Covenant Shores Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for residents with indwelling medical devices for 1 of 2 residents (Resident 20) reviewed with indwelling devices, properly store urinary catheter bags, and perform hand hygiene during catheter care for 1 of 2 residents (Resident 13) reviewed for urinary catheter use. Failure to implement EBPs, perform hand hygiene during urinary catheter care, and properly store a urinary catheter bag placed residents at risk of infection and other negative health outcomes.Findings included.<Facility Policy>Review of the facility's August 2022 Enhanced Barrier Precautions policy showed EBPs were used as an infection prevention and control intervention for residents with indwelling medical devices (such as central lines and urinary catheters) to prevent the spread of multi drug-resistant organisms. EBPs included staff use of gowns and gloves during high-contact resident care activities 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 interview and record review, the facility failed to implement a system by which residents received required written notices at the time of transfer or as soon as practicable for 3 (Residents 28, 5, & 7) of 4 residents reviewed for hospitalization. Failure to ensure notification to the resident and/or the resident's representative of the reason for transfer in writing and in a language and manner they understood, placed residents at risk for a transfer not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the facility's October 2022 Transfer or Discharge, Facility-Initiated policy showed for emergent transfers, the resident and their representative would be provided a Notice of Transfer as soon as practicable. The notice would be provided in a form and manner the resident could understand. <Resident 28> According to the 07/30/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 28 transferred to the hospital on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs requiring further assessment/treatment) assessment was accurately completed for 3 (Residents 33, 7, & 2) of 5 residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely services to meet their mental health needs. Findings included . <Facility Policy> According to the facility's revised March 2019 admission Criteria policy, all new admissions were screened to determine if the resident met the criteria for mental disorders, intellectual disabilities, or related disorders. This policy showed if the resident met any of the criteria, they would be referred to the state PASRR representative for a Level II evaluation and determination. <Resident 33> According to the 11/05/2024 admission Minimum Data Set (MDS - 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 ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a medical device for 1 of 1 (Residents 31) residents reviewed for positioning, and 1 supplemental resident (Resident 26). The failure to provide informed consent placed residents at risk for loss of autonomy. Findings included . <Resident 31> According to the 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 31 had diagnoses including a history of stroke and one-side paralysis. The MDS showed Resident 31had severe memory impairment, used a wheelchair for mobility, and depended on staff for most mobility needs. Observation on 12/10/2024 at 8:20 AM showed Resident 31 sitting at a table in the facility's [NAME] dining room. Resident 31 sat in a Tilt-in-Space wheelchair (a specialty wheelchair where the angle at which the user of the wheelchair is seated could be easily adjusted using handles behind the seat). The angle could not be adjusted by the chair's user,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess the resident's ability to self-administer their medications for 1 of 3 residents (Resident 29) reviewed. This failure placed residents at risk for overdose or under dose of medical treatment when self-administering of the wrong dose, frequency, route, and time. Findings included . Observations on 12/09/2024 at 8:40 AM and 12/12/2024 at 12:16 PM showed Resident 29 with an inhaler, a tube of ointment, and a nasal spray on their bedside table. Review of the 12/2024 Medication Administration Records (MAR) showed Resident 29 could keep their inhaler at the bedside. The MAR showed no authorization to keep the nasal spray or the ointment at the bedside. Review of Resident 29's medical record found no assessments were completed to ensure Resident 29 could self-administer their inhaler, nasal spray or ointment according to the physician's instructions. In an interview on 12/12/2024 at 2:16 PM, Resident 29 stated I have to use the inhaler all the time, I do not need anyone to tell me how to use it. I need it on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 2 (Residents 31 & 2) of 3 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> According to the facility's September 2022 Advance Directives policy, if a resident had any ADs, the facility would obtain and maintain the document(s) to be readily available when needed to any facility staff. <Resident 31> According to the 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 31 admitted to the facility on [DATE] and had diagnoses including a history of stroke and one-sided paralysis. The MDS showed Resident 31 had a severe memory impairment. According to 07/01/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to thoroughly investigate a fall for 1 (Resident 88) of 3 residents reviewed for accidents, and rule out abuse/neglect for 2 (Resident 23 & 33) of 3 sampled residents reviewed for abuse. Facility failure to complete thorough investigations placed residents at risk for further falls, potential abuse, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's Accidents and Incidents - Investigating and Reporting policy, all accidents and incidents involving facility residents should be thoroughly investigated. Review of the facility's September 2013 revised Skin Tears - Abrasions and Minor Breaks, Care of policy showed the facility would complete an in-house investigation of the cause of the skin injury. This policy showed when an abrasion/skin tear/bruise