hand Hygiene policy, all personnel were trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.…

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 failed to ensure 21 of 24 residents (Residents 33, 31, 9, 21, 11, 19, 23, 15, 17, 1, 20, 7, 8, 2, 5, 42, 51, 12, 46, 4, 37, 41, 40, & 27) who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . <Facility Document> According to the 07/09/2021 Surety Bond, the facility purchased a surety bond to secure and/or replace residents' personal funds that were deposited with the facility, including any interest accrued by these accounts, if misappropriated, misplaced or otherwise lost, withheld, or improperly distributed. The document showed the bond amount covered was not to exceed $21,000 and was effective on 06/30/2021. Record review of the facility's Trial Balance report showed 24 residents had funds in trust accounts. Three of the personal fund accounts totaled $21,036.60 (surety bond limit). The trust account report showed a total current balance of $33,771.68 for all…

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 failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 6 of 21 residents (Residents 60, 44, 28, 30, 226, & 3) reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed. Findings included . <Facility Policy> Review of the facility's policy titled Advanced Directives, revised May 2023, showed facility staff would determine upon admission whether the resident had an AD and if not, the resident would be offered information regarding ADs. This policy showed staff would document in the resident's record whether an AD was executed and each offering of information to the resident regarding ADs. <Resident 60> According to the 02/21/2024…

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 failed to ensure a clean, comfortable, and homelike environment for 4 of 4 halls. The failure to ensure resident rooms were free of wall scrapes, to provide an environment free of institutional-style overhead paging, to ensure resident bedroom windows had adequate coverings, and to ensure sufficiently warm water temperatures in resident bathrooms left residents at risk for a diminished quality of life, and a less than homelike environment. Findings included . <Walls> Observation on 03/17/0224 at 8:52 AM showed the wall behind bed 1 in room [ROOM NUMBER] had considerable scrapes where the head of the bed rubbed against the wall. There were black marks and gashes of exposed drywall. Observation on 03/17/2024 at 9:20 AM showed the baseboard in room [ROOM NUMBER]'s bathroom and on the wall outside the bathroom door had multiple dents and had areas where the paint was scraped off. Observation on 03/19/2024 at 10:07 AM showed in B hallway, in front of room [ROOM NUMBER]…

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 failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 3 of 4 sampled residents (Residents 60, 49, & 42) reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Facility Policy> According to the facility policy titled, Bed-Hold: Notification Notice of Bed-Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, revised 09/2022, the facility would provide the LTCO a copy of the transfer/discharge notices completed for hospitalized residents. <Resident 60> According to the 11/10/2023 and 01/12/2024 Discharge Minimum Data Sets (MDS - an assessment tool), Resident 60 was discharged to an acute hospital twice: On 11/10/2023 and was readmitted to the facility on [DATE]; and 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 interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 3 of 4 sampled resident's (Residents 60, 49, & 42) reviewed for discharge. This failure placed the residents and/or their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> According to the facility policy titled, Bed-Hold: Notification Notice of Bed-Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, revised 09/2022, the resident and/or representative would be provided a written notice of the bed hold policy. The policy showed, within 24 hours after transfer, the facility would elicit verbal communication regarding the resident/representative's choice whether to accept or decline a bed hold. The policy showed the resident/representative's bed hold decision…

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 the facility failed to ensure 8 of 24 residents' (Residents 55, 6, 7, 15, 27, 44, 60, & 42) Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . <Facility Policy> The facility's revised 03/2024 MDS/RAI [Resident Assessment Instrument] policy showed the facility adhered to the Long-Term Care RAI 3.0 User's Manual for all policies related to MDS completion. <Resident 55> According to the 02/03/2024 Annual MDS Resident 55 had a severe memory impairment and required substantial/maximal assistance or was totally dependent on staff for care. The MDS showed Resident 55 had diagnoses including a history of stroke, and difficulty swallowing. The MDS showed Resident 55 had a feeding tube (a tube connected directly to the stomach to provide nutrition artificially). According to this MDS, Resident 55 received less than 25% of their daily caloric intake, and a daily average of less than 500 Cubic…

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, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 3 of 21 (Residents 15, 276, & 226) sample residents whose CPs were reviewed, and failed to provide CP meetings for 3 of 5 sample residents (Residents 71, 28, & 44) reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings inlcuded . <Facility Policy> Review of the Care Planning Process facility policy revised 05/19/2023 showed the comprehensive CP was an interdisciplinary tool that must have measurable objectives with time frames and described the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP must be reviewed and revised at a minimum on admission, quarterly, and with a significant change in condition. <CP…

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 the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 of 5 (Residents 9, 30, & 46) who were assessed to be dependent on staff for ADLs, and 1 supplemental resident (Resident 27). The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> According to facility's 12/20/2022 Personal Needs policy showed the facility would provide ADL support to all residents who required assistance. The policy showed residents' ADL needs would be care planned, and identified bathing, nail care, and oral care would be provided by the facility.<Resident 46> According to the 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 46 had impaired memory and had a diagnosis of depression. The MDS showed Resident 46 required maximal assistance from staff with transferring, toileting, and personal hygiene. The MDS showed Resident 46 did not refuse care during 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.

Based on observation, interview, and record review the facility failed to ensure restorative nursing services were provided for 3 of 4 residents (Residents 7, 55, & 44) reviewed for rehab/restorative. This failure left residents at risk for diminished Range of Motion (ROM), loss of function, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 12/2022 Restorative Nursing policy, the facility would utilize the facility's Restorative Nursing Program (RNP) as needed to help residents attain or maintain their highest practicable level of physical, mental, and psychosocial functioning. The policy identified splinting as one type of RNP. <Resident 7> According to the 02/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had a moderate memory impairment and diagnoses including traumatic brain dysfunction, left-sided paralysis following a stroke, and a left-hand contracture (a permanent tightening of the muscles, tendons, and nearby tissues that causing ROM issues in joints). The MDS showed Resident 7 did 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.

