Clairidge House

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not provide appropriate treatment and services for 1 (R20) of 1 sampled residents with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.* R20 was observed during the survey to not receive activities or stimulation based upon individual preferences and identified interests with a diagnosis of dementia. R20 was observed engaging in behaviors of repeatedly tapping and banging objects on tables without redirection or encouragement to do participate in an activity.Findings include:The facility's Dementia Management policy and procedure last revised 9/22 documents:Purpose:To ensure that facility staff members understand the needs of resident who display or are diagnosed with dementia and provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of these individuals.Protocol:2. Staff 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 Based on interview, and record review the facility did not ensure 1 (R10) of 1 resident reviewed received medically related social services to attain their highest practicable mental and psychosocial well-being.* On 1/14/2025, R10 was committed for 6 months on a locked unit at a psychiatric facility for Suicidal Ideation (SI), mania and psychosis with substantial probability of physical harm to self, manifested by overt attempt or threat. R10 readmitted to the facility without a suicidal care plan put into place and no person-centered interventions specific to SI prevention in R10's care plan. Social Service Designee (SSD)-H was not aware of R10's history of SI and was not involved in R10's psychosocial care planning or follow up.Findings include:R10 was admitted to the facility on [DATE] with diagnoses including Major depressive disorder and generalized anxiety disorder.R10's Quarterly MDS, dated [DATE], indicates R10 has a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition, no 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 pharmaceutical services were provided to 1 (R10) of 1 sampled residents receiving pain medications. R10 was seen in the emergency room (ER) on 11/1/25 for hip pain. R10 returned to the facility with recommendations to take Tylenol 650mg 3 times per day with or without ibuprofen 600mg twice a day, as needed for pain. There is no indication this recommendation was reviewed with R10's physician or medication orders at the time were adjusted to implement this recommendation for pain management. Additionally, R10 received multiple doses of as needed (PRN) Tramadol for pain management without a rating of R10's pain prior to administration or documentation of the effectiveness of the medication. Findings Include:The facility's policy, titled Pain Recognition and Management, last revised 4/2025, documents: . 8. Quality Assurance/Performance Improvement Considerations: a. For residents experiencing ongoing/unresolved moderate to severe pain, review 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 record review and interview, the facility did not ensure a resident received an antibiotic medication with adequate indications for use for 1 (R5) of 6 sampled residents.*R5 was prescribed, and administered, the antibiotic (Macrobid) without adequate indications of an infection.Findings include: R5 was admitted to the facility on [DATE] and is currently receiving hospice services. The Nurses Note dated 2/11/2026, at 5:29 PM, By Registered Nurse (RN)-D documents: (R5) complained of burning sensation to her vagina area. RN-D called the hospice nurse and received orders to start Macrobid 100 mg (milligram) Po (oral) BID (twice a day) times 7 days. RN-D faxed order to primary and (name of) pharmacy. RN-D placed R5 on alert charting times 7 days.R5's February 2026 Medication Administration Record documents Macrobid 100 mg was administered, BID from 2/12 - 2/17/26, for a Urinary Tract Infection (UTI).R5's medical record does not have documentation of clinical indications for the antibiotic or 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 observations, interviews, and record review, the facility did not establish and maintain 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 (R9) of 5 residents observed with Enhanced Barrier Precautions (EBP).*R9 has a Facility acquired pressure injury to the left upper posterior thigh area and left medial thigh. On 3/02/2026, Surveyor observed R9's incontinence care and on 3/03/2026, observed R9's wound treatment. The Facility staff did not wear the proper Personal Protective Equipment (PPE) while performing R5's wound treatment or incontinence cares.Findings include:The Facility's police, titled Standard and Transmission-Based Precautions, with a last revised date of 2/2024, indicated, . 11. Enhanced Barrier Precautions . a. When required, Enhanced Barrier Precautions are used IN ADDITION TO Standard Precautions. i. Enhanced Barrier precautions…

