Lafayette Manor

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 39 residents. Nutritional supplements and food items were observed with improper dates. An employee walked through the kitchen with no hairnet. A scoop was observed inside a container of sugar. Findings include Example 1 On 12/10/24 at 8:48 AM, Surveyor, along with DM Q (Dietary Manager), observed the following in the kitchen's dry storage: *3 bags of unopened pasta with no use by date *28-6 lb. cans of various vegetables and pie fillings with no received or use-by dates At 9:00 AM, Surveyor and DM Q observed the following in the kitchen's main refrigerator: *A container of sunflower seeds with an open/prepared date of 5/17/24 and a use by 10/17/24 *4 thawed nutritional supplements with no thaw dates (manufacturer label states the supplement must be used within 14 days of thawing). At 9:07 AM, DM Q stated that the nutritional supplements need to be thrown away as there is no thaw…

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 identify issues to which quality assessment and assurance activities are necessary or make a concentrated effort to improve facility quality. This has the potential to affect all 39 residents. The facility does not have a Quality Assurance and Performance Improvement (QAPI) system in place and has failed to identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: . Documentation…

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 maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 39 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for any of the quarterly meetings in the past year. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The QAA…

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 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. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 39 residents (R) in the facility. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal. The facility does not have mechanism for tracking Multi-Drug Resistant Organisms (MDRO). The facility's monthly infection control rates were not segregated for specific infection types. The facility could not provide evidence their water management program included: 1) Descriptions of the building water system using text and flow diagrams. 2) Identification of areas where Legionella and other opportunistic waterborne pathogens can grow and spread. 3)…

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 2 of 2 Medication carts reviewed and 2 of 2 medication rooms for medication storage. The 2nd floor medication cart had an undated open insulin pen for R34, and expired morphine tablets for R25. The 3rd floor medication cart had a cough syrup for R1 with no open date or expiration date. The 2nd and 3rd floor medication storage rooms had expired stock meds. Evidenced by: The Facility's Policy, entitled Labeling of Medications and Biologicals, dated 1/5/2022 with last revision date of 11/2024 states, in part: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . 9. Labels for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 17 abuse investigations reviewed involving (R40). Facility became aware of an abuse allegation on [DATE] at 6:15 AM and did not report it to the State Agency until [DATE] at 11:14 AM. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . V1I. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 17 residents (R40) reviewed for abuse. Facility became aware of an abuse allegation on [DATE] and did not complete a thorough investigation. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, 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 did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 4 residents (R16, R31, and R142) reviewed for falls. R142 sustained a fall on 11/27/24 and the facility failed to find a root cause or implement a new intervention. R31 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls. R16 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls. Findings include: The facility policy, Fall Policy and Procedure, updated 11/2024, indicates, in part: Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: .Fall incident: .7) Documentation: a. Fall note .e. Update fall care plan of immediate intervention . Fall Team Meeting: .2) Fall team is to meet within 72 hours of fall to review fall data 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 residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 of 2 residents (R35 and R17) reviewed for nutrition. R35's weights were obtained using different methods and therefore it is unclear if they are accurate. R35's physician was not updated on weight gain/loss based on these weights. R17's physician was not updated on a 21 pound weight loss and there was no documentation of trialing supplements with R17. Findings Include: The facility policy, titled, Weight Monitoring, date reviewed 11/2024, indicates, in part: Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless…

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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 residents (R142) reviewed. R142 did not receive her scheduled Dupilumab (Dupixent) Subcutaneous (under the skin) Solution Auto-Injector 300mg/2ml on 12/6/24. Findings include: The facility policy titled, Medication Errors, date reviewed 11/2024, includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and right of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors . Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician orders .4. The facility will consider factors indicating errors in medication administration, including, but not limited…

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 residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents reviewed for unnecessary medications (R17 and R30). R17 was taking an antipsychotic medication without appropriate diagnoses and indications for its use. R30's comprehensive care plan and documentation did not indicate what side effects of antipsychotic, benzodiazepine, or antidepressive medication that R30 should be monitored for, nor was there any documentation to indicate that R30's side effects were being monitored by staff. Findings include The facility policy titled, Use of Psychotropic Medication, states, in part: *The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches, will be determined by: a) Assessing the residents underlying condition, current signs, symptoms,…

