St. Anne's Salvatorian Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure that staff discarded dispensed liquid medications that were not immediately administered to residents for one of two residents (Resident (R) 2) during medication administration for six residents in the sample. This failure had the potential to expose the resident to contamination in the medication. Findings include: Review of facility's undated policy titled, Preparation and General Guidelines: Equipment and Supplies for Administering Medications revealed, the facility maintains equipment and supplies necessary for the preparation and administration of medications to residents . Review of R2's annual Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 03/07/25 revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nonalcoholic steatohepatitis (NASH), end stage renal…

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, record review, staff interviews, and facility policy review, the facility failed to follow appropriate infection control practices for hand hygiene for one of one residents (Resident (R) 2) observed during medication administration of six residents in the sample. The failure had the potential for the spread of pathogens in the facility. Findings include: Review of the facility's policy titled Infection Control Hand Hygiene, dated 12/05/24 revealed I. Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. II. Procedure: A. Specific Indications for Hand Hygiene 1. Immediately before touching a patient .3. Before moving from work on a soiled body site to a clean body site on the same patient. 4. After touching a patient or the patient's immediate environment. 5. After contact with blood, body fluids, or contaminated surfaces .1. Wear gloves when in contact with blood, body…

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 conduct and document a facility-wide assessment. The assessment did not include the hours allocated for the (Infection Preventionist) IP, the Water Management Committee, infectious diseases, and staffing ratios. This had the potential to affect all 43 residents currently in the facility. Findings include: Surveyor reviewed the Facility assessment dated [DATE]. The staffing in the facility is not documented for shift ratios breakdown. This would assess the resident care levels and the staff needed to implement the care. Director of Nurses (DON)-B is also the facility IP and the time allocated to each role is not assessed. The facility's Water Management Committee is not documented in the assessment. The potential infection organisms such as Covid, influenza, Legionella, etc. are not assessed. CROSS REFERENCE F880 and F725. On 11/13/24 at 12:24 PM, Surveyor interviewed the Nursing Home Administrator (NHA)-A and reviewed the Facility Assessment. NHA-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.

Based on observation, record review and interview, the facility did not implement infection control measures. This was observed with 2 (R41 and R38) of 2 residents with glucometer's. The facility did not conduct an infection control program to prevent, and track, potential infections. This had the potential to effect all 43 residents in the facility. * R41 and R38 received blood sugar through a unsanitized glucometer machine. * The facility did not transport linens under sanitary conditions. * The facility did not implement and document Legionella control measures. * The facility did not track staff who can utilize a N95 mask during an outbreak. * The facility did not calculate infections to determine trends for preventative interventions. * The facility did not document surveillance of infections to identify concerns. Findings include: The facility's policy and procedure Infection Control, dated 9/20/2023. The procedure under surveillance states: Properly store, handle, process, and transport linens to minimize contamination.; Perform surveillance and investigation to prevent, 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 3.) R22 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus Type 2 with Chronic Kidney Disease, Atrial Fibrillation, Venous Insufficiency, Depression, Hypothyroidism, Urine Retention, Congestive Heart Failure, Peripheral Vascular Disease, Anemia, Acquired absence of left leg below knee and Atherosclerotic Heart Disease. R22 was hospitalized on [DATE]. Facility progress notes document: 7/30/24 at 9:05 AM: Called to Res (residents) room by CNA (Certified Nursing Assistant) stating that Res. had a large amount of blood on his diaper and around his penis. Catheter bag was full of [NAME] blood,100 cc (cubic centimeters). Blood in catheter tubing. No movement of blood in tubing. Resident A&O (alert and oriented) X 3. Denies pain/discomfort. Abdomen soft & non-distended. Incontinent of a large amount of SF (soft formed) stool. T (temperature) 98.6 p (pulse) 60 R (respirations) 16 B.P, (blood pressure) 90/40 checked X 2. Receives Eliquis 5 mg (milligrams). Call placed to NP (Nurse…

