Bailey-Boushay House

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 2 of 5 residents (Resident 13 & 17), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, adverse side effects, and a diminished quality of life. Findings included . Review of the facility policy titled, High-Alert Medication Monitoring Policy, updated in November 2022, showed, Residents prescribed medications falling under the definition of high-risk will be monitored for adverse side effects [or unexpected and harmful reactions from the use of medication] and the observations documented in the clinical record. Residents who use high-risk medications will be routinely assessed for side effects. RESIDENT 13 Resident 13 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (mental health…

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 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 23), reviewed for SCSA. The failure to complete an SCSA for a decline in eating and transfer placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed that a SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team has determined that a resident meets the significant change guidelines for either major improvement or decline. It showed that a significant change is a major decline or improvement in a resident's status that impacts more than one area of a resident's health status. It further…

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 care plans for 2 of 12 residents (Residents 17 & 13), reviewed for comprehensive care plan. The failure to develop care plans for Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) and use of an anticoagulant (medication to prevent blood clot) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Trauma-Informed and Culturally Competent Care, updated in March 2024, showed that the purpose of the facility policy was to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice .to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. It further showed, Work with residents and families to create a plan that embraces strengths. Review of the facility policy titled, Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 2 of 12 residents (Resident 19 & 23), reviewed for care plan revision. The failure to revise the care plan to include refusal to wear safety apron for smoking and identified activity preferences placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Discharge Planning, Discharge Summary and Post-discharge Plan of Care-Inpatient, updated in October 2022, showed, A comprehensive care plan will be developed by the interdisciplinary team within 21 days of admission and updated at minimum every three (3) months or more often if needed . Review of the facility's document titled, Resident Recreation and Activities Policy, updated in November 2022, showed [Facility will] Offer activities tailored to each individual resident's interest, abilities, and preferences, as identified through assessments and care planning. 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 observation, interview, and record review, the facility failed to ensure an activity program met the need of 1 of 1 resident (Resident 23), reviewed for activities. The failure to implement an individualized ongoing program to support the resident in their choice of activities based on the comprehensive assessment and care plan placed the resident at risk for unmet activity pursuit, social isolation, and a diminished quality of life. Findings included . Review of the facility policy titled, Resident Recreation and Activities, updated in November 2022, showed [Facility will] Offer activities tailored to each individual resident's interest, abilities, and preferences, as identified through assessments and care planning. Review of a face sheet printed on 05/01/2025, showed Resident 23 was admitted to the facility on [DATE]. In a phone interview on 04/29/2025 at 11:07 AM, Resident 23's Collateral Contact 1 [CC1] stated that Resident 23 was in their room 24/7 [24 hours, 7 days a week]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was a trauma survivor and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) was adequately assessed for trauma-informed care and associated triggers in accordance with professional standards of practice for 1 of 2 residents (Resident 17), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . Review of the facility policy titled, Trauma-Informed and Culturally Competent Care, updated in March 2024, showed that the purpose of the facility policy was to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice .to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. It further showed Work with residents 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 interview and record review, the facility failed to ensure adequate monitoring was conducted for use of anticoagulant (medication that prevents blood clot) for 1 of 5 residents (Resident 13), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility policy titled, High-Alert Medication Monitoring Policy, updated in November 2022, showed, Residents prescribed medications falling under the definition of high-risk will be monitored for adverse side effects and the observations documented in the clinical record. Residents who use high-risk medications will be routinely assessed for side effects. Review of the physician's order summary report printed on 05/05/2025 at 7:32 AM, showed Resident 13 had an order for apixaban (an anticoagulant medication) five milligrams (mg-a unit of measurement) to be given every 12 hours for pulmonary embolism (blood clot in the lungs) and deep vein thrombosis (blood clot in the deep vein). Further…

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 resident in the paid feeding assistance program was adequately assessed for appropriateness to receive paid feeding assistance for 1 of 4 residents (Resident 24), and failed to ensure staff providing the paid feeding assistance was properly trained for 1 of 10 staff (Staff O), reviewed for dining observations. These failures placed the residents at risk for choking and aspiration (inhalation of food or fluid into the lungs) and a diminished quality of life. Findings included . Review of the facility policy titled, Using Paid Feeding Assistants, updated in March 2024, showed that residents would be assessed for appropriateness for the program. The policy showed that the Charge Nurse or MDS (Minimum Data Set-an assessment tool) Coordinator will determine if a resident is safe to be fed by a Paid Feeding Assistant. The policy showed that no residents with complicated feeding problems will be deemed appropriate to be fed by the Paid…

