Martha And Mary Health Service

Based on observation, record review and interview, the facility failed to maintain a medication error rate of less than 5%, by having an error rate of 8%, with 2 of 25 medication administration errors for observed opportunities. This failure placed residents at risk of medication complications, misuse of medications, and a diminished quality of life. Findings included.MEDICATION NOT GIVEN AS ORDEREDOn 02/11/2026 at 9:37 AM, Staff E, Registered Nurse, said that Resident 13 had just finished their breakfast and she would be giving ferrous sulfate, a medication ordered to be taken with breakfast.On 02/11/2026 at 9:51 AM, Resident 13 was observed to be given the ferrous sulfate, along with pantoprazole.Review of the order for Pantoprazole, dated 11/18/2025, included to take the medication with an empty stomach approximately 30 minutes to 1 hour before meal. On 02/12/2026 at 11:13 AM, Staff E, said the pantoprazole should have been give on an empty stomach, not after breakfast. On 02/12/2026 at 11:35 AM, Staff B, Director of Nursing Services (DNS), when asked about Staff E giving ferrous…

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 follow physician orders for a surgical wound for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, infections and discomfort. Findings included . Resident 1 was admitted to the facility on [DATE]. Resident 1's Hospital's Skilled Nursing Facility Transfer Orders, dated 02/15/2025, showed the resident had a C2-T10 PSF, T4 Corpectomy (surgical procedure on the spine) on 02/06/2025. The orders showed discharge instructions to the SNF [skilled nursing facility] to remove the staples in the incisionthree weeks postop (post-surgery) unless there were any concerns about the incision and then call the surgeon. Review of Resident 1's electronic medical record on 05/13/2025, showed no documentation the staples were removed from the resident's incision and/or the surgeon was contacted. Resident 1's discharge orders, dated 03/03/2025, showed the resident had a follow up appointment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide assistance with toileting and bed mobility for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for skin breakdown, poor hygiene and pain. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses of cancer and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure). Resident 1's admission screening and history evaluation, dated 04/03/2025, showed the resident was cognitively intact, needed assistance from staff with bed mobility, totally dependent for toileting and had acute and chronic pain. Resident 1's care plan, dated 04/03/2025, showed the resident was a 1 PA [person assist] with bed mobility and a 1-2 PA with maximum assist using bed pan for bowel movements. The care plan showed the resident had impairments to the skin integrity in the perineal area (sensitive skin between the anus and the genitals), lower extremities, coccyx…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 25 sampled residents (Residents 73, 99, 81, 8, 11 and 91) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. A psychotropic drug use CP, revised 10/25/2024, showed the resident received clonazepam (an anxiolytic medication) and Seroquel (an antipsychotic medication) for anxiety. Staff were directed to monitor behaviors and document them on the behavior flowsheet. The CP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails/mobility bars for 4 of 5 residents (Residents 11, 51, 40,and 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy, titled Proper Use of Side Rails, revised 09/2024, documented side rails will not be offered to residents on admission. A full assessment will be completed and informed consent obtained prior to authorizing the use of side rails. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest), anxiety (increased stress), and post-traumatic stress disorder (traumatic event that triggers thoughts/distress/anxiety). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 4 of 8 sampled residents (Residents 11, 24, 78 and 355) when reviewed for unnecessary medications and pain. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life. Findings included . 1) Resident 78 was admitted to the facility on [DATE] with diagnoses including dementia and chronic pain. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 10/17/2024, showed the resident required partial to setup assistance with activities of daily living (ADLs) and was cognitively intact. A review of Resident 78's Electronic Health Record (EHR) showed an order for oxycodone 5 milligram (mg, a unit of measurement for weight in the metric system) every 4 hours as needed for chronic pain and an order for acetaminophen 325 mg tablet, to give…

