Sharon Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to obtain a physician's order for 2 of 4 sampled residents (3 & 288) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented .Nursing Staff will also obtain a physician order for the device/enabler. 1) Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 08/05/2024, documented Resident 3 was moderately cognitively impaired. On 09/09/2024 at 10:50 AM, Resident 3 was observed lying in bed on their left side with quarter length bed rails on left and right sides of the bed. At 3:17 PM, Resident 3 was observed lying in bed on their back with quarter length bed rails on left and right sides of the bed. Review of Resident 3's Electronic Health Record (EHR) did not show a physician's order…

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 copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 for 1 sampled resident (26) reviewed for transfer notice requirements. This failure placed residents at risk of loss of added protection from being inappropriately transferred or discharged from the facility. Findings included . Resident 26 was admitted to the facility on [DATE] with diagnoses including congestive heart failure exacerbation and physical deconditioning. The admission Minimum Data Set assessment, dated 07/24/2024, documented Resident 26 was alert and oriented. Record review of resident's electronic health records documented Resident 26 was transferred to and admitted to a local hospital on [DATE]. On 09/11/2024 at 2:01 PM, when asked if a Notice of Transfer for Resident 26 was sent to the Office of the State Long-Term Care Ombudsman, Staff A, Administrator, said he would check whether the notice was sent.…

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 the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's oral/dental status for 1 of 1 sampled resident (21) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 21 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 07/30/2024, documented Resident 21 was severely cognitively impaired, did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. Record review of the Dietitian Consulting Services - Nutrition Assessment, dated 07/29/2024, documented, natural teeth in poor shape. Record review of a Nutrition/Dietary progress note, dated 07/30/2024, documented, .teeth in poor shape. On 09/09/2024 at 10:19 AM, Resident 21's mouth was observed to have missing upper teeth, and lower teeth 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 ensure a comprehensive care plan was developed for 1 of 4 sampled residents (6) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented Use of the device/enabler will be appropriately care planned and added to the resident's [NAME]. Resident 6 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 06/12/2024, documented Resident 6 was severely cognitively impaired. On 09/09/2024 at 10:39 AM, Resident 6's bed was observed with the left side against the wall and a mat on the floor the full length of the bed along the right side. At 11:38 AM, Resident 6 was observed sitting up in a wheelchair in her room with the left side of the bed against the wall. Review of Resident 6's Electronic Health Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure activities of (ADLs) care was provided for dependent residents including nail care for 1 of 2 sampled residents (5) reviewed for ADLs. This failure placed residents at risk of not receiving the care and assistance needed for which they were unable to perform themselves. Findings included . The facility's policy entitled, Nail Care, dated 01/01/2024, indicated I. Nail care which we considered a part of personal hygiene/grooming and is provided by the certified nursing assistant if the resident is not diabetic, and the nails are not severe or complicated. II. If the resident is diabetic the nail care will be done by the licensed nurse due to being higher risk. III. The resident nails are checked for cleanliness and length as a standard of care in grooming/hygiene for the certified nursing assistant and cleaned as needed and nail care is offered. Resident 5 was admitted on [DATE]. The annual Minimum Data Set assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner of which the resident and/or representative understood for 1 of 3 sampled residents (25) reviewed for arbitration agreement. This failure placed residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of the facility's Optional Voluntary Arbitration Agreement documented, 5. Right to Rescind this Agreement. You may rescind this Agreement to arbitrate within thirty (30) days after signing it by giving written notice of your withdrawal to the Facility . Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 08/13/2024, documented Resident 25…

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

Based on observation, interview and record review, the facility failed to ensure infection prevention practices are being maintained including proper use of personal protective equipment (PPE) and hand hygiene for 2 of 8 sampled residents (26 & 30) reviewed for infection prevention and control. These failures placed residents at risk of communicable infections and a decreased quality of life. Findings included . Record review of the facility's Employee Training on Infection Prevention and Control policy, dated 11/01/2018, documented staff trainings and education regarding infection prevention and control included hand hygiene and use of PPE. 1) On 09/10/2024 at 1:58 PM, Staff F, Certified Nurse Assistant (CNA), was observed providing care for Resident 26. Staff F took off her gloves, opened Resident 26's door and proceed to retrieve gloves from the isolation cart located outside the room. Staff F then returned into the room, put on the new pair of gloves and continued to provide resident care. When asked about the process for doffing PPE between care, Staff F said she should have…

