Columbia Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 2 of 2 residents (Residents 22 & 9), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy and properly store nebulizer (medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask) equipment placed the residents at risk for respiratory infections, and related complications. Findings included . Review of the facility's undated policy titled, Oxygen Administration, showed, Oxygen is administered under orders of the physician .Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. It further showed, Keep delivery devices covered in a bag when not in use. RESIDENT 22 Review of the face sheet printed on 03/17/2025 showed that Resident 22 admitted to the facility on [DATE] with diagnoses…

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 required qualifications were up to date for 1 of 18 staff (Staff EE), reviewed for qualified dietary staff. This failure placed residents at risk of receiving unsafe dietary services from staff that did not have a current food handler's permit. Findings included . Review of the facility's undated policy titled, Dietary Services-Staff, showed, The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. Review of the facility's Dietary Aide job description, revised on 04/01/2015, showed Required Education and Experience: Ability to obtain and maintain a [NAME] Food Handler's license. In an interview and joint observation on 03/17/2025 at 8:20 AM with Staff D, Food Service Manager, stated they would expect dietary staff to have a current [NAME] Food Handler's permit. Joint observation showed Staff EE, Dietary Aide, had a [NAME] Food Handler's permit that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received weekly menus consistently for 1 of 2 residents (Resident 33) and to provide an ordered nutritional supplement for 1 of 1 resident (Resident 49), reviewed for dining services. This failure placed the residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Standardized Menus, showed The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents. Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and individualized plan of care .All menus used by the facility should be dated and posted. Menus should be kept on file for at least 30 days .The weekly menus are available by [Facility's] first and second floor elevators and delivered to each…

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 representative were provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record for 2 of 5 residents (Residents 22 & 63), reviewed for COVID-19 immunizations. This failure placed the residents at risk for COVID-19 infection and denied the residents and/or their representative of the right to make informed decisions. Findings included . Review of the Centers for Disease Control and Prevention online document titled, Staying Up to Date with COVID-19 Vaccines, dated 01/07/2025, showed that everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. It showed that for people ages 12-64 years are up to date when they have received one dose of the 2024-2025 COVID-19 vaccine. It further showed that for people ages 65 years and older are up to 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.

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 58 of 58 days (01/01/2024 to 02/27/2024), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility. Findings included . Review of the facility's undated policy titled, Nurse Staffing Posting Information, showed that the nurse staffing sheet will be posted on a daily basis and will contain the total number and the actual hours (by shift) worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Observations of the Staffing Summary staff posting by the reception desk on 02/22/2024 at 10:10 AM, on 02/23/2024 at 1:08 PM, on 02/26/2024 at 9:15 AM, and on 02/27/2024 at 8:59 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.

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 4 refrigerators (Kitchen and Dining Room Refrigerators) and 2 of 2 (Kitchen's Freezer and Walk-In Freezer) freezers reviewed for food services. The failure to label and discard expired food items and/or before use by date, 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 . FOOD ITEMS IN THE KITCHEN'S DESSERT REFRIGERATOR During a joint observation and interview on 02/22/2024 at 6:08 AM with Staff M, Dietary Manager, showed two cartons of strawberry shakes with best use by date of 06/21/2022. Staff M stated that the strawberry shakes should have been discarded. FOOD ITEMS ON THE FIRST FLOOR DINING ROOM REFRIGERATOR Joint observation of the first-floor dining room refrigerator on 02/27/2024 at 11:51 AM, with Staff W, Dietitian, showed one bottle of Gulden's [brand name]…

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 appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medication storage rooms (First Floor Medication Storage Room), and 1 of 2 medication carts ([NAME] Medication Cart), reviewed for medication storage and medication administration. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's undated policy titled, Labeling of Medications and Biologicals, showed, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. The policy further stated that labels for multi-use vials must include the date the vial was initially opened or accessed (needle punctured) and all opened or accessed vials should be discarded within 28 days unless the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident dignity was maintained related to urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 2 residents (Resident 123), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Catheter Care, showed to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling [urinary] catheters are in use. It further showed that privacy bags will be available and catheter drainage bags will be covered at all times while in use. Resident 123 admitted to the facility on [DATE]. Review of Resident 123's catheter care plan printed on 02/26/2024, showed an intervention to provide catheter care every shift and as needed. Observations on 02/22/2024 at 12:13 PM, on 02/23/2024 at 7:45 AM, and 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 inform residents and/or their representatives of risks and benefits before administering psychotropic (mind altering) medications for 2 of 5 residents (Residents 29 & 55), reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed before making decisions about their medications. Findings included . Review of the facility's undated policy titled, Use of Psychotropic Medication, showed residents and or their representatives shall be educated on the risks and benefits of psychotropic drug use as well as alternative treatments/non-pharmacological (not primarily based on medication) interventions. RESIDENT 29 Resident 29 admitted to the facility on [DATE] with diagnoses that included depression (a mental disorder that can cause persistent feelings of sadness, loss of interest, low self-esteem and other emotional or physical problems). Review of the November 2023 Medication…