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 offer the influenza immunization for 2 (R16 and R5) of 5 residents reviewed for immunizations.R5 and R17 were not offered the influenza (flu) immunization on admission to the facility and the facility did not document if the immunizations were offered and declined.Findings Include:The facility policy titled Influenza Immunization - Resident Reviewed 2/25, Revised 2/21 documented:All residents will receive vaccination annually between October 1st and mid November, at the direction of the facility medical director and Q API committee.Residents admitted during the winter months (October 1st through March 31st) will receive influenza vaccination at admission, if they have not already received it unless there is a medical contraindication.If a resident refuses vaccination, the refusal is to be documented in the nurse's notes of the residence record, and his statement included which states that the resident was made aware of the risks of refusing 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 record review and interview, the facility did not offer the COVID-19 immunization for 1 (R16) of 5 residents reviewed for immunizations.R16 was not offered the COVID-19 immunization on admission to the facility and the facility did not document if the immunizations were offered and declined.Findings Include:The facility policy titled Coronavirus (COVID-19) Vaccination - Resident. Last reviewed 3/24, last revised 4/25 documented:Coronavirus vaccination is strongly recommended and applies to all the residents. When COVID-19 vaccination is available to the facility, each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized.Before offering COVID-19 vaccine, each resident or the resident representative is provided with education regarding the benefits and risks and potential side effects associated with the vaccine. In situations where COVID-19 vaccination requires multiple doses, the resident or resident representative 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 record review, document review, and staff interview, the facility failed to designate a person to serve as the Director of Food and Nutrition Services. Failure to designate a person had the potential to result in food not being prepared, stored, or served in a sanitary manner with the potential to result in food borne illness. This had the potential to affect all 41 of 41 residents residing in the facility. Findings include: On 10/15/24 at 10:34 AM, during the initial tour of the dietary department, Cook1 and Dietary Aid (DA)1 were working in the kitchen and when asked who the Dietary Manager/Director of Food Services was they both stated they did not have one. Cook1 stated she used to be the interim supervisor until they hired one. They stated a Director of Dietary was hired and then quit and they have not had a supervisor since he left. Interview on 10/15/24 at 4:10 PM, the Corporate Clinical Consultant and the Administrator stated the facility had a consultant Dietitian who provided consulting services once a week. They stated they did not have a person designated as the…

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

Based on observation, staff interviews and policy/procedure review, the facility failed to ensure the low temperature dishwasher sanitizer was maintained at a level required to sanitize the dishes. Failure to ensure the sanitizer level of the dishwasher was at the required level had the potential to result in food borne illness or the spread of infections for all 41 of 41 residents residing in the facility. Findings include: On 10/15/24 at 10:34 AM, the sanitizer in the low temperature dishwasher was checked by Dietary Aid (DA)1. The chlorine test strip did not change color indicating the chlorine sanitizer was at zero parts per million (ppm). The sanitizer was checked three times and each time the test strip did not turn colors. DA1 was asked if she tested it prior to washing the breakfast dishes and she stated she had and stated the test strip had not turned colors prior to using it to wash the breakfast dishes. On 10/15/24 at 1:05 PM, DA1 was observed running the soiled plates from the lunch meal through the dishwasher. After running two racks of dishes through the dishwasher,…

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, record review, policy review, and interviews, the facility failed to ensure the residents' environment was clean, sanitary, and homelike. This had the potential to result in the spread of infection; residents being injured as the result of a loose toilet seat; a decline in residents' self-esteem. This affected five (Resident (R) 26, R32, R23, R9, and R22) of 41 residents in the facility. Findings include: 1. On 10/15/24 at 2:57 PM; on 10/16/24 at 9:00 AM, 12:28 PM, and 3:38 PM; on 10/17/24 at 9:36 AM and 3:30 PM; and on 10/18/24 at 11:00 AM there was an unlabeled urinal on the floor of R26 and R32's bathroom and the pull cord on the bathroom call light was soiled with a brown substance. The urinal was lying on its side to the back of the toilet. On 10/17/24 at 3:30 PM the Social Service Director (SSD) verified the urinal was on the floor and the call cord was visibly soiled. On 10/28/24 at 11:00 AM the Maintenance Director verified the observation. On 10/17/24 at 9:36 AM and 3:30 PM a soiled incontinent brief with bowel movement on it was observed on the floor…

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, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident out of 28 sampled residents (Resident (R) 36) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly regarding R36's feeding tube, could lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual dated 10/01/19, indicated, . information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy by the IDT [interdisciplinary team] completing the assessment.'' Review of Section K of the RAI manual indicated, DEFINITIONS PARENTERAL/IV [Intravenous] FEEDING Introduction of a nutritive substance into the body by means other than the intestinal tract (e.g., subcutaneous, intravenous). FEEDING TUBE Presence of any type of tube that can deliver food/nutritional substances/ fluids directly into the gastrointestinal system. Examples include, but are not limited 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, record review, and facility policy review, the facility failed to ensure a resident with an indwelling urinary catheter had a physician's order for the use of an indwelling urinary catheter for one of two residents (R)34) reviewed for indwelling urinary catheter care. As a result of this deficient practice, the resident had the potential for harm by staff performing interventions or actions without a physician's order. Findings include: Review of R34's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 03/27/24 with medical diagnosis of neurogenic bladder. Observation on 10/15/24 at 3:30 PM, R34 had an urinary catheter tubing sticking out of the bottom of his pant leg, connected to a urinary collection bag. Review of R34's Care Plan under the Care Plan tab in the EMR revealed, Has Foley [indwelling urinary catheter] due to spinal cord injury with subsequent development of neurogenic bladder with the intervention to…

