Shoreline Health And Rehabilitation

Based on interview and record review, the facility failed to ensure a physician's order was followed when administering medication for 1 of 5 residents (Resident 6), reviewed for unnecessary medications. This failure placed the resident at risk for side effects related to the medications, medical complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Administering Medications, revised in March 2022, showed, Medications will be accurately prepared, administered, and documented per physician order .follow the special directions for administering such as blood pressures .Review of Resident 6's physician orders printed on 03/19/2026 showed an order for metoprolol (medication for high blood pressure [measurement that shows how hard the heart is pumping to move blood through the body]) once a day, with an instruction to hold it if their systolic blood pressure (the first or top number in a blood pressure reading, showing the pressure in the arteries [muscular and elastic tubes that carry blood from the heart to the tissues and organs 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.

Based on observation, interview, and record review, the facility failed to ensure medication was stored in accordance with professional standards and manufacturer specifications for 1 of 2 medication carts (East 2 Medication Cart), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised and ineffective medications.Findings included .Review of the Amneal Pharmaceutical (manufacturer) prescribing information titled, Lorazepam [a drug used to quickly calm severe anxiety] Oral Concentrate USP, 2 mg [milligram - a unit measurement] per mL, [milliliter - a unit measurement] revised in December 2015 showed, Store at Cold Temperature-Refrigerate 2 [two degrees] to 8 C [eight degrees Celsius- a unit measurement] (36 to 46 F [Fahrenheit - a unit measurement]) . Discard opened bottle after 90 days.During a joint observation and interview on 03/22/2026 at 8:39 AM with Staff M, Licensed Practical Nurse, showed the East 2 Medication Cart had one unopened bottle of Lorazepam 30 ml oral concentrate USP (2 mg/mL) for Resident 76 was found…

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 consistently maintain an established Antibiotic (medication to treat infection) Stewardship Program to promote the appropriate use of antibiotics for 2 of 6 residents (Residents 63 & 95) and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs symptoms used to determine whether to treat an infection with antibiotic]). These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and an increased risk for multi-drug-resistant organisms (microscopic organisms that are resistant to many antibiotics).Findings included.Review of the facility's policy titled, Antibiotic Stewardship, revised in March 2023, showed, This policy is aligned with the CDC [Centers for Disease Control and Prevention] Core Elements of Antibiotic Stewardship for Nursing Homes. It is the policy of this…

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

Based on observation, interview and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 1 of 1 dining room (Second floor Dining Room), reviewed for dining services. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life. Findings included . Review of the facility's policy titled, Homelike Environment, revised in May 2017, showed, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Observation on 12/13/2024 at 11:39 AM, in the Second Floor Dining Room, showed Resident 60, Resident 25, Resident 21, Resident 42, Resident 50, and Resident 37 were eating their food on their lunch tray. Staff J, Restorative Nurse Assistant, assisted Resident 20 eat their lunch from their tray. Observation on 12/16/2024 at 11:38 AM, in the Second Floor Dining Room, showed Staff D, Resident Care Manager, delivered Resident 50, Resident 8 and Resident 20 their lunch tray. Staff D did…

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 appropriately store drugs and/or biologicals (diverse group of medicines made from natural sources) and medical supplies for 2 of 2 medication rooms (West 1 Medication Storage Room & Second Floor Medication Storage Room) and 1 of 3 medication carts (East 1 Medication Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications/medical supplies. Findings included . Review of the facility's policy titled, Storage of Medications, revised in March 2016, showed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. WEST 1 MEDICATION STORAGE ROOM A joint observation and interview on 12/17/2024 at 9:13 AM with Staff Y, Licensed Practical Nurse (LPN), showed the [NAME] 1 Medication Storage Room had one Aquacel Advantage (brand name of an anti-microbial wound dressing) dressing 10 centimeter (cm-a unit of measurement) by 12 cm with an expiration date of 11/01/2024. Staff Y stated, Yes it expired on 11/01/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room and 2 of 2 floors (First Floor & Second Floor), reviewed for food services. The failure to label food items and cover food items during meal tray delivery placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Procurement, Storage and Distribution, dated 07/08/2022, showed, Food safety requires consistent temperature control from the time food leaves the kitchen, to transport and distribution to prevent contamination (e.g. covering food items). FOOD LABELING IN THE DRY STORAGE ROOM Joint observation on 12/12/2024 at 8:32 AM with Staff C, Nutritional Services Manager, showed two unopened unlabeled bags of cereal. Staff C stated it was…