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

Based on interview and record review, the facility failed to ensure mail delivery was provided on Saturdays for residents receiving mail via the US Postal Service for 4 of 5 sampled residents (7, 12, 19 & 246) reviewed for communication with privacy. This failure placed residents at risk of not receiving their mail in a timely manner and a diminished quality of life. Findings included . The Nursing Facility admission Agreement, dated 09/2013, documented, Each resident has a right to . send and promptly receive mail . On 07/19/2023 at 10:55 AM, during a Resident Council group interview, Resident 7 said there was activity staff that worked on Saturdays, but no mail was delivered on Saturday. The residents got Saturday's mail delivered on Monday. Resident 12, Resident 19 and Resident 246 also said there was no mail delivery on Saturdays. At 12:01 PM, Staff H, Activity Director, said mail delivered on Saturdays by the post office was taken by the post office to the assisted living side of the facility and put in a locked area until Monday. At 12:59 PM, Staff A, Administrator, said 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 foods were prepared, stored, and served in a sanitary manner when the facility failed to ensure the kitchen was free from dust and debris, clean dishes and utensils were stored in a clean manner, and opened foods were not labeled and/or dated as required for all 42 facility residents who received meals from the facility kitchen. These failures placed all residents at risk for food-borne illness and a diminished quality of life. Findings included . On 07/17/2023 at 9:06 AM, during the initial kitchen tour, crumbs, grease, and debris were observed throughout the kitchen. In the dry food storage, a bag of stored food was on the floor. In the freezer, several eggrolls are noted on the floor. The hood had visible grease build-up and dust. A rack with clean dishes was in a high traffic area and had washcloths mixed in with the glasses. Several spices were noted without an open date. On 07/19/2023 at 2:10 PM, the kitchen was observed with Staff N, Dietary Manager. Four dented food cans were identified. Staff…

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 with a urinary catheter (foley catheter, a flexible tube inserted into the bladder to drain urine into a drainage bag), received appropriate care and services to minimize the risk of associated urinary infections for 4 of 5 sampled residents (10, 36, 24 & 1), and failed to ensure hand hygiene and glove changes were performed when indicated in the kitchen during tray line service by 1 of 3 sampled kitchen staff (Staff 0) reviewed for infection prevention and control. These failures placed the residents at risk for infections, medical complications and a diminished quality of life. Findings included <Hand Hygiene> On 07/19/2023 at 11:34 AM, Staff O, Dietary Cook, was observed preparing the lunch meal. No hand hygiene was observed when Staff O started prepping the meal. Staff O was observed gathering items needed for the meal with her bare hands. At 11:40 AM, Staff O was observed ready to serve the lunch meal. Staff O…

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 and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 4 of 6 sampled residents (5, 12, 32 & 39) reviewed for right to be informed and make treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . 1) Resident 5 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 06/29/2023, documented Resident 5 was moderately cognitively impaired. A physician's order, dated 01/25/2023, documented Resident 5 was prescribed Sertraline (an antidepressant). A physician's order, dated 06/10/2023, documented Resident 5 was prescribed Risperidone (an antipsychotic medication). Resident 5's Electronic Medical Record (EMR) did not show…

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 a comprehensive care plan for 4 of 14 sampled residents (39, 5, 8 & 36) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 06/17/2023, documented the resident was cognitively intact. A physician's order, dated 07/12/2023, documented the resident was ordered Macrobid, an antibiotic medication used to treat UTI's. Resident 39's July 2023 Medication Administration Record (MAR) documented, Macrobid oral capsule . give 1 capsule by mouth two times a day for UTI for 7 days. The MAR documented the medication was administered from 07/12/2023 to 07/18/2023. Resident 39's Comprehensive Care Plan did not address the resident had a UTI. On 07/17/2023 at 10:24 AM, Resident 39 said she was currently being treated for a UTI…

