Hallmark Manor

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 (Residents 46, 61 & 62) of 7 residents who were assessed to be dependent on staff for ADLs. 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 the facility's [ADLs] policy, revised 09/10/2024, residents would receive assistance with ADLs as needed. Any change in the ability to perform ADLs would be reported to the nurse. For bed and wheelchair mobility, staff would assist residents with bed/wheelchair repositioning as necessary to prevent skin breakdown. For fingernail care, staff would ensure fingernails were clean and trimmed to avoid injury and infection. <Resident 62> According to the 04/28/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 62 had a significant change in their health status, resulting in their transition to hospice care (a comfort-focused…

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 adequate laboratory testing for 2 (Resident 80 & 88) of 5 residents reviewed for unnecessary medications, failed to report changes of condition for 2 (Residents 44 & 46) of 2 sampled residents, and failed to administer pain medications for 1 (Resident 65) of 1 sampled residents. These failures to ensure adequate testing to prevent unnecessary medication use, identify changes of condition, and administer pain medications placed residents at risk for the administration of unnecessary medications, discomfort from skin impairments and untreated pain, and other negative health outcomes. Findings included . <Laboratory Testing> <Resident 88> According to the 04/22/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 88 had multiple medically complex diagnoses including hypothyroidism (HT - thyroid gland does not make enough thyroid hormones). Review of a 04/10/2025 physician order directed staff to administer a 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.

<Resident 3> Continuous observation on 05/08/2025 at 12:11 PM showed staff bring Resident 3 their lunch tray to their room. Staff elevated Resident 3's head of bed to a sitting position, placed their lunch tray on the over the bed table in front of them, and then exited the room. The lunch tray had ground pork in gravy, potatoes, and green beans. Observation showed Resident 3 did not feed themselves. At 1:04 PM Staff BB (CNA) entered Resident 3's room to remove the lunch tray and Resident 3 stated they could not feed themselves. Staff BB asked Resident 3 if they wanted assistance and Resident 3 stated yes but the food was probably cold now. Staff BB stated it was still warm and asked if Resident 3 wanted a bite of green beans, the resident replied yes. Staff BB assisted Resident 3 with a bite of green beans and the resident stated yuck, it's cold. Staff BB asked how about some meat and assisted Resident 3 with a bite of ground pork. Resident 3 stated yuck, it's cold. Staff BB stated they did not think they had a microwave to warm the food up and asked Resident 3 if they wanted some…

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, record review, and interview, the facility failed to ensure ongoing monitoring of bed rail use for 3 of 6 residents (Residents 5, 64, & 80) reviewed for accident hazards. This failure placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Bed Rails - Safe and Effective Use of Bed Rails, revised 09/06/2024, the facility would ensure, at a minimum, evaluation for bed rail use would be completed quarterly and with a change of condition. <Resident 5> According to a 01/09/2025 admission Minimum Data Set (MDS - an assessment tool) bed rails were not used on Resident 5's bed. Observation on 05/06/2025 at 1:06 PM showed bilateral bed rails on Resident 5's bed. Review of Resident 5's records showed a 06/17/2024 physician order for bed rails to be applied to their bed. Resident 5's health records did not show ongoing bed rail use monitoring was completed. <Resident 64> According to a 03/28/2025 Quarterly MDS bed rails were not used on Resident 64's bed. Observation 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.

Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to the resident records and that the recommendations were reviewed and acted upon for 2 (Resident 35 & 1) of 5 residents who were reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, risk for adverse side effects, and receiving medications without required pharmacist oversight. Findings included . <Facility Policy> According to the facility's Pharmacy Services and Medication Regimen Review policy, revised 09/16/2024, the facility would maintain the resident's highest practicable level of physical, mental, and psychosocial well-being while preventing or minimizing adverse side effects of medications by ensuring oversight by a licensed pharmacist. <Resident 35> According to the 03/13/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 35 received several medications including antipsychotic (medication that affects brain function), antidepressant,…

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 medications for 1 of 6 sampled residents (Resident 26) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antibiotic medication placed residents at risk for use of unnecessary medications and at risk for adverse side effects. Findings included . <Facility Policy> According to the facility's 11/28/2022 Antibiotic Stewardship guidelines, antibiotic stewardship would be accomplished by improved antibiotic prescribing, administration and management practices to reduce inappropriate use, to ensure that residents received the right antibiotic for the right indication, dose and duration. According to the 03/06/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 26 admitted to the facility on [DATE] with a history of urinary tract infections and a skin infection of the lower leg. Review of the 01/10/2025 Pain care plan,showed Resident 26 had pain in their lower…

