St Elizabeth Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 1 of 3 (R18) reviewed for advanced directives. The code status preference form for R18 was not completed when she went from Do Not Resuscitate (DNR) to wanting Cardiopulmonary Resuscitation (CPR). Findings include The facility's code status policy states, in part: *If an individual wishes to be a full code, the individual's wishes will be maintained within the medical record *Staff will identify an individual's code status by documentation within the medical record *The individual's medical record will be the primary reference in case of an emergency to verify code status. The facility commonly uses a Resident CPR Preference Form to indicate the resident's choice between 1) No--I do NOT want cardiopulmonary resuscitation attempts or 2) YES--I want cardiopulmonary resuscitation attempts. This form is then signed by the resident or their representative. R18 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep monitoring/tracking to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 6 residents (R8, R15, and R30) reviewed for unnecessary medications. R8 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R15 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R30 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. This is evidenced by: Example 1 R8 was admitted to the facility on [DATE] with diagnoses that include, in part: depression, unspecified (medical condition characterized by low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning); insomnia, unspecified (a sleep disorder characterized by difficulty falling or staying asleep, resulting in poor sleep quality and daytime…

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 resident environment remains as free of accident and hazards as possible for 1 of 1 sampled residents (R8). Surveyor observed R8's motorized wheelchair (Motorized Assistive Devices) being charged in her room. Staff state the wheelchair should be charged in the Beauty Shop. Evidenced by The facility policy, Motorized Assistive Device, reviewed 11/8/23, documents, in part, as follows: Policy: Individuals identified to use motorized assistive devices to reach the highest level of independent mobility will demonstrate safe and proper use of the equipment. Battery Storage: Batteries must be charged in a non-resident approved area. On 2/11/25 at 12:00 PM, Surveyor observed R8's motorized wheelchair battery plugged in and charging in her room next to R8's bed where R8 was sleeping. On 2/11/25 at 12:05 PM, Surveyor asked NHA A (Nursing Home Administrator) to come to R8's room. Surveyor asked NHA A, is it acceptable to charge R8's motorized wheelchair in her room. NHA A stated, no, all wheelchairs are to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents (R6) reviewed for pain management. The facility failed to provide R6 with his scheduled pain patch and effectively manage his pain causing him to miss two physical therapy sessions. The facility also failed to assess the resident's pain goal and complete a comprehensive care plan to include his pain goal and non-pharmacological interventions. This is evidenced by: The facility policy entitled, Pain, dated 8/10/23, states, in part: Policy: Nursing staff will identify appropriate treatment and services for each individual's pain management .2. Care Planning a. Staff will manage an individual-centered interdisciplinary care plan and implement interventions/approaches to pain management including non-pharmacological interventions . 4. Notification. a. The medical provider will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 (R) for 1 of 1 residents (R6). R6 did not receive his ordered Lidocaine (Numbing medication used for pain control) on 1/21/25, 1/22/25, 1/23/25, 1/24/25, 2/6/25, 2/7/25, and 2/10/25 due to the medication not being available. This is evidenced by: The facility policy entitled, Medication Administration-General Guidelines, dated 12/2019, states, in part, . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . D. Documentation (including electronic) . 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time . If electronic MAR (medication administration record) is used, documentation of the unadministered dose is done as instructed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents (R) receiving psychotropic medication were free from unnecessary medications for 2 of 5 residents (R16 and R22) reviewed for unnecessary medications. R16 receives psychotropic medications. R16 does not have a care plan with targeted behaviors or behavior tracking for the anti-anxiety or antidepressant medications. R16 was receiving an as needed (PRN) anti-anxiety medication beyond 14 days without physician follow up. R22 receives psychotropic medication. R22 did not have an Abnormal Involuntary Movement Scale (AIMS; screening to identify abnormal movements which can develop as a side effect of antipsychotic medication use). Findings include: The facility's Standard Psychoactive Medications Protocol, undated, states, in part: .Goal: Individual will have minimized side effects of psychotropic drug use. MAA (medication assistant): .document target behaviors and report changes to licensed nurse.Nursing: .document target behaviors,…

