Richland Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an incident of neglect regarding a fall to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency. Findings included . Review of the facility policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised on 01/2023, showed if the allegation involves neglect, that does not involve abuse or serious injury, the incident is reported within 24 hours to the state survey agency, as required. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated 12/07/2024, showed Resident 1 had severe cognitive loss. Review of Resident 1's plan of care, dated 12/17/2024,…

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 interviews and record review, the facility failed to supervise to ensure staff provided care according to the resident's plan of care and facility policy to prevent falls for 1 of 3 residents (Resident 1), reviewed for falls. This failed practice resulted in potential injuries to Resident 1 when they fell to the floor. Failure to follow residents' plans of care placed residents at risk for injury, falls, and a diminished quality of life. Findings included . Review of the facility policy titled, Gait Belt Policy and Procedure, not dated, showed it was the policy of the facility to use a gait belt with any resident that was not independent. If the resident was unsteady with their gait or unable to transfer independently, a gait belt should be used. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 4 residents (Resident 1 and 2) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a condition in which the body doesn't have enough oxygen in the tissues), heart disease, and kidney disease. The 10/28/2024 comprehensive assessment showed Resident 1 required substantial/maximum…

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 Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had required level II referral if residents had a positive level I PASARR, for 4 of 5 residents (Residents 43, 5, 23, and 34 ) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive level I PASARR screen (that would then require a referral for a level II PASARR) was Any of the questions in Section 1A…

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 develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 3 of 6 residents (Residents 7, 58, and 52) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs. Findings included . <Resident 7> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a recent fall with a head laceration (a deep cut or tear in skin) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's comprehensive assessment dated [DATE], showed Resident 7 required extensive assistance of one caregiver for activities of daily living (ADL's) and was cognitively intact. During an interview 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 observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 3 of 5 residents (23, 34 and 35) reviewed for unnecessary medications. The facility failed to ensure residents had an appropriate diagnosis for use of psychotropic medications, had person-centered behaviors being monitored to reflect adequate need for the medications or implement non-pharmacological interventions to attempt prior to administering psychotropic medications. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS, to assess for the presence and severity of abnormal movements of the face, limbs, and body) prior to beginning the psychotropic medications. These failures placed the residents at an increased risk for receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication. Findings included . <Resident 23>…

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 protection of residents from their Alleged Perpetrator (AP), after allegations of abuse/neglect were reported to the facility for 1 of 6 residents (Resident 51) reviewed for abuse/neglect. This failure placed all residents at an increased risk for unidentified abuse and/or further abuse, and unmet psychosocial care needs. Findings included . <Resident 51> Review of the resident's medical record showed the resident admitted to the facility with diagnoses of a coccyx (the bone at the end of the spinal column) fracture and heart failure. The 06/26/2024 comprehensive assessment showed the resident was cognitively intact and experienced frequent pain. During an interview on 08/05/2024 at 10:59 AM, Resident 51 made an allegation against a male staff member that worked at night. Resident 51 described the staff member as light skin colored, slightly balding head, taller than average, with a mustache/beard. Later identified as Staff F, Licensed Practical Nurse. Resident 51 stated they were afraid when Staff F…

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 report allegations of abuse and/or neglect to the State Agency for 2 of 6 residents (Residents 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect. Findings included . Review of the Code of Federal Regulations 483.12 (c)(1), F609, Reporting of Alleged Violations showed, facility's must Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and the other officials (including to the State Survey Agency . Review of the facility's policy titled, Abuse-Screening, Training, Identification,…