was discovered, an incident report would be completed. <Resident 88> According to the 12/06/2024 admission Minimum Data Set (MDS - an assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement comprehensive Care Plans (CPs) for 5 (Residents 5, 31, 33, 7, & 23) of 12 sample residents whose CPs were reviewed. The failure to develop and/or implement comprehensive CP interventions left residents at risk for unmet care needs and other negative health outcomes. Findings included . <Resident 5> According to the 11/27/2024 5-Day Minimum Data Set (MDS - an assessment tool) Resident 5 had medically complex diagnoses including a heart condition that could cause fluid in the lungs. The MDS showed Resident 5 used supplemental oxygen upon admission and during the assessment look back period. Observation on 12/09/2024 at 2:52 PM showed Resident 5 had an oxygen concentrator and a nasal cannula (tubing to deliver supplemental oxygen to the nostrils.) The nasal cannula was resting on Resident 5's bedside table Record review showed an 11/21/2024 physician's order directing staff to provide Resident 5 supplemental oxygen at two liters per minute via a nasal cannula. Review of the 09/25/2024…

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 complete a formal assessment prior to use of a Tilt-in-Space wheelchair (a specialty wheelchair with a seat and back that can be readjusted by a second party to reposition the user for comfort and/or pressure relief) for 1 of 2 residents (Resident 26) reviewed for accommodation of needs, and 1 of 1 residents (Resident 31) reviewed for positioning. The failure to ensure residents' Tilt-in-Space wheelchairs prior to use placed residents at risk for use of an inappropriate wheelchair, discomfort, and loss of bodily autonomy. Findings included . <Facility Policy> According to the facility's January 2020 Assistive Devices and Equipment policy, the facility would provide certain mobility equipment including wheelchairs to residents needing mobility assistance. The policy showed equipment recommendations would be made based on the comprehensive assessment and documented in the resident's Care Plan (CP). The policy showed an order to decrease the risk of avoidable accidents, to the extent possible, the appropriateness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications and biologicals were secured for 3 (Residents 14, 29, & 88) of 12 sample residents. The failure to ensure medications were not left at the bedside with residents not assessed to be able to self-medicate placed residents at risk for receiving the wrong medications, incorrect dosages, and non-assessed, self-administration of medications by residents. Findings included . <Resident 14> Observation on 12/09/2024 at 9:32 AM showed Resident 14 lying in bed with their over-the-bed table across their lap. A bottle of lubricating eye drops was on the table next to them. Observation on 12/12/2024 at 2:19 PM showed Resident 14 lying in bed with their over-the-bed table across their lap. A medication cup containing two, white, oblong pills were observed as well as a bottle of lubricating eye drops sitting on the table. In an observation and interview on 12/12/2024 at 2:28 PM, Staff G (Registered Nurse) went to Resident 14's room and confirmed the medications at bedside. Staff G stated they were supposed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failure to ensure food was prepared and served in accordance with professional standards of safety. Facility failure to ensure ready-to-eat foods were covered and kitchen staffs' hair was secured as required left residents at risk of food contamination and food-borne illness. Findings included <Uncovered Food> Observation in the [NAME] dining room on 08/28/2023 at 12:02 PM showed dietary staff preparing lunch trays for distribution to residents. Staff placed slices of apple pie on each tray. The slices of pie were left on the trays uncovered while staff continued preparing the lunch. Staff then added bowls of soup to some of the trays. The soup bowls were also left uncovered on the trays. On 08/28/2023 at 12:57 PM one uncovered soup bowl and six slices of pie remained on trays awaiting distribution. The pies were uncovered for over 45 minutes.The bowls of soup were uncovered for up to 30 minutes. On 08/28/2023 at 12:33 PM Staff K (Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise Care Plans (CPs) as needed to maintain accuracy for 9 of 14 (Residents 3, 13, 9, 11, 16, 6, 189, 1 & 29) sample residents. Failure to review and revise CPs when changes were required left residents at risk for unmet care needs, unnecessary care, and other frustrations. Findings included . <Resident 3> According to the 06/03/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 3 was assessed with moderate cognitive impairment (limited ability to problem solve and form new memories). The MDS included a section where Resident 3's preferences for daily and activity preferences could be documented. This section was not completed. The activity preferences CP showed Resident 3 read the newspaper daily. The CP directed staff to deliver the newspaper to Resident 3 each day. In an interview on 08/30/2023 at 12:31 PM Staff A (Administrator) stated it was important for CPs to be comprehensive, accurate, and revised as 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 medications and biologicals were dated when opened; dispose of timely expired and/or discharged resident medications for 1 of 2 medication carts and 1 of 1 medication room reviewed; and ensure medications were secured for 1 of 2 medication carts observed. These failures placed residents at risk for receiving expired medications, medication errors, adverse side effects of medications, or not receiving the full effect of their medications. Findings included . <Facility Policy> According to a facility's February 2023 Medication Labeling and Storage policy, the nursing staff were responsible for maintaining medication storage. The policy outlined all medications and biologicals were stored in locked compartments and only authorized personnel would have access to keys. The carts used to transport medications