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 COVID-19 Vaccine policy and procedure was up-to-date and implemented for 2 of 5 (R22 and R11) residents reviewed. R22 and R11 did not have, nor were they offered the 2024-2025 COVID-19 Vaccine. This is evidenced by: The facility's Policy and Procedure titled Individual Immunizations dated 12/5/24 documents in part: .1. Immunization a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered, b. Individual will be offered immunization based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP . The facility provided the following: The CDC's Recommendation Adult Immunization Schedule United States 2024 dated 11/16/23 documents, in part: .COVID-19 vaccination .2023-2024 Formula . It is important to note the facility's current recommendations are not up to date as they are for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 3 (R3) residents reviewed for physician notification. R3 had four instances of hypotension (low blood pressure) from November 2024 to January 2025. The facility did not call the on-call physician to report R3's hypotension to allow for an alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled Change of Condition and Provider Notification with a review date of 8/10/23 states in part; a change of condition (COC) is a deviation from an individuals baseline .a licensed nurse is involved in the assessment process and contributes to the collection of the data base, the planning of interventions and evaluation of the individuals response to the COC .The primary care provider will be contacted for notification and to obtain further orders from the provider as necessary. According to American Medical Directors Acute Change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality for 1 of 3 Residents (R3) reviewed for weights. R3 has a history of Congestive Heart Failure (Failure of the heart to adequately pump blood, causing fluid to back up into the lungs) and had no physician order for weights, and was not weighed for months at a time. This is evidenced by: The facility policy, entitled, Weighing Individuals, dated 6/13/23, states, in part: Policy: Individuals are weighed according to orders. Procedure: A. Weights are obtained per order and reviewed: 1. On admission/readmission, 2. Weekly for the first four weeks, 3. Monthly. B. Weights are documented and reviewed with previous weights for any changes. C. The Provider is updated with weights as ordered or indicated . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Obstructive Pulmonary Disease (Chronic lung disease that progressively obstructs the resident's ability to breathe), Congestive Heart…

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 drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles for 1 of 1 residents (R2) reviewed for insulin administration. Surveyor observed Medication Technician Med Tech E (Medication Technician) administer Humalog (Lispro) to R2 from a vial with no resident name indicated. This is evidenced by: The facility policy, Medication Administration, effective May 2018, documents, in part, as follows: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to he facility's medication distribution system (procurement, storage, handling, and administration.) Five Rights: Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple…

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 sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This has the potential to affect all 38 residents residing at the facility. Residents (R6 and R11) expressed long call light wait times due to not having enough staff. Staff voiced concerns with not being able to get tasks done due to not having enough staff per shift. Facility Scheduler indicated previous Administration directed Scheduler K to follow a grid that shows staff per resident ratio per shift. The grid does not take into consideration the acuity of the facility's resident population. The grid is currently being used to determine how to staff the facility. Evidenced by: The facility assessment titled Facility Wide Resource Assessment dated 12/22, states, in part: .Introduction: The Facility Wide Resource Assessment is required by the nursing home requirements of participation to identify…

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 conduct and document an up-to-date facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not review and update that assessment, as necessary, and at least annually. The lack of assessment has the potential to affect all 38 residents. The facility's Facility Assessment has not been updated annually and/or as necessary. Facility assessment dated 12/22, does not address current resident population at facility and resources/education needed for facility to appropriately care for resident population. Evidenced by: The facility document, Facility Wide Resource Assessment, dated 12/22, states in part; .The facility wide resource assessment is required by the nursing home requirements of participation to identify and analyze the facility's resident population and identify the personnel, physical plant, environmental and emergency response resources needed to competently care for the residents during day-to-day…