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 safe environment was maintained and free from hazards related to unsecured and/or unsupervised chemicals and/or tools for 1 of 1 rooms under construction (Resident room [ROOM NUMBER]) and 1 of 2 shower rooms (West Hall) reviewed for accident hazards. This failure placed residents at risk for avoidable accidents and injuries, negative health outcome, and a diminished quality of life. Findings included . <Unsecured Tools> On 07/17/2023 at 10:05 AM, Resident room [ROOM NUMBER] was observed to have the carpet removed with no flooring on the floor, the window was cracked open, and a fan on the floor was running. Resident room [ROOM NUMBER] had a bucket of adhesive with the lid secured on the floor with a scraper tool/trowel spatula on top of the bucket with sharp edges. Resident room [ROOM NUMBER] had a wheeled work cart with tools on the cart including a box cutters with a blade in the tool, plyers, and an Ace brand sharp scraper in the room.…

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 free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects, behaviors, and/or placing a stop date of 14 days for psychotropic as needed medications for 6 of 8 sampled residents (9, 15, 39, 5, 12 & 32) reviewed for unnecessary psychotropic medication. These failures placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . <Monitoring for Behavior/Medication Side Effects> 1) Resident 9 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a disorder that causes a persistent feeling of sadness and loss of interest) and post traumatic stress disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event). The quarterly Minimum Data Set (MDS), an assessment tool), dated 06/15/2023, documented the resident was cognitively…

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 were evaluated, assessed and a physician order was obtained for safe self-administration of medications for 1 of 1 sampled residents (24) reviewed for clinically appropriate self administration of medications. This failure placed residents at risk for medication errors, adverse medication interactions, and a diminished quality of life. Findings included . The facility policy entitled, Self-Medication Administration, undated, documented, Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. The policy documented, An assessment shall be done on the resident that will demonstrate the knowledge of indications for use and appropriate dose of this medication. The resident will also demonstrate the ability 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 interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD) for 1 of 6 sampled residents (7) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/25/2023, documented Resident 7 was cognitively intact. A review of the Resident 7's medical record did not show documentation of an AD. On 07/21/2023 at 11:43 AM, Staff F, Social Services, said they only request an AD when a resident was admitted . Staff F said Resident 7 had been in the facility a while. Staff F said they reviewed the AD at every care conference. Staff F said there was not an AD in Resident's 7 medical record and was unsure if they requested Resident 7's AD. At 11:46 AM, Staff B, Registered Nurse and Director of Nursing Services, said the facility did not have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) was issued timely, at least two calendar days before Medicare services ended, for 1 of 3 sampled residents (33) reviewed for SNF ABN and NOMNC notification. This failure placed residents and their representatives at risk for not having adequate information to make financial decisions related to a continued stay in the facility and a diminished quality of life. Findings included . Resident 33 was admitted to the facility on [DATE]. A medical record review showed Resident 33 had a Medicare Part A Skilled Services episode start date of 05/23/2023, and a last covered day of Part A service on 06/23/2023. After 06/23/2023, Resident 33 remained as a resident in the facility. Record review of Resident 33's SNF ABN documented Resident 33 was provided and signed the SNF ABN on 06/23/2023, the same as the last covered day of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure there was a system in place to resolve grievances (a resident concern or complaint) promptly for 1 of 2 sampled residents (7) reviewed for grievances. This failure paced residents at risk for unmet care needs, not being heard and a diminished quality of life. Findings included . Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/25/2023, documented the resident was cognitively intact, required extensive assistance with activities of daily living, and did not have a plan to return to the community. Resident 7's comprehensive care plan, dated 05/24/2023, documented Resident 7 would like to stay at the facility long-term. Interventions included the facility would periodically check with Resident 7 to verify no change in the discharge plan, and staff would encourage Resident 7 to decorate her room to make it more homelike. On 07/17/2023 at 2:14 PM, Resident 7 said she 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 ensure physician orders and consents were obtained for 2 of 7 sampled residents (1 & 36) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . The facility's policy, Devices/Enablers Policy and Procedure, undated, documented, The nursing staff will then inform the resident and responsible party of the risks/benefits of the device and will obtain an informed consent for the device. If the resident or responsible party are not in agreement with the device/enabler, the device/enabler will not be placed . Nursing Staff will also obtain a physician order for the device/enabler. 1) Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The Medicare/5 day Minimum Data Set (MDS), an assessment tool, dated 07/06/2023, documented Resident 1 was moderately cognitively impaired. Record review of Resident 1's Electronic 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 written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 3 sampled residents (8) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/30/2023, documented Resident 8 was cognitively intact. Resident 8's electronic medical record documented a transfer to the hospital on [DATE] with a readmission on [DATE]. The electronic medical record did not show a documentation of a bed-hold notice for the transfer. On 07/20/2023 at 10:41 AM, Staff D, Resident Care Manger and Registered Nurse, said a bed-hold notice was sent with the resident at the time of discharge to the hospital. Staff D said…

