Mirabella

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessment and care plan were in place for side rail use, and/or inform the resident and/or their representative the risks and benefits prior to side rail use/installation for 1 of 4 residents (Resident 9), reviewed for side rails. This failure placed a resident at risk for entrapment, injury, and a diminished quality of life. Findings included . Review of the facility policy titled: Side Rail Assessment, revised in April 2024 showed that individual side rail assessments will be performed on a regular basis and the side rail evaluation would include data collection analysis and determination of potential alternatives to side rail usage. The policy showed that when the side rails are deemed necessary and appropriate, the facility will provide education to the residents or residents' representatives pertaining to the risk and benefits of side rail use. The policy further showed that it is the policy of the facility to review the risk…

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 Medication Regimen Review (MRR- a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 1), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life. Findings included . Review of the facility's policy titled, Drug Regimen Review, Report & [and] Act on Irregularity, dated February 2024 showed, The Consultant Pharmacist will review the drug regimen, including medical records of each resident, at least once a month and will report any irregularities to the Attending Physician, Director of Nursing and Medical Director. Review of Resident 1's May 2025 MRR dated 05/21/2025 showed a pharmacist recommendation to discontinue melatonin (a medication/supplement to help with sleep) due to potential side effects. It…

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

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled with open date in accordance with current accepted professional standards for 1 of 2 medication carts (Health Center 2 [HC 2]), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications, unsafe medication administration, and potential adverse side effects. Findings included . Review of the facility's policy titled, Medication Storage and Accounting, dated February 2025, stated that all medications must be labeled in compliance with regulations. Labels must include the resident's name, prescribing physician, drug name/strength/quantity, date filled, prescription number, issuing pharmacy, instructions, and expiration date. During a joint observation and interview on 06/26/2025 at 8:29 AM with Staff K, Registered Nurse, showed the HC 2 medication cart had following medications: - One opened box with four Lidocaine (medication to treat pain) patches labeled for Resident 13 with no open or…

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 bed controls were in a safe operating condition for 1 of 4 residents (Resident 6), reviewed for environment. This failure placed the resident at risk for injury and a decreased quality of life. Findings included . Review of the facility's policy titled, Preventative Maintenance, dated in March 2024, showed, they practice preventive maintenance in order to minimize down time of equipment and machinery and maximize resident comfort. Preventive maintenance ensures that all equipment is operating at optimal efficiency. Staff is trained to monitor for early detection of malfunction to prevent further breakdown. Review of a face sheet printed on 06/27/2025 showed Resident 6 admitted to the facility on [DATE]. In an interview and observation on 06/24/2025 at 8:14 AM, Resident 6 stated that they were worried about their bed control. Observation showed that Resident 6's bed remote control wiring was exposed at the base of the bed control.…

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 conduct a thorough investigation for 1 of 2 residents (Resident 1), reviewed for abuse and/or neglect investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences . All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect. Review of the facility's…

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

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 F and Staff G), reviewed for nursing aide registry. This failure placed the residents at risk for potential abuse, neglect and unmet care needs. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting - SNF [Skilled Nursing Facility] [NAME], last revised in June 2024, showed, Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as board registrations and certifications. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This applies to all employees .The facility will not employ or otherwise engage an individual who: 1. Has a finding entered into the State Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement abuse and neglect policies and procedures to protect residents from misappropriation of property during the investigation of allegation for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for unidentified misappropriation/exploitation and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting, approved in June 2024, showed that a prompt and thorough investigation is the process used to determine what happened and the nurse supervisor or designee would immediately begin the investigation upon notification of an incident and/or alleged abuse. The policy further showed if a staff member is identified as allegedly/possibly involved in suspected abuse, they must be removed from all residents care pending further investigation in order to do all to protect the resident/other residents from further abuse. Review of the quarterly…