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 sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Surveyors made observations of residents waiting for assistance with delayed call light wait responses. Residents were interviewed and expressed concerns to surveyors that the facility does not have sufficient staff, resulting in delayed call light responses. Surveyor reviewed last 30 days of facility nursing schedules and nurse staff postings. Surveyor noted that the facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect a pattern of all 43 residents residing in the facility. Findings include: Delayed call light response On 11/11/24 at 11:12 AM, during initial interview, R2 reported they still have trouble getting to the bathroom either before or after meals. R2 reported that no staff is left on the floor to take anyone to the bathroom and call lights 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 observation, interview, and record review the facility did not ensure 1 (R16) of 1 resident reviewed for self-administration of medications was assessed prior to staff leaving medications at bedside for a resident. On 11/12/24, at 10:57 AM, R16 was observed to have multiple mediations sitting on her bedside table in a medication cup. R16 was not assessed to self-administer her medications and did not have an order from the facility provider for R16 to self- administer medications. Findings include: R16 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R16's diagnoses include End Stage Renal Disease (ESRD), Diabetes, Cerebrovascular disease, dependence on dialysis, heart failure, dementia, and Transient ischemic attack (TIA). R16's Quarterly MDS (Minimum Data Set) completed on 11/6/24 documents that R16 is independent with eating, oral hygiene, toileting hygiene, rolling left to right, and toilet transferring. R16 was documented as having a BIMS (Brief Interview for Mental Status)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs of 1 (R7) resident) of 12 sampled residents reviewed for accommodations of needs. *R7's call light was observed to be out of reach of R7. Findings include: R7 was admitted to facility on 08/22/2023 from a hospital with admitting diagnoses of urinary tract infection, Multiple Sclerosis and Quadriplegia. R7's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and documented R7 had a Brief Interview for Mental Status score of 15 which would indicate R7 is cognitively intact for daily decision-making skills. On 11/11/2024, surveyor reviewed R7's Care plan/call light. Focus includes, R7 is a high risk for falls r/t Deconditioning, Incontinence, Paralysis Tasks include, be sure R7's call light/pendant is within reach and encourage R7 to use it for assistance as needed. R7 needs prompt response to all requests for assistance. On 11/11/2024, 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 ensure residents the right to formulate an advance directive for 1 of 1 (R22) residents reviewed for advanced directives. R22's code status was not clearly indicated in the medical record. Findings include: R22 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus Type 2 with Chronic Kidney Disease, Atrial Fibrillation, Venous Insufficiency, Depression, Hypothyroidism, Urine Retention, Congestive Heart Failure, Peripheral Vascular Disease, Anemia, Acquired absence of left leg below knee and Atherosclerotic Heart Disease. R22's Annual MDS (Minimum Data Set) dated 8/13/24 documents a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. R22's care plan initiated 7/27/23 documents: Full Code. Interventions: SW (Social Worker) will follow up with resident and family as needed or as requested by resident or family. The Facility Policy and Procedure titled Code Status with a review date of…

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

Based on observation and interview the facility did not ensure residents' right to personal privacy and confidentiality of his or her personal and medical records for 2 of 2 (R38 and R41) residents reviewed. R38's medication cards and MAR (Medication Administration Record) were left on the medication cart unattended and in open view of residents or visitors. R41's MAR was left on the medication cart unattended and in open view of residents or visitors. The facility Policy and Procedure titled Medication Administration General Guidelines dated May 2018 documents (in part) . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration 2) Medications are administered in accordance with written orders of the prescriber. 16) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications,…

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 submit for a completion of a Level 2 Pre-admission Screening and Resident Review (PASARR) assessment for 2 (R9 and R38) of 2 residents reviewed for Level 2 PASARR Screens. R9 and R38 did not have a completed Level 2 PASARR screen for residents with mental illness or developmental disability. Findings include: 1.) R9 was admitted to the facility on [DATE] and has a diagnosis that includes Schizoaffective disorder, Bipolar, intellectual disabilities, dementia, and Altered Mental Status (AMS). R9's admission Minimum Data Set (MDS) assessment, dated 10/25/24, documents a Brief Interview of Mental Status (BIMS) score of 0, indicating R9 has severe cognitive impairment. R9's November 2024 Medication Administration Record (MAR) documents: Seroquel 50 mg (milligram). Give one tablet by mouth twice daily for psychosis/schizophrenia. Quetiapine Fumarate 400 mg. Give one tablet by mouth at bedtime for psychosis. Deutetrabenazine ER (extended release) 6 mg. Give one…