Based on interview and record review, the facility failed to ensure ongoing communication and collaboration about resident's health with the kidney center occured regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 2 of 2 sampled residents (Resident 60 & 3) reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> According to the facility's undated Dialysis Management (a type of dialysis treatment done in a clinic) policy the facility would coordinate with the dialysis center to ensure the resident's treatments needs were met. The policy directed nurses to ensure there was ongoing communication between the nursing home and dialysis staff. <Resident 60> According to the 02/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 60 had multiple complex medical conditions including kidney failure with dependence on dialysis and uncontrolled blood sugars. The MDS showed Resident 60…

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, the facility failed to have sufficient nursing staff to provide timely assistance with toileting and call light response in accordance with established clinical standards as evidenced by information provided from 8 (Resident 52, 3, 228, 276, 60, 178, 44, & 277 ) resident interviews, information provided by 2 (Resident 22 & 7) Resident Council residents, review of facility grievance forms for Residents 10, 8, 60, & 48, call light reports for Resident 277, 276, & 56, and staff interviews provided by Staff KK (Certified Nursing Assistant - CNA), Staff MM (Registered Nurse), and Staff N (Licensed Practical Nurse). The facility had insufficient staff to ensure Restorative Nursing Programs (RNPs) were provided to Residents 7, 55, & 44. These failures placed residents at risk for unmet care needs and other negative health outcomes. Findings included . <Facility Policy> Review of the Resident Call System facility policy dated 09/2022 showed when a resident utilized the call light system, staff should respond to the resident's needs in 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.

Based on interview and record review, the facility failed to ensure 1 of 4 sample residents (Residents 52) reviewed for food concerns received the diet prescribed to them, and 5 supplemental residents (Residents 227, 13, 37, 39, & 20). Failure to ensure residents received their diet as ordered, placed residents at risk for an inappropriate diet and related negative health outcomes. Findings included . <Resident 52> According to the 02/17/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 52 had clear speech, their memory was intact, and had medical conditions including heart failure, high blood pressure, localized edema, and diabetes (unstable blood sugar levels). The MDS showed Resident 52 was administered injectable and oral medication to treat high blood sugar level daily during the assessment period. The 02/15/2024 therapeutic diet care plan showed the staff should encourage food choices consistent with Resident 52's medical conditions and listed an intervention directing staff to serve the diet as ordered. Review of Resident 52's physician orders showed 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 observation and interview the facility failed to store and prepare food under sanitary conditions for 1 of 1 kitchens. The failure to ensure food items in the dietary department were properly labeled and stored, adequate hand washing supplies were available to dietary staff, and food brought to residents from outside the facility was properly, placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness. Findings included . <Facility Policies> According to the facility's July 2014 Preventing Food Illness - Food Handling policy, food would be stored, handled, and served in a manner to minimize the risk of foodborne illness. According to the facility's undated Safe Handling for Foods from Visitors facility staff would remind visitors to let a member of staff know when they brought food from outside the facility to a resident. The policy showed if the food brought in was intended to be eaten later, facility staff were responsible to ensure the food was contained…

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 failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 2 of 3 sampled residents (Residents 46 & 276) reviewed for dignity concerns. Failure to dress residents, provide privacy, and assist with toileting placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth. Findings included . <Resident 46> According to the 09/11/2023 Significant Change Minimum Data Set (an assessment tool), Resident 46 admitted to the facility on [DATE], had multiple medical conditions and impaired memory. Resident 46 was assessed to require one to two-person extensive assistance with transfers, dressing, toileting, and oral hygiene. Observations on 03/17/2024 at 11:23 AM and 2:02 PM, 03/18/2024 at 9:00 AM, and 03/19/2024 at 9:16 AM showed Resident 46 was lying in their bed wearing only a brief.…

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 failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 1 of 3 residents (Resident 68) reviewed for beneficiary notification. This failure placed Resident 68 and other residents at risk for not being fully informed and losing their right to an appeals process. Findings included . <Facility Policy> According to the facility policy titled, SNF Beneficiary Notices Under Medicare Part A, revised 11/14/2022, the facility would inform Medicare A beneficiaries when they no longer met the skilled coverage criteria. The policy showed a NOMNC was given by the facility to all Medicare beneficiaries at least two days before the end of their Medicare covered Part A stay because the notice contained information regarding the beneficiary's right to an expedited appeals process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 2 of 2 residents (Residents 42 & 71) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property (Resident 42) and how the environmental noise affected their quality of life (Resident 71). These failures placed residents at risk for frustration and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Grievances, revised 02/2024, employee responsibilities in the grievance process included: (1) initiating the Resident Grievance Report for all concerns brought forth by residents, and (2) immediately providing the completed report to the Grievance Officer or designee. The policy showed the responsible department for the grievance identified would communicate with the resident/representative and would attempt to resolve the issue within five days. The policy showed the Grievance…

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 failed to identify the need for and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) for 1 of 21 sample residents (Resident 15). The failure to identify and complete a SCSA MDS left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (RAI, a manual directing staff on requirements for completion of a Minimum Data Set- MDS) dated [DATE] showed a SCSA must be completed within 14 calendar days after the facility determined or should have determined there was a significant change in the resident's physical or mental condition. An SCSA was appropriate if there were consistent patterns of changes, with either two or more areas of decline. <Resident 15> According to the 02/25/2024 Quarterly MDS Resident 15 usually understood 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 record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 2 of 5 residents (Residents 7 & 44) reviewed for PASRRs. This failure left residents at risk for risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's April 2023 PASRR Requirements policy, if at any time the facility found a previous Level 1 PASRR was incomplete, erroneous, or no longer accurate the facility would immediately complete a new Level 1 PASSR screening. The policy showed as applicable the facility would submit the new level 1 to the state agency for consideration of Level 2 services. <Resident 7> According to the 02/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had moderate memory impairment and verbal behaviors four-to-six times a week that interfered 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.