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 proper storage and labeling of medications in 1 of 4 medication carts (Medication Cart 300/400) and 2 of 4 halls (600 & 300 Hall) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life. Findings included <Medication Cart 300/400> Observation on 05/06/2025 at 9:56 AM showed three opened inhaler medications without the open date on the inhalers. In an interview on 05/06/2025 at 10:15 Staff V (Licensed Practical Nurse) stated all inhalers should have an open date on them, but they didn't. Staff V stated the inhalers are only good for 30 days after the open date and would need to be disposed of after 30 days.<600 Hall> Observation on 05/06/2025 at 9:47 AM showed the door to the shower room on the 600 hall was propped open, no staff were present. The overhead cabinet was unlocked and contained 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.

Based on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance and palatable. Observations of meal trays and interviews with 5 (Residents 61, 46, 71, 145, & 29) sample residents and 4 supplemental (Residents 69, 45, 83, & 70) residents identified concerns about the taste and overall palatability of the meals served, and being offered alternate meals by the facility. Facility failure to ensure meals were palatable, appetizing in appearance, and alternate meals were offered by staff placed residents at risk for less than adequate nutritional intake and dissatisfaction with daily meals. Findings included . <Facility Policy> Review of the facility's Hydration and Nutrition policy revised 09/10/2024, showed if a resident refused a meal or particular food, staff would offer a substitute of similar nutritive value. <South Hall Day Room> Observation of breakfast on 05/09/2025 at 8:18 AM showed several residents in the South Hall day room eating breakfast. Resident 69 and Resident 45 were eating together at a table. Both breakfast…

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 staff followed infection control practices to help prevent the transmission of communicable diseases. The facility failed to ensure staff performed Hand Hygiene (HH) when providing personal care for 1 (Resident 50) and failed to follow an Enhanced Barrier Precaution (EBP) sign for 1 (Resident 50) who required EBP. These failures placed residents at risk for the development of contagious, communicable diseases, and an unclean environment. Findings included . <Facility Policy> Review of the facility's Hand Hygiene policy, revised 06/03/2025, showed staff would perform HH (even if gloves were used) before and after resident contact and after contact with body fluids. Review of the facility's Transmission-based Precautions and Isolation Procedures policy, revised 09/24/2024, showed EBPs were an infection control intervention designed to reduce transmission of multidrug-resistant organisms and utilized gown and glove use during high contact resident care activities. <Resident 50> Review of Resident 50's tube…

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 person designated to serve as the Dietary Manager (Staff C) had the proper training and qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . Review of the (undated) staff list showed Staff C (Dietary Manager) was employed by the facility on 08/07/2024. In an interview on 08/19/2024 at 9:48 AM, Staff A (Administrator) stated Staff C was required to have the ServSafe Manager Certification (verifies that a manager or person-in-charge has sufficient food safety knowledge to protect the public from foodborne illness) before being hired. Staff A stated they would provide a copy to the investigator. Staff A stated as a part of employment Staff C was required to take the Certified Dietary Manager (CDM) (certification and training on managing food service operations and ensuring food safety in a healthcare facility). Staff A stated Staff C was not registered for a CDM…

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 store, prepare and serve food to residents in accordance with professional standards for food service safety. The failure to check temperatures on foods served, prevent cross-contamination, label and date refrigerated foods after opening, throw out expired foods past three days of opening, prevent pests in food storage areas, clean kitchen vents that circulate air around foods, perform hand hygiene, and untimely service of meals placed all 92 residents at the facility at risk of foodborne illness, poor nutritional intake, and diminished quality of life. Findings included . <Food Temperatures> Observation on 08/19/2024 at 7:50 AM showed Staff C (Dietary Manager) plating food for resident tray service at breakfast. The foods in the steam table included sausage patties, over-easy eggs, toast, two types of hot cereal, hard boiled eggs, mechanically altered puree texture eggs and toast. Staff D (Dietary Aide) and Staff E (Dietary Aide) were setting up trays with milk, juices and other drinks. The milk was placed…