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 advance directives (healthcare directives) were obtained from the residents and/or their representatives and ensure a copy was readily available in the medical records for 3 of 6 residents (Residents 29, 17 & 47), reviewed for advance directives. This failure placed the residents and/or their representatives at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations. Findings included . Review of the facility's undated policy titled, Residents' Rights Regarding Treatment and Advance Directives, showed that on admission, the facility will determine if the resident has executed an advance directive such as a living will or durable power of attorney [DPOA - written authorization to represent or act on another's behalf, which may be financial or about healthcare]. Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as…

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 missing/lost items had resolutions for 1 of 2 residents (Resident 45), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Resident Personal Belongings and Missing Items, showed the facility and/or the resident would search for missing items and replace or reimburse the resident for missing items if it was determined that the facility had responsibility, or if the cognition of the resident causes the facility to be deemed responsible. Resident 45 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/08/2024, showed Resident 45 was cognitively intact. On 02/26/2024 at 11:20 AM, Resident 45 stated that they had reported to the facility multiple missing items including one perfume, one pearl necklace, one crystal necklace, and a new pair of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency for 1 of 2 residents (Resident 37), reviewed for abuse allegations. This failure placed the resident at risk for repeated incidents, potential unidentified mistreatment, and lack of protection due to unrecognized abuse. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), required the nursing home employee (or other mandated reporter) to make a report if they had reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations. Review of the facility's undated policy titled, Compliance with Reporting Allegations of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify abuse allegation and failed to ensure the abuse allegation was thoroughly investigated for 1 of 2 residents (Resident 37) reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, showed that when a suspicion of abuse, neglect or exploitation, or reports of neglect or exploitation occur, an immediate investigation was warranted. Investigations includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause and providing complete and thorough documentation of the investigation. Resident 37 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of transfer/discharge to the residents and/or representatives describing the reason for transfers for 2 of 3 residents (Residents 37 & 17), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make an informed decision about transfers/discharges. Findings included . Review of the facility's undated policy titled, Transfer and Discharge (including AMA [Against Medical Advise]), showed that for transfers/discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident the facility should provide transfer notice as soon as practicable to residents and representatives. RESIDENT 37 Resident 37 admitted to the facility on [DATE]. Review of the progress note dated 10/29/2023, showed Resident 37 was transferred to the hospital for further evaluation. Review of Resident 37's clinical record did not show documentation that a written notice…

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 bed-hold notices were provided at the time of transfer to the hospital for 2 of 3 residents (Residents 37 & 17), reviewed for hospitalization. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's undated policy titled, Resident Bed Hold Policy, showed that residents and/or family members/legal representatives will be provided with the facility bed hold policy upon admission and at the time of transfer for hospitalization or therapeutic leave. RESIDENT 37 Resident 37 admitted to the facility on [DATE]. Review of the progress note dated 10/29/2023, showed Resident 37 was transferred to the hospital for further evaluation. Review of Resident 37's clinical record did not show documentation that a bed-hold notice was provided to them and/or their representative. During a joint interview and record review on 02/26/2024 at 10:31 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for 3 of 6 residents (Residents 51, 58 & 1), reviewed for timeliness in transmitting discharge Minimum Data Set (MDS) assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, revised in October 2023, showed discharge (non-comprehensive) MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500+14 days) to the database as required. RESIDENT 51 Resident 51 admitted to the facility on [DATE]. Review of the Resident Discharge Summary and Recap of Stay document dated 10/23/2023, showed Resident 51 discharged to a community setting.…

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 accurately assess 1 of 6 residents (Resident 1), reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding discharge 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, Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's discharge MDS (return anticipated combined with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 6 residents (Residents 39 & 47), reviewed for baseline care plan. This failure resulted in the residents and/or their representatives 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 undated policy titled, Baseline Care Plan, showed baseline care plan will be developed within 48 hours of a resident's admission. The policy showed that the resident and/or representative will receive a copy of the .Individual Care Plan and the person providing the individual care plan shall obtain a signature from the resident/representative to verify that the summary was provided and make a copy of the summary for the medical record. RESIDENT 39 Resident 39 admitted to the facility on [DATE]. On 02/22/2024 at 8:19 AM, Resident 39 stated…