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

Based on interview, record review and policy review, the facility failed to ensure a resident with a feeding tube (gastrostomy tube) had a physician's order for the care and management of the feeding tube for one of one resident (Resident (R)36) reviewed for gastrostomy care. As a result of this deficient practice, the resident had the potential for harm by staff performing interventions or actions without a physician's order. Findings include: Review of R36's Face Sheet under the Face Sheet tab in the electronic medical record (EMR) revealed an admission date of 02/21/24 with medical diagnosis of Gastrostomy status [feeding tube]. Review of the Care Plan under the Care Plan tab in the EMR documented, Alteration in nutrition (less than body requirements) history of severe protein malnutrition, past history of significant weight loss, with recent improvement /rebound, wounds, has g-tube [gastrostomy tube] refuses to use, dysphagia [difficulty swallowing] due to a failed swallow study on 10/10/24. Review of R36's Medication Administration Record (MAR) revealed for the months of June…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure one Resident (R)41 out of three residents observed with a medication in a cup on the bedside table was administered his medication when the nurse dispensed the medication. This failure had the potential to place the resident at risk for health decline. Findings include: Review of the facility's policy provided by the facility titled, Medication Administration Scheduling Guidelines dated 5/19 revealed, .the facility requires that drugs be administered by the nurse until the care planning team has the opportunity to obtain necessary information of the residents' ability to safely self-administer medication. During an observation on 10/17/24 at 9:00 AM, with Register Nurse (RN)2, R41 was in his room and a pill was in a medication cup on the resident's bedside table. RN2 asked R41 if the night shift nurse had awakened him to give his medication. R41 stated, no the nurse did not wake him up during the night to give his…

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, document review, policy review, and interviews, the facility failed to ensure controlled substances were under double lock for one of two medication rooms (second floor), and that the individual controlled count sheets reflected the signatures of the nurses who had administered the narcotics to the residents for three of fourteen residents (R) 32, R37 and R24). This failure had the potential for controlled substances to be diverted. Findings include: 1. Review of the facility's policy, provided by the facility, titled Controlled Substance revised on 4/21 and reviewed on 7/24 revealed, purpose was to ensure appropriate and consistent procedures for safeguarding controlled substances are followed from delivery through the actual administration and/or destroying of medication. The policy further revealed the protocol to follow was all controlled substances will be counted by two nurses at each shift change. The ongoing nurse will count the controlled substances and the off going nurse will verify the count from the individual controlled substances count sheet…