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 conduct a thorough investigation into an allegation of abuse and/or neglect and prevent an elopement for 2 of 5 residents (Resident 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and/or continued abuse, recurrent elopements, and unmet care needs. Findings included . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated January 2023, showed that all allegation of abuse were to be thoroughly investigated. <Resident 27> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and a bladder infection. The comprehensive assessment dated [DATE], showed the resident had a moderately intact cognition, was able to understand others and make their needs known. During an interview on 08/06/2024 at 9:15 AM, Resident 27 stated their roommate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive resident centered care plans for 2 of 6 residents (Residents 34 and 51) reviewed for unnecessary medications and skin conditions. This failed practice put residents at risk for unmet care needs. Findings included . <Resident 34> Review of the resident's medical record showed the resident admitted with diagnoses to include metastatic (cancer spreads beyond the place where it started to other areas of your body) breast and bone cancer (a disease resulting from uncontrolled growth and division of abnormal cells), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and elevated blood pressure (the blood pressure in the arteries is persistently elevated.) The 07/10/2024 comprehensive assessment, showed the resident's cognition was intact. A concurrent observation and interview on 08/05/2024 at 3:27 PM, Resident 34 was observed 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 provide care and services for 1 of 2 residents (Residents 51), reviewed for skin care when they did not obtain a skin treatment order for an on-going rash for Resident 51. This failure placed the residents at risk for further skin irritation, discomfort, and pain. Findings included . <Resident 51> Review of the resident's medical record showed the resident admitted to the facility with a fracture to their tailbone and dermatitis (a term for conditions that cause inflammation of the skin). The 06/26/2024 comprehensive assessment, showed Resident 51's cognition was intact. A concurrent observation and interview on 08/06/2024 at 10:54 AM, Resident 51 was lying in bed, just had a shower, and complained of irritation under their breasts. The resident had bright red, shiny appearing skin underneath the creases of both breasts. Resident 51 stated the staff had been applying powder to their rash under their breasts but had not in a few days and thought they would since they just had a shower. A concurrent observation…

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 the adequate supervision and safety monitoring for 1 of 1 resident (Resident 52) reviewed for elopements (the potential danger when a resident, often deemed impaired to make sound decisions, leaves the facility premises or safe area unauthorized, posing immediate threats to their health or safety). This failure placed the resident at risk for serious injury related to an inaccurate risk assessment for elopement. Findings included . Review of the facilities policy dated 10/2022 titled, Elopement/Wandering, showed Residents are evaluated for potential for elopement during the admission/readmission process, and when a change of condition is noted, resulting in cognitive or behavioral changes placing them at risk for elopement. <Resident 52> Review of Resident 52's medical record showed that the resident was admitted to the facility on [DATE] with diagnosis to include vascular dementia (Problems with reasoning, planning, judgement,…

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 orders were obtained, the resident's respiratory status was monitored, or the maintaining of respiratory equipment was completed for 2 of 3 residents (Residents 58 and 5) reviewed for respiratory care. were provided such care, consistent with professional standards of practice. This failed practice placed these residents at risk for unmet respiratory needs and potential negative outcome. Findings included . Review of the policy titled Respiratory Treatment dated 06/22/2022, showed residents were to receive respiratory treatments and monitoring, per their physician orders and when oxygen tubing and nebulizer (a machine used to turn liquid medications into a fine mist) masks were not in use they would be stored in a bag. <Resident 58> Review of the resident's medical record showed the resident admitted to the facility with Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes breathing difficult and…

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

Based on observation, interview, and record review, the facility failed to ensure dialysis (a process that removes your blood from your body, filters out toxins in a machine, and then sends your filtered blood back into your body) care and services were consistent with professional standards of practice for 1 of 1 resident (Resident 23) reviewed for dialysis care. The facility failed to administer morning medications consistently, to include insulin (a medication that helps regulate blood sugar levels) and monitoring blood sugar levels (a procedure that required a stick to the fingertip with a lancet, and a drop of blood placed on the tip of a test strip that is inserted into a machine to determine what the blood sugar level is) to the resident prior to leaving for dialysis. This failed practice placed Resident 23 at risk for complications and adverse side effects from inconsistent medication administration. Findings included . <Resident 23> Review of resident 23's medical record showed the resident admitted to the facility with end stage kidney disease and required dialysis…

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 that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event) for 1 of 2 residents (Resident 13) reviewed for mood and behavior. This failure placed residents at risk for unidentified triggers and re-traumatization. Findings included . <Resident 13> Review of the medical record showed Resident 13 was admitted to the facility on [DATE] with a diagnosis of PTSD. Resident 13's comprehensive assessment dated [DATE] showed they required minimal assistance of one staff member for activities of daily living (ADLs, daily actions like dressing, transferring and toileting) and had an intact cognition. During an interview on 08/06/2024 at 1:55 PM, Resident 13 stated they had a very…