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 misappropriation of property was reported timely to the State Agency for 1 of 3 residents (Residents 1), reviewed for abuse allegation. This failure placed the residents at risk for potential unidentified misappropriation/exploitation and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting, approved in June 2024 showed, it was the policy of the company to protect the rights, safety and wellbeing of each resident ( regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual and mental abuse and from neglect, exploitation, financial abuse (including misappropriation of property), use of photographs or recording in any manner that would demean or humiliate a resident, abandonment, or any treatment that would result in physical harm, pain or mental suffering. The policy further showed 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 interview and record review, the facility failed to timely initiate and/or thoroughly investigate allegation of misappropriation of property for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the residents at risk for potential unidentified misappropriation and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting, approved in June 2024 showed, it was the policy of the company to protect the rights, safety and wellbeing of each resident ( regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual and mental abuse and from neglect, exploitation, financial abuse (including misappropriation of property), use of photographs or recording in any manner that would demean or humiliate a resident, abandonment, or any treatment that would result in physical harm, pain or mental suffering. The policy further showed that a prompt 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 4 of 5 residents (Residents 20, 12, 10, & 21), had a completed and an accurate Preadmission Screening 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) on admission. This failure placed these residents at risk for unmet care needs, unmet mental needs, and a decreased quality of life. Findings included . Record review of the facility's policy titled, PASSR-Preadmission Screening and Resident Review policy, dated October 2023, showed that the company will abide by the federal requirement for PASRR to ensure that individuals are not inappropriately placed in nursing facilities for long term care. This policy showed PASRR required that (1) all applicants to a Medicaid-certified nursing facility be evaluated for mental illness and/or intellectual disability;…

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 person-centered comprehensive care plans for 5 of 11 residents (Residents 230, 4, 19, 21, & 20) whose care plans were reviewed. The facility's failure to develop individualized, comprehensive care plans left residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Care Planning, revised in October 2023, showed that within 21 days of admission and/or 7 days after the completion of the comprehensive assessment the interdisciplinary team including the resident and/or responsible party would develop a comprehensive care plan. RESIDENT 230 Review of the physician's order, dated 05/29/2024, showed Resident 230 had an order of oxygen (O2) at two liters (unit of measurement) per minute via nasal cannula (flexible tubing that sits inside the nostrils and delivers O2 as needed for shortness of breath. Review of Resident 230's June 2024 Medication Administration Record (MAR) showed Resident 230 was using O2 since…

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 necessary respiratory care and services were provided in accordance with professional standards of practice for 3 of 3 residents (Residents 5, 19, & 230), reviewed for respiratory care. Specifically, oxygen (O2) equipment was not maintained to include care of O2 tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers O2) and did not have signage for when oxygen was in use. This failure had the potential to affect the resident's respiratory status, including respiratory infections and related complications and the potential to create a hazardous environment. Findings included . Review of the facility's policy titled, Oxygen/Respiratory Therapy and Safety, revised in January 2020, showed, The resident's room will have a sign signifying when oxygen is in use. The policy showed, Oxygen/respiratory equipment tubing/cannula/mask and plastic container bag will be changed at least weekly and anytime as needed…

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 maintain the medication room refrigerator temperature logs in 1 of 3 medication room refrigerators (Medicine Refrigerator) reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage in the Facility, revised on 01/01/2023, showed medications requiring refrigeration were kept in a refrigerator at temperatures between 36 Fahrenheit (F- a temperature scale)- 46 F with a thermometer to allow temperature monitoring. It further showed the facility should maintain a temperature log in the storage area to record temperatures at least once a day. Joint observation on 06/26/2024 at 3:25 PM with Staff B, Director of Nursing, showed that there were three refrigerators (medicine refrigerator, intravenous [within a vein] refrigerator and food refrigerator) in the medication storage room. The medicine refrigerator had one pneumococcal (helps protect against some…