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 complete neurological checks in accordance with policy and procedure for 2 (R25 & R 28) of 2 residents reviewed for unwitnessed falls. *R25 did not receive neurological checks in accordance facility's policy and procedure for 5 unwitnessed falls. *R28 did not receive neurological checks in accordance facility's policy and procedure for an unwitnessed fall. Findings include: Policy and Procedure Surveyor reviewed Facility's Policy and Procedure titled Neurological Observation dated 3/16/17 with a revision date of 6/13/23 documents the following: Licensed Nurse will monitor and record an individuals Neurological status as indicated .Neurological observation is to be done per the following Neurological Check Schedule, unless otherwise specified by a physician's order: 1. At the time of the event, 2. Every (Q) 15 minutes x 4, 3. Q 30 minutes x 4, 4. Q 1 hour x 4, 5. Q 4 hours x 4, 6. Then every shift up to 72 hours. 1.) R25 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents who are continent of bladder and bowel received services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 2 (R22) residents reviewed for bowel and bladder. R22 had a decline in bowel continence following admission to the facility. The facility did not comprehensively assess R22's decline and no new interventions were implemented. The facility was not documenting or monitoring R22's bowel movements. Findings include: R22 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus Type 2 with Chronic Kidney Disease, Atrial Fibrillation, Venous Insufficiency, Depression, Hypothyroidism, Urine Retention, Congestive Heart Failure, Peripheral Vascular Disease, Anemia, Acquired absence of left leg below knee and Atherosclerotic Heart Disease. R22 was hospitalized and readmitted several times while residing in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records review the facility did not ensure 1 (R16) of 1 resident who receive dialysis had physician orders, monitoring, and communication with dialysis facility. R16 was admitted to the facility needing dialysis and did not have physician orders regarding the care and treatment of dialysis. The facility did not monitor R16's dialysis access site daily. There wasn't consistent communication between the facility and the dialysis facility. R16 did not have a comprehensive care plan that addressed dialysis. Findings include: The facility's hemodialysis policy dated 3/20/2018, last reviewed documents: The care for an individual receiving dialysis will be coordinated and communicated between the Skilled Nursing Facility (SNF) staff and the relevant dialysis staff. A. An individual care plan will be developed/revised in the SNF in collaboration with information provided by the relevant dialysis facility. Individual record will reflect up to, and including: 1. Identification of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the Facility did not regularly assess the risk of entrapment and review the risk & benefits for 1 (R5) of 1 Residents observed having bed rails. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. R5, who is dependent on staff for mobility, was observed to have a half side rail/grab bar on the right side of the bed and did not have a completed side rail risk assessment since 9/18/2023. R5 was not included in the monthly safety audits of side rails completed by the maintenance department. Findings include: On 11/12/24 at 2:20 PM, Nursing Home Administrator (NHA)-A informed surveyor that the facility does not have a siderail policy. R5 was admitted to the facility on [DATE] with diagnosis that include Chronic Kidney disease, Type 2 Diabetes, Dementia, Stroke history, Encephalopathy and Adult Failure to Thrive. R5's Significant Change Minimum Data Set assessment dated [DATE] documents R5 has 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 did not ensure 1 (R10) of 3 residents reviewed, received medically related social services to attain their highest practicable mental and psychosocial well-being resulting in R10's increased level of depression, anxiety and uncertainty regarding transfer/discharge. Findings include: R10's facility Social Services did not communicate timely with family and R10, nor follow through with R10's expressed desire to leave the facility and transfer/discharge to another facility until Surveyor brought it to the attention of staff. R10 was admitted to the facility on [DATE] with a diagnosis to include depression and anxiety disorder. R10's quarterly MDS (Minimum Date Set) dated 9/11/24, Section C (Cognition) documents a BIMS (Brief Interview for Mental Status) score of 12, on a scale of 0 to 15, indicating that R10 has moderate cognitive impairment. Section E (Behavior) document that R10 does not experience hallucinations or delusions. Section GG (Functional…

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 observations, interviews and record review the facility did not ensure it's medication error rates are not 5 percent or greater. The facility had a medication error rate of 8%. Findings include: The facility Policy and Procedure titled Medication Administration General Guidelines dated May 2018 documents (in part) . .Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: 4). Five rights - right resident, right drug, right dose, right route and right time are applied for each medication being administered. B. Administration 2) Medications are administered in accordance with written orders of the prescriber. On 11/12/24 at 7:36 AM, Surveyor observed RN (Registered Nurse)-O prepare medications for R38. The following medications were prepared and placed in a plastic medication cup: Vitamin B1 100 mg (milligrams) 1 tablet Acetaminophen 500 mg 1 tablet Atorvastatin 20 mg 1 tablet Potassium Chloride 10 meq (milliequivalents) ER (extended release) 1 tablet (label read -…

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 observations and interview, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the and the expiration date when applicable for 3 of 3 (R9, R41 and R44) residents reviewed. Insulin pens and vials in the medication cart and medication room refrigerator were open and used, but not dated when opened. Findings include: The facility Policy and Procedure titled Vials and Ampules of Injectable Medications dated May 2018 documents (in part) . .Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, uses, and disposal. Procedures: B. Expiration dates: Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this shortened expiration date are both important to be recorded on multidose vials (on the vial label or an accessory label affixed for that purpose). At a minimum, the date opened must be recorded. The shortened…