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 . AMENDED 01/02/2024 Based on interview and record review, the facility failed to ensure 7 of 7 sampled residents (Residents 11, 73, 78, 27, 62, 22, and 82) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to fully complete the Abnormal Involuntary Movement Scale (AIMS, an assessment used to determine the severity of abnormal movements in a patient's body) for residents using antipsychotic (a class of drugs used to treat mental health conditions characterized by psychosis) medication. The facility also failed to identify, monitor, and document observed target behaviors and non-pharmacological interventions. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, unmet needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Drugs Utilization, dated 12/2024, documented, A. Movement disorder evaluation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure residents on enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care) had precaution signage implemented correctly for 5 out of 14 residents (Residents 19, 576, 59, 24, and 155) reviewed for EBP, that infection control precautions were followed for 2 of 3 residents (Residents 54 and 91) sampled for observation of infection control practices, the antibiotic surveillance was accurate and complete, the Legionella Water Management Program identified and monitored internal areas of risk, and to store and clean continuous positive airway pressure machines (CPAP, device that uses mild air pressure to keep breathing airways open while you sleep) for 1 of 3 residents (Resident 51) reviewed for CPAP. This failure placed residents at risk for spread of infection, health complications, unidentified care needs, and a diminished quality of life. 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 their representatives were provided accurate information regarding the risks and benefits associated with proposed drug therapies for 2 of 5 sampled residents (Residents 11 & 73) reviewed for unnecessary medications. The failure to accurately identify medication/drug class and associated adverse side effects (ASEs) detracted from residents' ability to make informed decisions about proposed drug therapies, and placed them at risk for making treatment decisions based on inaccurate information. Findings included . Review of the facility's Psychotropic Drug Utilization policy, dated 12/2024, showed a psychotropic drug was defined as any drug that affects brain activities associated with mental process and behavior. In the event a psychoactive medication was ordered, licensed staff would obtain informed consent for the use of the medication prior to initiating therapy. 1) Review of the Electronic Health Record (EHR) showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interview, and record review the facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for 1 of 4 residents (Resident 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set, an assessment tool, dated 09/19/2024, showed Resident 91 was dependent with mobility abilities, was rarely/never understood, and was moderately impaired for daily decision making. On 12/10/2024 at 2:49 PM, Resident 91 was observed in bed with body pillows (longer than standard pillows) on both sides of their bed positioned under the fitted sheet. Review of Resident 91's Electronic Health Record showed no assessment, consent, orders, or care plan documentation for the body pillows. On 12/11/2024 at 8:45 AM, Resident 91 was observed…

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 Minimum Data Set Assessments (MDS), assessment tool, were accurate for 2 of 25 sampled residents (Residents 54 and 11). This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 54 was admitted on [DATE]. Resident 54 had diagnoses of retention of urine and neuromuscular dysfunction of the bladder (problem with bladder control). Resident 54 had a suprapubic catheter (small tube that drains urine from bladder by an incision through the abdomen). Resident 54's Annual MDS, dated [DATE], documented they had an indwelling catheter (including suprapubic catheter and nephrostomy tube) and for urinary continence that they were always incontinent (no episodes of continent voiding). Further review of the MDS showed that for urinary continence another option that was available but was not selected was, Not rated, 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.

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) assessment accurately reflected the resident's mental health diagnoses and Level II PASRR evaluations were timely referred and completed for 1 of 5 residents (Resident 73) reviewed for PASRRs. The failure to ensure Level I PASRRs were accurately completed, and residents were timely referred for Level II PASRR evaluations, placed residents at risk for inappropriate placement, and not receiving timely and necessary mental health services to meet their mental health needs. Findings included . Resident 73 admitted to the facility on [DATE]. The Annual Minimum Data Set Assessment, dated 09/25/2024, showed the resident was severely cognitively impaired, and had diagnoses of non-Alzheimer's dementia (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform basic tasks) with agitation, and anxiety (a common reaction to stress that can cause…

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 review, revise and implement a comprehensive plan of care to included resident specific information for 5 of 25 sampled residents (Residents 59, 78, 91, 11 & 51) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . 1) Resident 59 was admitted to the facility on [DATE] with diagnosis of sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/06/2024, showed the resident required supervision to substantial assistance with activities of daily living (ADL) and was cognitively intact. Resident 59's altered respiratory status/difficulty breathing care plan, dated 05/16/2022, listed the resident had a continuous positive airway…