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 allegations of abuse were reported timely to the State Agency for 1 of 3 residents (Residents 1), reviewed for abuse allegations. This failure placed the residents at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and Neglect - Reporting and Investigating, updated in June 2024, showed that the facility employee was responsible to report suspicious incidents including sexual abuse to the State Hotline immediately. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, For the purposes of reporting abuse, abandonment, neglect, financial exploitation, sexual assault and physical assault, a nursing home employee (or other mandated reporter) is required to make a report if he or she has reasonable cause to believe the incident occurred. Examples of reasonable cause may include: the individual observes the incident or hears the victim state it happened; or the individual hears about an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS) assessments were completed within 14 days of admission for 2 of 14 residents (Residents 1 & 25) and failed to complete annual MDS assessments within 14 days from the ARD (Assessment Reference Date) for 2 of 14 residents (Residents 27 & 3), reviewed for comprehensive assessments. These failures placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.18.11, revised in October 2023, showed that, at a minimum, facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility (admission date + [plus] 13 days), when there is a significant change in the resident's status, and not less than once every 12 months (within 366 days) while…

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 quarterly Minimum Data Set (MDS) assessments were conducted timely within 14 days from the Assessment Reference Date (ARD or assessment period) for 8 of 12 residents (Residents 2, 5, 19, 6, 3, 22, 25 & 18), reviewed for quarterly MDS assessments. This failure placed the residents at risk for delayed and/or unidentified care needs. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed a quarterly assessment is considered timely if the MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + [plus] 14 days). RESIDENT 2 Resident 2 admitted to the facility on [DATE]. Review of Resident 2's quarterly MDS with an ARD of 01/02/2024, showed it was completed on 04/11/2024 (86 days late). Review of Resident 2's quarterly MDS with an ARD of 04/03/2024, showed it was…

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

Based on observation, interview, and record review, the facility failed to ensure expired food items were discarded appropriately in accordance with professional standards of food safety for 1 of 1 kitchen (Kitchen Dry Foods Storage Area), reviewed for food service. The failure to discard expired food items placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety Requirements, dated 02/28/2023, showed the food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. Joint observation and interview on 05/17/2024 at 8:16 AM with Staff L, Food Services Manager, showed the Kitchen Dry Foods Storage Area had four packages of small size tortillas with an expiration date of 02/18/2024 and six packages of large size tortillas with an expiration date of 05/05/2024. Staff L stated the tortillas were expired and that they should have been discarded by the…

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

Based on observation, interview, and record review, the facility failed to ensure the facility's water management program included a flow diagram to assess or monitor the potential growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease), and failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 1 of 7 residents (Resident 23), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility's policy titled, Water Management Policy, 198.00, revised in November 2021, showed to reduce the risk for health care associated infections from water sources through a protective program that includes systematic building management and infection control principles. Review of the online Centers for…