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 resident assessment data was encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 of 2 sampled residents (30) reviewed for resident assessments. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 30 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 05/25/2023, documented the resident was cognitively intact. Resident 30's progress notes, dated 04/25/2023, documented Resident 30 was discharged to home. Resident 30's discharge MDS assessment showed the MDS was not submitted. On 07/21/2023 at 9:19 AM, Staff G, Licensed Practical Nurse and MDS Coordinator, said the Registered Nurse (RN) did not sign off Resident 30's discharge MDS. The MDS did not get submitted as a result. Staff G said they have no formal process to ensure the facility was submitting the MDS. Staff G…

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 resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 14 sampled residents (10 & 32) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . 1) Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/18/2023, documented the resident was moderately cognitively impaired, required extensive assistance from two staff with activities of daily living, and used an indwelling urinary catheter. Resident 10's urinary care plan, dated 05/23/2023, documented Resident 10 required a foley catheter (flexible tube that is inserted into the bladder to drain urine) for retention issues. Resident 10's urinary care plan documented catheter care would be performed according to facility protocol. Resident 10's progress notes documented 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 the bowel protocol was initiated per physician's orders and when needed for 1 of 7 sampled residents (12) reviewed for quality of care related to bowel management. This failure placed residents at risk for medical complications, change in health status, increased pain and a decreased quality of life. Findings included . Resident 12 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 05/02/2023, documented Resident 12 was cognitively intact. Resident 12's physician's order, dated 01/24/2023, documented Milk of Magnesium (MOM, a laxative) 1200 MG (milligram)/15 ML (milliliter) by mouth every 24 hours as needed for constipation if no BM (bowel movement) x 3 days or at resident's request. Resident 12's physician order, dated 01/24/2023, documented, Dulcolax (a laxative) Suppository 10 MG insert 1 suppository rectally every 96 hours as needed for constipation every 4 days if MOM not effective.…

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 with an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) had a valid medical diagnosis and a complete provider order for 1 of 5 sampled residents (8) reviewed for catheter use. This failure placed residents at risk of acquiring potentially preventable catheter associated urinary tract complications and a diminished quality of life. Findings included . Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/30/2023, documented Resident 8 was cognitively intact. A physician's order, dated 06/06/2023, documented Resident 8 was ordered, foley cath (catheter) care with soap and water q (every) shift, cath care wipes done on night three times a day. A physician's order, dated 07/14/2023, documented Resident 8 was ordered, foley care per protocol every 30 days, change prn [as needed] if dislodged, occluded [closed…

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 an anticoagulant (blood thinner) medication related complications were monitored for 1 of 3 sampled residents (5) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life. Findings included . Review of facility policy, Coumadin (Warfarin) and Other Anticoagulation Medication, undated, documented residents receiving any type of anticoagulation were monitored for signs and symptoms of bleeding to promote the safe and effective use of these medications. Resident 5 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 06/29/2023, documented Resident 5 was moderately cognitively impaired. A physician's order, dated 06/13/2023, documented Resident 5 was prescribed, Coumadin (an anticoagulant medication) Oral Tablet 4 MG (milligram) by mouth at bedtime for anticoagulation therapy.…

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.