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, interviews, and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 2 residents (R5) reviewed for hospice care. R5 was being treated for an unstageable coccyx pressure injury and a Deep Tissue Injury (DTI) to R5's right heel. R5 was hospitalized from [DATE] through [DATE] with sepsis related to bilateral parotitis (inflammation and infection of both parotid glands [salivary glands located in front of the ears]). While hospitalized , R5's pressure injuries were both staged as unstageable. R5 was readmitted to the facility on [DATE] on hospice. Facility staff determined that hospice staff would be responsible for assessing and treating R5's pressure injuries. Communication between the facility and hospice staff was not clear. Hospice Nurse, Registered Nurse (RN)-J told Surveyor that RN-J was not aware that RN-J was the only staff member caring for R5's pressure…

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 upon interview and record review, the facility did not ensure it maintained an antibiotic stewardship program for 1 (R7) of 1 residents reviewed receiving an antibiotic prophylactically for clostridium difficile (c-diff). R7 started receiving vancomycin prophylactically for c-diff in April of 2023. The facility infection preventionist (IP)/Director of Nursing (DON)-B was not aware R7 received an antibiotic prophylactically. R7's antibiotic use was not monitored or reviewed during infection prevention and control surveillance and reporting to the facility quality improvement team (QAPI). Findings include: The facility's Policy & Procedure titled: Infection Control, with review date of 09/20/2023 documents: Subject: Antibiotic Stewardship. II. Procedure Leadership-The infection Preventionist (IP) will be identified to support the facility's safe and appropriate use of antibiotics. Accountability: 1. Review infections and monitor antibiotic usage patterns through Quality Assurance Performance Improvement (QAPI) process. 3. Monitor antibiotic resistance patterns and infections. On…

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

Based on interview, record review, and facility policy review, the facility failed to report to the State Survey Agency (SA) an allegation of physical abuse for one of two residents (Resident (R) 6) reviewed for abuse out of a total sample of 16. This had the potential to compromise or impede the protection of residents when allegations of abuse were made. Findings include: Review of R6's admission Record, from the electronic medical record (EMR) Profile tab, showed a facility admission date of 05/31/24 with medical diagnoses that included psychosis, intellectual disabilities, type II diabetes, neuropathy, cognitive communication deficit, and major depressive disorder. Review of R6's Progress Note, dated 06/20/24 at 5:41 PM and located under the Progress Notes tab of the EMR, revealed, . Writer was informed by CNA [Certified Nurse Aide] staff a man slapped resident while in the dining room during supper, resident was taken to the room by staff, writer proceeded to go and talk to resident to obtain details as to what happened in the dining room. Resident stated she was given 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.

Based on interview, record review, and facility policy review, the facility failed to complete a thorough investigation of an allegation of physical abuse for one of two residents (Resident (R) 6) reviewed for abuse out of a total sample of 16. The failure to conduct a thorough investigation had the potential to compromise and/or impede the protection of residents against abuse. Findings include: Review of R6's admission Record, from the electronic medical record (EMR) Profile tab, showed a facility admission date of 05/31/24 with medical diagnoses that included psychosis, intellectual disabilities, type II diabetes, neuropathy, cognitive communication deficit, and major depressive disorder. Review of R6's Progress Note, dated 06/20/24 at 5:41 PM and located under the Progress Notes tab of the EMR, revealed, . Writer was informed by CNA [Certified Nurse Aide] staff a man slapped resident while in the dining room during supper, resident was taken to the room by staff, writer proceeded to go and talk to resident to obtain details as to what happened in the dining room. Resident stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of Residents with the potential to affect all 37 Residents currently residing in the facility. Findings Include: 1. Surveyor requested a policy and procedure for linen distribution within the facility, but no policy was able to be provided by the facility. On 8/7/23 at 8:15 AM, Surveyor observed and approximately counted clean linen located on each of the 4 units located in the facility which included the following: [NAME]- 11 Residents Clean Linen Room-no towels, no washcloths, 2 bath blankets, 3 bed blankets, 1 fitted sheet, 1 flat sheet. 1st basket cart in hallway-1 gown, 2 fitted sheets 2nd basket cart in hallway-5 towels, 2 fitted sheets, 2 washcloths St. [NAME]- 13 Residents Clean Linen Room-1 bath blanket Basket Cart-3 gowns, 4 fitted sheets, 6 washcloths, 4 towels, 3 bath blankets, 5 flat sheets [NAME]- 7 Residents Clean…