and biologicals would be locked and not left unattended if open or otherwise potentially available to others. If the facility had discontinued, outdated, or deteriorated medications or biologicals, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the Infection Prevention and Control Program (IPCP) was followed during observance of Transmission Based Precautions (TBP) for Residents 16 & 22 on Contact Enteric Precautions; transport and delivery of resident's personal clothing; maintenance of Resident 140 & 6's wheelchair equipment; and hand hygiene with wound care for Resident 29 and during medication administration. These failures placed residents at risk for exposure to infections and a decreased quality of life. Findings included . <TBP> <Facility Policy> The 01/18/2017 Categories of TBP facility policy regarding the use of contact precautions showed, prior to exit, staff were to remove their gloves, perform hand hygiene, and avoid touching any potentially contaminated environmental surfaces. The policy outlined the use of a gown and to not allow clothing to come in contact with potentially affected areas. The policy showed signs were posted to alert visitors to report 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 observations, interview, and record review the facility failed to ensure 6 of 14 (Residents 9, 3, 15, 1, 16 & 6) 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 care needs. Findings included . <Resident 9> According to an 08/15/2023 admission MDS Resident 9 had multiple medically complex diagnoses including a brain bleed that caused muscle weakness to one side of their body. This MDS showed staff assessed Resident 9 to require extensive physical assistance from staff for bed mobility, transfers and had no impairment with functional limitation in Range Of Motion (ROM). Observation on 08/30/2023 at 9:07 AM showed Resident 9 using their left hand to try to remove a lid off a food container. In an interview at that time, Resident 9 stated they could no longer use their right arm for tasks due to having a stroke. Review of an 08/09/2023 Occupational Therapy (OT) evaluation showed documentation Resident 9 had decreased strength and ROM with 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 ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intelectual disabilty needs which required further assessment/treatment) assessment was obtained to reflect the residents' mental health conditions for 1 of 6 (Resident 9) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . According to a revised March 2019 facility admission Criteria policy, all new admissions and readmissions are screened for Mental Disorders (MD), Intellectual Disabilities (ID) or Related Disorders (RD) per the PASRR process. This policy stated the facility would conduct a Level 1 PASRR screen for all potential admissions to determine if the individual meets the criteria for a MD, ID, or RD and, if indicated, would refer the resident to the state PASRR representative for a Level 2 (evaluation 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 develop and implement comprehensive Care Plans (CPs) for 5 of 14 (Residents 3, 13, 11, 139 & 6) sample residents. Failure to develop comprehensive CPs for refusals (Resident 3), dementia care (Residents 13 and 11), catheter care (Residents 139), and implement CP interventions identified related to antipsychotic medication use (Residents 6) left residents at risk for unmet care needs, and other negative health outcomes. Findings included . <Resident 3> According to the 06/03/3023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 3 was moderately cognitive impaired (had moderate difficulty with problem solving and forming memories), and had diagnoses including traumatic brain dysfunction (impaired brain function after trauma), right-sided hemiplegia (one-sided paralysis) and dementia (a progressive disease affecting thought processes). The MDS showed Resident 3 had no refusals of care during the assessment period. Review of the . Mobility Deficit . CP showed Resident 3 had limited range of motion 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 follow/implement Physician's Orders (POs) for 3 (Residents 13, 189, & 21) of 14 sample residents reviewed, and failed to clarify POs for 2 (Residents 11 & 141) of 14 sample residents reviewed. These failures left residents at risk for unmet care needs, and frustration. Findings included . <Follow/Implement POs> <Resident 13> According to the 08/01/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 13 had diagnoses including arthritis and an infection/inflammatory reaction due to a right prosthesis (artificial joint). The MDS showed Resident 13 experienced occasional pain and received opioid pain medications. Review of the August 2023 Medication Administration Record (MAR) showed Resident 13 had two orders for a narcotic pain medication. The first order was for 2.5 Milligrams (MG) to be given every hours as needed for a pain range of 5-7 out of 10. The second order was for 5 MG every four hours as needed for a pain range 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 assess, monitor, and/or treat wounds for 2 of 3 (Resident 1 & 239) residents reviewed for non-pressure skin issues. These failures placed residents at an increased risk for infection, untreated skin impairments, and a diminished quality of life. Findings included . <Resident 1> Review of the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 1 had a memory impairment, required extensive assistance for bed mobility and rolling from right to left. Resident 1 had diagnoses including dementia, chronic pain, and depression. Observation on 08/29/2023 at 10:12 AM showed a bandage wrapped around Resident 1's right lower leg just above the ankle. Review of the 08/2023 Treatment Administration Record (TAR) showed no treatment order for the right lower extremity. Weekly documentation under the skin check section of the 08/2023 TAR showed Staff O (Registered Nurse) documented the presence of a chronic wound on the right leg (ankle) on 08/07/2023, 08/21/2023, and 08/28/2023. Review of the Care…

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