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 keep the kitchen refrigerator and storage free of expired food and staff failed to demonstrate handwashing while preparing lunch for all residents. These failures placed all residents at risk for a food borne illness by potentially serving expired food products and cross contamination from poor hand hygiene during food preparation. Findings included . Review of the facility's General Food Storage Standards, dated January 2023, showed the food storage should incorporate specific standards and criteria to maintain a clean and safe environment for healthful delivery to the residents. The procedure included that any food items that reached their expiration date would be discarded. Review of the facility's Hand Hygiene policy, dated 02/21/2022, showed that the facility considered hand hygiene the primary means to prevent the spread of infections. The policy showed all personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the 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 to review infection prevention and control policy (IPCP) at least annually. Additionally, the facility failed to ensure proper hand hygiene practices were followed during room tray and activity flyer delivery for 2 of 6 staff (Staff H & I) and failed to put isolation precautions for Aerosolizing Generating Procedure (AGP-a medical procedure that produce minute particles that become suspended in the air) for 1 of 2 residents (Resident 4), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . LEGIONELLA WATER MANAGEMENT PROGRAM In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consent for psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) was completed prior to administration for 2 of 5 residents (Residents 15 & 20), reviewed for unnecessary medications. 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 medications prior to administration. Findings included . Review of the facility's policy titled, Psychotropic Medication Management, revised in November 2021, showed that the resident/resident representative would be informed of the medication order, indication for use, and the right to refuse. The policy further showed that resident would be informed of the risk versus benefits of the medication to be administered. RESIDENT 15 Review of the physician's order dated 03/09/2024 showed Resident 15 had an order for a medication for anxiety. Review of the March 2024 to June…

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 an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 2 of 3 residents (Residents 4 & 21), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives, revised in March 2024, showed, If the resident or legal representative has executed one or more advance directive(s), these documents are obtained, incorporated and consistently maintained in the same section of the resident's health information record readily retrievable. RESIDENT 4 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 04/17/2024, showed Resident 4…

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 issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 1 of 3 residents (Resident 331), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk for not being fully informed and losing their right to an appeals process. Findings included . Review of the facility's policy titled, Medicare and Medicare Advantage Notices for Skilled Nursing Facilities, revised in February 2023, showed, It is the policy of the Company that notices for skilled nursing facilities are delivered to residents according to Medicare and Medicare Advantage plan guidelines. Review of the undated Centers for Medicare and Medicaid Services online form titled, Form instructions for the notice of Medicare Non-Coverage (NOMNC) CMS-10123, showed, The NOMNC must be delivered at least two calendar days…

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 provide a written transfer/discharge notice to the residents/representatives and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) for 2 of 3 residents (Residents 230 & 10), reviewed for hospitalization. These failures placed the residents at risk for not having an opportunity to make informed decision about transfers/discharges. Findings included . Review of the facility's policy titled, Discharge/Transfer, revised in November 2017, showed that the transfer/discharge notice would be issued as soon as practicable when an immediate transfer or discharge is required by the resident's urgent medical condition. The policy further showed that the copy of discharge notice must be sent to the State office of Long-Term Care Ombudsman. RESIDENT 230 Review of the nursing progress note dated 06/14/2024 showed that Resident 230 was sent to the hospital for further evaluation. Review of the Electronic Health Record (EHR) did not show documentation that a written notice 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 bed hold (the opportunity to pay for the bed the resident currently occupied while out of the facility in order to ensure their bed/room was available when they are ready to return) notices were offered to residents who were hospitalized for 2 of 3 residents (Residents 230 & 10), reviewed for hospitalization. The failure to offer bed holds placed residents at risk for unwanted, avoidable room changes upon readmission, and frustration. Findings included . Review of the facility's policy titled, Bed Hold, revised on January 2020, showed before a nursing facility transferred a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed hold policy under the State plan, if any during which the resident is permitted to return and resume residence in the nursing facility and the bed…

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 3 residents (Resident 28) reviewed for hospitalization. The failure to ensure accurate assessment regarding discharge status resulted in inaccurate information in the resident's clinical record and placed the resident at risk for unidentified care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, 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 (i.e., comprehensive, quarterly, annual, significant change in status). Review of Resident 28's electronic health record showed a nursing progress note dated 06/07/2024 that showed, This resident was cleared .to go home safely.…