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 comprehensive care plans for 3 of 15 residents (Residents 45, 47 & 29), reviewed for care planning. The failure to develop care plans for antibiotic (medication to treat infection) use, care of diabetes (the body has trouble controlling blood sugar used for energy), and hospice (end of life care), placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Comprehensive Care Plans, showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. RESIDENT 45 Resident 45 admitted to the facility on [DATE]. Review of the February 2024 physician orders showed an order 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 interview and record review, the facility failed to revise comprehensive care plans for 2 of 15 residents (Resident 16 & 55), reviewed for care plan revision. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Comprehensive Care Plans, showed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. RESIDENT 16 Resident 16 admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting their right dominant side. Review of Resident 16's care plan printed on 02/23/2024, showed an intervention for RNP [Restorative Nursing Program] as tolerated to maintain range of motion. On 02/27/2024 at 1:22 PM, Staff C, Resident Care Manager, stated that the facility did not have a restorative program 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 staff documented in accordance with professional standards for 2 of 4 staff (Staff R & Staff Y), reviewed for medication administration. This failure placed the residents at risk for medication errors and negative outcomes. Findings included . Review of the facility's undated policy titled, Medication Administration, showed to ensure Medication Administration Record (MAR) was signed after medication administration. STAFF R Observation on 02/26/2024 at 9:02 AM, showed Staff R, Registered Nurse (RN), was preparing and signing off medications in the MAR prior to medication administration for Resident 12. On 02/26/2024 at 9:19 AM, Staff R stated that once the medication had been pulled, it was considered administered. Staff R further stated that they signed off medications prior to administering them to Resident 12. STAFF Y Observation on 02/26/2024 at 9:30 AM, showed Staff Y, RN, was preparing and signing off medications in the MAR prior to medication administration for Resident 1. On 02/26/2024 at 9:48…

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 bathing/showers and personal/grooming care were consistently provided for 2 of 2 residents (Residents 1 & 27), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decreased self-esteem, and a diminished qualify of life. Findings included . Review of the facility's undated policy titled, Activities of Daily Living, showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, personal and oral care. Review of the facility's undated policy titled, Bathing a Resident, showed the facility will assist residents with bathing to maintain proper hygiene and help prevent skin issues. RESIDENT 1 Resident 1 readmitted to the facility on [DATE] with diagnoses that included end stage renal disease (a disease where kidneys no longer work as they should to meet the body's needs) requiring 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 use of respiratory equipment were maintained to include care of oxygen tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) in accordance with professional standards of practice for 3 of 3 residents (Residents 46, 37 & 47), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility's undated policy titled, Oxygen Administration, showed change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The policy showed, change humidifier [a device that contains purified water that adds moisture to the air to prevent dryness] bottle when empty, weekly, or as recommended by the manufacturer and keep delivery devices in plastic bag when not in use. RESIDENT 46 Resident 46 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive…

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 assess bed rails (bed enablers) and provide risks/benefits of use to meet the needs of 2 of 3 residents (Residents 46 and 65), reviewed accident hazards. This failed practice placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's undated policy titled, Proper Use of Bed Rails, showed that informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rail. The policy showed the facility should provide risks and benefits for the use of bed rails. It further showed that the facility will attempt to use appropriate alternatives prior to installing or using bed rails and If no appropriate alternatives are identified, the medical record should include evidence of .assessment of the resident, the bed, the mattress, and rail for entrapment risk. RESIDENT 46 Resident 46 admitted to the facility…

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 handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag appropriately for 1 of 2 residents (Resident 123) and failed to ensure hand hygiene was performed during dining observations for 2 of 2 residents (Residents 66 & 30), 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 undated policy titled, Catheter Care, showed, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Review of the facility's undated policy titled, Hand Hygiene, showed staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. It further showed that hand hygiene is indicated and will be performed between resident contacts, and after handling…

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 3 of 5 Residents (Residents 5, 55 & 47) related to pneumococcal vaccinations (vaccines use to prevent pneumonia [lung infection]). This failure placed residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from pneumonia. Findings included . Review of the facility's policy titled, Influenza [an infectious disease caused by a flu virus] and Pneumonia Vaccination, updated 02/03/2022, showed maintain policy and procedure for immunization of residents against influenza and pneumococcal disease in accordance with national standards of practice and to prevent and control the spread of disease. It showed that for adults 65 years or older who have already received one or more doses of PPSV23 (Pneumococcal Polysaccharide Vaccine- vaccine that protects against…

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 routine maintenance to ensure bed rails (bed enablers) were safe to use for 2 of 3 residents (Residents 65 & 46), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's undated policy titled, Proper Use of Bed Rails, showed the facility will assure the correct installation of bed rails, prior to use. This includes ensuring that that the bed's dimensions are appropriate for the resident by checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. RESIDENT 65 Resident 65 admitted to the facility on [DATE]. Review of Resident 65's physician order dated 01/24/2024, showed Safety devices: Hi/low bed and bilateral [both] bed enablers, bed and chair alarms. Review of the safety devices assessment dated [DATE], showed Resident 65 was assessed for bilateral bed rails to promote…