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 inform a resident and/or their representative of risks and benefits before installation/use of a transfer pole for 1 of 2 residents (Resident 27), reviewed for accidents. This failure placed the resident at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care. Findings included . Resident 27 admitted to the facility on [DATE]. Review of the annual Minimum Data Set (an assessment tool) dated 02/22/2024, showed Resident 27 was independent for lying to sitting and for sit to stand. Review of Resident 27's activities of daily living care plan printed on 05/14/2024, showed an intervention for safety devices, which included use of a transfer pole. Review of Resident 27's electronic health record showed no documentation that Resident 27 had been provided risks and benefits for their use of a transfer pole. Observation and interview on 05/14/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency for 2 of 2 residents (Residents 3 & 25), reviewed for abuse allegations. This failure placed the residents at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Prevention of Abuse and Neglect of Residents and Clients, updated in January 2018, showed that the facility prohibits and prevents abuse, neglect, involuntary seclusion, misappropriation of property of all residents and clients. The policy further showed that the Administrator On Call (AOC) will be responsible for investigating all alleged incidents of abandonment, abuse, neglect, or mistreatment, including injuries of unknown source and misappropriation of resident property. The AOC will utilize the State's Nursing Home Guidelines for Incident, Identification, Investigation and Reporting. Review of the Nursing Home Guidelines, The Purple Book, 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 ensure allegation of abuse was thoroughly investigated for 1 of 2 residents (Resident 25), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Findings included . Review of the facility's policy titled, Prevention of Abuse and Neglect of Residents and Clients, updated January 2018, showed that the facility prohibits and prevents abuse, neglect, involuntary seclusion, misappropriation of property of all residents and clients. The policy further showed that the Administrator On Call (AOC) will be responsible for investigating all alleged incidents of abandonment, abuse, neglect, or mistreatment, including injuries of unknown source and misappropriation of resident property. The AOC will utilize the State's Nursing Home Guidelines for Incident, Identification, Investigation and Reporting. Review of the Nursing Home Guidelines, The Purple Book, 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 provide a written notice of transfer/discharge to the resident and/or their representative describing the reason for transfers for 1 of 1 resident (Resident 10), reviewed for hospitalization. This failure placed the resident at risk for not having an opportunity to make an informed decision about transfers/discharges. Findings included . Resident 10 admitted to the facility on [DATE]. Review of Resident 10's clinical record showed Resident 10 was transferred to the hospital for further evaluation on 03/19/2024 and on 05/04/2024. Further review of Resident 10's clinical record showed no documentation that Resident 10 and/or their representative had been provided written notification of transfer to the hospital. On 05/16/2024 at 10:29 AM, Staff N, Charge Nurse, stated that when a resident transferred to the hospital, they notified residents and/or their representatives by phone. Staff N stated that it was not their policy to notify residents and/or their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed-hold notice was provided at the time of transfer to the hospital for 1 of 1 resident (Resident 10), reviewed for hospitalization. This failure placed the resident at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed Hold and Return Notice for Hospitalization of Social/Therapeutic Leave, updated in January 2018, showed, At the time of hospitalization, clinical staff will . ask the resident to sign a copy of the policy to be placed in their medical record. Give a copy of the policy to the resident. Resident 10 admitted to the facility on [DATE]. Review of the progress notes dated 05/04/2024, showed Resident 10 was transferred to the hospital for further evaluation. Review of Resident 10's Electric Health Record (EHR) did not show documentation that a bed-hold notice was provided to Resident 10 and/or their representative. In an interview…

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 accurately assess 1 of 14 residents (Resident 25), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding tube feeding (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach) and fall incidents placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.18.11, dated October 2023, showed Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI…

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 the Level 1 Pre-admission Screening and Resident Review (PASRR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities, or related conditions are not inappropriately placed in nursing homes for long term care) accurately reflected the current diagnosis for 1 of 5 residents (Resident 3), reviewed for PASRR. This failure placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Resident 3 admitted to the facility on [DATE] with diagnoses that included anxiety (feeling anxious) and unspecified psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality) not due to a substance or known physiological (anything that has to do with the body and its systems) condition. Review of Resident 3's Level 1 PASRR dated 01/11/2022 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of the baseline care plan (preliminary care plan) to the residents and/or their representatives for 2 of 2 residents (Residents 230 & 29), reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Care Planning-Inpatient, dated February 2018, showed that the preliminary care plan will be completed within 48 hours of admission. It further showed that the resident or their representative will receive a copy of the preliminary care plan and that staff will document in the resident's medical record that the copy of the preliminary care plan was given to the resident or their representative. RESIDENT 230 Resident 230 admitted to the facility on [DATE]. Review of Resident 230's Electronic Health Record (EHR) did not show a copy of the baseline…

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 a comprehensive care plan for 1 of 2 residents (Resident 1), reviewed for care plans. The failure to develop a care plan for oxygen care/management placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning - Inpatient, dated February 2018, showed that the facility will have a care plan that directs the care of each resident. The comprehensive care plan will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's physician orders with a start date of 04/06/2024, showed an order for oxygen 0-6L [zero to six Liters - unit of measurement) O2 [oxygen] by NC [nasal cannula - flexible tubing that sits inside the nose and delivers oxygen] as needed for comfort. Review of Resident 1's comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 2 of 13 residents (Residents 15 & 25), reviewed for care plan revision. The failure to revise care plans for denture use, tube feeding (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach), and failure to conduct an interdisciplinary (different areas of expertise) review placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning, dated February 2018, showed that the comprehensive care plan will be reviewed every three months, or more frequently if there is a change in status. The policy further showed, The comprehensive care plan will be revised based on the changing goals, preferences, and needs of the resident. RESIDENT 15 Resident 15 admitted to the facility on [DATE]. Review of the oral and dental health care plan printed on 5/15/2024,…

