Marianwood Health And Rehabilitation

Based on observation, interview, and record review the facility failed to ensure resident responsible parties were notified when there was a change in condition or when a resident experienced a fall for 1 (Resident 1) of 3 residents reviewed. These failures violated a resident's right to have their representative involved and informed of any changes in condition. Findings included . Review of the facility policy titled, Fall Prevention and Response, revised 08/2023, showed after a resident experienced a fall the licensed nurse was required to notify the provider and the resident's representative. <Resident 1> Review of an admission Minimum Data Set (MDS, an assessment tool), dated 06/06/2024, showed Resident 1 was not able to make their own decisions, was rarely or never understood by others, and was assessed with an altered level of consciousness ( a change in the resident's awareness of the environment with reduced alertness). The MDS showed Resident 1 had impairments to one side of their body, affecting one arm and one leg. The MDS showed Resident 1 was dependent on staff for bed…

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

Based on observations, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents including assistance with Activities of Daily Living (ADL) and timliness of call light response in accordance with established clinical standards, Care Plan (CP), and resident preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Council (RC)> Review of the 01/24/2024 RC meeting notes showed residents reported poor response times. The notes showed the administrator had coordinated with staff members who were unable to perform the needed duties and the short-term plan was for the facility to stack nursing shifts for supervision and the long-term plan was to hire staff to oversee the weekends and night shifts. During an observation on 07/23/2024 at 2:37 PM, two rooms observed to have call lights alarming. At 2:48 PM, the same two call lights were still alarming while day and evening nurses were observed to be in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident meals were stored, prepared, and served in a sanitary manner for 1 of 1 kitchens and 1 of 4 unit pantries (Unit 400). These failures left residents at risk for spoiled or contaminated foods, and food-borne illness. Findings included . <Facility Policy> According to the facility's 07/2024 Food Storage policy all food items would be labeled with with a manufacturer's expiration date or the date of receipt. The policy showed refrigerated foods would be discarded using either the manufacturer's expiration date or seven days after the written date. The policy showed all refrigerators used for nutrition would be cleaned weekly by dietary staff. The policy showed food in facility refrigerators should be covered. <Dry Storage> Observation of the facility's dry food storage on 07/23/24 at 9:11 AM showed a box of thickening powder (used to alter the fluids for residents with swallowing difficulties) was left open. The plastic liner…

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 maintain a system to ensure resident grievances were identified, logged, and resolved timely for 4 of 4 residents (Residents 28, 31, 30, 6) reviewed for personal property and living environment. Facility failure to ensure missing personal items were found or replaced and resident environmental concerns were addressed placed residents at risk for missing property, an uncomfortable or less-than-homelike environment, and a decreased quality of life. Findings included . <Facility Policy> According to the 07/2024 Complaint and Grievance Policy, the facility would attempt to resolve all grievances as promptly as possible, but no longer than 10 days. The policy showed the facility would maintain grievance records for no less than three years. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and was dependent on staff for self-care and grooming. The MDS showed…

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

Based on interview and record review, the facility failed to ensure the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of resident assessments was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 3 residents (Residents 67, 20, & 45) whose Quarterly MDS assessments were reviewed for accuracy and timeliness. The facility's failure to report accurate MDS data placed residents at risk for violations of the Social Security Act. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2023 RAI Manual showed signatures of persons completing the assessment would certify that the accompanying information accurately reflected resident assessment information. The RAI manual showed, by attesting and signing the MDS, the RN coordinator and its signatories understood these information were used as a basis for ensuring residents receive appropriate and quality care, a basis for payment from federal funds, and that payment of such federal funds and continued…