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, resident and staff interview, and record review the facility did not did not ensure sufficient nursing staff to answer residents' call lights and provide care in accordance with the plans of care. This had the potential to affect all 37 residents residing in the facility at the time of the Survey. *There were multiple observations during Survey of a lack of nursing staff supervision in the dining room while residents were eating. *Observations of R1 not being assisted with meals. Per Certified Nursing Assistant (CNA)-FF, she assists a resident with meals in their room and also R1 who eats in the dining room. CNA-FF stated it is impossible to be in two places at once. * R1 was observed bringing R1's breakfast tray into R1's room. The CNA stated she would get R1 out of bed before lunch because they were extremely short staffed that morning. R1's care plan indicates R1 was to be in the dining room with supervision for all meals. R1 was left to eat breakfast in bed on the morning of 8/14/23 due to staffing issues. R1 was later observed in the dining room for 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 use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day 7 days a week. This deficient practice had the potential to affect all 37 residents residing in the facility. * On the following weekends there was no RN in the building for 8 consecutive hours: [DATE], [DATE], [DATE], [DATE] & [DATE]; [DATE] & [DATE]; [DATE] & [DATE]; [DATE] & [DATE]; [DATE], [DATE] & [DATE]; [DATE] & [DATE]; [DATE], [DATE], [DATE] & [DATE]; [DATE], [DATE] & [DATE]. Findings include: Surveyor noted the facility's PB & J (Payroll Based Journal) report documented a lack of an RN on duty on weekends including the following dates: [DATE], [DATE], [DATE], [DATE] & [DATE]; [DATE] & [DATE]; [DATE] & [DATE]. Surveyor reviewed the facility's nursing staff schedule for the above dates and noted all of the nurses on duty were Licensed Practical Nurses (LPNs). Surveyor noted the facility had a waiver for the State regulation to have an RN on duty on day shift. Per…

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 maintain an infection prevention and control program in accordance with professional standards of practice having the potential to affect all 37 residents residing in the facility. *The facility did not have documentation from December 2022 regarding an influenza outbreak and control measures/interventions during the outbreak. *The facility's water management program was not comprehensive and lacked a thorough assessment of risk areas and measures taken to reduce contamination. *Observations of glucometers not being disinfected between uses. *Observations throughout Survey of linen carts not being covered. Findings include: 1. The Facility policy entitled, Infection Prevention and Control Program, dated 6/18/21 documented: Procedure: 1. Prevention and Surveillance the facility will: i. Perform Surveillance and investigate to prevent, to the extent possible, the onset and the spread of infection . iii. Use records of symptom onset or…

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

Based on interview and record review the facility did not have a qualified Infection Preventionist who worked at least part time which had the potential to affect all 39 residents residing in the facility. *The Director of Nursing (DON)-B was serving as the facility's Infection Preventionist and did not have proper credentials. Findings include: On 08/16/23 at 9:09 AM, Surveyor interviewed DON-B. DON-B informed Surveyor she had not completed an infection control certification training program. Per DON-B she had started the CDC (Center for Disease Control) modules numerous times but had never completed them. DON-B stated she does plan on completing the training. DON-B stated she knew she needed an Infection Preventionist who worked at least part time and given her duties as the DON she was not capable of dedicating those hours to infection control. Per DON-B, her goal is to pass off the infection control job, but she had just come into the facility about a month prior and had no one else to do it. No additional information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the Facility did not ensure a baseline care plan was developed and implemented within 48 hours of a Resident's admission for 10 (R9, R21, R33, R31, R34, R10, R137, R20, R13, & R1) of 13 Residents. * R9 was originally admitted to the facility on [DATE]. The Facility did not complete the baseline care plan and has a status of in progress. * R21 was admitted to the facility on [DATE]. The Facility did not complete the baseline care plan and has a status of in progress. * R33 was admitted to the facility on [DATE]. The Facility did not have any interventions on the baseline care plan to incorporate R33's needs. * R31 was admitted to the facility on [DATE]. The Facility did not have any interventions on the baseline care plan to incorporate R31's needs. * R34 was admitted to the facility on [DATE]. The Facility did not complete the baseline care plan and has a status of in progress. * R10 was admitted to the facility on [DATE] . The Facility did not have any interventions…

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 2. R21 was admitted to the facility on [DATE]. The physician orders with an order date of 2/23/23 documents Eliquis Oral Tablet 5 MG (Apixaban). Give 1 tablet by mouth two times a day for clot in the lung for 6 Months. Surveyor reviewed R21's comprehensive care plans and noted the following care plans: * Code status initiated 7/4/23. * Alteration in nutrition Initiated 2/7/23 & revised 6/23/23. * Activities 3/24/23 & revised 6/29/23. * ADL (activities daily living) self care performance deficit initiated & revised 12/29/22. * Peripheral Vascular Disease initiated 12/29/22 & revised 3/9/23. * Wishes to rehab, work on getting a prosthesis & eventually go back to SSR ([Name of] Residence) initiated 12/5/22 & revised 7/4/23. * Diabetes Mellitus Initiated 12/29/22 * Actual fall Initiated 12/8/22. * At risk for falls Initiated & revised 12/29/22. * Uses antidepressant medication. Initiated 12/29/22 & revised 7/4/22. * History of mood problem Initiated 12/5/22 & revised 7/4/23. * Pain Initiated & revised 12/29/22. *…