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 laboratory services according to professional standards of practice for 8 of 10 Residents (Residents 1, 2, 3, 4, 5, 6, 7 & 8) reviewed for COVID-19 testing. The facility failed to obtain Physician Orders (PO) to conduct COVID-19 testing for 6 of 10 residents (Residents 1, 2, 3, 4, 5 & 6), and failed to document the results of the testing for 3 of 10 residents (Resident 6, 7 & 8). This failure increased the likelihood for the delayed identification/diagnosis of COVID-19. Findings included . COVID-19 is an infectious virus which causes respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. During an interview on 05/06/2024 at 10:20 AM, Staff B (Director of Nursing), stated the facility was in a COVID-19 outbreak, since 04/20/2024. The facility was…

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

Based on interview and record review, the facility failed to respond to abuse allegations in a timely manner, for 2 of 3 sampled residents (Resident 1 & 8). In addition, the facility failed to ensure residents were protected to prevent further potential abuse or mistreatment when they allowed Staff E, Certified Nursing Assistant (CNA), to continue to work with residents after an allegation of abuse. Failure to recognize possible abuse, suspend the alleged perpetrator pending investigation, and immediately investigate allegations, placed the resident at risk for diminished quality of life, and continued possible abuse. Findings included . Review of the facility policy, Abuse - Protection of Residents, dated 07/18/2023 showed the facility would ensure that all residents were protected from physical and psychosocial harm during and after investigations. The methods to ensure the protection of residents during investigation, may included, but were not limited to responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any…

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 residents received required written notices at the time of transfer/discharge, or as soon as practicable for 4 (Residents 25, 91, 8, & 68) of 5 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to the facility's 05/12/2023 Transfers and Discharges policy, when a resident transferred emergently to an acute care setting (i.e. a hospital) this was categorized as a facility-initiated transfer. The policy showed when the facility initiated a discharge, the facility was responsible to provide the receiving provider specific information including diagnoses, medications, and other significant…

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 8> According to the 01/09/2024 admission MDS, Resident 8 readmitted to the facility from the hospital on [DATE] and had intact memory. The MDS showed Resident had diagnoses including respiratory failure, and dependence on oxygen. According to a 12/31/2023 progress note, Resident 8 transferred to the hospital with no new concerns with cognition noted at time of discharge. A second 12/31/2023 progress note showed no new concerns with mood noted at time of discharge. An 11/23/2023 progress note showed Resident 8 reported having shortness of breath . MD notified [,] ordered transfer resident to the hospital. In an interview on 03/06/2024 at 9:15 AM Resident 8 they were not offered a bed hold when they went to the hospital on [DATE] or 12/31/2023. Resident 8 stated they recalled being offered one at a sister facility, so they noticed when they were not offered one at the current facility. In an interview on 03/05/2024 at 10:55 AM Staff C (Unit Care Manager) stated the facility's business office was…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 6 of 27 medications for 3 of 5 residents (Resident 77, 16, 80) observed during medication pass resulted in a medication error rate of 22.22 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> According to the facility's revised 02/13/2023 Administration of Medications policy, the facility must maintain a medication error rate of less than five percent. The policy defined a medication error as the failure to prepare or administer a medication in accordance with the physician's order, manufacturer recommendations, and professional standards of nursing. The policy showed nurses should verify the right medication, right resident, right dose, right route, right time/frequency, and right documentation. <Resident 77> Observation of medication pass on 03/01/2024 at 8:46 AM 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 observation, interview, and record review the facility failed to appropriately store drugs and/or biologicals (medicine derived from natural sources) for 1 of 2 medication storage rooms, and 1 of 2 treatment carts reviewed for medication storage. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . <Facility Policy> Review of the facility policy titled, Medication Storage in Refrigerator/Freezer, dated 08/24/2023, showed the facility must store all drugs and biologicals in locked compartments in accordance with applicable state and federal laws. <Medication Storage Room> An observation on 02/29/2024 at 11:55 AM showed two bottles of a controlled medication in the refrigerator sitting on top of a gray lockbox. An interview on 02/29/2024 at 12:00 PM, Staff C (Unit Care Manager-UCM) stated controlled medications were required to be double locked. Staff C stated the two bottles of controlled medication should be locked inside the lockbox but were not. An interview on 03/06/2024 at 10:00 AM, Staff B (Interim…