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 services provided met professional standards of practice for 3 of 25 sampled residents (Residents 73, 51 and 40) reviewed for professional standards. Facility staff failed to timely transcribe and timely carry out physician orders, and/or clarify confusing or incomplete orders. Additionally, staff failed to ensure medications were secure, as nurses left the medication cart unlocked when unattended and/or left medication at a residents' bedside without an order to do so, or a self-medication assessment being completed. These failures placed residents at risk for medication errors, complications of treatments, and other potential negative health outcomes. Findings included . <Failure to Clarify Incomplete Orders> 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, a diagnosis of heart failure and required the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to provide assistance with bathing for 1 of 5 residents (Resident 90) reviewed for activities of daily living (ADLs). The failed practice placed residents at risk for a decline in care and quality of life. Findings included . Resident 90 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 09/04/2024, documented the resident had severe cognitive impairment and required supervision for ADLs. A review of the Point of Care (nursing assistant task documentation) response history for 30 days, the 'Shower Book' and the 'Marina Daily Shower' sheets documented Resident 90 only received a shower on 11/17/2024, 12/02/2024, and 12/08/2024. A review of Resident 90's care plan, dated 11/29/202,3 listed a problem of ADL self-care performance deficit . and an intervention of if unable to perform shower, offer bed bath. On 12/12/2024 at 2:26 PM, Staff E, Unit Manager/Licensed Practical Nurse, said Resident 90 did not receive…

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 care and services in accordance with accepted professional standards for 3 of 6 residents (Residents 82, 11, and 99) reviewed for quality of care related to bowel management and hospice services. This failure placed the residents at risk for discomfort and complications related to constipation and risk for substandard care related to lack of coordination with hospice (provides end of life orders/interventions). Findings included . <Bowel management> Facility Bowel Management Policy, dated 2024, said the licensed nurse was to check the bowel record each day. If there was no BM (bowel movement) or small BM, the nurse would implement non-pharmacological interventions. If no BM for three days or more, pharmocological interventions would also be offered. It was the responsibility of the nurse to complete documentation and to notify the medical provider if interventions were ineffective. 1) Resident 82 admitted to the facility on [DATE]. 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 pressure relieving device was working correctly for 1 of 3 sampled residents (Resident 81) reviewed for pressure ulcers. This failure placed residents at risk for delayed healing and further skin impairment. Findings included . Resident 81 was admitted to the facility on [DATE] with diagnoses of Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves) and malnutrition (lack of sufficient nutrients in the body). The Quarterly Minimum Data Set, an assessment tool, dated 09/23/2024 showed Resident 81 was moderately cognitively impaired, needed extensive assist for activities of daily living, and had one or more unhealed pressure ulcers. On 12/09/2024 at 10:18 AM and 3:30 PM, Resident 81 was observed lying in bed. A pressure relieving mattress was in place with a setting of 5 (1-softest setting through 5-firmest setting). On 12/10/2024 at 10:30AM, on 12/11/2024 at 9:27 AM and 10:57AM, and on 12/12/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure oxygen (O2), continuous positive airway pressure services (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep), and breathing treatments via nebulizer (a machine that turns liquid medicine into a mist that can be inhaled) were provided in accordance with accepted professional standards of practice for 3 of 5 residents (Residents 73, 51 and 81) reviewed for respiratory care. The failure of staff to document the amount of O2 administered, to ensure O2 orders included checking and replacing of humidifier bottles, and CPAP orders included the prescribed pressure settings, type of mask to be used (e.g. nasal pillows, nasal mask, full face mask), direction to check and refill the humidifier reservoir, and identification of the solution to be used (e.g. distilled water), placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . Review…

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 promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 sample residents (Resident 73) reviewed for unnecessary medications. This failure placed residents at risk for delayed treatment and potential negative outcomes. Findings included . Review of the facility's, Provider Notification - Labs policy, dated 12/2024, showed the facility must promptly notify the attending provider of lab results that fall outside of clinical reference ranges. Delayed notification may contribute to delayed changes to the treatment plan. Promptly meant that results would be relayed with little or no delay to the ordering physician, or in accordance with facility policy regarding which labs require immediate versus non- immediate notification. Lab results requiring non-immediate provider notification could be placed in the providers folder for review upon next visit. 1) Resident 73 was admitted to the facility on…