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 recommendations from the Pharmacist's monthly medication review (MMR) were reviewed and appropriately completed by the medical provider for 1 of 5 residents (Resident 23) reviewed for unnecessary medications. This failed practice put the resident at risk for receiving duplicate therapy (more than one, same class of medication used for the same indication) of depression (a persistent feeling of sadness and loss of interest) medications that were unnecessary and a negative medical reaction. Findings included . Review of a policy titled Drug Regimen Review dated 04/2019, showed the pharmacist would review medications, to include drugs used in duplication [duplicate therapy] monthly and make recommendations as needed. Then the facility would notify the physician of the recommendations and the physician would follow-up in a timely fashion. <Resident 23> Review of the resident's medical record showed the resident admitted to the facility with diagnoses of dementia (a group of symptoms affecting memory, thinking and social…

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

Based on observation, interview, and record review, the facility failed to ensure 1) the labeling of several small containers of syrup on three trays located in dry 1 of 1 dry storage rooms in the kitchen, and 2) the resident's nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded for 1 of 1 nutritional refrigerators in the facility. These failures placed residents at risk for consuming contaminated, expired foods, and food-borne illness. Findings included . <Dry storage> A concurrent observation and interview on 08/05/2024 at 9:45 AM, showed in the dry storage room, on the third shelf, had three trays of syrup poured into small condiment containers with no dates on containers to show expiration date. Staff Y, Dietary Director, acknowledged there were no dates on the condiment containers and stated, they need to have a date. <Nutritional Refrigerator> An observation on 08/06/2024 at 11:01 AM, of the nutritional refrigerator located in the dining room showed in the freezer there were large ice cream containers brought in with only 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions for, 1) hand hygiene and glove change for 2 of 6 residents (Resident 3 and 23) reviewed during daily resident cares and wound care treatment, and 2) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols and procedures when control measures (actions or steps taken) were not met to reduce the risk of growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water for 1 of 1 water management program (WMP) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of Centers for Disease Control and Prevention (CDC) recommendations titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024 showed that hand hygiene was to be…

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 provide a functional, comfortable and sanitary environment for 1 of 1 laundry rooms (LR1) reviewed for environmental conditions. This failure placed staff and residents at an increased risk for infections related to unsanitary surfaces. Findings included . During a concurrent observation and interview on 08/07/2024 at 3:54 PM, with Staff H, Housekeeping/Laundry Director, showed a washing machine with rolled up towels on the laminate (a type of flooring) floor surrounding the base of the washing machine. The towels were soaked with water that had been leaking from the washing machine. Staff H stated that the washing machine had been leaking for a couple of months. When surveyor walked over by the washing machine, the laminate floor squished down, and a grayish sludge (a thick, soft, wet mixture of liquid) oozed out from in-between the laminate flooring. During an interview on 08/08/2024 at 4:05 PM, in the laundry room, Staff G, Maintenance Director, and Staff H, stated the washing machine had been leaking on/off for months.…

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 interviews and record review, the facility failed to ensure hemodialysis (a machine that filters wastes, salts and fluids from the blood when the kidneys no longer were working properly) care and services were consistent with professional standards of practice for 1 of 2 residents (Resident 1) reviewed for dialysis care. The facility failed to remove the pressure dressing applied to the A/V fistula (arteriovenous fistula - surgically created connection between vein and artery to allow direct access to the bloodstream for dialysis) following dialysis treatment, failed to consistently monitor the resident's condition following dialysis and to ensure facility policies and procedures were implemented. This failed practice placed Resident 1 at risk for complications and adverse medical conditions. Findings included . Review of the facility policy titled, Hemodialysis Care, last revised on 11/2023, showed staff were to assess bruit (listen for blood flow through the fistula by placing stethoscope on the fistula, any changes in the pitch might indicate a clot or narrowing of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to timely and thoroughly evaluate and monitor a change of condition for 1 of 3 residents (Resident 1) reviewed for changes in condition. Failure to assess and monitor Resident 1 in a timely manner following a significant change of condition placed the resident at risk for a delay in medical treatment. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included diabetes, respiratory disease, kidney disease and heart disease. Review of Resident 1's comprehensive assessment, dated 03/12/2024, showed the resident had no cognitive impairments. Review of Resident 1's plan of care, dated 03/05/2024, showed they required maximum assistance with one staff for dressing, bathing, personal hygiene; minimal to moderate assistance with one staff for transfers and walking; stand by assistance by staff for toileting; and was independent with eating. Review of a PN, dated 04/19/2024…