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 4 (R21, R137, R31, & R1) of 4 Residents reviewed received required assistance with their ADL's (activities daily living). * R21, R137, and R31 did not receive their weekly showers/baths consistently per their plan of care. * R1 did not receive supervision and assistance by staff to eat despite assessments indicating R1 needed assistance. Findings include: 1.) R21 was admitted to the facility on [DATE] with diagnoses which includes below right knee amputation, diabetes mellitus, and depression. The admission Minimum Data Set (MDS) with an assessment reference date of 12/14/22 assesses R21 has having a Brief Interview for Mental Status (BIMS) score of 15 which indicates cognitively intact. R21 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer, does not ambulate and is assessed as not having any bathing. Under interview 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 observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for neurological checks after a potential head injury for 3 (R89, R20 and R9) out of 7 residents reviewed for neurological checks and clarification of orders for an orthopedic device for 1 (R288-A) out of 14 residents reviewed for quality of care. *R288-A was observed wearing a CAM boot to the Left Lower Extremity (LLE). There were no orders clarifying when to don or doff the boot and the boot was not care planned. *R89 sustained a fall and did not have neurological checks completed. *R20 sustained a fall and did not have neurological checks completed. *R9 sustained a fall and did not have neurological checks completed. Findings include: 1. R288-A was admitted to the facility on [DATE] and had diagnoses including maxillary fracture, 5th metatarsal fracture, unsteady gait and generalized muscle weakness. R288-A's admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure adequate supervision to prevent accidents for 7 (R18, R288-A, R228-B, R20, R9, R89, R137) 7 residents reviewed for accidents. *R18 had multiple falls without thorough investigations and root cause analyses *R288-A had two falls without thorough investigations *R288-B had a fall and there were no new interventions put in place. *R20 had multiple falls, one with a fracture, without thorough investigations and root cause analyses. *R9 had two falls without thorough investigations and root cause analyses *R89 had multiple falls without thorough investigations. *R137 had a fall that was not thoroughly investigated, and care plan not revised. Findings: Facility policy entitled, Falls, last reviewed on 06/24/2022, documented: .2. Procedure of Fall Event and Implementation of Intervention: .b. The care plan will be updated with an identified intervention . 3. Administrative Review a. The Interdisciplinary Team will review Fall Incident report…

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, and interview, the facility did not label medications with open dates, store medications in sanitary conditions, or removed expired medications in accordance with currently accepted professional principles affecting 4 (R9, R91, R7, R3) residents with medications not labeled when open and potentially affecting all residents that take stock medications in the facility. *The first floor medication cart had an expired stock medication. The second floor medication room had expired stock medications. The second floor medication room refrigerator was dirty, damp, and had food commingled with medications. *R9 had hydrocortisone 25 mg suppositories in the medication refrigerator that had expired. *R91 had latanoprost eye drops, timolol eye drops, dorzolamide eye drops, and brimonidine eye drops in the medication refrigerator that were not dated when opened and were not stored in individual bags with pharmacy labels. *R7 was administered fluticasone propionate and salmeterol 115 mcg/21 mcg inhaler. R7's name was illegible on the inhaler. Atropine sulfate…

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 2 of 5 direct staff chosen at random received effective communication training. CNA (Certified Nursing Assistant)-U & LPN (Licensed Practical Nurse)-W did not receive effective communication training. This has the potential to affect 24 Residents who reside on the 2nd floor where CNA-U & LPN-W typically are assigned. Findings include: The Facility Assessment last revised August 11, 2023 under the section staff training/education and competencies documents [Facility Name] provides comprehensive orientation and continuing education to ensure all staff is equipped with the knowledge and skill set to perform the duties assigned to them in a manner respectful of our residents and mission. For training topics includes Communication - effective communications for direct care staff. Effective communications describes a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening 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.

Based on record review and interview, the facility did not ensure 5 of 5 Certified Nurse Aides (CNAs)(CNA-R, CNA-S, CNA-T, CNA-U, CNA-V), Licensed Practical Nurse(LPN-W), Housekeeper(HK-X), and Assistant [NAME] (AC-Y) reviewed received behavioral health training to care for Residents diagnosed with mental health illnesses as indicated on the facility assessment. *CNA-R with a date of hire 12/18/13 did not receive Behavioral Health Training. *CNA-S with a date of hire 1/10/23 did not receive Behavioral Health Training. *CNA-T with a date of hire 4/4/23 did not receive Behavioral Health Training. *CNA-U with a date of hire 6/7/23 did not receive Behavioral Health Training. *CNA-V with a date of hire 2/20/18 did not receive Behavioral Health Training. *LPN-W with a date of hire 7/25/22 did not receive Behavioral Health Training. *HK-X with a date of hire 6/18/20 did not receive Behavioral Health Training. *AC-Y with a date of hire 2/20/23 did not receive Behavioral Health Training. This deficient practice has the potential for all staff to lack current knowledge to work with the unique…