Based on observation, interview, and record review the facility failed to identify and provide interventions to prevent the development of a pressure injury for 1 of 3 (Resident 29) sampled residents reviewed for pressure ulcers. This failure resulted in the development of pressure injuries, unmet care needs, and a diminished quality of life. Findings included . <Facility Policy> The April 2018 Pressure Ulcers/Skin Breakdown - Clinical Protocol facilty policy showed the nursing staff assessed and documented residents' significant risk factors for developing pressure ulcers including immobility. The policy showed the physician would help identify and order medical treatment and intervnetions related to wound management. <Resident 29> Review of the 07/28/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 29 had a stage 3 (involving multiple layers of skin) pressure ulcer and was assessed to be at risk for the development of new pressure injuries. The MDS showed Resident 29 was provided with extensive assistance of two or more nursing staff with bed mobility 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 proper positioning approaches were provided for 1 of 2 (Resident 3) residents reviewed for positioning. Failure to provide proper positioning left residents at risk for contractures (irreversible tightening of a joint), discomfort, and pain. Findings included . <Resident 3> According to the 06/03/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 3 had diagnoses including traumatic brain dysfunction (loss of brain function after a head injury), dementia (a progressive condition where a person's memeory and thight function diminish over time), and hemiplegia (one-sided paralysis). The MDS showed Resident 3 required extensive assistance with transfers and used a specialty wheelchair for mobility/positioning. Record review showed the Comprehensive Care Plan (CP) included a . Mobility deficit . CP. This CP showed Resident 3 needed extensive one-person assistance with transfers. The CP showed Resident 3 frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the fall management policy for 1 of 3 (Resident 15) sample residents reviewed for falls. This failure left residents at risk for falls, injuries, and a diminished quality of life. Findings included . <Facility Policy> The facility's March 2018 Fall and Fall Risk Management policy showed if a resident fell despite fall interventions, facility staff must implement additional or different interventions to prevent further falls. The policy showed if a resident continued to fall, staff must reevaluate the efficacy of the interventions. <Resident 15> According to the 08/17/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 15 was assessed with severe cognitive impairment (a diminished ability to make decisions/form new memories) and required one-person supervision for walking in their room and in the corridor, and for transferring from a seated or lying position to standing. The MDS showed Resident 15 was assessed with moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: (1) follow Physician Orders (POs) and ensure the correct dose was administered, and (2) provide proper care of nasal tubing for oxygen concentrator (a breathing therapy that pumps oxygen into the lungs through the nose or mouth) for 1 of 1 (Resident 4) resident reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, and related respiratory complications. Findings included . <Facility Policy> The October 2010 Oxygen Administration facility policy outlined guidelines for safe oxygen administration including the verification and review of the resident's PO for the procedure. The policy showed the resident's Care Plan (CP) was reviewed to assess for any special needs as part of the preparation process. <Resident 4> <POs> According to the 07/30/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 4 was assessed to be cognitively intact and received oxygen therapy while a resident at the facility. The MDS showed Resident 4 had complex medical conditions 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.

Based on observation, interview, and record review the facility failed to identify and treat 1 of 2 (Resident 29) residents reviewed for pain management. Failure to assess and implement interventions to relieve pain resulted in Resident 29 experiencing episodes of uncontrolled pain during daily movement and wound care treatments which placed the resident at risk for a decreased quality of life. Findings included . <Facility Policy> According to the October 2022 Pain Assessment and Management facility policy, pain management was a multidisciplinary care process that incuded recognizing the presence of pain, addressing the underlying causes of the pain, and monitoring for the effectiveness of interventions. The policy outlined the process of alleviating the residents' pain based on their clinical condition and established treament goals. <Resident 29> According to the 07/28/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 29 had no indicators of pain or possible signs of pain. Resident 29 was identified in the MDS assessment to have a Stage 3 (involving multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents remained free of unnecessary psychotropic medications for 2 of 5 (Residents 13 & 6) sample residents whose medications were reviewed for unnecessary psychotropic medications. Failure to: (1) identify the adequate indications for use/extended use, and (2) adequately monitor and document excessive sedation behaviors as adverse consequences placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related Adverse Side Effects (ASE), and a diminished quality of life. Findings included . <Resident 13> According to the 08/01/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 13 admitted to the facility from an acute hospital on [DATE] and had diagnoses including memory impairment and major depression. The MDS showed Resident 13 demonstrated no behaviors during the assessment period. Resident 13's Physician's Orders (POs) included an 08/01/2023 order for an Antipsychotic (AP)…

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