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 meals that accommodated resident food allergies and preferences for 5 (Resident 14, 8, 18, 56, & 245) of 7 sample residents reviewed for preferences. This failure placed residents at risk for weight loss, frustration, and a diminished quality if life. Findings included . <Facility Policy> According to the facility's 06/08/2020 Resident Rights policy, residents had the right to make choices about aspects of his or her life in the facility that were important to them. The policy showed all residents had the right to self-determination. <Resident 14> According to the 12/01/2023 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 14 had intact memory and medically complex conditions including Diabetes Mellitus (a condition making the regulation of blood sugar harder). The MDS showed Resident 14 required a therapeutic diet. In an interview and observation on 02/27/2024 at 12:46 PM, Resident 14 requested a surveyor look at their lunch tray and their menu. Resident 14 showed they were…

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 store food under sanitary conditions for 1 of 1 kitchens. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness. Findings included . <Facility Policy> According to revised 04/26/2023 Food Safety policy the facility would store food in a clean, safe, and sanitary manner. The policy showed pre-packaged food must be placed in leak-proof containers with a tight-fitting lid. The policy showed the container must be labeled with the name of the food and the date the item was placed in the container, with a use-by date as applicable. The policy showed dented cans must be returned to the vendor. The policy showed opened dry food must be resealed tightly and labeled with a use by date. <Facility Kitchen> During initial observations of the dietary department on 02/27/2024 at 8:51 AM the following was noted: In the walk-in freezer: - a bag of chicken…

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, sanitary environment to prevent placing residents at risk for facility acquired infections. The failure to ensure staff used appropriate Personal Protective Equipment (PPE) on 2 of 2 Units, and to ensure proper Hand Hygiene was performed on 2 of 2 units before and after care/contact placed residents at risk for facility-acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy> The facility's revised 07/15/2022 Hand Hygiene policy showed facility staff may use Alcohol-Based Hand Rub to perform hand hygiene in most clinical situations unless hands were visibly soiled. The policy showed facility staff should perform hand hygiene before and after contact with residents, after contact with blood, other body fluids, and visibly contaminated surfaces, and after removing PPE. The facility's revised…

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 in a manner that promoted resident dignity for 5 (Residents 38, 55, 25, 56, & 91) of 24 sample residents reviewed, and 1 of 2 assisted dining rooms. The failure to provide care with dignity placed residents at risk for frustration, unmet care needs, and a diminished sense self worth. Findings included . <Facility Policy> According to the facility's 06/08/2020 Resident Rights policy, residents had the right to a dignified existence. The policy showed residents had the right to respect and dignity. The facility's 05/06/2019 Dignity policy showed all residents should be treated with respect and dignity. The policy provided examples, including treating resident possessions and space with respect, not using bibs or clothing protectors when dining unless by resident choice, ensuring catheter bags were covered, and referring to the resident by their name of choice. <Resident 38> According to the 11/16/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 38 had intact memory…

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 Significant Change Minimum Data Set (SCSA- an assessment tool) was completed as required for 1 (Resident 68) of 24 sampled residents reviewed. The failure to complete a Significant Change MDS timely left residents at risk for unassessed 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 68> According to the 12/15/2023 SCSA Resident 68 admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 4 (Residents 2, 18, 91, & 7) of 24 residents 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 . <Resident 2> According to a 01/29/2024 Significant Change MDS, Resident 2 had multiple medically complex diagnoses including dementia and depression, had no psychosis, and was taking an antipsychotic medication during the assessment period. Review of Resident 2's February 2024 Medication Administration Records showed the resident was not receiving antipsychotic medication during the assessment period. In an interview on 03/06/2024 at 11:32 AM, Staff Q (MDS Nurse) reviewed Resident 2's records and confirmed the resident was not receiving any antipsychotic medications during the assessment period and stated, I do not know why I marked that. Staff Q stated the MDS was coded inaccurately and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 6 residents (Resident 47) 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> The facility's revised 10/06/2022 PASRR policy showed positive Level 1 PASRR screenings required an in-depth evaluation of the resident by the state-designated agency. The policy showed any resident with a newly evident or possible serious disorder, . intellectual disability or related condition must be referred to the state agency. <Resident 47> According to the 02/01/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 47 had severe memory impairment, and diagnoses including non-traumatic brain…