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 attending physician when there was an allegation of sexual abuse and of a significant weight loss involving 1 (R20) of 12 Residents reviewed for notification of changes. Findings Include: Surveyor reviewed the facility's policy and procedure for Change of Condition and Provider Notification last reviewed 8/10/23 and notes the following: .l. Policy: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. ll. Procedure: 1. Change of Condition a. Change of condition(COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. 3. Notification a. Primary Care Provider (PCP) will be contacted for notification and obtain further orders from provider as necessary. R20 was admitted to the facility on [DATE] 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 interview and record review, the facility did not thoroughly investigate an allegation of abuse to prevent further potential abuse for 1 (R30) of 3 residents with allegations of abuse. *R30 reported an allegation of abuse by a Certified Nursing Assistant and that allegation was not thoroughly investigated by the facility to determine if the allegation was substantiated. No staff statements were obtained, and no determination was made of which staff member was rough with R30 to further the investigation and prevent potential further abuse. Findings: The facility policy and procedure entitled Comprehensive 'Abuse', Neglect, Mistreatment and Misappropriation of Resident Property Program dated 12/1/2022 states: E. INVESTIGATION Abuse Policy Requirements: It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI Incident Report and Investigation process. PROCEDURE: The investigation is the process used to try to determine what happened.…

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 proper foot care for 2 of 2 (R20 and R33) Residents. *On admission it is documented that R20 would benefit from seeing the podiatrist, but no referral was made. *R33, who is diabetic had a very long toe nail on the right foot and no timely referral to the podiatrist was completed. Findings include: A facility Services and Performance Standards policy and procedure dated [DATE] documents the following applicable: .Facility Responsibilities -Assign facility contact within 14 days of effective date to coordinate with [name of company] a. the announcement of services to facility Residents and Residents' responsible part b. assistance with enrollment of Residents in services, and c. assist with obtaining orders and other authorizations necessary to commence the services -Authorization Assistance: Facility shall provide [name of company] with assistance in obtaining appropriate consents, authorizations and necessary physician orders 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 observation, interview and record review, the Facility did not provide services and treatment to restore or improve as much bladder function to the extent possible for 1 (R33) of 1 Residents reviewed for bladder function. R33 was admitted to the facility on [DATE] with an indwelling Foley catheter. The indwelling catheter was removed during an urology appointment on 8/2/23. After the Foley catheter was removed, the Facility did not complete a comprehensive bladder assessment to assist R33 to improve or restore as much bladder function as possible, did not implement a urinary care plan, did not discontinue the catheter care plan and monitoring R33's catheter was not discontinued. Findings include: R33 was admitted to the facility on [DATE] with diagnoses which include urinary retention, blindness both eyes, diabetes mellitus, and hypertension. The indwelling Foley catheter care plan initiated & revised on 5/22/23 has the following interventions: *CATHETER: The resident has 16 FR (french) 10cc (cubic…

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 2 (R13 and R21) of 2 Residents reviewed for side rails had assessments for the need to use side rails, that consent was obtained for their use prior to installation, risks and benefits were discussed, and that alternatives were attempted prior to installation. *R13 had no current side rail assessment. *R21 had no side rail assessment completed. Findings Include: 1.) R13 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus, Paraplegia, Rheumatoid Arthritis, Agoraphobia with Panic Disorder, and Depression. R13 is currently R13's own person. Surveyor reviewed R13's Quarterly Minimum Data Set (MDS) dated [DATE] which documents that R13 has Brief Interview for Mental Status (BIMS) of 15, indicating R13 is cognitively intact for daily decision making. R13's MDS also documents that R13 requires extensive assistance of 1 for bed mobility, dressing, and toileting. R13's MDS documents R13 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 identify and seek ways to support Resident's individual needs through the assessment and care planning process, make referrals and obtain needed services from outside entities, and provide and arrange for needed mental and psychosocial services related to difficulty coping with change in condition and loss of meaningful life, and need for emotional support for 1 of 1 Resident's (R20) reviewed for medically related social services. R20 was not provided medical related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: R20 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Adult Failure to Thrive, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Cognitive Communication Deficit. R20 has an activated Health Care Power of Attorney…