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

Based on observation, interview and record review, the facility failed to ensure 3 of 3 staff members (Staff A, B and C) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19. Findings included . A 03/18/2024 CDC update titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, showed when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. When a N95 respirator was used during the care of a resident with a COVID 19 infection, they should be removed and discarded after the resident care encounter and a new one should be donned. A…

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

Based on interview and record review, the facility failed to ensure resident choices regarding bathing frequency were honored for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices related to bathing. The facility's failure to accommodate resident preferences related to frequency of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth, and diminished quality of life. Findings included . 1)On 10/23/2023 at 3:58 PM, Resident 33 said they were supposed to be showered weekly on Mondays but felt facility staff did not consistently do so. Review of resident 33's comprehensive care plan showed their desired bathing frequency was not identified. Resident 33's September and October 2023 bathing records showed from 09/01/2023 through 10/25/2023, the resident was offered/provided bathing on three (09/11/2023, 09/25/2023 and 10/02/2023) of eight opportunities. On 10/27/2023 at 12:15 PM, Staff B, Director of Nursing (DNS), said it was the expectation that residents' bathing preferences be honored and acknowledged Resident 33's had…

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

Based on interview and record review, the facility failed to ensure resident admission and annual Minimum Data Sets (MDS, an assessment tool) were completed within the required timeframes for 8 of 11 sampled residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed for resident assessments. Failure to complete admission and annual assessments within the required timeframes, placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's) showed annual assessments must be completed no later than the assessment reference date (ARD) plus14 calendar days and admission assessments must be completed no later than the admission date plus13 days. 1) Resident 1's electronic health record (EHR) showed an annual MDS had an ARD of 08/10/2023. Review of the annual MDS completion date showed it was not completed until 10/08/2023, 59 days after the ARD. On 10/26/2023 at 1:44 PM, Staff E, MDS Director, said Resident 1's…

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

Based on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 9 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33, 90 & 94) reviewed for resident assessments. Failure to timely complete resident quarterly assessments, placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's), showed quarterly assessments must be completed no later than the ARD plus 14 calendar days. 1) Resident 1's electronic health record (EHR) showed a quarterly MDS had an ARD of 05/10/2023. Review of the quarterly MDS completion date showed it was not completed until 07/16/2023, 69 days after the ARD. On 10/26/2023 at 1:44 PM, Staff E, MDS Director, said Resident 1's 05/10/2023 quarterly MDS assessment was completed late. 2) Resident 37's EHR showed a quarterly MDS had an ARD of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include trimming residents' fingernails and toenails and providing assistance with eating for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADL's. The failure to provide assistance with eating and nail care to dependent residents, placed them at risk for decreased intake, weight loss, poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Assistance with Eating> 1) Review of Resident 100's quarterly Minimum Data Set (MDS, an assessment tool), dated 09/05/2023, showed the resident was cognitively intact and required extensive assistance with eating and personal hygiene. Resident 100's ADL care plan, revised 10/23/2023, showed the resident required one-person extensive assistance with meals. On 10/23/2023 at 11:58 AM, Staff N, Certified Nursing Assistant (CNA) delivered Resident 100's lunch tray, positioned her in bed and exited the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents received care and services as ordered for 4 of 7 residents (Residents 93, 31, 97 and 51) reviewed for bowel management. The failure to provide bowel care in accordance with the facility's bowel protocol and/or physician's orders placed residents at risk for constipation, pain/discomfort and other potential negative health outcomes. Findings included . The facility's Bowel Management Protocol, dated May 2018, documented that if a resident had had not produced a bowel movement after two days, nursing staff would initiate the bowel management protocol. On day three staff would offer Miralax (laxative) or bisacodyl (laxative) and these could be repeated the following day. If no bowel movement was produced on day four, staff would offer a bisacodyl suppository. If no bowel movement, on day five staff would offer an enema. 1) Resident 31 was admitted to the facility on [DATE]. The annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice and physicians' orders for 2 of 2 residents (Residents 97 & 100) reviewed for respiratory care. The facility's failure to ensure nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs) tubing and masks were cleaned and periodically changed, and a residents' peripheral oxygen saturation were monitored, as ordered to determine if administration of supplemental oxygen was indicated, placed residents at risk for unidentified and/or unmet respiratory needs and potential negative outcomes. Findings included . 1) Resident 97's quarterly Minimum Data Set (MDS), an assessment tool, dated 08/10/2023, showed the resident had no respiratory related diagnoses but required supplemental oxygen during the assessment period. Resident 97's physician's orders, dated 02/17/2023,…