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 Level 1 Preadmission Screening and Resident Reviews (PASRR - a Serious Mental Illness (SMI)/Intellectual Disability (ID) screening for the need for further assessment for outside resources while in a nursing home environment) were accurate upon admission and updated as needed after a significant change as required for 3 of 5 residents (Residents 28, 45, & 32) reviewed for unnecessary medication. This failure left residents at risk for unassessed mental health needs, and other negative health outcomes. <Facility Policy> According to the PASRR facility policy, revised 01/2023, all residents would undergo a Level 1 PASRR screening prior to admission. The policy showed current residents must undergo a Level 1 PASRR if a significant change in their physical or mental condition was identified. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and medical diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were revised and updated to reflect residents' current care needs for 6 of 21 sampled residents (Residents 28, 32, 66, 239, 64, & 189) whose CP were reviewed. This failure left residents at risk for unmet care needs, unsafe provision of care, and a decreased quality of life. Findings included . <Facility Policy> Review of the Resident Care Plan policy, revised 03/2012, showed the Resident's CP should be a communication tool for staff to provide consistency and continuity in resident care based on resident needs, values and preferences. The policy showed CPs would describe a specific plan that reflected resident preferences and care needs with measurable, specific, realistic, and achievable goals so the resident could attain or maintain their highest practicable physical, mental, and psychosocial well-being. The policy showed CPs should be revised quarterly and as needed. <Resident 28> According to the 05/20/2024…

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

Based on observation, interview, and record review, the facility failed to ensure 4 of 7 residents (Residents 45, 20, 58, & 239) reviewed for limited Range of Motion (ROM) were evaluated or provided care and services they were assessed to require, including Restorative Nursing Program (RNP). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> The RNP facility policy, revised 01/2022, showed the facility would provide restorative nursing services to promote a resident's ability to function at their highest level and live as independently and safely as possible. The policy showed residents who would benefit from RNPs included those who were at risk for functional decline, and residents with identified deficit(s) and had an established need. The Rigid Splint Application facility policy, revised 02/19/2024, showed splints applied incorrectly could cause unnecessary injuries such as skin or soft-tissue complications including pressure injuries and contact…

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 implement the necessary care for 2 of 3 sampled residents (Residents 45 & 26) and 1 supplemental resident (Resident 75) reviewed for Tube Feeding (TF) management including: (1) documentation of the amount of TF being administered, (2) weight monitoring, and (3) maintenance and labeling of TF tubing consistent with professional standards of practice. These failures placed residents at risk of not meeting their nutritional requirements, developing TF complications including infection, and a decreased quality of life. Findings included . <Facility Policy> The Enteral Nutrition policy, revised 01/2023, showed it was a nursing responsibility to document the amount of feeding given on each shift in the Medication Administration Record (MAR). The policy showed the facility would label TF bags with the date, time, initial of the nurse hanging the feeding, and the amount hung to prevent contamination when open feeding systems were used. The policy showed new formula would not be added to formula already hanging, and…

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

Based on observation, interview and record review, the facility failed to provide meals that accommodated resident food preferences for 2 of 4 sampled residents (Resident 31 & 20) reviewed for preferences. This failure placed residents at risk for weight loss, frustration, and a diminished quality of life. Findings included . <Resident 31> According to a 07/12/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 31 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. In an interview on 07/24/2024 at 10:07 AM, Resident 31 stated they were unhappy with the food and reported they had to keep returning their meal trays to staff as they continued to serve them food they disliked. Resident 31 stated they informed staff many times they did not like sausage or rice, but stated staff continued to serve them those food items. Observations on 07/26/2024 at 8:37 AM showed Resident 31 had a breakfast tray in front of them with only sausage left on their plate. In an interview at this time, 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 obtain a consent for the use of an Antidepressant (AD) medication for 1 of 5 residents (Resident 79) reviewed for unnecessary medications. This failure placed Resident 79 at risk for receiving unwanted psychotropic medications, altered level of consciousness, and a decreased quality of life. <Facility Policy> The facility's Psychotropic Medications Policy, revised 01/2023, showed psychotropic medications should only be used after careful evaluation of potential risks and benefits. <Resident 79> According to the 07/02/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 79 had impaired memory and an acute onset change in their mental status, with fluctuating attention and consciousness. The MDS showed Resident 79 had medical diagnoses including uncontrolled muscle movements, schizophrenia (a mental disorder), and a history of cancer. The MDS showed Resident 79 received an AD medication during the assessment period. Review of Resident 79's Physician's Orders showed a 07/15/2024 order for an AD medication; 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.