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

Based on observation, interview, and record review, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 35), reviewed for infection control. In addition, the facility failed to appropriately use Personal Protective Equipment (PPE -use of gown and gloves) and perform hand hygiene in the laundry room for 1 of 1 staff (Staff X), reviewed for infection control. These failures placed the residents, staff, and visitors at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Transmission Based Precautions, revised in October 2022, showed that Contact Precautions are intended to prevent transmission of infectious agents .that are spread by direct or indirect contact with the resident or the resident's environment. It showed, Donning [putting on] PPE upon room entry and properly…

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 hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered to 1 of 3 residents (Resident 65), reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled Bed Hold, revised in December 2023, showed, It is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provision upon admission and provide a second notice before transfer to a general acute care hospital .In the event of an emergency transfer, the second notice will be provided within 24 hours. Resident 65 admitted to the facility on [DATE]. Review of the nursing progress note dated 12/09/2024 showed Resident 65 was discharged 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 accurately assess 1 of 20 residents (Resident 20), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding preferences to guide the development of a comprehensive activity care plan placed the resident at risk for 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 when completing an MDS) Version 1.19.1, dated October 2024, showed, .The intent of items in this section (Section F- Preferences for Customary Routine and Activities) is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. 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 implement activity care plan for 1 of 20 residents (Resident 20), reviewed for care planning. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, revised in August 2017, showed, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment .The comprehensive care plan will be developed by the IDT within seven days of completion of the Resident Minimum Data Set [MDS - an assessment tool] and will include resident's needs identified in the comprehensive assessment .The resident's comprehensive plan of care will be reviewed and/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 revise comprehensive care plans for 3 of 20 residents (Residents 17, 20 & 6), reviewed for care plan revision. The failure to revise care plans for medication administration and behaviors with oxygen use placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in August 2017, showed, The resident's comprehensive plan of care will be reviewed and/or revised by the IDT [Interdisciplinary Team] after each assessment. RESIDENT 17 Observation on 12/16/2024 at 11:49 AM, showed Staff E, Registered Nurse, entered the Second Floor Dining Room holding two medication cups. Staff E gave one medication cup to Staff D, Resident Care Manager, who then administered the medication to Resident 17. Review of Resident 17's nutritional problem care plan intervention initiated on 12/16/2024, showed that Resident 17 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a physician's order in accordance with professional standards for 2 of 13 residents (Residents 26 & 335), reviewed for medications. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . RESIDENT 26 Review of Resident 26's December 2024 Medication Administration Record (MAR) showed an order for oxycodone (pain medication) oral tablet 5 milligrams (a unit of measurement) to be given every eight hours as needed for pain level greater than six out of 10 started on 12/06/2024. Further review showed that Resident 26 received oxycodone when their pain was documented as less than six out of 10 for five out of 11 days. A joint record review and interview on 12/16/2024 at 9:53 AM, with Staff E, Registered Nurse (RN), showed the December 2024 MAR had a physician order to give Resident 26 oxycodone for pain level greater than six out of 10. Staff E 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 observation, interview, and record review, the facility failed to ensure an activity program met the need of 1of 1 resident (Resident 20), reviewed for activities. The failure to implement an individualized ongoing program to support the resident in their choice of activities based on the comprehensive assessment and care plan placed the resident at risk for unmet activity pursuit, social isolation, and a diminished quality of life. Findings included . 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 when completing a Minimum Data Set [MDS - an assessment tool]) Version 1.19.1, dated October 2024, showed, .The intent of items in this section (Section F- Preferences for Customary Routine and Activities) is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident 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.