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified for 2 (Residents 6 & 30) of 21 sample residents; blood pressure was measured as ordered for 2 (Residents 15 & 7) of 21 sample residents; and POs were followed for 2 (Residents 55 & 52) sample residents. These failures placed residents at risk for unmet care needs, inappropriate care, falling, weight loss, and other negative health outcomes. Findings included . <Clarifying Orders> <Resident 6> According to the 01/04/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had medically complex diagnoses including insomnia, muscle spasms and three Stage 4 Pressure Ulcers (open areas of skin caused by pressure over bony prominences; Stage 4 indicating full thickness tissue loss with exposed bone, tendon, or muscle). The MDS showed Resident 6 received as-needed pain medications, and experienced pain that occasionally affected their sleep and day-to-day activities. Record review showed Resident 6 had two as-needed pain POs: a 01/08/2024 PO for a non-narcotic…

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, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of skin care/treatment and self-medication administration for 3 of 21 residents (Resident 15, 30, & 52) reviewed for quality of care. These failures placed residents at risk for undiagnosed condition of the skin and soft tissues, skin breakdown, unsafe medication administration, and a decreased quality of life. Findings included . <Resident 15> According to the 02/25/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 15 had highly impaired memory and medical diagnoses including heart failure, diabetes (unstable blood sugar in the body), mental health diagnoses, and heart failure. The MDS showed Resident 15 was assessed with no skin impairments. In an interview on 03/17/2024 at 8:31 AM, Resident 15 stated they were supposed to get a growth on the right side of their neck treated. Resident 15 stated nothing was done yet. Resident 15 showed a small lump under 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.

Based on observation, interview, and record review, the facility failed to ensure residents with vision deficits were assessed and provided Assistive Devices (ADs) to maintain vision abilities for 1 of 1 residents (Resident 42) reviewed for vision needs. These failures placed Resident 42 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's policy titled, Vision and Hearing, revised 05/2023, the facility would assist residents in obtaining routine and prompt vision/hearing care. The policy showed the social services department would identify residents who needed eye examinations and would coordinate routine services. <Resident 42> According to the 01/05/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 42 had clear speech, understands and understood others during communication, and had a diagnosis of diabetes (unstable blood sugar levels in the body). The MDS showed it was very important for Resident 42 to have reading materials. The MDS showed Resident 42 had adequate vision…

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 the facility failed to ensure 1 of 5 residents (Resident 6) reviewed for Pressure Ulcers (PU) were provided ordered interventions they required for the prevention or worsening of PU. This failure to implement pressure reducing devices in accordance with physician's orders placed residents at risk for PU development, worsening of PU, pain, and a diminished quality of life. Findings included . <Facility Policy> The facility's revised 02/03/2023 Pressure Ulcer Prevention and Treatment policy showed all residents would be assessed for the risk of acquiring a PU, and individualized interventions would be identified and implemented. The policy identified support surfaces such as a bed or a wheelchair as possible interventions. <Resident 6> According to the 01/04/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had medically complex diagnoses including Diabetes Mellitus (DM - a condition making regulation of blood sugar more difficult), Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) PU, and 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 the facility failed to identify, assess, and implement interventions to prevent accidents for 3 of 6 residents (Residents 60, 71, & 72) reviewed for accidents. The facility failed to identify and assess 1 of 1 resident (Resident 60) for smoking, 1 of 1 resident (Resident 71) for a bolster air mattress (an air inflated mattress with propped up support to prevent accidental roll-outs), and 1 of 1 resident (Resident 72) for wander guard monitoring related to an elopement risk. These failures left residents at risk for injury, entrapment, and elopement. Findings included . <Facility Policy> Record review of the facility policy titled, Smoking, updated on 08/2022, showed the facility would screen all residents who smoked upon admission, quarterly, and as needed to determine any special needs and to assess their ability to smoke independently. The policy showed the facility would store all smoking materials in a locked storage cabinet in the resident's room, at 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 the facility failed to ensure 2 of 2 sampled residents (Residents 176 & 226) reviewed for respiratory care received care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to the physician ordered flow rates (Resident 176 & 226) and to ensure correct equipment use (Resident 226) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, and a decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled, Oxygen Management, revised 08/2023, the facility would require that a physician's order be obtained prior to the administration of oxygen and all orders of oxygen therapy must include duration of use. The policy showed equipment used, including the oxygen concentrator (a medical device that delivered supplemental oxygen) and the prefilled humidifier to prevent possible nasal dryness.…

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 failed to provide medically-related social service interventions that addressed refusal of care for 1 of 2 residents (Resident 226) reviewed for rehabilitation services and 1 of 5 residents (Resident 52) reviewed for unnecessary medications. Failure to have a process for resident refusals, identify, and find ways to support residents needs related to refusals placed residents at risk for early termination of skilled care benefits (Resident 226), unnecessary use of pain medications (Resident 52), unmet care needs, and a decreased quality of life. Findings included . <Skilled Services> <Facility Policy> Review of the undated facility policy titled, Therapy Policy and Procedures, showed the facility's therapy evaluations served as a care plan (CP) and should clearly indicate why therapy services was reasonable and medically necessary. The policy showed the facility would conduct Interdisciplinary Team (IDT) communication, including nursing, social…