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 record review and interview, the facility did not ensure that 4 of 4 sampled residents (R7, R8, R1, and R15) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to ensure daily diabetic foot checks were completed for R7, R8, R1, and R15. As evidenced by: The facility policy Standard Diabetes Mellitus Protocol, undated, indicates in part as follows: Problem: Patient has potential for fluctuating blood sugar and/or complications of diabetes mellitus.Complete daily foot checks. Example 1 R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2, neuropathy, BKA (Below the Knee) amputation to LLE (left lower extremity) (12/16/22), toe amputation to right foot (7/28/21), peripheral arterial disease, phantom limb pain, history of MRSA (Methicillin-Resistant Staphylococcus Aureus) (unclear source), and Chronic Kidney Disease Stage 3b. Surveyor reviewed R7's medical record and current…

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 in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 15 residents (R2) reviewed for abuse. On 8/2/24, the facility became aware of an allegation of abuse by a Certified Nursing Assistant to a resident and did not conduct a thorough investigation. Findings include. The facility's policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property states, Investigation of abuse: When an incident or suspected incident of abuse is reported, the Executive or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include i.) Who was involved ii.) Residents' statements, iii.) Resident's roommate statements (if applicable), iv.) Involved staff and witness statements of events . Additionally, the policy goes on to state, It is the policy of this facility that the resident(s) will be protected from…

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 resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 3 of 3 residents reviewed for indwelling catheters (R1, R11, and R14.) R1 has an indwelling urinary catheter, and his urine output is not being monitored. Additionally, R1 has a physician order for monthly catheter changes, which is not current standard of practice. R11 has an indwelling urinary catheter, and her urine output is not being monitored. Additionally, R11 has a physician order for monthly catheter changes, which is not current standard of practice. R14 has an indwelling urinary catheter and has active orders for two different sizes of foley catheter. This is evidenced by: Facility policy titled Bowel and Bladder - Catheter Care, dated 6/24/22, states in part: Policy: Nursing staff will assess catheter use to promote proper care. Procedure: A. Upon admission or Insertion of Catheter . 2. Obtain Physician's Order including…

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 3 (R11, R10, and R12) of 5 residents reviewed for receiving a psychotropic medication were free from unnecessary drugs. R11 receives Quetiapine, an antipsychotic medication, for agitation/anxiety. R10 receives Citalopram (antidepressant) and was receiving Haldol (antipsychotic) and the physician orders do not indicate which diagnoses are associated with these medications. R12 receives Quetiapine, an antipsychotic medication, for dementing illness with behaviors. This is evidenced by: The facility policy titled, Medication Monitoring and Management, with an effective date of May 2018, indicates, in part: .Procedures: A.5) When a resident receives a new medication, the medication order is evaluated for the following: .b. A written diagnosis, an indication, and/or documented objective findings support each medication Example 1 R11 was admitted to the facility on [DATE] with diagnoses including breast cancer, multiple sclerosis, bipolar disorder,…

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 are free of significant medication errors for 3 of 7 total sampled residents (R1, R9, and R13). R9 did not receive a dose of her Apixaban (blood thinner) on 9/7/24 at 8:00 PM. R13 did not receive 2 doses of her Insulin Glargine (Long-Acting Insulin) on 9/20/24 and 9/22/24 at 8:00 PM. R1 did not receive scheduled doses of insulin and had an anticoagulant held and not given without a valid signed physician's order, nor was the doctor notified of these medication errors. Example 1 R9 admitted to the facility on [DATE] with diagnoses that include, in part: Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, Acute embolism and thrombosis of inferior vena cava, dysphagia (difficulty swallowing) . R9's September 2024 Medication Administration Record (MAR) indicates, in part: Apixaban Oral Tablet 2.5mg - Give 2 tablet via G-Tube two times a day for antiplatelet. Start date: 9/7/24. R9's 9/7/24 8:00 PM dose has documented…