Based on interview and record review, the facility failed to implement bowel management protocol in accordance with professional standards of practice for 1 of 1 resident (Resident 48), reviewed for quality of care. This failure placed the resident at risk for discomfort, bowel impaction, and related complication. Findings included . Review of the facility's undated policy titled, Bowel Management Program, showed, Accurate and complete documentation is required to determine the resident's bowel integrity and certified staff documents bowel movements for each resident each shift. Review of Resident 48's constipation care plan, revised on 10/16/2023, showed an intervention to monitor medications for side effects of constipation. It further showed to record bowel movement (BM) pattern each day. Review of the facility's document titled, Documentation Survey Report for November 2024, showed Resident 48 did not have a BM from 11/06/2024 through 11/10/2024 (5 days) and from 11/13/2024 through 11/17/2024 (5 days). Review of the facility's document titled, Task: Bowel movement/Bowel…

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 respiratory care in accordance with accepted professional standards of practice for 3 of 5 residents (Residents 6, 16 & 285), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy, properly store nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) and oxygen equipment placed the residents at risk for respiratory infections, and related complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised in July 2019, showed, Obtain appropriate physician's order and Reassess oxygen flowmeter for correct liter flow. Review of the facility's policy titled, Respiratory Therapy-Prevention of Infection, revised November 2011, showed under Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol [constant mist of medication over a period ranging from 30 minutes to several hours] to take care not to…

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

Based on interview and record review, the facility failed to ensure clinical records were accurate for 1 of 3 residents (Resident 32), reviewed for resident medical records. This failure placed the resident at risk for unmet care needs and medical complications. Findings included . Review of the facility's policy titled, Charting and Documentation, revised in July 2017, showed, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's policy titled, Charting Errors and/or Omissions, revised in December 2006, showed, Accurate medical records shall be maintained by this facility. INACCURATE DISCHARGE/TRANSFER NOTICE Review of Resident 32's Nursing Home Transfer or Discharge Notice form dated 03/11/2024 and 10/22/2024, showed that it was provided to their daughter. In an interview on 12/16/2024 at 3:08 PM, Resident 32's financial power of attorney stated that Resident 32 did not have any children. In an interview on 12/16/2024 at 3:15 PM, Staff B, Director of Nursing, stated that the Nursing Home Transfer 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 interview and record review, the facility failed to ensure admission Minimum Data Set (MDS) assessments were completed within 14 days of admission for 5 of 25 residents (Residents 20, 48, 67, 637 & 77) reviewed for comprehensive assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life. Findings included . According to the Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revised October 2019, at a minimum, facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months (within 366 days) while a resident. RESIDENT 20 Resident 20 was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE], showed the MDS was completed late on 04/23/2023. The admission comprehensive MDS assessment was not completed within 14 days 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.

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with the actual hours worked for each shift for 4 of 5 days reviewed for sufficient and competent staffing. In addition, the facility failed to post daily nurse staffing in one of two prominent locations (Second Floor). This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels. Findings included . Observations on 09/26/2023 at 9:50 AM, on 09/28/2023 at 7:50 AM, and on 09/29/2023 at 8:21 AM, showed the facility's daily nursing staffing form posted on the wall by the first-floor elevator did not display the actual nursing staff hours worked for the shift. Further observation showed no daily nursing staffing form posted on the second floor of the facility. Observations on 09/26/2023 at 3:19 PM, on 09/28/2023 at 2:35 PM, and on 09/29/2023 at 2:45 PM, showed the facility's daily nursing staffing form on the wall by the first-floor elevator did not display…

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

Based on observation and interview, the facility failed to discard food products on or before their use by date in 1 of 1 walk in freezer (main kitchen walk-in freezer) and 1 of 1 walk-in refrigerator (main kitchen walk-in refrigerator). This failure placed the residents at risk for developing foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . WALK-IN FREEZER On 09/26/2023 at 8:12 AM, a joint observation of the main kitchen walk-in freezer with Staff R, Dietary Supervisor, showed a box of potato hash browns opened on 08/18/2023 and had a use by date of 09/18/2023. WALK-IN-REFRIGERATOR On 09/26/2023 at 8:25 AM, a joint observation of the main kitchen walk-in refrigerator with Staff R showed the following: - One can of sweet pickle relish, opened on 08/19/2023 and had a use by date of 09/19/2023. - One can of cherry maraschino, opened on 08/16/2023 and had a use by date of 09/16/2023. On 09/26/2023 at 8:57 AM, Staff R stated that the above food products with a past use by date should have been discarded.…