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 the Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN - a required form that provides an estimated cost of continuing services, which may no longer covered by Medicare [government health insurance program]) for 1 of 4 residents (Resident 1), reviewed for liability notices. This failure placed the resident and/or their representative at risk for not having adequate information to make financial decisions related to continued stay in the facility. Findings included . Review of Resident 1's progress notes dated 08/28/2023, showed Resident 1 discharged from the facility on 08/28/2023 at 1:35 PM. Further review of the progress notes showed Staff B, Social Services, stated that they received a message on 08/25/2023 that the receiving facility for Resident 1 was not able to admit them until 08/28/2023. In an interview on 11/06/2023 at 10:15 AM, Collateral Contact 1 (CC1), stated that Resident 1's last Medicare covered stay was 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 allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 2), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse. Findings included . Review of the facility's undated policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, showed that all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources .are reported to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Resident 2 admitted to the facility on [DATE]. Review of Collateral Contact 2's (CC2) written report dated 10/26/2023, showed Resident 2 stated that they were mistreated in the facility and that they did not want Staff C, Nurse Manager, to take care of them…

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 thoroughly investigate allegation of abuse for 1 of 1 resident (Resident 2), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the undated facility's policy titled, Abuse, Neglect, and Exploitation, showed that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. It also showed that the investigation will include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, the cause; and Providing complete and thorough documentation of the investigation. Resident 2 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, record review, the facility failed to have an effective Infection Prevention and Control Program (IPCP) by ensuring acceptable hand hygiene was consistently performed to prevent the potential transmission of infections for 7 of 38 residents (Residents 30, 22, 1, 8, 24, 31 & 59). The facility did not ensure that staff performed hand hygiene during incontinence care and assisting residents in the dining room to prevent cross contamination. These failures placed the residents at risk for facility acquired or healthcare-associated infections, and related complications. Findings included . Review of facility-provided undated policy titled, Perineal Care revealed It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible, and to prevent and assess for skin breakdown .Perineal care refers to the care of the external genitalia and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to ensure residents were provided with dignified existence and self-determinations for 4 of 38 residents (Residents 12, 30, 8 & 22) reviewed for resident rights. The facility failed to ensure Resident 12 received showers per her preference. Additionally, the facility failed to ensure Residents 30, 22 & 18 were treated in a dignified manner during meal service. These failures placed the residents at risk for a diminished quality of life, self-worth, and overall well-being. Findings included . RESIDENT 12 Review of Resident 12's undated admission Record found in the resident's electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses which included hemiplegia/hemiparesis (paralysis of one side of the body[left]) following cerebrovascular disease (stroke) and depression. Resident 12's quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 07/29/2022, revealed the facility…

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 self-administration of medication had been adequately assessed to self-administer medication for 1 of 1 resident (Resident 45) reviewed for administration of medications. This failure placed the resident at risk for unsafe medication administration, medication error and related complications. Findings included . Review of facility provided policy titled Resident Self-Administration of Medication revised November 2017 indicated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer after the facility's interdisciplinary team has determined which medication may be self-administered safely. Continued review indicated Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's room or to confused roommates of the resident who self-administers medication. The following conditions are…

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 1 resident (Resident 66) reviewed for limited Range of Motion (ROM) was provided treatment/services to maintain/increase range of motion to bilateral [both] feet/ankles. This failure placed the resident at increased risk for decreased ROM, contractures (limited movement of a joint), and a diminished quality of life. Findings included . Review of facility-provided un-dated policy titled, Prevention of Decline in Range of Motion revealed .Residents .will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .'Range of Motion' means the full movement potential of a joint .The facility in collaboration with .physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care .The assessment should…

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, and the facility failed to ensure expired medication solution were not stored with un-expired residents' medications/supplies in 1 of 2 medication storage rooms (Second Floor Medication Room). This failure placed the residents at risk for receiving compromised and/or ineffective medication solutions, which potentially result to the residents not receiving the therapeutic effect of the medication solution, and/or possibly experience adverse side effects. Findings include . Review of facility-provided undated policy titled Medication Storage revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security .all medication rooms are routinely inspected .for discontinued, outdated .medications . Review of facility-provided policy titled MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS,…

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' code status were consistent throughout the electronic medical record (EMR) for 2 of 3 residents (Residents 269 & R270) reviewed for advance directives. This failure placed the residents at risk for incorrect life sustaining treatment and a diminished quality of life. Findings included . Review of facility-provided undated policy titled Communication of Code Status revealed It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .the directive will be clearly documented in designated sections of the medical record .The resident's code status will be reviewed at least quarterly and documented in the medical record . RESIDENT 269 Review of Resident 269's undated admission Record located in the resident's EMR under the Profile tab…

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.