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 Care Plans (CP) were revised as needed for 6 of 24 (Residents 14, 38, 8, 2, 91, & 35) sample residents reviewed. The failure to ensure CPs were updated to reflect current care needs left residents at risk for unmet care needs, inappropriate care, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 08/22/2023 Comprehensive CP and Conferences policy, the facility would ensure each resident's CP was reviewed and revised by an interdisciplinary team. The policy showed the CP should be revised based on changing goals and needs for care. <Resident 14> According to the 12/01/2023 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 14 had intact memory and no mood concerns. The MDS showed Resident 14 had medically complex conditions including a Stage 4 pressure ulcer. The Stage 4 pressure ulcer was noted to be present on admission. The 08/30/2022 Enhanced Barrier Precautions (EBP - an approach of targeted gown and glove…

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's Orders (POs) were followed for 5 (Residents 16, 80, 25, 19, & 8) of 24 sample residents; POs were clarified as needed for 2 (Resident 19 & 68) of 24 sample residents; nurses signed only for tasks completed for 3 (Resident 2, 16, 80) of 24 sample residents; and adequate rationale was provided for a late onset mental health condition for 1 (Resident 38) of 5 residents reviewed for unnecessary medication. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Following PO> <Resident 16> According to a 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 16 had multiple medically complex diagnoses and received scheduled pain medications during the assessment period. Review of the March 2024 Medication Administration Records (MAR) showed Resident 16 had orders for pain medication patches to be applied to the lower back and right…

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 1 of 1 residents reviewed for rehab/restorative (Resident 90) and 2 supplementary residents (Residents 18 & 85). 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 09/11/2023 Restorative Nursing policy to promote the resident's optimum function, the facility would develop and implement a Restorative Nursing Program (RNP). The policy showed residents were placed on a restorative as appropriate when they discharged from physical therapy. <Resident 90> According to the 01/17/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 90 was able to make themselves understood and understood others during communication. The MDS showed Resident 90 was assessed to have intact memory and thinking. The MDS showed Resident 90 had muscle weakness and was unsteady on their feet. Review of the 01/23/2024 Care Area…

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 resident supervision, thorough accident investigation to determine the cause of incidents, and implement interventions required to prevent injury for 2 of 11 (Resident 11, & 55) sampled residents reviewed for accidents and supervision. The facility's failed practice resulted in the continued risk of receiving injuries related to avoidable incidents. Findings included . <Facility Policy> Review of the facility policy titled, Incident and Reportable Event Management, dated 05/04/2023, showed residents received assistance and supervision as addressed by the care plan. The Interdisciplinary Team (IDT) would conduct a thorough review of an event to determine the most likely cause of the incident and ensure the interventions in place were appropriate to prevent recurrence. Review of the facility policy titled, Fall Management, dated 09/22/2023, showed supervision refers to an intervention and means of mitigating the risk of an accident. The facility was obligated to provide adequate supervision to prevent…

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 respiratory care was provided within professional standards of nursing for 2 of 4 sample residents (Residents 8 & 295) reviewed for respiratory care. The failure to ensure Oxygen (O2) tubing was replaced per facility policy, O2 tanks were replaced when empty, and O2 concentrators were set per the Physician's Order (PO) placed residents at risk for Shortness of Breath (SOB), respiratory distress, and other negative health outcomes. Findings included . <Facility Policy> The facility's 08/2021 policy showed residents requiring O2 therapy should have a PO in place specifying the flow rate in liters. The policy showed O2 supplies should be replaced weekly and when visibly soiled and should be labeled with a date. <Resident 8> According to the 01/09/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 8 was assessed with intact memory and cardiac respiratory conditions including asthma (inflammatory lung condition),…

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 ongoing communication and collaboration with the Hemodialysis (HD- a process to remove blood waste) center for 1 of 1 (Resident 295) residents reviewed for dialysis. This failure to communicate and collaborate with the dialysis as required, placed dialysis residents at risk for adverse health outcomes, inadequate quality of care and a decreased quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Hemodialysis Offsite Policy, dated 08/23/2023, showed the facility would assure that each resident received .ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. <Resident 295> According to the 02/29/2024 admission Minimum Data Set (MDS- an assessment tool) showed Resident 295 admitted to the facility on [DATE], received HD services, and had medically complex diagnoses…

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 received the appropriate treatment and services for 1 of 1 (Resident 55) residents reviewed for dementia care. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered Care Plan (CP) prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings included . <Facility Policy> According to the facility's 08/22/2023 Care of the Cognitively Impaired (Dementia Care) policy, the facility would utilize an individualized, non-pharmacological approach to dementia care. The policy showed the facility would develop, implement, review, and revise as needed, a person-centered CP to address the dementia diagnosis, symptoms, and dementia progression. <Resident 55> According to the 01/04/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 55 had severely impaired memory, and physical behavior towards others on one-to-three 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.

