Beloit Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 1 resident's (R2) reviewed for medications. The facility did not ensure R2 was provided his Seroquel (Antipsychotic medications) for several days. This is evidenced by: The facility policy titled Medication Error Reporting and Counseling Procedure, dated 12/12/23, includes the following: Medication errors .should be reviewed for the potential of a negative outcome. When a medication error occurs, the licensed nurse/employee needs to be able to report the error .to Nursing Management. The facility should consider reporting the error to their contracted pharmacy provider for any desired information or needed follow-up. A prompt assessment of the resident(s) involved to be completed to determine harm or the potential risks to the resident. Three general guidelines in determining whether a medication error is significant or not: resident condition, drug category and frequency of error.…

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 did not ensure each resident received meals at their desired time in accordance with resident needs, preferences, or requests. This has the potential to affect all 58 residents residing at the facility. Residents (R8, R41, and R35) voiced concern regarding meals being served over an hour after the scheduled time. Surveyors observed meals being served 1-1.5 hours after the scheduled mealtimes. Evidenced by: The facility policy, Frequency of Meals, dated, 7/17, states, in part: .The following mealtimes have been established by our facility for residents, Breakfast 7:45AM, Lunch 11:45AM, Dinner 4:45PM . Example 1: R8 was admitted to the facility on [DATE]. R8's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/14/24 indicated R8 has a BIMS (Brief Interview for Mental Status) score of 13 indicating R8 is cognitively intact. R8 is own person. On 9/10/24 at 8:28AM, R8 indicated meals are often served over an hour after the…

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

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 58 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for five fiscal year quarters, dated 4/1/23 - 6/30/24, for inadequate weekend staffing. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications…

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 has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19. This has the potential to affect the census of 58 residents (R). The facility infection prevention and control policies have not been updated annually. The facility did not ensure contact tracing and testing was completed accurately and timely during a COVID outbreak. Surveyor observed cares for R35 with breaches in infection control technique. Evidenced by: The facility policy titled Infection Prevention and Control Program dated 5/16/23, states, in part: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per acted…

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 did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 sampled Residents (R35, R52, & R15) and 1 of 1 supplemental (R49). R35 and R49's floor in their room had not been cleaned and had visible dirt on the floor. R15's room was not homelike with visible repairs needed. R52 voiced concern that R52 is unable to use closet in bedroom because of roommate thinking R52 is stealing clothes. R52 voiced concern that her dresser is broken as well. R52 indicated she has to keep all of her clothes and items in boxes in R52's room. Surveyor observed R52 to have boxes stacked up in her room. This is evidenced by: Facility Policy entitled 'Routine Cleaning and Disinfection,' dated 8/2022, states in part: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission 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 did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 4 of 24 total sampled Residents (R48, R38, R15 & R16). R48 did not receive her showers twice a week every week. R38 did not receive the appropriate oral hygiene care recommended by the dentist. R15 did not receive oral hygiene daily R16's nails were visibly long and staff did not assist R16 in trimming them. Evidenced by: Facility policy entitled 'Oral care,' dated 8/22, states in part: Policy: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque- associated oral diseases. Equipment and supplies. soft- bristle tooth brush, toothpaste; tongue depressor; penlight; mouthwash (optional); dental floss; emesis basin; glass of cool water; face towel; gloves. Policy explanation and compliance guidelines: .4. Apply…

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 Example: 2 R23 was admitted to the facility on [DATE] with diagnoses that include in part: polyosteoarthritis (arthritis where at least 5 joints are affected), Polyneuropathy, Lymphedema (A buildup of lymph fluid that causes swelling), Difficulty in walking, and Low back pain. R23's chart indicates she is her own decision maker. R23's ADL (Activities of Daily Living) Care Plan, with a revision date of 5/2/23, indicates R23 requires staff intervention to complete ADL's. Interventions include, in part: .Hoyer (full body lift) sling with hole cut out for bed side commode toileting needs. On 9/9/24 at 3:00PM Surveyor interviewed R23 who indicated about once a month she waits an hour to get assistance with toileting. R23 indicated that a month ago she was sitting on the bedpan or the commode, could not recall which for certain, and after an hour called the front desk 3 to 4 times and no one came so she called the police. The police did not come as someone came to help her then and she called to tell them she received…