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 staff interviews, record reviews, and document review, the facility failed to ensure the staff were prepared and educated for the care of one resident (Resident (R)26) with a portable infusion pump delivering chemotherapy drugs through a surgically implanted port. As a result of this deficient practice, the residents and staff had the potential for harm and/or injury due to lack of knowledge for: the care of the pump and tubing; awareness of the hazards of the chemotherapy drug and potential exposure risks with a leak or spill; and biohazard containment of a chemotherapy drug if a leak/spill did occur. Findings include: Review of R26's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 03/15/24 with medical diagnoses that included chronic viral hepatitis C, Human immunodeficiency virus (HIV) disease, and new rectal cancer diagnosis. Review of the 24-Hour Nursing report sheet (not a part of the resident medical record) dated 10/13/24, provided by the facility, documented R26 returned from a clinic appointment at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not have a system in place on how staff should respond, what staff should do in the event of a Resident requiring cardiopulmonary resuscitation (CPR), and ensure the necessary equipment was provided for R3's code event. This deficient practice has the potential to affect 23 Residents residing in the Facility who have determined their code status to be CPR. On [DATE] R3 had a change of condition which led to CPR being performed. LPN-E started compressions prior to checking R3's code status. LPN-E instructed CNA-F to call 911 and the other nurse, who was working on the other floor. CNA-F was unable to get through to 911 or the other nurse on the telephone. LPN-E while doing compressions used his personal cell phone to call 911. CNA-F had to take the elevator to the 2nd floor to inform RN-D there was an incident with R3. The Automated External Defibrillator (AED) which is located on either the first or 2nd floor was not brought up to the 3rd floor for R3. 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 1 (R6) of 6 Residents was given the right to formulate their preference regarding their code status and have the facility correctly reflect that preference. *R6's POLST (Provider Orders for Scope of Treatment) signed, not dated by R6 is checked for Do Not Attempt Resuscitation/DNR. On [DATE] R6 was hospitalized and returned to the facility on [DATE]. The hospital discharge summary for date of discharge [DATE] documents Code Status: Full Code. R6's medical record contained conflicting details regarding R6's code status and there is no evidence the Facility spoke with R6 regarding this conflicting code status. Findings include: The Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) Orders policy and procedure last revised 6/22 under protocol documents: 1. Upon admission, the licensed nurse or social worker will discuss the options, CPR or DNR and any other advance directives with the resident and/or legal representative, and receive 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 notify a Resident's representative of a new form of treatment involving a cream medication to treat scabies involving 2 (R7 and R3) of 2 Residents reviewed for notification of a representative. *R7 was diagnosed with scabies on 9/14/23 and 10/14/23 with a treatment ordered upon each occurrence. There is no indication in R7's medical record that R7's guardian was notified with each occurrence. *R3 was diagnosed with scabies on 9/17/23 and a new treatment was ordered. R3's activated Health Care Power of Attorney (HCPOA) was not notified. Findings Include: Surveyor reviewed the facility's change in Residents Condition/Status: Resident, Physician and Family/Legal Representative Notification/Consultation policy and procedure last revised 8/21 and notes the following applicable: .5. Unless otherwise instructed by the competent Resident, the Licensed Nurse will notify the Resident's family or legal representative when: d. There is a need to alter treatment…

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, prepared and served under sanitary conditions in 1 of 1 serving kitchens. This had the potential to affect all 48 residents currently in the facility. *Opened cereal stored in 12 QT (quart) containers did not have a date. *Expired taco meat dated 8/14/23 was observed in the main cooler. *Unit refrigerator in 3rd floor kitchenette was not monitored for appropriate temperatures and frost build-up was an inch thick on the inside back wall of refrigerator. Findings include: Food Storage The facility policy, entitled, Food Storage Standards, dated 5/2022, states: #3. Criteria for Dry Food Storage f. Working containers holding dry food or ingredients that are removed from their original packages are identified with the common name of the food, unless the food is easily recognizable such as dry pasts. g. Staff receives training on the proper dry food storage time and temperature. j. Personnel look for and follow best before dates. They also honor Store in a cool dry place or keep 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 record review and interview, the facility did not implement an effective Infection Control Program. The facility did not develop an effective Water Management Plan to prevent Legionella. The facility did not maintain accurate Surveillance of infections. This had the potential to effect all 48 residents residing in the facility. -The Water Management Plan did not identify areas of risk, surveillance process, control measures, monitoring, the review process along with identified staff responsible. -The facility did not have accurate data for an effective surveillance program to prevent the spread of infection. Findings include: The facility's policy and procedure Infection-Prevention-Water Management Program (Legionella) [name of facility] dated 6/23 was reviewed by Surveyor. The Protocol indicates: 1. Water Management Program Team-The water program is overseen by the team consisting of the Infection Preventionist, Maintenance Manger, Medical Director, Facility Administrator, Risk Manager or external…

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, interviews and record review the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 elevators in the facility. The facility elevator, which is used by both ambulatory and wheelchair residents, was not in proper working order. While on survey, the doors to the elevator closed quickly, bumping into both Surveyor and residents, causing them to stumble and lose balance. Findings include: On 8/23/23 at 8:06 AM Surveyor noted the facility elevator (east/left side) was not working. Corporate Consultant-C reported parts have been on order for a couple of months. On 8/23/23 at 12:01 PM while entering the right (west) elevator, Surveyor turned to hold the door for an oncoming resident and visitor using a walker. The elevator door began to close abruptly, slamming into Surveyor's left side/back, causing her to stumble. Surveyor held the door open for the resident and visitor. While in the elevator, Surveyor asked if the door always closes that quickly and abruptly. The visitor reported it just started…