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance committee that met at least quarterly and included the required participants. This failure placed residents at risk for unmet care needs due to on going non-compliance with federal regulations and detracted from the interdisciplinary effectiveness of the nursing home Quality Assurance team. Findings included . Facility Policy According to an 08/26/2021 revised Quality Assurance and Performance Improvement Plan [QAPI] facility policy, the facility must maintain documentation and demonstrate evidence of its ongoing QAPI program. The policy indicated the QAPI program was a way to promote continuous improvement of the facility. The gaps in the systems would be addressed through planned interventions with a goal to improve quality of life, quality of care, and services provided to residents in the facility. Review of the facility's QAPI logs showed the last documented meeting was held 06/17/2022. This log showed the Medical Director (MD) attended the meeting but not the pharmacist.…

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 74 Review of Resident 74's record showed no AD available. Review of Resident 74's admission Packet showed the packet included no information indicating whether or not Resident 74 wanted the facility to provide them assistance to formulate an AD. The 09/05/2022 Quarterly MDS showed Resident 74 was assessed as cognitively intact, had multiple complex conditions including severe kidney failure and diabetes. The MDS showed Resident 74 had no legally authorized representative. A review of Resident 74's medical record showed no AD or POA documents on file or available to staff. In an interview and record review on 11/07/2022 at 9:20 AM, Staff J verified Resident 74's admission agreement in section H showed no current AD was in place prior to admission and no documentation the resident was offered assistance to formulate an AD. Resident 50 Review of the 09/26/2022 Quarterly MDS showed Resident 50 had multiple medically complex diagnoses including severe kidney and lung disease. This MDS showed Resident 50 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) assessments accurately reflected residents' mental health conditions and/or a PASARR was completed for 5 (Resident 63, 66, 38, 12, & 24) of 7 residents reviewed. 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 . Facility Policy According to a revised 10/06/2022 PASARR policy, the facility was to ensure potential admissions were screened for possible serious mental disorders or intellectual disabilities and related conditions. The PASARR process was to ensure residents with a mental or intellectual disorder received the care and services they needed in the most appropriate setting. Resident 63 According to an 08/13/2022 Significant Change Minimum Data set (MDS - an assessment tool), Resident 63 had diagnoses of depression, bipolar disorder, and anxiety. The MDS indicated…

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 who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided necessary assistance for 7 (Residents 22, 16, 8, 50, 38, 63, & 70) of 7 sample residents reviewed. Failure to provide assistance to residents who were dependent on staff for bathing placed residents at risk for unmet needs, poor hygiene, embarrassment, and diminished quality of life. Findings included . Facility Policy According to an 08/22/2022 Activities of Daily Living facility policy, residents would receive assistance to complete ADLs and maintain hygiene based on their needs, choices, and assessment. A resident who was unable to carry out ADLs would receive the necessary services to maintain grooming, personal and oral hygiene. Resident 22 According to an 08/10/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 was cognitively intact with clear speech and had no rejection of care during the assessment period. This MDS assessed Resident 22 to require extensive…

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 mobility and Range of Motion (ROM) treatment and services to increase, maintain, or prevent further decrease in mobility and ROM for 3 of 5 (Residents 63, 70 & 16) residents and 2 supplemental residents (Residents 25 & 379) reviewed for limited ROM. The failure to place residents on a Restorative Nursing Program (RNP) after completion of Physical Therapy (PT) or Occupational Therapy (OT), and implement RNP established by therapy placed residents at risk for functional decline, mobility, and loss of ROM. Findings included . Facility Policy According to a 09/19/2022 facility Restorative Nursing Policy, the facility must provide the necessary care and services to ensure a resident's Activities of Daily Living (ADL) did not diminish unless the individual's clinical condition demonstrated such diminution was unavoidable. The facility was to ensure residents were given the appropriate treatment and services to maintain or improve their…