Based on interview and record review, the facility failed to notify 1 of 16 residents (Resident 10) who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries were permitted to possess without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. Findings included . <Facility Policy> Review of the facility's revised 05/2017 Resident Trust policy stated the facility would notify the resident and/or resident's guardian/durable power of attorney, facility social worker, and the local department of social and health services, in writing, when a resident, who was on Medicaid, reached an individual account balance of two hundred dollars less than the Supplemental Security Income (SSI) resource limit for one individual. The policy stated the notification would advise if the amount in the account exceed the SSI limit, the resident may lose eligibility for Medicaid or SSI. <Resident 10> Review of the facility's Fund Balances report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely assistance to formulate an Advanced Directive (AD - documentation explaining the resident's wishes for care if they were unable to speak for themselves) for 5 of 6 residents (Resident 68, 31, 75, 189, & 6) reviewed for ADs. This failure left residents at risk for unmet healthcare needs, unwanted care, and other negative health outcomes. Findings included . <Resident 68> According to the 06/13/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 68 admitted to the facility on [DATE]. The MDS showed Resident 68 had intact memory. Record review showed a document scanned into Resident 68's chart on 07/23/2024 at 12:34 PM (the first day of annual survey, 47 days after admission). This document had only two typed lines. The first read Advanced directive toolkit has been provided to the resident/family. Underneath this line, someone hand wrote, Received. The second line read, Advanced directive toolkit obtained from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to thoroughly investigate incidents for an unwitnessed fall for 1 of 9 residents (Resident 239) whose facility incident report was reviewed to rule out abuse and/or neglect. Facility failure to conduct a complete and thorough investigation as required left residents at risk for unidentified abuse and/or neglect. Findings included . <Facility Policy> The Abuse Prohibition and Prevention facility policy, revised 01/2024, showed a thorough investigation of the alleged violation would be completed and would include conducting interviews with the alleged victim and representative, accused person(s), witnesses, provider, personnel from outside agencies as appropriate. The policy showed the facility would conduct a record review for pertinent information related to the alleged violation such as progress notes and documentation sources as appropriate. The policy showed investigation results of all investigations would be reported to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written transfer/discharge notices and/or complete notification to the Office of the State Long-Term Care Ombudsman (LTCO) as required for 2 of 4 residents (Residents 32 & 20) reviewed for hospitalization. Failure to provide notification to the resident and/or the resident's representative of the reasons for the discharge in writing or notify the LTCO placed residents at risk for a discharge that did not meet the resident's stated goals for care and preferences, and at risk for preventing the Ombudsman from advocating for residents. Findings included . <Facility Policy> According to the facility's 01/2022 Transfer or Discharge and Ombudsman Notification policy, when a facility resident was temporarily/emergently hospitalized , a notice of transfer must be provided to the resident or their representative as soon as practical. The policy showed copies of all transfer notices were provided to the LTCO office on at least a monthly basis. <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 complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 1 of 3 residents (Resident 67) reviewed for resident assessments and timing. The failure to ensure MDS assessments were completed timely placed residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2023 RAI Manual showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual onset of significant change(s) in their status. The RAI outlined a Quarterly MDS must be completed no later than 14 days after the established Assessment Reference Date (ARD) of the assessment and no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 of 21 residents (Residents 189, 28, & 68) whose Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition at the time of assessment. This failure placed residents at risk for unidentified and/or unmet care needs. Findings included . <Resident 189> According to a 06/12/2024 admission MDS, Resident 189 admitted to the facility on [DATE]. Review of a 06/23/2024 Discharge MDS showed Resident 189 was transferred to an acute care hospital with their return to the facility anticipated. Upon Resident 189's return to the facility 12 days later, staff completed a 07/05/2024 Entry Tracking MDS and indicated the resident's type of entry was an admission, rather than a reentry as required. In a joint interview with Staff T (MDS Coordinator) and Staff X (MDS Coordinator) on 08/01/2024 at 2:25 PM, Staff X stated it was their expectation an Entry Tracking MDS be coded as a reentry if a resident 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 develop and/or implement a comprehensive Care Plan (CP) for 5 of 21 sampled residents (Residents 68, 31, 66, 75, & 189) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy> According to the 03/2012 Resident Care Plan policy, within 21 days after admission, the facility would develop and implement a comprehensive CP to address all the resident's care needs. The policy showed the CP should include measurable, resident-specific goals. <Resident 68> According to the 06/13/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 68 had intact memory and diagnoses including a wound infection, malnutrition, and depression. The MDS showed Resident 68 was on a physician-prescribed weight loss program. Observation on 07/24/2024 at 1:44 PM showed Resident 68 was very thin. At that time, Resident 68…