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 gastrostomy tube (G-tube - a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 1 resident (Resident 21), reviewed for tube feeding management. The failure to check for G-tube placement by visual inspection of aspirated stomach content prior to medication administration placed the resident at risk for medical complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Enteral [tube placed in the stomach to provide nutrition and medications] Tube Feeding and Medication Administration, dated November 2022, showed that medication administration would include checking placement prior to administration. It further showed that placement would be checked before each feeding and before each medication administration or intermittently as ordered. Review of the quarterly minimum data set (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 observation, interview, and record review, the facility failed to conduct routine maintenance to ensure side rails were safe to use for 1 of 6 residents (Resident 4) reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Side Rail Assessment, revised in August 2022, showed, The Maintenance department will conduct regular inspection of all the bed frames, mattresses, and side rails as part of their regular maintenance program to identify areas of possible entrapment. Review of the admission minimum data set (an assessment tool) dated 04/17/2024, showed Resident 4 admitted to the facility on [DATE]. Review of the mobility care plan revised on 04/30/2024 showed Resident 4 was one person limited to extensive assist for bed mobility and transfers. In a joint observation and interview on 06/25/2024 at 11:52 AM with Resident 4, showed Resident 4's bed with the right-side rail in the raised position.…

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 in 2 of 3 freezers were labeled/dated with use by date and food products discarded on or before the use by date. These failures placed the residents at risk for food borne illnesses (an illness caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility provided policy titled, General Storage Standards - Dining revised in August 2022, showed that Frozen items should be wrapped or in commercial cartons, dated and labeled. All potentially hazardous foods must be labeled with a date sticker as soon as the package is opened, or the item is prepared. Only such items that have a date sticker less than seven days old will remain on our shelves for consumption by the residents. TENTH FLOOR KITCHEN Observation and interview on 03/15/2023 at 9:10 AM with Staff G, Chef de Cuisine, showed the tenth-floor kitchen refrigerator had a clear plastic container with crushed ginger in it that was labeled ginger with a sticker discard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while dining for 2 of 3 Residents (Residents 18 & 24) and failed to remove mechanical lift (Hoyer lift - a device used to assist with transfers and support mobility) slings from underneath the residents for 3 of 3 residents (Resident 13, 18 & 24) reviewed for dining. The failure to provide a dignified experience during dining placed the residents at risk of diminished self-worth and over-all well-being. Findings included . STANDING OVER WHILE ASSISTING RESIDENTS WITH MEALS RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the Activities of Daily Living (ADL) care plan dated 07/20/2021, showed that Resident 18 had severe cognitive/communication deficits (nonverbal) and required total assist with eating. On 03/15/2023 at 12:11 PM, Staff I, Certified Nursing Assistant (CNA), was standing over while assisting Resident 18 with eating in the dining…

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 the resident and/or their designated representatives before administering psychotropic (mind altering) medications for 2 of 7 residents (Residents 16 & 18) reviewed for unnecessary medications. In addition, the facility failed to inform the residents and/or their representatives before the use of reclining wheelchair and bed/chair alarms for 2 of 2 residents (Resident 18 & 23) reviewed for assistive devices. These failures placed the residents and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about their medications and the appropriate use of assistive devices. Findings included . Review of the facility policy titled, Psychotropic Medication Management, reviewed in November 2022, showed that the resident/resident representative will be informed of the medication order, indication for use, and the right to refuse. The resident will be informed of the risk versus…

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 failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 2 out of 3 residents (Residents 18 & 21) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 3 of 15 residents (Residents 22,16, and 31) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding alarms and diagnosis 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, significant change in status). The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan and/or provide written summary of the baseline care plan to the residents and/or their representatives within 48 hours of admission for 3 of 3 residents (Residents 182, 10 and 332) reviewed for baseline care plans. This failure placed newly admitted residents at risk of not receiving necessary care and services, not being informed of their initial plan for delivery of care and services, and a decreased quality of life. Findings included . The facility policy titled Baseline Care Plan revised in January 2020 showed that a written summary of the baseline care plan in the language the resident/resident representative understand will be provided to the resident/resident representative. The policy also showed that the medical record will show that a written summary of the baseline care plan was given to the resident/resident representative. RESIDENT 182 Resident 182 admitted to the facility on [DATE]. Review of the clinical…