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 have sufficient nursing staff to provide care and services as evidenced by seven resident interviews and ten staff interviews. The failure to ensure adequate Registered Nurse (RN) and Certified Nursing Assistant (CNA) staffing to maintain infection control standards related to COVID-19 (Coronavirus, a highly contagious infectious respiratory disease) and Tuberculosis (TB) screening, provide Restorative Nursing Programs (RNP), verify and maintain staff credentials and competency, ensure assistance with showers according to resident care plan and preferences, and timely call light response to resident needs, placed residents at risk for unmet care needs, decline in condition and negative outcomes. Findings included . Facility Assessment The 02/14/2022 Facility Assessment (FA) showed Staff assignments are made based on census and acuity. Resident schedules for bathing are based on resident's preference and on resources available. Residents are involved in their plan of care and preferences are noted and updated as needed per…

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 obtain verification from the state survey registry to ensure Certified Nursing Assistants (CNA) met competency evaluation requirements before the staff's start date for 3 of 5 staff (Staff P, Q & CC) reviewed. The failure to ensure the competency of staff placed residents at risk of unmet care needs and abuse. Findings included . In an interview and record review on 11/07/2022 at 11:54 AM, Staff I (AP/Payroll) confirmed Staff P (CNA) was hired on 06/28/2022, Staff Q (CNA) was hired on 07/15/2022 and Staff CC (CNA) was rehired on 10/20/2022. Staff I reviewed the human resources records, medical records, and a binder labeled OBRA for the CNA registry verification for the three staff and stated, there was no verification of competency document in the files. Staff I stated the Staff Development Coordinator was responsible for the registry verification and the position was vacant since 09/09/2022. Staff I stated no one was assigned the task when the other staff left employment. In an interview on 11/08/2022 at 10:55 AM, Staff 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 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 2 of 4 medication carts (Hall 700 medication cart and Hall 400 medication cart). This failure placed residents at risk for misappropriation of property and drug diversion. Findings include . Review of the Inventory Control of Controlled Substances policy, revised on 01/01/2022, showed instructions for incoming and outgoing nurses to count all controlled substances at the change of each shift and document the results on a shift count sheet. Hall 700 Medication Cart Observation of Hall 700 medication cart on 11/02/2022 at 10:27 AM with Staff U (LPN- Licensed Practical Nurse) showed two inventory of controlled substances books with missing signatures on the shift count sheet for the months of August 2022 and November 2022. In an interview on 11/02/2022 at 10:35 AM, Staff U stated it is important to have complete signatures on the shift count…

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 5 of 5 (Residents 9, 379, 24, 63, & 12) residents reviewed for unnecessary medications and 3 supplemental residents were free from unnecessary psychotropic medications (a drug that affects brain activities associated with mental processes and behavior). The facility failed to obtain informed consent prior to administering psychotropic medications (Residents 379, 9, 12, 24, & 63); identify and monitor target behaviors (Residents 379, 9 & 38); identify and implement non-medication, behavioral interventions prior to administering an antianxiety medication (Resident 379); and initiate gradual dose reductions (GDR- stepwise tapering of a dose to determine if symptoms, conditions, or risks could be managed by a lower dose or if the dose or medication could be discontinued) or obtain a rationale from the physician that a GDR was clinically contraindicated (Residents 2 & 6). These failures placed residents at risk of being over medicated, medication side effects, and diminished quality of life. Findings included . Informed…

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 and contain the transmission of communicable diseases including Covid-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure staff completed hand hygiene during medication administration for 3 of 3 residents (Resident 66, 72 and 19), conduct cleaning and sanitizing procedures for reusable medical equipment before, after, and in between resident use, and adhere to N95 fit testing requirements for 2 of 5 staff (Staff M and N). These failures placed residents, staff, and visitors at risk for the development and transmission of infections, including Covid-19. Findings included . Hand Hygiene Record review of the facility's policy titled, Hand Hygiene, revised on 07/15/2022, showed that 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.

Based on interview and record review, the facility failed to establish an infection prevention and control program that implemented an antibiotic stewardship program, to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use, including the development of antibiotic resistance, for 5 (Residents 12, 71, 13, 49, & 8) of 6 residents reviewed who were treated with antibiotics. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of Antibiotics (ABO). Findings included . Review of a revised 08/22/2022 facility Antibiotic Stewardship policy, ABO stewardship was a set of commitments and activities designed to optimize the treatment of infections while decreasing the adverse events associated with ABO use and included ABO use protocols and a system to monitor ABO use. The ABO Stewardship Team would demonstrate support and commitment to safe and appropriate ABO use. Actions included: assessment of residents suspected having an infection using McGeer's criteria (surveillance definitions of…