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

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed for 1 (Resident 13) and POs were clarified as needed for 1 (Resident 189) of 21 sampled residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Following Orders> <Resident 13> During observations of medication pass on 07/29/2024 at 8:56 AM, Staff E was observed to prepare a pain medication gel for Resident 13 by squeezing the tube into a 30-milliliter medication cup until 3/4 of the bottom of the cup was filled with the gel. Staff E did not use a dose measuring card to prepare the dose. Review of Resident 13's July 2024 Medication Administration Records (MAR) showed a 04/04/2024 order to apply four grams of the pain medication gel to the resident's right knee twice daily for pain. In an interview on 08/01/2024 at 11:36 AM, Staff L (Manager Long Term Care, Registered Nurse) stated there was no way for staff to determine how much four grams of the gel was if they used 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 provide assistance with Activities of Daily Living (ADL) for 2 of 3 residents (Residents 32 & 64) reviewed who were dependent on staff for daily cares. The failure to provide required bathing and grooming assistance placed residents at risk for poor hygiene, diminished feeling of self-worth, and a decreased quality of life. Findings included . <Resident 32> According to the 05/07/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 32 sometimes understood conversation, difficulty focusing, and disorganized thinking. The MDS showed Resident 32 was dependent on staff assistance for bathing and required and substantial to maximal assistance for personal hygiene. The MDS showed Resident 32 had a diagnosis of Alzheimer's disease (a memory impairment). The 06/15/2022 preferences Care Plan (CP) showed Resident 32 preferred showers. This CP showed Resident 32's preferences would be honored. The 06/15/2022 risk for deterioration in ADL function .' CP showed Resident 32 may require assistance…

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 activity programs met the needs of each resident for 1 of 3 residents (Resident 64) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Resident 64> According to a 05/15/2024 Quarterly admission Minimum Data Set (MDS - an assessment tool) showed Resident 64 preferred to have books, newspapers, listen to music, and choose daily activity preferences. The assessment showed Resident 64 had unspecified dementia and behavioral disturbances. Review of a revised 04/16/2/2024 Resident Care Plan (CP) the Problems/Strengths focused area showed Resident 64 needed encouragement to participate in daily scheduled activities. The CP showed that Resident 64 was dependent on staff for locomotion and needed supervision for ambulation and transfers. The CP showed Resident 64 would obtain assistance in choosing and…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 12) reviewed for pain management received the necessary treatment, services, and follow-up care to manage their pain. This failure placed residents at risk for avoidable pain and a diminished quality of life. Findings included . <Facility Policy> According to the 08/2024 Pain Management Policy, its purpose was to establish how residents would be assessed, care planned, and treated in accordance with professional standards of practice. The policy showed resident choices would be honored related to pain management. The policy showed a resident who had a major change in pain status should be placed on alert charting and their pain should be assessed every shift while on alert. <Resident 12> According to the 05/29/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 12 had clear speech, intact memory, and with medical conditions including chronic pain and discomfort due to osteoarthritis (joint pain and stiffness). The MDS showed Resident 12 had limited…