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, the facility failed to ensure expired medications were disposed of timely and controlled pain medications were properly secured for 1 of 1 medication room reviewed for medication storage. This failure placed residents at risk for receiving medications with decreased effectiveness and predisposes the staff to potentially diverting medications (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings included . <Facility Policy> Review of the facility policy titled, Storage and Expiration, Dating of Medications, Biologicals [a therapeutic substance such as a vaccine or drug], revised 08/07/2023, the facility would ensure medications and biologicals that expired were destroyed or returned to the pharmacy. The policy showed after controlled substances (medications prone to misuse and abuse) were received and added in the inventory, the facility would ensure they were immediately placed in a separate compartment within the locked medication carts. <Medication Room> Observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to assess and ensure prompt dental care and services were provided for 2 of 9 residents (Residents 42 and 46) reviewed for oral/dental health. The facility's failure to assess and/or follow-up on dental exam recommendations placed resident at risk for oral pain, unmet dental needs, and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Dental Services, revised 12/30/2022, the facility would assist the residents in obtaining routine and 24-hour emergency dental care. The policy showed the social services department would coordinate dental services including prompt referrals and would document all dental interventions performed in the resident's medical record. <Resident 42> Review of the 01/05/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 42 admitted to the facility on [DATE], had clear speech, and understood others during communication. The MDS showed…

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 failed to ensure the arbitration agreement was signed by the resident's Durable Power of Attorney (DPOA) for financial affairs as required for 1 of 1 residents (Resident 41) whose Arbitration Agreements (AA) were reviewed. This failure placed Resident 41 and residents at risk of forfeiture of their right to a jury or court trial and a diminished quality of life. Findings included . <Resident 41> According to the 03/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 41 was non-English speaking, non-communicative, had memory impairment, and was incapable of daily decision-making. In an interview on 03/17/2024 at 10:05 AM, Staff Q (Regional Director of Operations) stated the AA was offered to residents and their representatives during admission and was conducted by the facility's Business Office Manager (BOM). Staff Q stated on Resident 41 had an active AA on file. Review of Resident 41's AA 03/18/2024 showed the resident's name was not written in the AA and was signed by Resident 41's representative on 07/23/2021.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 3 of 21 residents (Residents 30, 226, & 71) whose CPs were reviewed for individualized care. The facility failed to implement CP interventions (Resident 30) and develop a discharge CP regarding discharge disposition, needs, and/or barriers (Residents 226 & 71). These failures placed residents at risk for inconsistent and unmet care needs, anxiety regarding discharge, and a decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled, Care Planning Process, revised 05/19/2023, the CP was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. The policy showed the facility would personalize the CP and add additional focuses, goals, and interventions as indicated regarding the resident's care. Review of the facility policy titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure pharmacy services were provided to meet the residents needs for 4 of 5 residents (Residents 1, 2, 3, & 5) reviewed. The failure to ensure medications were acquired and administered on the day of admission, follow facility process for medications that were not available for administration, reconcile medications delivered from the pharmacy for accuracy, ensure proper storage and disposition of medications that required disposition / return to the pharmacy, and reconcile medications upon resident discharge placed the resident's at risk for adverse health complications, significant medication errors, and diminished quality of care. Finding included . <Policy> According to the facility's December 2022 revised Medication Administration Policy, the licensed staff were directed to verify the prescription label on the drug matched the Medication Administration Record (MAR) and if there was a discrepancy, they would check the original…

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 failed to ensure food was stored, prepared and served in a sanitary manner and in accordance to professional standards for food service safety. The failure to ensure food: had cold storage temperature was maintained at or below 41 degrees; was stored in a clean refrigerator, was free of expired, unlabeled and undated food products for one of one unit refrigerators; failure to ensure staff performed adequate hand hygiene during food preparation and food service; and ensure food was prepared in a kitchen free of potential food contamination placed residents at risk for food-borne illness and unsavory food. Findings included . Facility Policy According to the facility's revised August 2019 Handwashing/Hand Hygiene policy, facility staff should perform Hand Hygiene (HH) using Alcohol Based Hand Rub (ABHR - hand sanitizer) before and after direct contact with residents. The policy showed staff should perform HH after contact with objects in the immediate…

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 failed to ensure residents had the ability to exercise self-determination related to aspects of life in the facility that was significant to the resident including the frequency and type of bathing for 3 of 3 residents (Residents 51, 6, & 65) reviewed for choices. The facility's failure to identify and/or honor resident preferences related to bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth and diminished quality of life. Finding included . Resident 51 According to a 09/29/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 was cognitively intact, with clear speech, able to understand others, and be understood. This MDS indicated Resident 51 reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 12/02/2022 at 10:44 AM, Resident 51 stated they get bathing, one time a week if you're lucky. The resident stated they preferred to 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 and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 3 (Residents 221, 223, 222) of 3 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Additionally, the facility failed to notify 2 (Residents 38 & 2) of 28 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. Findings included . According to a 12/01/2017 facility Personal Funds- Your Rights policy, the facility would notify a resident who receives Medicaid benefits when the balance of the resident trust account is 200 dollars less than the resource limit. The facility would advise the resident they may lose eligibility for Medicaid if the amount in the account was to reach…

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 failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 9 (Residents 6, 35, 45, 52, 20, 32, 65, 12, & 40) of 18 residents reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed. Findings included . Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 6 admitted to the facility on [DATE] and was cognitively intact, able to make themselves understood and understood others. Review of Resident 6's record on 11/30/2022 at 1:03 PM, showed no AD documentation. In an interview on 12/01/2022 at 7:48 AM, Resident 6 stated no one from the facility spoke with them about an AD. Resident 6…

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 failed to provide timely notice, in writing, of changes in payment status and potential charges for services not covered by Medicare/Medicaid for 2 of 3 (Residents 27 & 371)residents reviewed for Advanced Beneficiary Notices (ABN, a notification of costs when services provided may not be paid by Medicare) and assist residents or their representatives to understand these notices or assist with the appeal process placed residents at risk for insufficient information to make informed decisions about care and finances. Findings included . Resident 27 On 05/21/2022 Resident 27 began skilled nursing/therapy services under their Medicare A benefit. Resident 27 was issued a Notice of Medicare Non-Coverage (NOMNC) on 06/15/2022 showing their last day of Medicare A coverage was 06/17/2022. In a 12/07/2022 10:30 AM interview, Staff G (Business Office Manager) stated Resident 27 should have been issued the federally required ABN because they no longer qualified for skilled nursing services under their Medicare A benefit and continued to reside…