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 record review and interview, the facility did not ensure a Registered Nurse (RN) worked for 8 consecutive hours in a day, 7 days a week. This has the potential to affect all 32 residents (R) residing within the facility. On Saturday July 6, 2024, and Sunday July 7, 2024, the facility did not have an RN in the building 8 consecutive hours. On 6/17/24 at approximately 4:00 PM, after reviewing the facility provided schedules, surveyor interviewed ADON C (Assistant Director of Nursing) regarding RN (Registered Nurse) coverage. Surveyor requested ADON C review the schedules and indicate which nursing staff listed were RNs. Nursing staff listed for Saturday July 6, 2024 and Sunday July 7, 2024 schedules were not noted to be RNs. ADON C indicated there is not always a Registered Nurse in the facility on weekends for 8 consecutive hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social service assistance for 4 (R2, R5, R3, and R4) of 4 residents reviewed for social services. R2, R5, R3, and R4 were not assisted with their care conference meetings. The facility indicated they went several months without a social worker. The facility failed to support all residents in having care conference meetings at least quarterly to ensure person centered care and goals were priority while residing at facility. Evidenced by: The facility policy titled, Individual Advance Care Planning, dated 2/21/24, states, in part; .Individual, guardian and/or their individual representative will be provided the opportunity to discuss advance care planning with appropriate interdisciplinary team members and providers .B. Upon admission/re-admission, change in condition, and at Care Conferences: 1. Advance Care Planning will be discussed and/or verified 2. The resources available in the skilled nursing facility to treat symptoms and conditions will…

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 On 7/17/24 at 9:41 AM, Surveyor interviewed R4. Surveyor asked R4 if medications are given to her or if they are left at her bedside. R4 stated staff generally bring her medications into her room and leave them on her bedside table. R4 stated, I am usually somewhere between sleep and awake when they come in. I don't like when they hover over me, so they leave the medications on the bedside table, and I take them within the hour. Surveyor asked R4 if the facility had performed an assessment for safe medication administration. R4 stated she did not recall an assessment. Surveyor reviewed R4's care plan, orders, and MAR/TAR (Medication Administration Record/Treatment Administration Record). R4's documentation does not have any notation indicating that R4 can safely self-administer medications. On 7/17/24 at 2:28 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that R4 does not have a self-administration of medication assessment. DON B stated that medications should not be left at R4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 2 of 3 residents (R4 and R6) reviewed for abuse. On 6/23/24, the facility became aware of an alleged violation of abuse between R4 and R6 and did not conduct an investigation. Evidenced by: The Facility policy entitled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 11/8/2023, states in part; Procedure: *Individuals will be protected from abuse, neglect, and harm while they are residing at the facility *No abuse or harm of any type will be tolerated. *Individuals and staff will be monitored for Protection .The facility will follow the attached Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to comply with the seven-step approach to abuse and neglect detection and prevention. R4…

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 develop and implement a discharge planning process that included preparation for discharge, ensuring discharge needs are identified and incorporated into a discharge planning care plan for 1 (R2) of 3 reviewed out of a total sample of 5 residents. Facility staff knew R2 had a plan to discharge home however, the facility was not discussing R2's discharge plan with R2. On 6/15/24 R2 decided to discharge home without a safe discharge plan in place. The facility was aware of R2's desire to return home but was not working on a safe discharge plan. Evidenced by The facility policy titled, Individual Transfer and Discharge, dated 2/21/24, states, in part; .The interdisciplinary Team will facilitate successful individual transfer and/or discharge, while complying with applicable regulations . R2 was admitted to the facility on [DATE] with a diagnoses including alcohol polyneuropathy, hypertension, insomnia, restless leg syndrome, depression,…