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 medications were stored, labeled, and dated when opened and/or discarded when expired for 3 of 4 medication carts (Unit A, Unit B, & Unit D) and 2 of 2 medication rooms (Unit A & Unit B) observed. The failure to ensure unneeded medications were returned to the pharmacy, medications carts were secured when not in use by a nurse, and medications were not left at the resident's (Resident 240) bedside placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications. Findings included . <Facility Policy> Review of a 07/2024 facility Medication Storage and Disposal policy showed all drugs and biological will be stored in locked compartments and access granted to authorized personnel only. This policy stated outdated medications were to be removed from medication carts and disposed of according to procedures for medication disposal. The policy stated all medications were to be properly labeled and stored, separated from other residents medications, and separate from food or toxic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility: failed to ensure sharps containers were emptied before they reached an unsafe volume for 3 of 16 resident rooms reviewed (room [ROOM NUMBER], 104, & 416); maintain an environment free of uncleanable surfaces for 1 of 16 resident rooms reviewed (room [ROOM NUMBER]); failed to maintain a Water Management Program (WMP) for 1 of 1 buildings; failed to provide wound care within professional standards of infection control for 1 of 5 residents (Resident 68) reviewed for pressure ulcers; failed to ensure urinary catheter placement did not create an infection control risk for 1 supplementary resident (Resident 55) reviewed for catheter care. The failures placed residents at risk for facility acquired or healthcare-associated infections and related…

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 beds did not have gaps that could pose as an entrapment risk or assess the mattress used and/or obtained/purchased separately from the bed frame to ensure they were well-fitting for 1 of 21 residents (Resident 45) whose beds were observed for accident hazards. This failure placed residents at risk for injury, entrapment, or death. Findings included . <Facility Policy> The Medical Devices and Equipment facility policy, revised 07/2024, showed the facility would establish guidelines for the assessment, use, and maintenance of medical devices and equipment, including beds and mattresses, to ensure the safety and well-being of residents. The policy showed the facility would conduct regular inspections and preventative maintenance of medical devices/equipment. <Food and Drug Administration (FDA) Document> The 03/10/2006 FDA document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, identified seven potential zones of entrapment: Zone 1- Within the Rail, Zone 2-…

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 safe discharge for 1 of 3 residents (Resident 1) reviewed for discharges. The facility failed to ensure the Home Health Agency (HHA) was provided with all required information and documents to initiate home services as expected after discharge and failed to ensure indwelling catheter care education was provided and documented as provided to the Collateral Contact (CC). These failures placed the resident at risk for unmet care needs after discharge, potential for re-hospitalization, distress, and diminished quality of life. Findings included . Review of the facility, Transfer and Discharge policy, dated 04/2024, showed all discharges would be consistent with the needs of the resident and in conformance with the policy. The policy showed transfer documentation and appropriate medical information would be noted in the medical record and include all special instructions or precautions for on-going care. The policy showed the facility would provide sufficient preparation for the resident or the resident representative,…