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 3 of 15 residents (Residents 23, 18 and 22) reviewed for comprehensive CPs. The failure to develop CPs for residents' eating preference, use of tilt-in-space wheelchair (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) and bed rails placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Care Plan: Comprehensive dated February 2023, showed It is the policy of the company to have a comprehensive and individualized person-centered care plan in place for every resident . The comprehensive care plan will address . choices/preferences, needs . and will include person-centered interventions . RESIDENT 23 Resident 23 admitted to the facility on [DATE] with diagnosis that included dementia (symptoms affecting memory, thinking and social abilities). Review of Resident 23's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to follow physician bowel medication orders for 1 of 3 residents (Resident 14) reviewed for constipation. This failure placed the resident at risk for discomfort or bowel impaction and a diminished quality of care. Findings included . Review of the policy titled, Bowel Care Management, revised on 02/2023 stated, The Charge Nurse will review all resident's bowel monitoring records/reports/dashboard alerts or the 24-hour report daily .Any resident that has gone three days without a bowel movement recorded will be added to the Bowel Care List. The Bowel Care List will be given the following bowel care interventions or as ordered by physician: a. Evening shift (third day of following no bowel movement [BM] for three days)-Milk of Magnesia (MOM) will be given. b. If no BM by morning on day four- A suppository will be…

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

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 suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction tip (Yankauer) for 1 of 1 resident (Resident 12) and failed to cover the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) tubing and mask when not in use and label the distilled water (a type of purified water) used for CPAP for 1 of 1 resident (Resident 21). These failures placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility policy titled, Suctioning revised in February 2022 showed After completing a single episode of suctioning, wrap the suction catheter around a gloved hand . Discard both into a designated trash receptacle . clean suction collection canister . the suction connecting tubing…

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 bed rail was placed on a resident's bed with resident knowledge, consent, education, assessment, and care plan developed to meet the needs of 1 of 4 residents (Resident 10) reviewed for bed rail use. This failure placed the resident at risk for entrapment, injury, and a diminished quality of life. Findings included . Review of the facility policy titled: Side Rail [bed rail] Assessment last revised in August 2022 showed that individual side rail assessments will be performed on a regular basis. The side rail evaluation will include data collection analysis and determination of potential alternatives to side rail usage. When the side rails are deemed necessary and appropriate, the facility will provide education to the resident or resident's representative pertaining to the risk and benefits of side rail use. The policy also showed that it is the policy of the facility to obtain informed consent, obtain physician order, and 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 interview and record review, the facility failed to ensure 1 of 6 residents (Resident 14) reviewed for unnecessary medications were free from unnecessary use of antibiotic ointment. This failure placed the resident at risk for receiving unnecessary medication and a diminished quality of life. Findings included . Review of the facility policy titled, Antibiotic Stewardship, revised and/or approved on 04/2022 stated, Monitoring will include (but not limited to): . Monitor antibiotic use . Monitoring of inappropriate use of Antibiotics. Examples may include .Prescribing course of antibacterial therapy that are no longer necessary. Resident 14 admitted to the facility on [DATE] with care needs including an ingrown nail to right great toe. Review of the October 2022 to March 2023 Treatment Administration Record (TAR) showed a treatment for the Right great toe wound that included the following: 1. Clean area with wound cleanser. 2. Apply topical antibiotic. 3. Skin Prep to periwound (surrounding skin) 4.…

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 Gradual Dose Reduction (GDRs) for the use of psychotropic (mind altering) medications were followed for 1 of 6 residents (Resident 12) reviewed for unnecessary medications. The failure to attempt a GDR for the administration of psychotropic medications placed the resident at risk to receive unnecessary medications and/or experience adverse side effects. Findings included . Review of the facility policy titled, Psychotropic Medication Management revised on June 2021, showed that Residents who use psychotropic drugs receive GDR . first year after admission or initiation: GDR or tapering in two separate quarters with at least one month in between unless clinically contraindicated, after first year: GDR annually unless clinically contraindicated. Resident 12 admitted to the facility on [DATE] with diagnoses that included Alzheimer's (problems with memory, thinking and behavior) and major depressive disorder with severe psychotic symptoms (a…

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