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 sufficient staff to assess resident care needs, and to provide and supervise that care as evidenced by the failure to complete resident assessments within required time frames for 8 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed, to honor resident preferences related to bathing frequency for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices, and to provide assistance with activities of daily living (ADLs) for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADLs. These failures placed residents at risk for poor hygiene, unidentified and unmet care needs, feelings of powerlessness, and decreased quality of life. Findings included . <Resident Assessments> On 10/26/2023 at 1:52 PM, when asked what was preventing the facility from completing resident assessments within the required time frames, Staff E, MDS (Minimum Data Set) Director, said it was staffing. Staff E explained the facility had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 3 of 3 nourishment refrigerators (Bay Unit, Hydration Station, and [NAME] Unit). This failure placed residents at risk for cross-contamination and food borne illness. Findings included . <Bay Unit Refrigerator> On 10/23/2023 at 11:35 AM, the Bay Unit refrigerator, in the corner of Bay Dining Hall, was observed with an undated, unlabeled, and partially filled glass jar of Smuckers jelly, and 2 liter bottles of Sprite and Root Beer. At 11:35 AM, Staff J, Certified Nursing Assistant (CNA), stated, This all should have been dated here. <Hydration Station Refrigerator> On 10/27/2023 at 09:33 AM, the Hydration Station small refrigerator, was observed with an undated, unlabeled, and partially consumed glass jar of Smuckers jelly, and a jar of sweet chili sauce. In the same refrigerator unit, was an undated, and unlabeled small, orange, plastic container with unidentifiable contents of food. At 9:35 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure infection control principles were followed related to management of urinary drainage bags, proper use of Personal Protective Equipment (PPE), appropriate infection control measures during COVID-19 (a disease which can be very contagious and spreads quickly and capable of progressing to severe symptoms including death) testing, and following transmission-based precautions (TBP) for COVID-19 virus for 4 of 8 sampled residents (97, 102, 10 & 311) reviewed for infection control measures related to urinary drainage bags, PPE, COVID-19 testing and TBP. These failures placed residents at risk for contracting COVID-19 and a diminished quality of life. Findings included . Facility policy entitled COVID-19 Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19, revised 10/23/2023, showed nurses should test one resident at a time. Nurses should wash their hands or use hand sanitizer before and/or after securing 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 and interview, the facility failed to ensure visibly dirty/soiled bed linen was removed and clean linen provided for 1 of 2 residents (Resident 97) reviewed for environment. This failure placed the resident at risk of feeling unclean, undignified, for potential infections and diminished self-worth. Findings included . A progress note, dated 10/18/2023 at 12:14 PM, documented Resident 97 had a new open area to their left ear. On 10/23/2023 at 2:08 PM, Resident 97 was observed in a left side-lying position in bed, with the left side of their head/face laying directly on the mattress without a pillow. Multiple dime and quarter sized brownish/red stains were noted on the fitted sheet clustered around Resident 97's head. Additionally, two large dry brown stains were observed on the right top side of the fitted sheet and continued off the edge of the mattress towards the floor. On 10/24/2023 at 9:54 AM and 11:18 AM, and 10/25/2023 at 12:22 PM, Resident 97's soiled bedding had not been changed. The cluster of dime and quarter sized reddish brown stains were still…