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 develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 sampled residents (R1) and failed to report to the State Agency for 2 of 3 sampled residents (R2, R3). R1 had a sexual abuse allegation reported to the facility. The facility did not report this allegation to law enforcement. R2 reported that a certified nursing assistant (CNA) was rough with her. The facility did not report this allegation of abuse to the State Agency (SA) or law enforcement. R3 reported that the CNA left her unsupervised in the tub. The facility did not report this allegation of neglect to the SA. This is evidenced by: The Facility's Policy and Procedure entitled Abuse, Neglect and Exploitation dated 11/20/23 documents in part: .Crime is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by 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 did not investigate an alleged violation of abuse or neglect for 2 of 3 sampled residents (R2 and R3). On 2/6/24, the facility became aware of an alleged violation of abuse to R2 and the facility did not conduct an investigation. On 5/31/24, the facility became aware of an alleged violation of neglect to R3 and the facility did not conduct an investigation. Evidenced by: Facility policy entitled, Resident and Family Grievances dated 1/30/2024, states, in part: .Take any immediate actions needed to prevent further potential violations of any resident rights. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations . Facility policy entitled, Abuse, Neglect, and Exploitation dated 11/20/2023, 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…

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 a resident received a complete involuntary discharge notice including the information for the right to appeal the notice for 1 of 1 residents (R1). R1's Power of Attorney (POA) was issued an involuntary discharge notice for R1 that did include all the requirements for an involuntary discharge notice, including the right to appeal to the Division of Quality Assurance and contact information. Findings include: The facility's policy, Transfer and Discharge (Including AMA) states the following: * The facility's transfer/discharge notice will be provided to the resident and the resident's representative and in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a) the specific reason and basis for transfer discharge b) the effective date of transfer discharge c) the specific location to which the resident is to be transferred or discharged d) an explanation of the right to appeal…

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 food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 36 residents residing at the facility. Surveyor observed: -Undated, unlabeled, uncovered, expired ready to eat foods and beverages in the refrigerator. -Undated, unlabeled, uncovered, expired food, and improper storage of food in freezer -Cross Contamination -Towel Drying clean/sanitized dishes and wetsacking dishes (process of placing wet dishes in to storage) -Facility staff filling out 3 Compartment Sinks Part Per Million (PPM) Log before processes had begun. -Not taking/documenting food temps -Improper hand hygiene -Improper sanitization of food prep surfaces and kitchen cart The facility policy, entitled Dishwashing dated 3/2019, states Dishwasher Operation. 1. Turn on dishwasher, booster heater, add soap dispenser. 2. Prepare items for cleaning. scrape, rinse, or soak items before washing. Presoak items with dried on-food. 3. Loading dish racks. Use…

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 does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 36 and 1 of 7 hand hygiene opportunities. Staff returned to work too early with gastrointestinal (gs) symptoms (sx) and COVID per Centers for Disease Control and Prevention (CDC) guidelines. 2 staff and 3 residents (R4, R3, R12) with positive COVID were not included on the staff line lists for surveillance. 7 residents (R4, R12, R3, R15, R18, R29, R1) were allowed off isolation for COVID too early per CDC guidelines. Resident and staff line lists were not complete with well dates and return to work dates. COVID testing was not initiated with outbreak. Facility did not test appropriately per CDC guidelines during testing or to conclude outbreak status. Medical Director was not notified when outbreak began. Staff did not perform glucometer check per standards of 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 the resident's physician was consulted with a deterioration in a pressure injury for 1 of 2 Residents reviewed for pressure injuries (PI) out of a total sample of 15 Residents (R9). R9 was admitted to the facility with a pressure injury to her left elbow and the physician was not notified when the wound was not improving/worsened. This is evidenced by: The facility policy titled Documentation of Wound Treatments, with a reviewed/revised date of 4/12/23, indicates, in part: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: .c. Measurements: height, width, depth, undermining,…

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 protect the resident's (R35's) right to be free from physical abuse by R33. R33 has a history of striking residents. The facility failed to put aggressive measures in place to prevent R33 from physical abusing R35. R33 entered R35's room and willfully hit R35 in the chest. The facility failed to protect R35 by not providing adequate supervision. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routine or staff. VI. Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after…

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 all alleged violations involving abuse were reported immediately, but not later than 2 hours to the state agency for 1 (R35) of 3 allegations of abuse. -The facility failed to identify and report an incident an alleged violation involving potential abuse immediately, but not later than two hours, to the administrator as well as the state survey agency. The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. 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…

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 all alleged violations of abuse were thoroughly investigated to prevent further abuse for 1 of 3 resident's (R33) reviewed for of abuse. The facility failed to complete a thoroughly investigation into the incident between R33 and R35 that occurred on 10/26/23. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. IV. 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 include1. identifying staff responsible for the investigation…

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 a discharge summary, with a recapitulation of the resident's stay, includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 14 sampled residents (R37) reviewed for discharge summary/recapitulation. R37 did not have a recapitulation of his stay. Evidenced by The facility's policy, entitled Transfer and Discharge ., dated 4/10/23, states in part; . 14. Anticipated Transfers or Discharges . b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary of the resident's status.…