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 residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene. R4 did not receive a shower between 7/5/24 and 7/17/24. Evidenced by: Surveyors requested a policy related to ADL (Activities of Daily Living)/Showers and no further information was provided by the facility. R4 was admitted to facility on 9/7/23, with diagnoses that include, in part: need for assistance with personal care, morbid obesity due to excess calories, anemia (not enough oxygen in the blood which can cause tiredness, weakness, and shortness of breath), depression, urinary incontinence (inability to control bladder function), muscle weakness, and difficulty in walking. R4's Minimum Data Set (MDS), with target date of 6/21/24, indicates R4 has a BIMS (Brief Interview of Mental Status) of 13, indicating resident is cognitively intact. R4's Care Plan indicates: Focus- R4 has an ADL self-care performance deficit r/t (related to) weakness, morbid obesity, anemia, 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 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 for 1 of 1 residents (R1). R1 was admitted to the facility with a diagnoses of C. diff (Clostridium difficile) infection and isolation precautions were not implemented per current standards of practice. This is Evidenced by: The facility policy, Outbreak and Isolation Procedures, with a review date of 9/20/23, indicates, in part: .3. Isolation precautions are encouraged for individuals and/or staff for any contagious element according to the CDC (Centers for Disease Control) guidelines . According to the CDC website (https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html) C. Diff: Facts for Clinicians, Treatment and Recovery: .Isolate patients with possible C. diff immediately, even if you only suspect CDI (C. diff Infection) .If CDI is…

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, record review, and facility policy review, the facility failed to notify the physician when 1 of 3 sampled residents reviewed discharge (R1), left the facility against medical advice (AMA). Findings included: A facility policy titled, Individual Discharge, with a review date of 08/10/2023, revealed, B. Discharges Against Medical Advice 1. Staff to complete Discharge Against Medical Advice (AMA) assessment. Per the policy, 3. Staff to notify Physician, Adult Protective Services (APS), Activated Power of Attorney for Health Care agent, or Guardian, as indicated. R1 was admitted to the facilty on 05/07/24. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/24, revealed R1 discharged from the facility on 05/12/2024. R1's Progress Note, dated 05/12/24 at 1:30 PM, revealed Resident #1 left the facility AMA with a family member. R1's Progress Notes for the timeframe 05/07/24 to 05/12/24, revealed no evidence to indicate the physician was notified. During an interview on 06/21/24 at 11:24 AM, the Executive Director stated the physician…

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, document review, and facility policy review, the facility failed to timely report an allegation of misappropriation for 1 of 7 (R1) sampled residents reviewed for abuse. Findings include: A facility policy titled, Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program with a review date of 11/08/2023, indicated, It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to arrange home health services for 1 of 5 sampled residents reviewed for discharge (R55). Findings included: A facility policy titled, Individual Transfer and Discharge, reviewed on 02/21/24, revealed, I. Policy: The Interdisciplinary Team will facilitate successful individual transfer and/or discharge while, while complying with applicable regulation. The policy specified, F. Records 1. Upon transfer or discharge of an individual, the appropriate documents shall be prepared and provided to the facility admitting the individual. An admission Record revealed the facility admitted R55 on 12/21/23. According to the admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, acute right ankle and foot osteomyelitis, acquired absence of other right and left toes, and peripheral vascular disease. The admission Record revealed R55 discharged home with home health…

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 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 31 residents. The facility does not have a staff call-in process to ensure appropriate signs and symptoms (S/Sx) of illness are known, length of time off is adequate, and that staff are testing for COVID when they have S/Sx that may be indicative of COVID. Resident surveillance does not include S/Sx and symptom onset dates. The facility only tracks residents that are being treated with antibiotics. Facility was unable to provide McGeers documentation to show criteria was met for antibiotic use. Facility does not have infection control rates for the past year. The facility has little to no information for COVID outbreaks in December 2023 and January 2024. Return to work (RTW) dates are incorrect and staff were returning to work too soon. Facility could not provide testing for residents and staff for outbreak in December 2023…

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 record review, observation, and interviews, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 18 sampled residents (R20, R13, R29, and R22) and 1 of 3 supplemental residents (R35). R20, R13, R35, R29, and R22 voiced concerns related to facility cleanliness. Surveyor observed dust to be gathered in corners, under heat registers, under beds, along baseboards, and along floor transition strips in the facility hallways, resident rooms, and the dining area. Surveyors observed dried spills and stains on the floor and overflowing waste baskets. Facility staff voiced concerns related to not having enough housekeeping staff to complete daily cleaning and deep cleaning. Evidenced by: Facility admission Packet indicates the following services and supplies are included in the Basic Rate- Housekeeping, linens, and personal laundry. The facility did not…