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 in a manner that promoted resident dignity for 1 of 2 (Resident 74) sampled residents. Facility failure to fully dress Resident 74 left them at risk for feelings of embarrassment, helplessness, and diminished self-worth. Findings included . <Resident 74> According to the 03/21/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 74 had diagnoses of dementia, and required extensive physical assistance with activities of daily living including dressing. This assessment showed Resident 74 never or rarely made decisions and required assistance with cues and supervision. According to the 04/17/2023 Pocket Care Guide (a document providing facility staff directions for care) Resident 74 required supervision assistance from staff related to dressing. On 04/18/2023 at 9:30 AM and 04/19/2023 at 8:59 AM, Resident 74 was observed dressed in a t-shirt and brief. Resident 74 was observed ambulating independently around their room from the hallway in t-shirt and brief. The door to their room 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, interviews, and record review, the facility failed to investigate falls and/or injuries of unknown origin to determine cause, rule out abuse, and implement interventions to prevent reoccurrence for 3 of 18 (Residents 64, 234, & 23) sampled residents reviewed. The failure to initiate and conduct a thorough investigation, initiate appropriate corrective actions, and outline all contributing factors regarding unwitnessed falls (Resident 64), skin tears (Resident 234 & 23), and bruising (Resident 23) placed the residents at risk for recurrent falls with potential for significant injury and unidentified abuse or neglect. Findings included . <Facility Policy> Review of the undated Providence Home and Community Care Event Reporting using Datix [facility's incident reporting system] policy identified the facility's process for investigation of adverse events. The policy showed investigations would include interviewing applicable staff including involved caregivers; inspect, review, and secure all relevant material, equipment, and devices; and document findings,…

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 received bed hold notification for 3 of 6 (Residents 7, 58 & 64) residents reviewed for transfers, discharges, and hospitalizations. This failure placed the residents and/or their resident representatives at risk for lack of knowledge regarding their right to hold their bed during transfers, discharges, and hospitalizations. Findings included . <Facility Policy> The 02/2022 Skilled Nursing Facility Bed Hold and Return To Facility policy showed residents and their representatives were provided with bed hold and return information before a hospital transfer. The policy outlined staff were educated about the resident's bed hold and return rights to ensure this information was provided at the time a resident left the facility. <Resident 7> Review of Resident 7's record showed they were transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review showed no indication a bed hold…

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 accurately assess 2 of 18 (Residents 58 & 1) residents reviewed for Minimum Data Set (MDS - an assessment tool) accuracy. Failure to ensure accurate assessments regarding oral status (Resident 58) and special treatment/procedures (Resident 1) placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 58> According to the 03/13/2023 Significant Change MDS, Resident 58 had complex medical diagnoses including a stroke resulting in difficulty swallowing and loss of function on the left arm and left leg. The assessment showed Resident 58 did not have any oral/dental issues. There was no Care Area Assessment (CAA) completed for Resident 58's oral/dental status. On 04/18/2023 at 10:54 AM, Resident 58 was observed to be edentulous (without natural teeth). Resident 58 stated they do not use or have any dentures. In an interview on 04/21/2023 at 11:18 AM, Staff G (Registered Nurse, MDS) stated the accurate assessment of a resident's oral/dental health status was very important for 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 ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 1 of 5 (Resident 64) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 64> According to the 01/19/2023 Significant Change Minimum Data Set (an assessment tool) Resident 64 had multiple medically complex diagnoses including anxiety and required the use of an antidepressant medication. Review of Resident 64's records showed a 03/08/2023 admission provider note stating the assessment and plan was to continue an antidepressant medication for anxiety and depression. Subsequent provider progress notes from 03/14/2023, 03/20/2023, 03/23/2023, and 03/27/2023 indicated the assessment and plan continued to include a diagnosis of depression. Pharmacist progress notes on 03/17/2023 and 03/30/2023 indicated Resident 64 was taking 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 observation, interview, and record review, the facility failed to ensure comprehensive Care Plans (CPs) had measurable goals, and were complete, accurate, revised as needed, and implemented for 4 of 18 (Residents 31, 68, 64 & 66) sample residents whose CPs were reviewed. Facility failure to ensure CPs were complete, accurate, revised, and implemented left residents at risk for unmet care needs and diminished quality of life. Findings included . <Facility Policy> The 01/2023 Resident Care Plan (CP) facility policy showed the CP was reviewed, updated, and printed for the CP book at least quarterly and in the event of a significant change in condition for long-term care residents. The policy showed the CP would include measurable, specific, realistic, and achievable goals and would include a specific plan reflecting the resident preferences and care needs. The policy indicated facility staff should integrate external providers' CPs with the facility's CP in order to coordinate services with the external…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 18 (Residents 31, 234, 1, 68, 58 & 23) sampled residents related to bed rails, pacemakers (a small device implanted in the chest to regulate heart rate), and the failure to follow or clarify Physician Orders (POs). Findings Included . <Pacemakers> <Resident 31> According to the 03/28/2023 Admissions Minimum Data Set (MDS - an assessment tool) Resident 31 readmitted to the facility on [DATE]. The MDS showed Resident 31 had diagnoses including atrial fibrilation (irregular/rapid heartbeat), heart failure, and high blood pressure. The MDS showed Resident 31 had a pacemaker. Review of the 02/13/2023 at risk for pacemaker malfunction Care Plan (CP) showed Resident 31 had a goal to maintain a heart rate between 60-100 beats per minute. The CP directed staff to check the pacemaker as ordered. Review of Resident 31's POs showed no orders were in place to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: implement post-surgical interventions for 1 of 5 (Resident 31) residents reviewed for positioning; treat non-pressure skin in accordance with professional standards and Physicians' Orders (POs) for 2 of 5 (Resident 234 & 23) residents reviewed for non-pressure skin. These failures left residents at risk for avoidable skin issues, discomfort, and pain. Findings included . <Resident 31> According to the 03/28/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 31 readmitted to the facility on [DATE] and was assessed with intact cognition. The MDS showed Resident 31 had diagnoses including an infection of an artificial joint, arthritis, and weakness. The MDS showed Resident 31 did not refuse care. According to a 03/22/2023 progress note, Resident 31 admitted to the facility for treatment of an infection of their left shoulder artifical joint. According to the 03/21/2023 hospital discharge instructions, Resident 31 needed 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.