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 receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (R33 & R34) reviewed for supervision and accidents out of a total sample of 14. R33 had 9 falls since August 1, 2023. Facility did not identify root/cause for these falls. No new interventions or care plan updates were added with these 9 falls. R34 is known to be exit-seeking and staff did not monitor him. Evidenced by: The facility policy, entitled Fall Policy and Procedure, dated 3/2019, states, in part: . Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: Fall risk assessment: . 2. Upon assessment, staff will provide needed intervention to prevent fall. Intervention is added to care plan . Example 1 R33 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia, moderate, with agitation, unspecified dementia,…

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 continent of bladder and bowel on admission receives services and assistance to maintain continence for 1of 3 resident's (R33) reviewed for bowel and bladder program. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2. The facility failed to implement and conduct a toileting program for R33 after an assessment indicated that R33 is categorized as being a candidate for scheduled toileting. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2. Findings include: The facility policy, entitled Preventing Bowel Constipation or Obstruction dated 12/13 states, Policy: To assure adequate bowel movements for residents in order to prevent discomfort or complications from constipation or bowel obstruction. Procedure: 1. Bowel diary assessment will be completed upon admission,…

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 prescribing provider evaluated the resident and documented a clinical rationale for extending as needed (PRN) anti-psychotic medication beyond 14 days for 1 resident (R33) of 5 residents reviewed for unnecessary medications. The facility failed to implement and document nonpharmacological interventions before administering PRN psychotropic medications to R33. Facility administered PRN Lorazepam past the 14-day limitation, failed to follow the facility's use of psychotropic medication policy, evaluate the effects of PRN psychotropic medication use and respond to/provide reasoning for not following Dementia Stabilization Unit (DSU) recommendations to decrease R33's PRN psychotropic medication. Findings include: The facility policy, entitled Use of Psychotropic Medication, dated [DATE], states: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in 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 that it was free of medication error rates of 5% or greater. There were 4 errors in 27 opportunities that affected 2 out of 5 residents (R7 & R25) included in the medication pass task, which resulted in an error rate of 14.81%. Staff mixed R7's Valproic Acid, clonidine, and tizanidine together and administered through R7's gastrointestinal tube (g-tube). R25 received senna plus and R7's physician order was for senna. Evidenced by: Example 1 The facility policy, entitled Medication Administration via Enteral Tube, dated 1/1/23, states, in part: . Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . Policy Explanation and Compliance Guidelines: . 6. Each medication will be administered separately, not combined, or added to an enteral feeding formula . 9. Procedure: a. Verify physician orders for medication and enteral…

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 grievances were filed per facility policy for 1 of 1 sampled residents (R3). Findings include: The facility policy, entitled Resident and Family Grievances, dated 1/30/23, stated in part, Policy Explanation and Compliance Guidelines: . SW F, SW (Social Worker) has been designated as the Grievance Official .The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion .issuing written grievance decisions to the resident .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . The Grievance Official, or designee, will keep the resident apprised of progress towards resolution of the grievances .In accordance with the residents right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents and hazards for 1 of 1 resident reviewed (R6). -R6 left 3rd floor 2 times using the staircase without complete supervision. -R6 eloped from the building -R6 left 3rd floor 1 time using elevator unsupervised. -R6 left 3rd floor 1 time using unknown route. -R6 wandered into other residents' room [ROOM NUMBER] times. -R6 hit staff or was physically aggressive towards. Findings include: R6 was admitted to the facility on [DATE] and has diagnoses that include dementia in other diseases classified elsewhere, moderate, with agitation, sensorineural hearing loss, bilateral (hearing loss in both ears). R6's Minimum Data Set (MDS) admission assessment, dated 7/3/23, indicates that R6 has a Brief Interview for Mental Status (BIMS) score of 3 indicating that R6's cognition is severely impaired. R6's Care Plan, dated 7/28/23, states: -I do not like being told what to do, I get aggressive, and headstrong.…

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 the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents reviewed (R4). R4 did not receive all medications as ordered on 9/10/23 and 9/11/23. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible .c. Document actions taken in the medical record. d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report . R4 was admitted to the facility on [DATE] with diagnoses 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 did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices in 1 of 2 residents reviewed (R5). R5's Medication Administration Record (MAR) had documentation of medication administration that did not occur. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration. b. Right resident and right documentation . On 9/12/23 Surveyors requested a list of medication errors from the facility. The facility provided a copy of R5's MAR for 9/1/23 - 9/30/23. The PM dose of metoprolol was highlighted for 9/1/23 through 9/10/23. No Medication Error report was provided by the…

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