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 failed to ensure a clean, comfortable, homelike environment for 4 of 4 Wings (Wings A, B, C & D) reviewed. Facility failure to ensure a sufficient supply of linens in adequate condition, hallways were clean and homelike, resident rooms were free of wall gouges and damaged furniture, hand sanitizer dispensers were intact, call lights were within reach, clocks in resident rooms were accurate, and Blood Pressure cuffs were kept clean left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . Linens On 11/30/2022 at 8:53 AM Staff Y (CNA, Certified Nursing Assistant) reported to surveyors that the facility did not have an adequate supply of fitted sheets. Staff Y stated the CNAs told the facility about it for months. Observation on 11/30/2022 from 8:56 AM to 9:01 AM showed the linen cart in Wing D had four flat sheets and some pillowcases but no other bed sheets, the linen cart in the hallway in Wing A had no bed…

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 failed to implement a system to ensure resident concerns were identified and addressed timely and the outcome communicated to residents, including concerns brought up during Resident Council meetings. Facility failure to identify, address timely, and provide residents with the outcome of the grievance investigation left residents at risk for unresolved concerns, feeling unheard, frustrated, diminished self-worth and decreased quality of life. Findings included . On 12/07/2022 at 12:58 PM, Staff M (Life Enrichment Director) provided all available Resident Council Meeting Minutes from the last 6 months. Meeting minutes were provided for meetings on 10/25/2022 and 11/16/2022. Staff M stated they were unable to provide any other meeting minutes, the two sets of Minutes provided were the only ones available. Staff M stated they held the position of Life Enrichment Director since 10/04/2022 and did not know if/where their predecessor stored meeting minutes. Staff M stated their predecessor didn't leave me any records. Staff M stated they…

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 failed to ensure Minimum Data Sets (MDS - an assessment tool) were complete and accurate for 6 of 20 (Residents 35, 55, 51, 6, 27, & 49) sample residents reviewed. Facility failure to complete accurate MDS assessments prevented the facility from transmitting accurate information to the Centers for Medicare and Medicaid Services (CMS) for facility quality ratings, and left residents at risk for unidentified and/or unmet needs. Findings included . Resident 35 According to the 10/31/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 35 had diagnoses including debility (physical weakness), respiratory failure, and malnutrition. The MDS showed Resident 35 had no falls while a resident of the facility. According to the 09/16/2022 progress notes, Resident 35 was found on the floor of their room after a fall at 10:00 AM on 09/16/2022. Resident 35 was noted to have a 3 x 3 inch hematoma (build up of blood under the skin secondary to trauma)…

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 failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained, and/or implemented and incorporated into the Care Plan (CP) for 2 of 5 (Residents 55 and 32) residents and 1 supplemental resident (Resident 18) reviewed for PASRR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . Resident 55 According to a Quarterly Minimum Data Set (MDS - an assessment tool), Resident 55 had medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 55's records revealed a 05/31/2022 Level 1 PASRR completed by facility staff that identified the resident with a serious mental illness indicator of depression. Staff identified Resident 55 required a Level 2 evaluation referral for the serious mental illness diagnosis. Record review showed a social services progress note on 06/02/2022 at 11:32 AM…

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 failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 3 of 5 (Resident 51, 34, and 49) residents and 1 supplemental (Resident 18) resident reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . According to an undated facility MI [mental illness]/MR [developmental disability] Preadmission Screening policy, staff were to determine if a new resident had a Level 1 screen, directed staff to review the Level 1 screen, at least quarterly, ensure the Level 1 screen was filed in the resident's record, and accurately reflected the resident's current status. This policy stated the state mental health authority, as applicable, upon admission, annually, promptly after a significant change in mental or physical condition of a resident who had a mental disorder for resident review, or upon learning of an MI/MR diagnosis which…

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 failed to ensure Care Plans (CPs) were revised and implemented for 9 (Residents 35, 51, 34, 55, 42, 6, 52, 65, & 22) of 20 sample residents reviewed. The failure to include residents and/or their resident representatives participation in the CP process prevented residents from exercizing their rights in developing person-centered care plans and deterred the facility from providing individualized resident informaiton to staff caring for residents placing residents at risk for unmet needs, feeling institutionalized, depersonalization, and diminished quality of life. Findings included . Facility Policy According to an undated Care Plans facility policy, the facility was to review and revise care plans. The care plans were written to be consistent with the services provided. The policy identified care plans were not only driven by resident issues or conditions but also by their unique characteristics, strengths, and needs. The facility was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 18 (Residents 45, 51, 34, 6, 40 & 41) residents reviewed. Nursing staff failed to follow physician orders (Resident 45, 51, & 34), clarify physician orders (Residents 45, 51, 6, & 40), and signed for tasks not performed (Residents 51), which placed the residents at risk for medication and treatment errors and adverse outcomes. Findings included . Follow Physician Orders (PO) / Edema Monitoring Resident 45 Professional Standard: According to the American Heart Association, the monitoring of fluid balance status in the management of a resident with heart failure (which usually directly affects the kidney function) is to weight the resident at the same time of the day, everyday. For a weight increase of three pounds in two days or five pounds in a seven days, the nurse should notify the provider of the increase and the resident most recent labs / lab…