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 did not ensure grievances were documented and thoroughly resolved for 1 of 24 sampled residents (R23). R23 reported a grievance regarding her Hoyer (full body lift) transfers, and this was not documented or thoroughly resolved. R23 reported a grievance regarding an interaction with a staff member and this was not documented or thoroughly resolved. Evidenced by: The facility policy, Grievance Guideline, revised on 5/31/23, indicates, in part: Purpose: To provide a process to voice grievances (such as those about treatment, care .or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or representative appropriately apprised of progress toward resolution . Guideline: .Filing a Grievance .A grievance or concern may be expressed orally or in writing to the Grievance Officer or facility staff .Grievances may be given to any staff member who will forward the grievance to the Grievance Officer, or they may file…

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 did not ensure that information from the baseline care plan was reviewed with the resident/resident representative and a copy of or summary of the care plan was provided to the resident/resident representative within 48 hours of admission for 1 of 3 residents (R27) reviewed for baseline care plan out of a sample of 24 residents. R27 did not have a baseline care plan review within 48 hours of admission. Evidenced by: The facility policy, entitled Baseline Care Plan dated February 2023, states, in part: .The baseline care plan will be developed within 48 hours of the resident's admission.A written summary of the baseline care plan shall be provided to the resident and representative . R27 was admitted to the facility on [DATE] with diagnoses that include anoxic brain damage and personal history of traumatic brain injury. R27's Care Conference Interdisciplinary Team (IDT) note dated 6/18/24, states met with guardian. Discussed plan of care and discharge goals.…

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 did not develop a comprehensive person-centered care plan for 1 of 3 (R54) residents reviewed for person-centered care plans out of 24 total sampled residents. R54's Activities of Daily Living (ADL) care plan was reviewed by Surveyor. The care plan does not contain R54's individualized preferences in regard to her left arm. Evidenced by: The facility policy, Comprehensive Care Plans, implemented 1/2024, indicates, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. .Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .…

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 did not ensure each resident (R), or their representative had the right to participate in the care planning process for 2 of 24 total sampled Residents (R48 & R14). R48 indicated she does not have quarterly care plan meetings to discuss her care. R14's care plan was not revised to address her change in code status. This is evidenced by: Facility policy entitled 'Comprehensive Care Plans,' dated 8/22, states in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences…

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 that services provided by the facility meet professional standards of quality for 1 of 21 residents (R45) reviewed for orders out of a total sample of 24. R45 received orders and those orders were not transcribed for two (2) days. This is evidenced by: The Facility's Policy and Procedure entitled Medication Orders dated 4/16/24, documents the following in part: .a. Handwritten Order Signed by the Physician- The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic order format, if not written by the physician . R45's wound documentation shows that R45's right heel wound was healed on 6/21/24 with placement of graft. Documentation from R45's Physician dated 6/26/24 includes the following orders: 1) Ensure 1 bottle 2x (2 times) a day in-between meal 2) Daily dressing change of pressure ulcer of right foot 3) General surgery for debridement of the thumb of left hand 4) Keflex 500mg (milligrams) 1 cap (capsule) q (every) 8 hours x (times) 10…

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 did not ensure that residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 3 of 5 (R34, R45 and R14) residents reviewed for pressure injuries out of a total sample of 24. R34 did not have his wound treatments completed as ordered. R45 did have her wound treatments completed as ordered. R14 did not have wound treatments completed as ordered. This is evidenced by: The Facility's Policy and Procedure entitled Wound Treatment Management dated 2/14/23, documents in part: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. Example 1 R34 has the following diagnoses: paraplegia complete, chronic pain,…

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 did not ensure each residents environment was free of accidents and hazards for 3 of 24 total sampled Residents (R48, R34 and R52.) R48 indicated she smokes. R48 did not have a smoking assessment or care plan completed for smoking even though nursing staff were aware that she smoked occasionally. R34's electric wheelchair was charging in his room. R52 indicated she would use her electric scooter and go out in the community on her own. Therapy did not complete an assessment for safe operation of electrical wheelchairs/scooters until after R52 went out in community by herself. Evidenced by: Facility policy entitled 'Smoking Policy,' (no date), states in part: when the resident requests to smoke, the interdisciplinary team will assess the resident capabilities and deficits to determine appropriate supervision and assistance. Smoking will only be allowed in designated (outdoor) area(s) in the facility that are not near flammable substances or where…

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 did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident for 1 of 1 Supplemental Resident (R32). On 9/10/24 R32 had a lidocaine patch still on her arm that was not removed the night before. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: .medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so . Procedures: Medication Preparation: .3.Prior to administration, review and confirm medication orders for each individual resident on the medication administration record. Compare the medication and dosage schedule on the Resident's MAR (Medication Administration Record) with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions,…