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 record review and interview, the facility did not have a system in place to ensure there was at least one licensed staff member available 24 hours a day, seven days a week who could immediately initiate cardiopulmonary resuscitation (CPR) to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 13 of 31 (R) residents residing in the facility. The facility failed to provide licensed staff on two partial shifts who could immediately initiate CPR to any resident whose advanced directive indicated they desired to be a full code. The facility failed to have a process in place or a tracking system to ensure employees are current and up to date on their CPR certifications. Evidenced by: Per CMS S & C 14-01, nursing homes must have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless and non-breathing. unless: (1) the resident has…

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 the facility crash cart was checked by facility staff to ensure appropriate basic life support (BLS) could be provided to any resident requiring such care prior to arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 13 of 31 (R) residents residing in the facility. Facility did not ensure to follow standards of practice for wound care for 1 of 2 Residents reviewed for wounds out of a total sample of 18 Residents (R4). The facility did not ensure the necessary supplies and equipment were readily available for residents of the facility who have chosen to receive basic life support if needed. The facility did not complete R4's wound care treatments per physician orders. The facility did not complete R4's Skin assessments per physician orders. R4 was observed during wound care, where the Registered Nurse (RN) did not consistently follow correct infection control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service for 1 Resident (R17) reviewed of a total sample of 18 Residents. R17 voiced concerns of his Amazon packages being opened prior to being delivered to his room. This is evidenced by: The facility policy titled, Exhibit E Resident Rights, undated, states in part, 1. Dignified Existence; Communication and Access. Resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside Facility. A resident of Facility has the right to private and unrestricted communications with Resident's family, physician, attorney, and any other person, unless medically contra-indicated as documented by Resident's physician in Resident's medical record, except that communications with public officials or with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility did not ensure prompt resolution of all grievances for 1 of 18 sampled residents (R4) and 1 of 1 supplemental residents (R35) reviewed for grievances. Resident Representative L indicated she has brought forth concerns regarding R35's care and treatment and has not received any follow up. Facility staff voiced being aware of Resident Representative L's concerns regarding R35 and did not follow the facility's grievance process. R4 voiced concern of calling the police due to the call light not being answered and having to be incontinent in her bed. R4 voiced concern of being left on the bed pan and forgotten about to staff. Evidenced by: Facility policy, entitled Grievance, last reviewed 3/8/23, includes: . Individual, Guardian, and/or Individual Representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolving grievances . the facility fosters an environment of direct…

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 record review and interview, the facility did not ensure their abuse policy was implemented for 1 of 8 (CNA I) (Certified Nursing Assistant) employees reviewed for caregiver background checks. Findings include: The Facility's policy titled Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program with a review date of 11/08/2023, documents, each individual will be free from abuse, neglect, and misappropriation of property, abuse. It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check.A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation. The facility's policy titled Caregiver Background Checks, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Residents (R) receive care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 4 Residents reviewed for Pressure Injuries out of a total sample of 18 Residents (R4, and R9). The facility did not follow R4's physician orders for wound care treatment. The facility did not follow R9's physician orders for wound care treatment. This is evidenced by: The facility policy entitled Pressure Injury Prevention and Managing Skin Integrity, Review date of 8/10/23, states in part: . I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries . II . 2. Identify Interventions and Care Plan a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with 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 the environment remained free of hazards for 2 of 2 Residents (R35 and R29) who smoke, out of a total sample of 4 Residents. NHA A (Nursing Home Administrator) indicated there were no residents who smoke during Entrance Conference while Surveyors observed two residents smoking near the front door entrance. The facility failed to assess R35 and R29 for safety, failed to have a plan in place for storing smoking materials, and failed to have a designated area for smoking that includes a safe way to dispose of cigarette butts. Evidenced by: On 1/24/24 at 9:20 AM, during Entrance Conference, NHA A indicated there are no residents who smoke residing in the home. NHA A provided a Survey Ready Binder with the following: Facility's Survey Ready Binder included a form, undated, stating: (Facility Name) has a non-smoking campus. Therefore, we do not have any designated smoking times nor specific locations on our grounds. On 1/25/24 at 1:00 PM,…