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 provide residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 12 (R48) residents residing in the facility. R48 was not provided an appropriate wheelchair to allow her to get out of bed while residing in the facility. Findings include: R48 admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of endometrium, hypertension, Diabetes Mellitus Type 2, morbid obesity, asthma, urinary incontinence, shortness of breath and weakness. On 8/22/23 at 10:45 AM during initial interview with R48, Surveyor observed her lying in bed, on her back with the head of bed elevated. R48's television was on and she was wearing a gown. Surveyor asked R48 if she gets dressed and out of bed. R48 stated: Not really, I don't have a wheelchair. They usually don't get…

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 provide residents the right to formulate an advance directive for 1 of 12 (R48) residents residing in the facility. R48 did not have an advanced directive or code status clearly indicated in the event of an emergency. Findings include: R48 admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of endometrium, hypertension, Diabetes Mellitus Type 2, morbid obesity, asthma, urinary incontinence, shortness of breath and weakness. The facility policy and procedure titled Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) Orders dated revised 6/22 documents (in part) . Each resident will choose between CPR or DNR designation upon admission to the nursing home. 1. Upon admission, the licensed nurse or social worker will discuss the options, CPR or DNR and any other advance directives with the resident and/or legal representative, and receive the corresponding physician orders. The Physician Order Summary (POS) is 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 and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect 1 (R3) of 12 sampled residents. R3 was missing paint on the wall behind the headboard of the bed and there was a large circular hole in the drywall. Findings include: The facility policy, entitled, Maintenance requests, dated 1/2023, states: Purpose: To provide a central location for all staff to inform maintenance staff of maintenance requests throughout the facility and for maintenance staff to check off and date items as repairs and/or upkeep is completed. R3 was admitted to the facility on [DATE] with diagnoses that include traumatic brain injury, paraplegia, depression, and expressive language disorder. R3's Annual Minimum Data Set, dated [DATE] assesses R3 as having short- and long-term memory problems. On 08/22/23, at 10:23 AM, during the initial screen of residents, Surveyor entered R3's room (room [ROOM NUMBER]).…

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 an allegation of abuse, neglect, or misappropriation of resident property for 1 of two facility self-reports reviewed was reported to the State Agency within the required 24 hours. *R43 reported to the Activity Director (AD)-H on the afternoon of 6/10/23 that $40 was missing from R43's wallet. The facility started an investigation into the missing money to determine if the claim was credible before reporting this allegation to the State Agency until 6/12/23. Findings include: The facility policy, entitled, resident safety Abuse Policy, date revised 2/2022, states: Protocol: 3. REPORTING SUSPECTED VIOLATIONS: a. The supervisor on duty shall IMMEDIATELY safeguard the residents) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The Administrator will notify the DON and/or others as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure all allegations of abuse, mistreatment, exploitation, misappropriation of property, or mistreatment were thoroughly investigated for 2 (R6 and R43) of 2 self-reports reviewed for abuse, neglect and misappropriation of property. The facility did not interview other residents to determine the scope of the potential allegations. * On 11/10/22 the facility was made aware of an alleged mistreatment and potential abuse of R6 by Certified Nursing Assistant (CNA)-J. The allegation was that the CNA patted R6's buttock during cares and stated that the can of sardines in the room smelled like pussy. An investigation was started and residents were safeguarded from this CNA. R6 was interviewed and other staff. There is no documentation of other residents interviewed as part of the thorough investigation to determine the scope of the potential allegation. * On 6/10/23, R43 reported to the facility that $40 was missing from R43's wallet. 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 ensure that instructions for ongoing care were provided to the receiving provider upon discharge and was not documented by a physician for 2 (R50 and R51) of 3 residents reviewed for discharge. *R50 was transferred to the hospital on 7/2/2023 per family request. No transfer summary including the discharge summary was provided to the hospital and the physician did not document an order to have R50 transferred to the hospital. *R51 was discharged to another skilled nursing facility on 6/1/2023 per resident request. No transfer summary including the discharge summary was provided to the receiving facility and the physician did not document an order to have R51 transferred to another facility. Findings include: The facility policy and procedure entitled Transfer and Discharge Policy dated 10/2022 states: The facility will comply with regulations regarding initiating a transfer or discharge of a resident and the accompanying documentation that must 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 record review and interview, the facility did not develop a discharge plan involving the resident, resident's representative, and interdisciplinary team to develop goals of a discharge, document referrals to appropriate entities, revise the care plan to address the changing needs of the resident, and document the evaluation of the resident's discharge needs and discharge plan for 1 (R51) of 2 residents reviewed for discharge. *R51 did not have any documentation in their medical record by any discipline of the desire to discharge to another skilled nursing facility. R51's Discharge Care Plan was not revised to incorporate R51's desire to discharge from the facility. No documentation was found that the facility assisted R51 in referring R51 to another skilled nursing facility. No documentation was found addressing an evaluation of R51's discharge needs. Findings include: The facility policy and procedure entitled Discharge Planning dated 10/2022 states: The facility will develop and implement an effective…