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 medical equipment used in 9 of 9 residents' room (Rooms 221, 223, 211, 218, 120,115, 121, 122 & 116) were sanitized/disinfected between resident use, and failed to ensure hand hygiene practices were followed for 1 of 1 resident (Resident 81), reviewed for wound care. In addition, the facility failed to ensure 2 of 4 soiled utility rooms (West 1 and East 2) had an accessible sink for staff to perform hand hygiene and accessible garbage bin to dispose soiled materials and failed to ensure clean linens/personal clothing were transported properly. These failures placed the residents at risk for facility acquired or healthcare-associated infections, and related complications. Findings included . Review of the facility's policy titled, Infection Control Prevention and Control Program-Hand Hygiene, revised on 02/21/2022, showed that the facility considers hand hygiene the primary means to prevent the spread of infections. It also showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an updated guardianship letter was readily available in medical records and accessible to staff for 1 of 2 residents (Resident 37), reviewed for Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care). This failure placed the resident and/or their representative at risk of 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 [DATE], showed the care plan team will periodically, at least quarterly, annually, and on a change of condition, review the advance directive and/or preferences regarding treatment options with the resident and their representative to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded on, among possible other places in the medical record. Additionally, the policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative when there was a significant weight loss for 1 of 4 residents (Resident 55) reviewed for nutrition. The failure to notify the resident's representative regarding the resident's significant weight loss placed the resident at risk of not having the representative involved in health care decisions. Findings included . Review of the facility's policy titled, Best Practice in Change of Condition and Endorsement, revised in May 2016, showed that changes in weight is one of the examples of change of condition. The policy also showed that the resident's physician, resident, and responsible party will be notified of any changes in the resident status or condition. Resident 55 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS- an assessment tool) dated 08/28/2023, showed Resident 55 had moderately impaired cognition and needed supervision with eating. The MDS also showed Resident 55 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 2 of 2 residents (Residents 24 and 63) 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…

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 21 Residents (Residents 7, 40 & 25) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding the use of antibiotic (medication used to treat infection) and Insulin (medication used to improve/control blood sugar level) placed the residents 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, 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the date of completion of Minimum Data Set (MDS) assessment was accurate for 1 of 8 residents (Resident 637) reviewed for resident assessment. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revised October 2019, showed, Federal regulation requires the RN [Registered Nurse] assessment coordinator to sign and thereby certify that the assessment is complete . For Z0500B [Date RN Assessment Coordinator signed assessment as complete], to use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date must be equal to the latest date at Z0400 or later than the date(s) at Z0400, which documents when portions of the assessment information were completed by assessment team members. The RAI also showed that Federal statute 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 observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 3 of 20 residents (Residents 76, 63 & 24) reviewed for comprehensive care plans. The failure to develop and implement care plans for antibiotic (medication used to treat infection) use, toileting and nail care placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . RESIDENT 76 Resident 76 admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary disease (COPD-long term lung condition that makes it hard to breathe). Review of Resident 76's physician order dated 04/20/2023, showed the resident had an order for Azithromycin (an antibiotic) oral tablet 250 milligrams, one tablet three times a week (Monday, Wednesday, Friday). Further review of Resident 76's physician's note dated 08/08/2023, showed that Azithromycin was prescribed for long-term use related to Resident 76's chronic lung condition. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan interventions were initiated and revised for 2 of 2 residents (Residents 22 & 30), reviewed for care planning. This failure placed the residents at risk for poor hygiene, unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.11, revised in October 2019 showed, As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. RESIDENT 22 Resident 22 admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal hygiene was performed for 1 of 4 residents (Resident 30) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and diminished quality of life. Findings included . Review of the facility's policy titled, Policy/Procedure-Activities of Daily Living, revised in July 2015, showed the Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. Resident 30 admitted to the facility on [DATE]. Review of Resident 30's ADL care plan, revised on 05/11/2023, showed an intervention that the resident was one staff set up assist with personal hygiene. Review of the quarterly MDS assessment dated [DATE], showed Resident 30 was cognitively intact, and required extensive assist with personal hygiene. The ADL care plan was not updated to reflect this. An interview and observation on 09/26/2023 at 8:56 AM, when asked how…

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.