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 fed by enteral means receives the appropriate treatment and services 1 of 1 sampled resident (R2) reviewed for G/T (gastrostomy tube) care. Facility staff checked R2's G/T placement by auscultation prior to a bolus feeding. The facility did not follow the current standard of care of checking G/T placement. This is evidenced by: The facility provided book entitled Nursing Procedures, eight edition, author [NAME], pages 796-797, states in part, . Tube Feedings .verify tube placement before administration using at least two of the following methods: . Aspirate contents from the tube with an enteral syringe . and evaluate the color of the aspirate; . If performed in your facility, measure the pH (potential of hydrogen) is usually 5 or less . R2 was admitted to the facility for long term care on 11/2/18 and has the following diagnosis of unspecified dementia (a condition in which a person loses the ability to think,…

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's drug regimen is free from unnecessary drugs for 1 of 5 Residents (R30) reviewed for unnecessary medicaitons. R30 is taking Trazadone and Melatonin for sleep. R30 does not have a sleep assessment to show the need or effectiveness of the medication. This is evidenced by: Facility Policy entitled 'Medication Monitoring and Management,' dated May 2018, states in part: .IIIB2:Medication Management. Policy .when selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. Procedures. A. the interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication -related problems [on an ongoing basis/quarterly]. 1) When possible, non-pharmacologic interventions are considered before initiating a new…

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 medication regimen was free of unnecessary psychotropic medications for 3 of 5 Residents (R24, R3, and R2) reviewed for unnecessary medications. R24's care plan is not personalized and does not include non-pharmacological interventions related to receiving psychotropic medications. R24 does not have consents signed for her psychotropic medications. R24's behavior tracking is incomplete for multiple shifts. R3 had a physician order for as needed lorazepam (a psychotropic medication used for anxiety) that extends greater than 14 days without a provider documented rationale. R2 has a dementia diagnosis and is receiving an antipsychotic medicaiton for behaviors that are not persistent or harmful to himself or others. This is evidenced by: Facility Policy entitled 'Medication Monitoring and Management,' dated May 2018, states in part: .IIIB2:Medication Management. Policy .when selecting medications and non-pharmacological…

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 an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 1 of 18 sampled residents (R2) and 2 supplemental residents (R23 and R6). R23 was treated with antibiotics for a urinalysis culture and sensitivity (UA C/S) dated 11/13/23. Facility did not provide sensitivity to show antibiotic ordered was effective. Facility did not provide Standards of Practice (SOP) McGeers documentation to show criteria was met. R23 was treated with antibiotics for urinary tract infection (UTI) dated 11/16/23. Facility could not provide the UA C/S or McGeers. R2 was treated with antibiotics for a UA C/S dated 12/29/23 that indicated a recollection recommended due to mixed multiple morphologies present including potential uropathogens. Facility could not provide documentation this was completed. R6 was treated with antibiotics for a UA C/S dated 1/30/24 that indicated a recollection recommended due to mixed multiple morphologies present including potential uropathogens.…