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 failed to implement effective discharge planning processes to transition residents to post-discharge care for 2 of 3 (Residents 161 & 69) residents and 1 supplemental resident (Resident 51) reviewed for discharge planning. The failure to identify and plan for the individual discharge needs of each resident placed residents at risk for unmet needs after discharge, lack of medical equipment, distress about plans to go home, unsafe discharge location, and rehospitalization. Findings included . Resident 121 According to the 10/28/2022 admission Minimum Data Set (MDS, an assessment tool) Resident 121 admitted to the facility on [DATE], was cognitively intact, and made their own decisions. Resident 121 had medically complex conditions, including Atrial Fibrillation (A-fib, abnormal heart rhythm), Coronary Artery Disease (damage in the heart's major blood vessels), and Hypertension (high blood pressure). Resident 121 received a blood thinning (anti-coagulant) 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 observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 18 residents (Resident 12, 51, 6, 41, & 46) reviewed for ADL care to dependent residents. The failure to provide dependent residents with bathing, nail care, oral care, and overall grooming placed them at risk for poor hygiene, embarrassment, and diminished quality of life. Findings include . Resident 12 According to the 05/13/2022 admission Evaluation, Resident 12 had a full upper denture and natural bottom teeth. The 12/02/2022 Kardex (a care guide) showed Resident 12 required set up and standby assistance with oral care. A 07/08/2022 Sound Dental Care consultation showed Resident 12 needed help to remove and clean their upper denture. Observation on 11/30/2022 at 1:16 PM showed Resident 12's was wearing their upper denture. The upper denture was noted with food residue outlining the teeth and in between the gum line. When asked if they have rinsed their mouth or brushed…

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 Emergency Exit Doors During a life safety inspection on 12/01/2022 from 8:45 AM to 9:50 AM, a Washington State Fire Marshal identified the two EE doors (door 2 and 3) on the east side of the building did not function as required. The Fire Marshal determined the EE doors were locked and could not be opened, which prevented residents and staff from exiting emergently. In an interview and observation on 12/01/2022 at 11:51 AM, Staff I (Maintenance Assistant) stated they took the door pins to their private home and needed to collect the pins before they could get the EE doors open. Staff I stated they removed pin from each of the push-bars for EE doors 2 and 3 after a resident wandered through the doors outside to the patio area, unsupervised. Staff I was unable to recall the name of the resident or the date they removed the pins from the door but stated that it was a while ago. Staff I was observed using multiple tools to install the pin into the push-bar and 11 minutes later EE Door 2 was unlocked and opened. At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 4 (Residents 19, 66, 51, & 20) of 8 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent and timely weights, notify physicians of changes, and implement interdisciplinary interventions and physician ordered nutritional supplements, placed residents at risk for weight loss and/or delayed implementation of interventions to prevent continued weight loss. Findings included . Facility Policy According to a revised 11/2022 facility Nutrition Assessment policy the facility was required to measure and record food intake three times daily with meals for all residents in the electronic medical record (EMR). If changes in intake or an intake less than 50% was noted, the resident's condition would be evaluated during the clinical meeting to determine if there were new risk factors for nutrition. This policy provided recommendations for consideration to develop individualized…

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 the facility failed to provide pharmaceutical services (including procedures that assured timely acquiring, receiving, and administering of all drugs) to meet the needs of each resident for 8 of 10 residents (Resident 51, 23, 2, 42, 49, 4, 65, and 32) reviewed. The facility failed to implement a system of medication records that ensures accurate reconciliation and accounting of all controlled medications for 4 of 5 inventory of controlled substance books reviewed from 3 of 3 medication carts. This failure resulted in residents not receiving their medications as ordered, placed residents at risk for adverse effects from not receiving prescribed medications, at risk for misappropriation of property, and drug diversion. Findings included . Unavailable Medications Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 had multiple medically complex diagnoses including depression and fractures and required the use of an antidepressant and scheduled pain medication. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure the availability of hand sanitizer, and failed to ensure staff: performed hand hygiene during medication administration, and performed wound care without wearing gloves in accordance with the Centers for Disease Control (CDC) recommendations. These failures placed residents at risk for the development and transmission of communicable disease and infections. Findings included . The facility's Infection Prevention and Control Program (IPCP) policy revised in October 2018 showed that IPCP was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Hand Hygiene The facility policy Handwashing/Hand Hygiene revised in August 2019 showed 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 interview and record review, the facility failed to ensure influenza and/or pneumococcal vaccines were offered and/or provided for 4 of 5 residents (Residents 32, 34, 51, and 49) reviewed for immunizations/unnecessary medications. These failures placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza and pneumococcal disease. Findings included . The revised October 2019 facility Influenza Vaccine policy showed all residents who have no contraindications to the vaccine would be offered the influenza vaccine annually between October 1 and March 31 of each year. For those who received or refused the vaccine, documentation would be placed in the resident's records. The revised October 2019 facility Pneumococcal Vaccine policy showed all residents would be offered the vaccine series within 30 days of admission. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if 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.

Based on observation, interview, and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 1 of 18 (Residents 50) sampled residents. Failure to communicate with residents in a dignified manner placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth. Findings included . Resident 50 On 12/08/2022 at 7:30 AM Resident 50 was observed to approach an unattended beverage cart left in the dining room. Staff Y (Certified Nursing Assistant) called out loudly to Resident 50 from the nurse's station outside the dining room directing the resident to get off the cart twice. Staff Y then approached Resident 50 and asked the resident if they wanted a drink. Resident 50 left the dining room in frustration and went to the resident lounge. In an interview on 12/09/2022 at 3:53 PM Staff C (Licensed Practical Nurse, Unit Manager) stated they expected staff to treat residents with courtesy.…

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 failed to provide advanced written notice for room changes, to include the reason for the move, for 3 (Residents 2, 6 & 41) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life. Findings included . Facility Policy According to the facility's undated Change in Room/Roommate Assignment policy, the facility was to provide reasonable notice of the room/roommate change, including oral or written explanation of the reason of the change. The policy stated a resident had the right to refuse the room change if the purpose of the transfer was to relocate the resident from the skilled (short term) section of the center to the non-skilled (long term care) section of the center. The room move was to be documented in the medical record and include the reason for the move, effective date of proposed change, location of new room, discussion with the resident/family, 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 the facility failed to ensure 15 of 28 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . Record review of the facility's Trial Balance report showed 28 residents had trust accounts. The trust account report showed a current balance of 25,984.29 dollars on 12/06/2022. Review of the facility's surety bond, effective July 2021 showed the bond amount covered a trust account balance of $21,000 which did not cover the total trust account balance. In an interview on 12/12/2022 at 11:14 AM, Staff G (Business Office Manager) stated, Yes, the surety bond should be more than the amount in trust. REFERENCE: WAC 388-97-0340(6). .