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

Based on observation, interview, and record review the facility failed to recognize and treat 1 of 3 residents (Resident 24) who were reviewed for pain management. Failure to implement identified interventions to alleviate pain, including administration of pain medication after conducting the scheduled pain assessment, resulted in Resident 24 experiencing daily episodes of untreated pain, and placed the resident at risk for a decreased quality of life. Findings included . Resident 24 According to the 09/13/2022 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 24 had diagnoses including Diabetic Neuropathy (nerve damage that occur in people with diabetes) and unspecified pain. The cognitive assessment showed Resident 24 had intact short-term and long-term recall and usually understood and understands others. According to the 02/02/2022 Significant Change in Status MDS, Resident 24 had diagnoses including chronic pain. Review of the medical diagnosis list showed Resident 24 was diagnosed with low back pain dated 10/01/2021 during their facility stay. Review of Resident…

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

Based on interview and record review, the facility failed to implement a system to ensure ongoing collaboration with the dialysis center for 1 (Resident 74) of 1 residents reviewed for hemodialysis (purifying the blood of a person whose kidneys were not functioning normally). Facility failure to establish an agreement with the dialysis center, collect run sheets (a document describing all the care provided at a dialysis session) and monitor weights, left the resident at risk for fluid overload (too much fluid in the body) and negative health outcomes. Findings included . Facility Policy The facility's revised 12/29/2021 Dialysis policy showed the facility must ensure all residents requiring dialysis received care and services within professional standards of nursing, including ongoing communication and collaboration with the dialysis facility. The policy directed nurses to ensure they did not obtain Blood Pressure (BP) on the resident's arm with the shunt (dialysis access site), and to provide ongoing assessment of the resident's condition and monitoring for complications before and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent (%). Failure of 1 of 2 nurses (Staff W) to properly administer 7 of 25 medications for 1 of 4 residents (Resident 68) observed during medication pass resulted in a medication error rate of 28%. This failure placed the residents at risk for adverse side effects due to improper medication administration. Findings included . Resident 68 The revised 08/25/2022 Administration of Medications policy showed, staff who are responsible for medication administration will adhere to the 10 rights of Medication Administration. These rights include right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation, and right education and information. Right resident included the use of two identifiers: the resident's full name on the Medication or Treatment Administration Record (MAR/TAR) and the resident's photo.…

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 and vaccines (a preparation that is used to stimulate the body's immune response against diseases) were disposed of timely, in accordance with currently accepted professional standards of practice for 1 of 2 medication rooms reviewed. Additionally, the facility failed to secure all medications in a locked storage area for 1 of 1 resident (Resident 39) during medication administration. These failures placed residents at risk for receiving compromised medications with decreased or no potency and inadvertent ingestion of unsecured medications. Findings included . South Hall Medication Room Observation of South Hall medication room on 11/02/2022 at 10:30 with Staff U (LPN- Licensed Practical Nurse) revealed 49 pieces of rectal suppositories and four vials of vaccines that expired 09/28/2022. In an interview on 11/02/2022 at 10:38 AM, Staff U validated the dates of the expired medications and vaccines. Staff U stated the expired medications and vaccines should be removed from the medication 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 pneumococcal vaccines were provided for 1 of 5 residents (Resident 63) and influenza vaccinations were provided for 1 of 5 residents (Resident 9) reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and influenza diseases. Findings included . Resident 63 Review of Centers for Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends PCV15 or PCV20 [Pneumococcal Conjugate Vaccine] for adults 19 through [AGE] years old with certain medical conditions or risk factors. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 [Pneumococcal polysaccharide vaccine] vaccination. The CDC guidelines went into effect on 10/21/2021 per recommendations from the Advisory Committee on Immunization Practices (ACIP). 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 establish and maintain infection control practices that provided a safe environment to help prevent and contain the transmission of Covid-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure staff completed the required Covid-19 vaccination verification for 2 of 2 contracted staff (Staff Z and AA). These failures placed residents, staff, and visitors at risk for the development and transmission of Covid-19 infection. Vaccination Verification The 03/31/2022 Covid-19 Vaccination Program Policy for Associates showed the facility vaccination tracking requirements included tracking each staff member's vaccination status including the specific vaccine received, the dates of each dose received including booster. The tracking mechanism would clearly identify each staff's role, assigned work area and how they interact with residents, including contracted staff, volunteers,…

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.