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 before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 3 of 5 residents (R2, R30, and R24) reviewed for immunizations. R2 was not offered pneumococcal vaccines. Facility does not have a declination or consent for the pneumococcal vaccine. R30 was not offered the influenza or pneumococcal vaccines. Facility does not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents receive care and treatment in accordance to professional standards for 2 of 7 sampled residents (R1 and R6). R1 did not attend a scheduled appointment that was part of her admission orders to the facility. The facility failed to follow R6's hospital discharge instructions. R6's orders indicated R6 should utilize Bipap machine every HS (at night/bedtime), and this was not done. R6 went from 10/9/23 to 11/9/23 (time of survey) without utilizing Bipap machine. This is evidenced by: Example 1 The Facilities Policy and Procedure entitled Resident Appointments and Transportation, undated, documents in part: .Appointments/Transportations (A/T) How do I notify HIS (Health Information Systems) of a Resident appointment for either a new admit or an existing resident? Powered by Survey Monkey, a form to request A/T scheduling is available in the EHR (Electronic Health Record) system. To access this form, please login to EHR. On the Home Page,…

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 that an allegation of misappropriation of resident's property was reported within 24 hours to the State Survey Agency (SSA) for 1 of 2 residents (R11) reviewed for misappropriation of property. Findings include: Review of the January through July 2023 facility Grievance logs showed R11 reported a missing cell phone on 06/23/23. Review of R11's Receipt of Grievance form showed the Social Services Director (SSD) received the allegation of missing property on 06/23/23. In the Investigation Findings portion of the document, the SSD wrote, emailed [laundry person's name], checked room. Then, written in the Resolution Description portion of the document was: not [sic] found 6/27/23 - spoke with son, [name], and he will replace when he returns home. Review of the SSA's Facility Reported Incidents (FRIs) for the past six months, contained two incidents, one was a misappropriation allegation (including a cell phone) of an intake the survey team was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an allegation of misappropriation incident was thoroughly investigated for one of two residents (R11) reviewed for misappropriation of resident's property. Findings include: Review of R11's admission Record from the Electronic Medical Record (EMR) Profile tab showed an admission date of 06/09/23 with medical diagnoses that included bipolar and panic disorders. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 06/16/23 showed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicative of being cognitively intact. Review of January through July 2023 facility Grievance logs showed R11 had reported a missing cell phone on 06/23/23. Review of R11's Receipt of Grievance form showed the Social Services Director (SSD) received the allegation of missing property on 06/23/23. In the Investigation Findings portion of the document, the SSD wrote emailed [laundry…

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 record review and interview, the facility failed to ensure 2 of 2 residents (R4 and R19) or their representatives were provided with written transfer notice that contained all required information. Findings include: Example 1 Review of R4's admission Record from the Electronic Medical Record (EMR) Profile tab showed an admission date of 02/05/23. Review of R4's EMR Progress Notes showed the last entry as: Effective Date: 04/11/2023 20:31 [8:31 PM] Note Text: Tonight, at approximately 2015 [8:15 PM] resident complained of numbness and tingling in her right jaw/face. Writer noted slurred speech .911 called, transported to [name] hospital for further evaluation. Review of R4's EMR Assessments, Progress Notes, and Misc. (Miscellaneous) tabs did not show evidence a written notice of transfer/discharge was provided to the resident or resident representative (RR). Example 2 Review of R19's admission Record from the EMR Profile tab showed an admission date of 04/08/22. Review of R19's significant change 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, record review and policy review, the facility failed to maintain a complete medical record for 2 of 23 residents (R4 and R22). Findings include: Example 1 Review of R4's admission Record from the Electronic Medical Record (EMR) Profile tab showed an admission date of 02/05/23 with medical diagnoses that included flaccid hemiplegia following a cerebral infarction, type II diabetes, hypertension, and altered mental status. R4 was discharged to the hospital on [DATE]. a. Review of R4's EMR Tasks (Certified Nurse Aide Point of Care (POC) documentation) tab indicated R4 was to have baths on Wednesday day shift and Saturday evening shift and showed the following dates that bathing occurred during her stay at the facility: 03/04/23 03/11/23 03/25/23 04/08/23 In an interview on 08/14/23 at 1:05 PM, the Covering Administrator stated the expectation of was 100% completion of POC documentation. During an interview on 08/15/23 at 4:15 PM, the Covering Administrator reviewed R4's bathing record 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.