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 did not ensure that it was free of medication error rates of 5% or greater. There were 3 errors out of 28 opportunities that affected 2 out of 4 supplemental residents (R32 & R31) included in the medication pass task, which resulted in an error rate of 10.71%. RN H (Registered Nurse) did not give R31 the correct dosing of his Sevelamer (phosphate binder to prevent low levels of calcium) LPN I (Licensed Practical Nurse) omitted R32's lidocaine patch and dispensed R463s medication into R32's medication cup. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: .medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so . Procedures: Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the medication administration record. Compare the medication and dosage schedule on the…

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

Based on observation, interview, and record review the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 1 of 2 Medication carts and 1 of 1 medication rooms reviewed for medication storage. Medication room had 5 bottles of expired liquid Tylenol on the shelf. Medication room fridge had an undated open insulin vial for R57. Needlepoint medication cart had three bottles of artificial tears that did not have the residents full name or date opened on them. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: . Medication administration: 1. Medications are administered in accordance with written orders of the prescriber . 8. Check expiration date on package/container. No expired medications will be administered to a resident.b. The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. c. Certain products or package types such as multi-dose vials and ophthalmic drops have…

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 did not ensure that all residents receive food at a palatable temperature for 1 of 1 sampled (R467) and 1 of 1 supplemental residents (R41) and 1 of 1 test trays. Residents R467 and R41 voiced concerns with receiving hot foods cold. Test tray was observed to have hot foods served cold and food not palatable. Evidenced by: The facility policy, Record of Food Temperatures, dated 3/24, states, in part; .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperatures before trays are assembled .11. No food will be served that does not meet the food code standard temperatures . Example 1 R467 admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 Diabetes Mellitus, Essential Hypertension, atherosclerotic heart disease. On 9/9/24 at 11:16 AM Surveyor interviewed R467 and asked about the food. R467 stated the food is cold. Example 2 R41 was admitted to the facility 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.

Based on observation, interview, and record review the facility did not ensure food was stored or labeled in accordance with professional standards for 1 of 2 medication room refrigerators. Three cartons of thickened liquids and two half gallons of chocolate milk were opened and expired in the medication room refrigerator. Evidenced by: Facility policy entitled 'Food Safety Requirements,' states in part: .Policy explanation and compliance guidelines: .3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: .iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen . On 9/9/24 at 3:20 PM, Surveyor observed the medication room refrigerator and found the following: One Ready care thickened apple…

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, record review, and facility policy review, the facility failed to ensure medication administration was provided according to professional standards for one resident (R) out of nine sampled (R4). Specifically, the facility failed to follow physician insulin orders in the electronic medical record (EMR) and document the rationale for not administering the insulin. This failure had the potential to cause R4 not to receive the necessary care for treatment of R4's diabetes. Findings include: Review of the facility's policy titled Timely Administration of Insulin dated 4/23/23 revealed, .It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition . and .All insulin will be administered in accordance with physician's orders . Review of R4's undated admission Record, located in the Resident Documents tab of the EMR, revealed R4 was admitted to the facility on [DATE], with a diagnosis…

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 did not ensure residents receive and consume foods in the appropriate therapeutic diet for 1 (R4) of 3 residents sampled for altered special diets out of 4 total sampled residents. R4 did not receive a controlled carbohydrate diet as ordered by her physician. This is evidenced by: The facility policy entitled, Food and Nutrition Services, undated, states in part: . 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. A resident-centered diet and nutrition plan will be based on this assessment . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing…

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 did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 52 residents residing at the facility. Surveyor observed: -facility staff personal items in food preparation workstations -dirty floors in the dry storage, walk-in cooler, and walk-in freezer -dirty hood vent -undated and uncovered foods and beverages -milk served that were not on ice and not within safe zone -wet stacking Findings include: Example 1: Personal items On 6/12/23 at 10:38 AM, Surveyor observed two cell phones and a plastic container with food on the food prep workstations. Surveyor asked DS V (Dietary Staff) what was in the plastic container with food, DS V stated, that's someone's lunch, a co-worker's lunch. Surveyor asked DM D (Dietary Manager) if staff food or cell phones should be on the food prep workstations, DM D stated, no, they should not be. On 6/14/23 at 11:27 AM, Surveyor observed a drink and doughnut sitting on the food prep…