Based on observation, interview, and record review the facility failed to ensure residents with urinary incontinence received the appropriate treatment and services for 2 of 3 (Residents 23 & 67) residents reviewed for urinary incontinence. Failure to provide treatment and services related to incontinence care placed residents at risk for Urinary Tract Infections (UTIs), continued decline in urinary function with potential loss of bladder control, and skin issues. Findings included . <Facility Policy> Review of the 2023 facility policy Promoting Residents' Urinary Health Status showed, the facility was to implement a prompted voiding trial once the resident was identified as incontinent [loss of bladder control]. If the resident was excluded from a prompted voiding [urinating] trial, then alternative care planning approaches were implemented. Alternatives included: bladder retraining, pelvic floor muscle rehabilitation, intermittent catheterization [a process that uses tubing to drain urine from the bladder], medication therapy, or urine containment devices. <Resident 23> According…

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 5 percent (%). Failure of 1of 2 nurses (Staff I) to properly administer 3 of 26 medications for 3 of 7 residents (Resident 46, 32,& 64) observed during medication pass resulted in a medication error rate of 11.11%. 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 . <Resident 46> Observation of medication pass on 04/24/2023 at 9:30 AM showed Staff I (Licensed Practical Nurse) prepare and administer multiple medications to Resident 46, including two tablets of medication intended for constipation. Review of Resident 46's Physicians' Orders (PO) showed staff were to administer one tablet for constipation. The April Medication Administration Record (MAR) showed staff were to administer one tablet twice daily. <Resident 32> Observation of medication pass on 04/24/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain the commercial cooking equipment for 1 of 1 facility kitchens in a safe operating condition. The failure to conduct maintenance and cleaning of the stove hood per manufacturer's recommendations had the potential to result in fire in the hood due to excessive grease build up which could endanger the residents, staff and/or visitors within the facility. Review of a revised 04/2023 facility Equipment Maintenance policy showed the facility was to properly maintain all equipment to ensure the safety of residents, caregivers, and visitors. This policy showed the Director of Maintenance would oversee the implementation of this policy and maintain records for each piece of equipment, including maintenance schedules, inspections, repairs, and cleaning. During initial kitchen observations on [DATE] at 9:18 AM, a label was observed on the stove hood indicating the last service date was on [DATE]. The label was marked that it would expire six…

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.