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 and interview, the facility failed to ensure the garbage dumpster area was maintained in a manner to prevent the harborage (shelter) of pests during 4 of 4 observations made on three days of the survey. This failure placed the facility at risk for an unsanitary environment. Findings included . An observation on 06/06/2023 at 8:55 AM, showed the outside dumpster was a large metal container with two plastic lids that covered half of the surface area opening. Inside the dumpster were several bags of garbage and cartons of shakes and milk. An observation on 06/08/2023 at 12:18 PM, showed both dumpster lids were completely open that exposed the garbage. The dumpster had multiple bags of garbage inside. A concurrent observation and interview on 06/08/2023 at 1:51 PM, showed the dumpster was completely open with multiple bags of garbage inside. Staff E, Registered Dietician (RD), stated that both lids to the dumpster should be closed to prevent contamination. During an interview on 06/08/2023 at 1:47 PM, Staff F, Dietary Manager, stated that the lids to the dumpster…

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

Based on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary manner for prevention of cross contamination. The dishwasher was not maintained and repaired as needed, perishable (food that will go bad quickly) food labeling was inconsistent, expired food was observed in the refrigerator, and a staff beverage was located with clean dishware. These failures placed all residents that ate food from the kitchen at risk for food borne illnesses and a diminished quality of life. Findings included . Dishwasher During a concurrent observation and interview on 06/06/2023 at 8:55 AM, Staff F, Dietary Manager (DM), showed a discolored and frayed, eighteen by one inch dish towel, wedged into the vertical edge of the front panel of the dishwasher. The dish towel was wet when exposed to the dishwashing cycles when the dishwasher was operated. Staff F stated that the dish towel was placed there by the Maintenance Director to prevent leaks and water from being sprayed out of the dishwasher. A concurrent observation and interview 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 observation, interview and record review, the facility failed to ensure standard infection prevention and control precautions were implemented for 2 of 2 residents (Residents 18 and 163) observed during wound care dressing changes. Additionally, hand hygiene was not performed during personal care (cleaning the private areas of a resident) by 2 of 2 staff (Staff G and Staff H) observed for hand hygiene. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the Centers for Disease Control and Prevention's January 30, 2020, document Hand Hygiene Guidance, showed that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water: • Immediately before touching a resident; • Before moving from work on a soiled body site to a clean body site on the same patient; • After touching a resident or the resident's immediate environment; • After contact 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 observation, interview and record review, the facility failed to ensure a right calf rash was identified, the cause determined, and monitoring occurred in 1 of 1 Residents (Resident 55) reviewed for non-pressure related skin conditions. This failure placed the resident at risk for a delay in identification and treatment of new skin impairments, a delay in preventative measures put in place to prevent worsening, discomfort, and decreased quality of life. Findings included . Review of the facility policy titled, Skin at risk/skin breakdown, updated on 09/2020, showed that a full body skin evaluation would be completed upon admission, then weekly by a licensed nurse. The licensed nurse would place monitoring and ordered treatments on the treatment administration record (TAR). The policy further showed that all non-pressure related skin impairments would continue to be monitored weekly during the healing process and were to coincide with weekly skin assessments. Resident 55. Review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 23) reviewed for accidents, was assessed for safe, independent use of a smoking device, after the resident's roommate reported to staff that Resident 23 had been using a vape pen (an electronic cigarette device that simulates tobacco smoking) in their room. This failure placed the residents at risk for preventable accidents and a diminished quality of life. Findings included . Review of the undated Resident Orientation Guidebook, showed No Tobacco: Smoking and the use of tobacco products are not allowed anywhere on facility grounds by the residents. Tobacco products, lighters, and matches must be given to family or friends upon admission, or we can assist with disposal. Review of the No Smoking Policy for Residents, dated 03/2020, showed No smoking or use of smoking materials is allowed on the grounds, including parking lots, except at the following locations: In personal vehicles (vehicles are considered…

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 1 of 4 residents (Resident 215) who utilized adaptive eating equipment was provided with the necessary adaptive equipment for eating as ordered by Staff S, Occupational Therapist (OT). Resident 215 was not provided with a plate guard (a curved assistive device that helps to keep food from falling off of the plate) for two of three meals observed. This failure placed the resident at risk for increased dependence for eating and the potential for decreased food consumption. Findings included . Review of the 02/2019 facility policy titled Assistive Devices, showed that the facility was to provide special eating equipment and utensils for residents that required them. Further review showed the assistive devices were provided to residents at each meal. Resident 215. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that causes uncontrolled body…

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.