Based on observation, interview, and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), were completed within 14 days from the date of determination for 3 of 3 residents (Residents 27, 42, & 19) reviewed for significant changes in status. The failures to identify the need for a SCSA for: decline in cognition, eating abilities, new swallowing disorder, and repeated falls for Resident 42; decline in ability to feed self, decline in mood, and significant weight loss for Resident 19; and a terminal prognosis with initiating hospice services for Resident 27 placed the residents at risk for further decline, diminished quality of life/quality of care, and unmet care needs. Findings included . Resident 27 According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status is required) a . SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at 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 the facility failed to develop and/or implement comprehensive, person-centered, and/or individualized care plans for 5 of 18 residents (Resident 12, 27, 45, 49, & 51) whose care plans were reviewed. Failure to establish care plans that were individualized and accurately reflected care needs, placed residents at risk of unmet care needs due to inaccurate or absent direction to staff. Resident 12 According to the 11/20/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 12 required total assistance during transfers from the bed to the chair and the support was provided by two staff during the assessment period. The MDS showed Resident 12 did not reject care from staff. Review of the 06/20/2022 Care Plan (CP) indicated Resident 12 would sit in chair for 2-3 hours a day every day for the rehabilitation of their weakened muscles and for trunk control. The CP stated staff would ensure Resident 12 was sitting in the chair for meals and that staff 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 observation, interview, and record review the facility failed to ensure weekly skin assessments, documenting and monitoring of wounds for infection, and wound treatment supplies were available for 1 of 3 (Resident 6) residents reviewed for Pressure Ulcers (PUs). Failure to complete weekly skin checks as ordered, assess and document wound progress, and/or ensure the availability of ordered skin care and treatment supplies placed residents at risk for deterioration in skin condition, and diminished quality of life. Findings included . According to the facility's undated Wound Prevention and Treatment policy, pressure injuries would be monitored weekly, and documentation of the size, color, odor, healing progression, notifications, and other information related to skin condition would be documented in the medical record, including physician and resident/responsible party notifications. Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 admitted 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 observation, interview, and record review the facility failed to ensure residents that can eat enough orally is not fed by enteral (feeding by tube into body) methods for 1 of 1 resident (Resident 40) reviewed for tube feeding. The failure to complete on-going interdisciplinary team (IDT) assessments of the clinical indications and rationale to continue tube feeding and to identify the residents wishes and requests for oral intake placed Resident 40 at risk for possible unnecessary artificial tube feeding and diminished quality of life. Findings included . Resident 40 The 10/13/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 40 admitted to the facility on [DATE] from another skilled nursing facility. Resident 40 had diagnoses including recent stroke, aphasia (difficulty speaking), dysphasia (difficulty swallowing), unable to take food or fluids by mouth and had a tube into the stomach for administration of nutrition and fluids. A 09/24/2022 speech therapy discharge summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the attending physician failed to ensure and/or adequately supervise the complete medical care for 1 of 20 (Resident 45) residents reviewed. The failure to follow up on the status of repeated orders given to nursing staff for a referral to a kidney specialist, address the omission of daily weight monitoring, and facility failure to follow Physician orders (POs) resulted in Resident 45 not being evaluated for worsening fluid balance status by a kidney specialist for over 12 months, required a possibly avoidable hospitalization with the removal of a significant amount of water weight, experienced acute kidney injury and acute respiratory failure. Findings included . Resident 45 According to the 08/23/2021 provider visit note, the resident was referred to Nephrologist (kidney specialist) due to recurrent abnormal and worsening kidney function lab values and critical potassium levels. A 05/03/2022 nurse note showed the Physician ordered repeat labs due to worsening…

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 the facility failed to ensure residents with dementia receive the appropriate treatment and services for 1 of 2 (Resident 20) residents reviewed for dementia care. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered care plan prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings included . Resident 20 The 09/17/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 20 had clear speech, was able to make self-understood and was able to understand others. The MDS showed Resident 20 was not able to complete a cognitive interview and had a diagnosis of dementia. The MDS showed Resident 20 had no adverse behaviors, no wandering, and no refusals of care. Resident 20 was assessed to require extensive physical assistance with toileting, supervision, encouragement and cueing for eating. The MDS did not match the comprehensive care plan (CP) for Resident 20. 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.

Based on interview and record review, the facility failed to ensure resident's drug regimens were free from unnecesary psychotropic medications for 2 (Residents 32 & 49) of 5 residents and one supplemental resident (Resident 66) reviewed for unncessary medications The failure to obtain consent and review the risks and benefits of psychotropic medicaitons and failure to monitor for Adverse Side Effects (ASEs) left residents at risk for use of unnecessary psychotropic medications, adverse side effects and diminished quality of life. Findings included . Resident 49 According to the 11/17/2022 admission Minimum Data Set (MDS, an assessment tool) Resident 49 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 49's December 2022 Physician Order (PO) summary showed an order for an antianxiety (AA) medication dated 11/10/2022 for a diagnosis of anxiety. The November 2022 Medication Administration Record (MAR) showed Resident 49 started receiving the AA medication on 11/10/2022 and started receiving 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.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent (%). Failure of 1 of 3 nurses (Staff Q) to properly administer 3 of 26 medications for 1 of 8 residents (Resident 23) observed during medication pass resulted in a medication error rate of 11.54%. This failure placed residents at risk for adverse side effects due to improper medication administration. Findings included . Facility Policy The undated facility policy titled, Medication Administration, showed the licensed nurse and/or medication assistant would document administration of medication on the Medication Administration Record (MAR) as soon as medications were given. The policy instructed nursing staff to remove a dose from the back-up supply when medications were not available. Resident 23 Observation of the medication pass on 12/06/2022 at 9:28 AM showed Staff Q (Licensed Practical Nurse-LPN) prepare medications for Resident 23. Staff Q went to Resident 23's room, administered one type of eye drops, handed Resident 23 the medicine cup containing…