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 develop a discharge summary to include a recapitulation of the resident's stay that includes the course of illness/treatment or therapy with a final summary of the resident's stay for 1 ( R51) of 3 residents reviewed for discharge. *R51 was discharged from the facility on 6/1/2023 to another facility and there was no documented evidence a discharge summary was completed. Findings include: R51 was admitted to the facility on [DATE] with diagnoses of right pubis fracture, electrolyte and fluid balance disorders, and atherosclerosis. R51's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R51 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 and the facility assessed R51 as needing supervision with bed mobility, eating, and hygiene, limited assistance with transfers, dressing, and toilet use, and extensive assistance with bathing. On 6/1/2023 at 9:22 AM in the progress notes, Social Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents' environment were free from accident hazards and residents received adequate supervision. This was observed with 1 (R15) of 1 residents reviewed for elopement and 1 (R49) of 1 water exceeding safe temperature range. - R15 has a Legal Guardian appointed and was found to have left the facility without staff knowledge or supervision. The local police department contacted the facility to inform them R15 was located at their prior community home. The facility staff was unaware R15 had left the facility until notified by the police. - R49's room hot water temperature was above the safe temperature range for use. Findings include: The facility's policy and procedure, entitled: Resident Signing Out, dated 4/2023, documents: Purpose: All residents leaving the premises must be signed out to enable the facility to know the whereabouts of residents not on the premises. Protocol: Documenting in the medical record that a resident signing…

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 resident received an antibiotic per definitions of an infection. This was observed with 1 (R32) of 1 resident's reviewed on antibiotics. R32 was prescribed an antibiotic and did not have documentation to support it use. Findings include: The facility's policy and procedure Infection Prevention and Control Program, revised 8/22, was reviewed by Surveyor. Section 9. Antibiotic Stewardship includes: antibiotic prescribing will include documentation of the dose, duration( indication and rationale) and treatment site; antibiotics will not be utilized in residents with asymptomatic bacteriuria by following the protocol urinary tract infection. On 08/22/23 at 11:03 AM Surveyor spoke with R32 in their room about antibiotic use. R32 indicated they have frequent UTI's (urinary tract infection). R32 indicated they go to see the Doctor for them. R32's medical record was reviewed by Surveyor. R32 's Physician Visit paperwork on 8/3/23 indicates Cipro 500 mg for 5 days for UTI. There is no additional clinical data to support 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 received specialized rehabilitative services of physical and occupational therapy that were ordered upon admisstion to the facilty for 1 (R48) of 1 residents reviewed for rehabilitation services. R48 did not receive therapy services as ordered upon admission to the facility. Findings include: R48 admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of endometrium, hypertension, Diabetes Mellitus Type 2, morbid obesity, asthma, urinary incontinence, shortness of breath and weakness. R48's admission Physician's order dated 6/22/23 documented: PT (Physical Therapy)/OT (Occupational Therapy) eval (evaluate) and treat. R48's Physician's order dated 7/26/23 documented: PT order: PT evaluate and treat 3-5 times/week for 4 weeks to address therapeutic exercise, therapeutic activity, nm (neuromuscular) re-education, gait training, w/c (wheelchair) training, manual, group. On 8/22/23, at 10:45 AM during initial…

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 resident received an antibiotic per definitions of an infection. This was observed with 1 (R32) of 1 resident's reviewed on antibiotics. R32 was prescribed an antibiotic and did not have documentation to support it use. Findings include: The facility's policy and procedure Infection Prevention and Control Program , revised 8/22, was reviewed by Surveyor. Section 9. Antibiotic Stewardship includes: antibiotic prescribing will include documentation of the dose, duration( indication and rationale) and treatment site; antibiotics will not be utilized in residents with asymptomatic bacteriuria by following the protocol urinary tract infection. 1.) On 08/22/23 at 11:03 AM Surveyor spoke with R32 in their room. R32 was queried regarding antibiotic use. R32 indicated they have frequent UTI'S (urinary tract infection). R32 indicated they go to see the Doctor for them. R32 medical record was reviewed by Surveyor. R32 Physician Visit paperwork on 8/3/23 indicates Cipro 500 mg for 5 days for UTI. There is no additional clinical…

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