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 has not established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect the census of 52 residents. The duct work over the top of a folding table was observed to be leaking onto the table while the laundry aide was folding clean linens on the table. This is evidenced by: The facility policy entitled Laundry, dated 12/22, states in part: . Policy: The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens . The facility policy, entitled Infection Prevention and Control Program, dated 6/16/23, states, in part: . Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission 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 did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 1 of 21 residents (R47) and 4 of 5 supplemental residents (R14, R28, R26, & R19). R47 was treated with antibiotics for a urinalysis culture and sensitivity (UA & C/S) that was not susceptible to the bacteria. R14 was treated with antibiotics for UA & C/S without documentation of a sensitivity report. R28 was treated with antibiotics for UA & C/S without meeting McGeers criteria. R28 had no signs and symptoms (s/sx.) of a urinary tract infection (UTI). R26 was treated with antibiotics for UA & C/S that was not susceptible to the bacteria. R19 was treated with antibiotics for UA & C/S without documentation of a sensitivity report. This is evidenced by: The facility policy, entitled Antibiotic Stewardship Program, dated 12/22, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic…

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 did not ensure that all residents are clinically appropriate to self-administer medications for 2 of 2 residents (R53 and R65) of the total sample of 21 residents observed. R53 was observed to have an analgesic ointment cream in his room on his bedside table. R65 had medications located at the bedside. R65 did not have an order to self-administer medications. This is evidenced by: The facility policy entitled, Resident Self-Administration of Medication, dated 12/22, states in part: . Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use 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 interview and record review, the facility did not implement their written policy which includes completing background checks for 3 of 8 employees. The facility did not implement their written policy which includes completing reference checks for 8 of 8 employees reviewed. CNA P (Certified Nursing Assistant), CNA S, and Dietary Aide V's personnel files did not contain Background Information Disclosure (BID) checks and reference checks. CNA O, CNA Q, CNA R, RN T (Registered Nurse), and LPN U's (Licensed Practical Nurse) personnel file did not contain reference checks. Evidenced by: The facility policy, Background Investigation, dated 12/22, states, in part; Policy: Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company Policy Explanation and Compliance Guidelines: 1. The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee…

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 did not report an alleged violation of abuse to the State Survey Agency for 1 of 21 sampled residents (R38). R38 alleged he was told by a staff member you can get fd and the facility did not report this to the State Survey Agency. This is evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated 12/22, states in part: .VII. Reporting/Response A. The facility will have written procedures that include: Reporting of all alleged violation to the Administrator, state agency . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . R38 was admitted to the facility on [DATE] with diagnoses to include: type 2 diabetes mellitus (a disease of inadequate control of blood levels…

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 did not have evidence that all alleged violations are thoroughly investigated for 1 of 21 sampled residents (R38). R38 alleged he was told by a staff member you can get fd and the facility did not conduct a thorough investigation into this allegation. This is evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated 12/22, states in part: . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, 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 did not ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, this has the affected 1 of 6 residents (R1) reviewed for activities of daily living out of a total sample of 21. R1 was noted to have chin hairs that were approximately 1/4- 1/2 long. Evidenced by: The facility's policy titled Activities of Daily Living (ADLs) dated 12/2022, states in part: .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . R1 was originally admitted to the facility on [DATE]. R1 has diagnoses that include: cerebral infarction (stroke), hemiplegia 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 did not ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents out of a sample of 21 residents (R66) resulting in R66 in missing dialysis. R66 missed dialysis on 6/10/23 due to the facility not ensuring the transport service provider was available to transport R66 to scheduled dialysis appointment. According to <Gray, K. P., [NAME], D., & [NAME], S. M. (2017). In-center hemodialysis absenteeism: prevalence and association with outcomes.>Clinic Economics and Outcomes Research, Volume 9, 307-315. https://doi.org/10.2147/ceor.s136577 One absence due to a non-medical reason is associated with a 40 percent greater risk of hospitalization and a more than double risk of mortality in the subsequent 30 days. This is evidenced by: The facility policy, entitled Hemodialysis, dated 12/2022, states: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater during medication administration. This affected 1 of 6 residents (R4) observed for medication pass. The facility medication error rate was 6.67%, for 2 errors out of 30 opportunities. R4's first medication error was administered 30 minutes late making this a timing error. The second medication error was administered without a complete physician order. The order was not found on the current Medication Administration Record (MAR) and was signed as administered under a different medication order that had been discontinued. This is evidenced by: Example 1 The facility's policy titled Medication Administration, dated 12/22, states in part: . 11. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, mediation name, form, dose, route, and time . b. Administer within 60 minutes prior to or after scheduled time unless otherwise…

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.