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 an assessment was completed prior to use of a transfer pole (a type of assistive device for transferring in and out of bed) for 1 of 2 residents (Resident 27), reviewed for accident hazards. The failure to assess for safe use of transfer pole placed the resident at risk for accidents, injury, and other negative outcomes. Findings included . Resident 27 admitted to the facility on [DATE]. Review of the annual Minimum Data Set (an assessment tool) dated 02/22/2024, showed Resident 27 was independent for lying to sitting and sit to stand. Review of the fall care plan printed on 05/14/2024, showed an intervention to, Observe and monitor for [Resident 27's] continued ability to use this pole as an assistive device with transfers. Review of Resident 27's electronic health record showed no documentation that Resident 27 had been assessed for safe use of their transfer pole. Observation and interview on 05/14/2024 on 10:05 AM, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services related to tube feeding (the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, are unable to safely swallow, or need nutritional supplementation) were followed for 1 of 1 resident (Resident 10), reviewed for tube feeding management. The failure to check the gastric residual volumes (GRV - fluid/contents that remain undigested in the stomach) prior to tube feeding administration placed the resident at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Care and Treatment of Feeding Tubes, revised on 11/28/2022, showed it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Resident 10 admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Abnormal Involuntary Movement Scale assessments (AIMS- a rating scale that measures involuntary movements known as tardive dyskinesia [uncontrollable facial, oral, trunk and extremity movements]) were conducted timely for 3 of 5 residents (Residents 20, 6 & 3), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Antipsychotic [used to treat psychotic (a collection of symptoms that affect the mind) disorders) Medication Use, revised in September 2021, showed that residents receiving an antipsychotic medication should have an AIMS assessment completed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, or as needed. RESIDENT 20 Resident 20 to the facility on [DATE]. Review of Resident 20's physician's order summary…

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 received education regarding the potential risks and benefits when offering pneumonia vaccine (use to prevent pneumonia [lung infection]) for 2 of 5 residents (Residents 3 & 20), reviewed for immunizations. This failure placed the residents and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about their pneumonia immunizations. Findings included . Review of the facility's policy dated, Influenza and Pneumococcal Immunizations, reviewed in March 2023, showed for pneumococcal immunizations each resident, or the resident's legal representative, will be provided education regarding the benefits and potential side effects and possible medical contraindications of the immunization. RESIDENT 3 Resident 3 admitted to the facility on [DATE]. Review of the immunization record for Resident 3 showed they received a dose of Pneumococcal Conjugate Vaccine (PCV20-vaccine that protects…

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 inform the resident and/or their designated representatives before administering psychotropic (mind altering) medications for 5 of 7 residents (Residents 15, 18, 19, 20 & 23) reviewed for unnecessary medications. This failure placed the residents and/or the resident representatives at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Review of the facility policy titled, Psychotropic Drug Use: Implementation, Monitoring and Reduction revised in February 2018, showed that Physician and ARNP (Advanced Registered Nurse Practitioner) to weigh risk vs benefits of new or increased therapy and provide informed consent to the resident. RESIDENT 15 Resident 15 admitted to the facility on [DATE] with diagnoses that included neurological disorder (a progressive breakdown of nerve cells in the brain that affects movement, cognitive functions, and emotions). Review of the January 2023 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure comprehensive assessments and Care Area Assessments (CAA) were completed timely as required for 8 of 15 residents (Residents 23, 1, 2, 12, 15, 5, 20 & 25) reviewed for comprehensive Minimum Data Set (MDS) assessments and CAAs. The facility's failure in ensuring comprehensive assessments and CAAs were completed timely as required placed the residents at risk for delayed or unidentified care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument (RAI) process, facilities are required to complete a comprehensive assessment and CAAs for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status, and annually- not less than once every 12 months (within 366 days) while a resident. RESIDENT 23 Resident 23 admitted to the facility on [DATE]. Review of Resident 23's Annual MDS assessment dated [DATE], showed it was completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were conducted timely for 8 of 12 residents (Residents 11, 15, 18, 4, 5, 10, 14 & 19) reviewed for quarterly MDS assessments. The failure to ensure quarterly MDS assessments were completed timely as required placed the residents at risk for delayed and unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument (RAI) Manual, October 2019 edition, indicated that a quarterly assessment must be completed at least every 92 days when a comprehensive assessment was not required. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. A quarterly assessment is considered timely if the MDS completion date (Item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD). RESIDENT 11 Resident 11 admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess 5 of 15 residents (Residents 1, 23, 2, 20 and 25) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding condom catheter (external catheter - urine collection device), weights, indwelling urinary catheter (a flexible tube placed into the bladder to drain urine), diet, mood, and hospice services placed the residents at risks for unidentified or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual,…