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 the monthly pharmacist recommendations were reported to the attending physician, medical director, and the director of nursing and the reported recommendations were acted upon for 2 (R30 and R21) of 5 residents reviewed for unnecessary medications. *R30 had a recommendation from the pharmacist on 8/3/2023 for the physician to provide an appropriate diagnosis for the use of Quetiapine. The facility was unaware of the recommendation until Surveyor brought forth the concern. *R21 had a recommendation from the pharmacist on 1/25/2023 for lab work to be completed. There was no documentation showing the physician was notified of this recommendation and the labs were not drawn. Findings include: 1.) R30 was admitted to the facility on [DATE] with diagnoses of right humerus fracture, compression fracture of the spine, diabetes, anxiety, depression, peripheral vascular disease, and anemia. R30's admission Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 2 (R9 & R21) of 5 Residents reviewed. The Facility did not monitor R9 & R21 for potential negative side effects associated with anticoagulant use. Findings include: 1.) R9 was admitted to the facility on [DATE] with diagnoses which includes congestive heart failure and diabetes mellitus. On 8/14/23 at 3:39 p.m. Surveyor reviewed R9's physician orders and noted an order dated 6/7/23 documents Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for NURSE TO ENTER DIAGNOSIS Surveyor noted there is an anticoagulant therapy care plan initiated 1/11/23 which include interventions of Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness q (every) shift. Initiated 1/11/23 and Monitor/document/report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry…

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 (R21, R30, & R13) of 5 Residents were free from unnecessary drugs. * R21 receives Duloxetine HCI delayed release sprinkle 80 mg (milligram) in the morning and Bupropion HCI extended release 150 mg in the morning for depression without consistent side effect monitoring of the antidepressant medications and behavior monitoring. * R30 receives Seroquel without behavior monitoring or negative side effect monitoring and there is no diagnosis for use of the Seroquel. * R13 receives Sertraline HCl Tablet 100 MG without any behavior monitoring. Findings include: The Standard Psychoactive Medication Protocol not dated documents under nursing: Administer medications as ordered. Report changes to Physician. Monitor medication side effects. (Arrhythmia, falls, lethargy, behavior/cognition changes, etc.) Monitor and report labs as indicated. Document target behaviors, interventions and effectiveness. Obtain psych consult as needed. Psychoactive Team 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 observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 7 medication errors in 29 opportunities which resulted in a medication error rate of 24.14%. Medication errors were identified for R33, R7 & R17. * R33 received Eliquis 5 mg and Metoprolol Tartrate 25 mg late. * R7's Brimodine Tartrate Solution 0.15%, Atropine Sulfate Solution 1%, Dorzolamide HCI-Timolol Mal Solution 22.3-6.8 mg/ml & Prednisolone Acetate Suspension 1% eye drops were not dated when opened. LPN-P did not wait 5 minutes after administering Atropine Sulfate Solution 1% eye drops before administering Dorzolamide HCI-Timolol Mal Solution 22.3-68 mg/ml eye drops. * R17 received the incorrect dose of Lisinopril. R17 received 5 mg (milligrams). R17 should have received 2.5 mg. Findings include: 1.) On 8/14/23 at 10:03 a.m. Surveyor observed LPN (Licensed Practical Nurse)-P prepare R33's medication which consisted of Amlodipine 10 mg (milligram) one tablet, Tamsulosin 0.4 mg two capsules, Eliquis 5 mg one tablet, Ferrous Sulfate 325 mg…

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 obtain laboratory services when ordered by a nurse practitioner for 1 (R137) of 1 residents reviewed for laboratory services. *R137 had a CBC (complete blood count) and CMP (comprehensive metabolic panel) ordered by a nurse practitioner on 1/26/2023. The lab tests were not drawn or reported to the ordering nurse practitioner that the order was not carried out. Findings include: R137 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, protein-calorie malnutrition, depression, anxiety, anemia, and compression fracture of the spine. R137's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R137 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R137 as needing limited assistance with bed mobility, transfers, dressing, and hygiene. R137 did not have an activated Power of Attorney. R137 was discharged from the facility on 3/8/2023 and was not a resident of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the Facility does not conduct regular inspection of all bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 (R13 and R21), of 2 Residents observed with side rails/enabler bars up during the survey process. *R13 did not have regular inspection of R13's half side rails for possible entrapment. *R21 did not have regular inspection of R21's enabler bars for possible entrapment. Findings Include: On 8/13/23 at 3:18 PM, Director of Nursing (DON-B) stated there is no policy for side rails or required regular inspection of side rails. 1.) R13 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus, Paraplegia, Rheumatoid Arthritis, Agoraphobia with Panic Disorder, and Depression. R13 is currently R13's own person. Surveyor reviewed R13's Quarterly Minimum Data Set (MDS) dated [DATE] which documents that R13 has Brief Interview for Mental Status (BIMS) of 15, indicating R13 is cognitively intact…

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.