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, the facility failed to ensure expired medications, liquid feeding supplement, and medical supplies were disposed of timely in accordance with current accepted professional standards of practice for 1 of 1 medication room, 1 of 3 medication carts, and 1 of 2 emergency crash carts reviewed. These failures placed residents at risk for receiving compromised supplies and medications with decreased or no potency. Findings included . Medication Room Observation of the medication room on 12/02/2022 at 10:06 AM with Staff E (Registered Nurse-RN Unit Manager) showed five bottles of Iron supplement that expired 10/2022, five bottles of liquid feeding supplement that expired 12/01/2022, six anti-nausea suppositories that expired 10/2022, two boxes of alcohol swabs that expired 08/2022, nine swab collection tubes, two urinary catheters (tube that drains urine from the bladder) that expired 07/10/2021 and one urinary catheter that expired 10/11/2022. In an interview on 12/02/2022 at 10:33 AM, Staff E validated the dates of the expired medications, liquid…

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 failed to obtain timely laboratory services to meet the needs of 3 (Residents 51, 49, and 32) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services. Findings included . Review of an undated facility Laboratory/Diagnostic Test Values- Monitoring policy showed the facility strived to ensure each resident's laboratory/diagnostic test order requested was ordered. This policy identified the daily nurse manager's responsibility was to ensure all scheduled labs were drawn and if a test was missed, make arrangements for the lab/diagnostic test to be completed that day or have it rescheduled. This policy stated the unit manager must notify the provider and Director of Nursing. Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 had multiple medically complex diagnoses including malnutrition, diabetes, and a thyroid disorder.…

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, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident 45) reviewed for dental services was assisted in obtaining emergent dental care. The facility's failure to follow through with the resident's request for outside emergent dental care, failure to follow a hospital transfer order for dental services follow-up, failure to follow up on two separate dental exam recommendations for emergent dental care placed resident at risk for an oral infection, hospitalization, pain, and diminished quality of life. Findings included . According to the undated facility dental policy, when residents require emergency dental service for acute pain in teeth, gums, or palate; broken or otherwise damaged teeth; any problem requiring the immediate attention of a dentist, the facility would schedule an appointment and arrange transportation. Resident 45 According to the 11/12/2022 5 Day Minimum Data Set (MDS, an assessment tool) Resident 45 had their own natural teeth and had…

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 failed to provide foods according to the resident's preferences for 1 of 2 (Resident 52) residents reviewed for food preferences. The failure to accommodate a resident's religious dietary preferences placed residents at risk for inadequate nutrition and well-being. Findings included . Resident 52 According to the 11/08/2022 Quarterly Minimum Data Set (MDS, an assessment tool), Resident 52 readmitted to the facility on [DATE], was assessed as cognitively intact, able to make themselves understood and understood others. The MDS showed Resident 52 was able to participate by answering questions and making decisions about their care. The MDS showed it was very important to Resident 52 to have snacks available between meals. In an interview on 11/30/2022 at 9:10 AM, Resident 52 stated they did not get to make choices about food. Resident 52 stated they did not eat pork or beef according to their religion but the facility kept serving them bacon 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 failed to identify a designated interdisciplinary team member appointed as the responsible party for coordinating care and communication with hospice services, and to ensure the development of a coordinated plan of care for 1 of 1 residents (Resident 27) reviewed for hospice care services. These failures placed the resident at risk for not receiving necessary hospice services, lack of continuity of care, and unmet care needs. Findings included . Facility Policy The undated facility policy titled, Hospice Residents- admission and Discharge of and Care and Treatment Provided to, showed the Center would designate a Registered Nurse (RN) from the interdisciplinary team to be responsible for working with hospice representatives in coordinating care for hospice residents receiving facility and hospice services. The policy showed Hospice and the Center would jointly develop and agree upon a coordinated plan of care and the description of the services furnished 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.

Based on interview and record review the facility failed to establish an infection prevention and control program that included developing an antibiotic (ABO) stewardship program to promote appropriate use of antibiotics; failed to analyze and complete monthly surveillance effectively for 4 of 4 months (July 2022 to October 2022) reviewed; failed to have an effective Infection Control Committee to meet regularly and analyze/review Antibiotic usage in the facility. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug resistant organisms (MDRO). Findings included . The October 2018 revised facility policy named Infection Prevention and Control Program showed the facility would use surveillance tools to recognize the occurrence of infections .and detecting unusual pathogens with infection control implications. The facility would use culture reports, sensitivity data and antibiotic usage reviews for surveillance activities, data gathering, and analysis and medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 2 of 5 residents (Resident 51 and 49) were offered the COVID-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) vaccination and had education on the benefits and potential risk associated with COVID-19. These failed practices placed the residents at risk of COVID-19 infection and placed residents at risk for not having their medical records reflect complete and/or accurate information to be considered when making a medical decision. Findings included . Review of a revised November 2021 facility COVID-19 - Vaccination of Residents policy showed each resident would be offered the COVID-19 vaccine unless the immunization was medically contraindicated, or the resident had already been immunized. This policy stated the resident had the opportunity to accept or refuse a COVID-19 vaccine, and to change their decision. The policy stated 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.