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 a comprehensive care plan (CP) for 5 of 15 residents (Residents 2, 12, 15, 20, and 25) reviewed for comprehensive CPs. The failure to develop CPs for bed rails, dental care, hip positioning device, psychotropic (mind altering) medication, and use of Foley Catheter (FC- flexible tube placed into the bladder to drain urine) management placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care Planning-Inpatient, dated February 2018, showed that the facility will have a CP that directs the care of each resident. The comprehensive CP will include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. RESIDENT 2 Resident 2 re-admitted to the facility on [DATE] with diagnosis that included paraplegia (the loss of muscle function in the lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure controlled substances (medications that have the potential for abuse) were locked in a permanent affixed compartment for 1 of 2 medication rooms (Second Floor Medication Storage) and 2 of 4 medication carts (West & East Medication Carts). In addition, the facility failed to ensure expired medication and medical supplies were discarded for 1 of 2 medication storage rooms (Second Floor Storage). The facility's deficient practice had the potential to allow drug diversion and/or abuse of controlled substances. Additionally, this failure placed the residents at risk for receiving compromised and/or ineffective medications and possibly experience adverse side effects. Findings included . Review of the facility policy titled, Controlled Substance Storage, updated in February 2017, showed that medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications. 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.

Based on observation, interview, and record review, the facility failed to ensure foods stored were properly labeled/dated with use by date, ensure kitchen thermometer was sanitized in-between use, and ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety. These failures placed the residents at risk for food borne illnesses (an illness caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility provided policy titled, Food Safety Requirements dated 02/28/2023 showed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, distributed, and served in accordance with professional standards for food safety service safety. UNDATED FOOD ITEMS IN THE KITCHEN Observation on 02/22/2023 at 8:35 AM, showed that the storage area in the kitchen had three large containers of dry items without labels, use by…

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 received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 6 of 7 residents (Residents 4, 19, 25, 180 & 23) related to influenza (flu - an infectious disease caused by a flu virus) and/or pneumococcal (pneumonia - lung infection) vaccinations. In addition, the facility failed to review the flu and pneumonia vaccination policy annually as required. These failures placed the residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from flu and pneumonia. Findings included . The facility's policy titled, Influenza and Pneumococcal Immunization dated February 2011, showed that each resident, or legal representative on their behalf, will be offered a flu and pneumococcal immunization as directed by best medical practice in relating to timing, resident's prognosis, and possible medical contraindications. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper care of respiratory equipment such as nasal cannula tubing (flexible tubing placed in the nose to administer oxygen [O2]), prefilled single-use humidifier bottle (a device that adds moisture to the air when using O2), and suction machine tubing (medical device used for removing mucus, saliva, blood, or secretions from a person's airway) for 1 of 1 resident (Resident 12) and failed to ensure nebulizer tubing (medical equipment used to deliver medication in the form of a mist) were properly stored when not in use for 2 of 2 residents (Residents 12 & 11) reviewed for respiratory care. These failures placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility's policy titled, Respiratory Care Equipment Maintenance, dated 02/28/2023, showed, O2 tubing is to be changed weekly on Sunday and as needed if secretion can be seen in the tubing . Label to be placed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 2 of 3 staff (Staff N and O) reviewed for nursing aide registry. The facility's failure to receive registry verification that the individual has met competency evaluation requirements placed the residents at risk for abuse and unmet care needs. Findings included . STAFF N Staff N was hired by the facility on [DATE] as a Certified Nursing Assistant (CNA). Review of the employee's record did not include documentation from the nurse aide registry. STAFF O Staff O was hired by the facility on [DATE] as a CNA. Review of the employee's record showed that Staff O's state registry expired on [DATE]. On [DATE] at 11:54 AM, Staff B, Interim Director of Nursing, stated that the facility was unable to locate Staff N's nurse aide registry paperwork. Staff B also acknowledged that Staff O's state registry was expired. On [DATE] at 1:06 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were provided education about COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccination, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the residents' medical records for 3 of 5 residents (Residents 4, 25 & 180) reviewed for COVID-19 immunization. This failure denied the residents and/or their representative of the right to make informed decisions about the COVID-19 vaccination. Findings included . The facility policy titled, COVID-19 Infection Prevention and Control Plan, issued in March 2020, showed that residents will be given the education about the importance of the COVID-19 vaccine and the opportunity to have the vaccine. RESIDENT 4 Resident 4 admitted to the facility on [DATE]. Review of the resident's immunization record showed the 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.