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

Based on observation, interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised and accurately reflected resident care needs for 3 of 25 sampled residents (Resident 97, 73, and 100) reviewed for care plans. This placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 97's activities of daily living CP, revised 10/09/2023, showed the resident received a mechanical soft diet with thin liquids. Resident 97's chewing and swallowing difficulty CP, revised 10/19/2023, showed staff were to provide a mechanical soft diet with thickened liquids. Physician orders for Resident 97 showed an order, dated 02/20/2023, for a mechanical soft diet with thin liquids. Resident 97's activities of daily living CP, revised 10/09/2023, showed the resident had the following restorative programs (nursing interventions that promote the residents' ability to adapt and adjust to living as independently and safely as possible): 1) Active range of motion (ROM) utilizing motorized therapeutic cycle on level one for 15…

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 services provided met professional standards of practice for 2 of 25 sampled residents (Residents 97 & 100) reviewed. The failure to follow and/or clarify physicians' orders when indicated and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) Resident 97's physician orders showed an order, dated 02/20/2023, for oxycodone (narcotic pain medication) every six hours, as needed, for pain. Resident 97's October 2023 Medication Administration Record (MAR) showed the resident was medicated with oxycodone on 10/02/2023 at 5:28 PM and 10/04/2023 at 4:06 PM for a pain level of zero. Resident 97's physician orders showed an order, dated 10/15/2023, to administer oxycodone liquid concentrate every two hours, as needed, for pain or difficulty breathing and directed staff to notify hospice after two doses. Resident 97's October 2023 MAR showed the resident was medicated with oxycodone on 10/16/2023 at 9:15 PM and 10/23/2023 at 9:19 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) were assessed for catheter removal as soon as possible, had a documented justification for ongoing catheter use if removal was contraindicated, or were referred to urology for evaluation in the absence of a documented justification. Additionally, the facility failed to ensure catheter care and management was provided in a manner that minimized the risk for complications and catheter related urinary tract infections for 1 of 2 residents (Resident 97) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections and other potential negative health complications/outcomes. Findings included . Per the Centers for Disease Control Guideline for Prevention of Catheter-associated Urinary Tract Infections 2009, catheter tubing must be placed in a manner…

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 adaptive equipment with meals, for 1 of 1 resident (Resident 100) reviewed and who required assistance. Failure to provide adaptive equipment placed residents at risk for decreased independence with self-feeding, poor meal intake, and diminished quality of life. Findings included . Resident 100's activities of daily living care plan, revised 10/23/2023, showed staff were directed to provide light-weight silverware with built up handles (makes silverware easier to grasp) for all meals. On 10/23/2023 at 11:58 AM, Staff N, Certified Nursing Assistant (CNA) delivered Resident 100's lunch tray, positioned her in bed and exited the room. Observation of the tray showed Resident 100 was not provided silverware with built-up handles as they were assessed to require. At 12:52 PM, Resident 100 said there were attachments for the silverware in her top drawer of her bedside table that staff were to apply to the handles of her silverware. She indicated they were effective in improving her ability to handle…

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 designate a member of their inter-disciplinary team (IDT) who would be responsible for working with hospice representatives to ensure effective coordination of care between the facility and hospice staff, for 1 of 1 resident (Resident 97) reviewed for hospice services. Additionally, the facility failed to obtain a copy of the resident's hospice plan of care, which identified what services were to be provided, and which delineated hospice/facility responsibilities. These failures detracted from establishing a system by which consistent communication between the facility and hospice staff occurred and placed the residents at risk for not for receiving necessary care and services. Findings included . Review of the facility's hospice program policy, revised July 2017, showed the facility would designate a member from their IDT to coordinate care with the hospice provider. The designee would be responsible for obtaining the most recent hospice plan of care and the names and contact information for hospice personnel involved…

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 offer the pneumococcal vaccine to 1 of 5 sampled residents (Resident 93) reviewed for pneumonia vaccinations. This failure placed residents at risk for developing pneumonia with potential negative outcomes. Findings included . Resident 93 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and congestive heart failure. The quarterly Minimum Data Set, an assessment tool, dated 07/13/2023, documented the resident was severely cognitively impaired. The facility's Pneumococcal Vaccine policy, revised 07/2017, documented, Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Resident 93's electronic health record (EHR) did not document the resident's pneumococcal vaccine status. The EHR did not document…

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.