Pleasant View Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not afford the resident or resident's representative the right to refuse to transfer to another room in the facility for 3 of 3 residents (R1, R2 and R3) reviewed for room transfers. R1, R2, and R3 received room change notices and the facility did not afford the residents' representatives the opportunity to refuse the room change. This is evidenced by: The facility's policy titled Room Change/Roommate Assignment revised 3/2021 states in part; changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. 1. Resident room or roommate assignment may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 2. Room changes initiated by the facility are limited to moves with the same building in which the resident currently resident resides unless the resident voluntarily agrees to move to another building within the same facility. Prior…

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 that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 (R2) of 3 resident rooms observed. R2's bathroom toilet was soiled with stool and family reported it had been soiled for several days. This is evidenced by: On 10/8/24 at 6:45 PM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/24 8:20 AM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/25 at 8:15 AM, Surveyor met R2's Guardian FM K (Family Member) and Spouse. R2's guardian asked Surveyor if she had observed R2's bathroom. Surveyor observed R2's bathroom and noted the bathroom remained dirty with stool observed around and in the stool. FM K stated this has been like this for several days; the facility does not clean R2's bathroom or room. FM K stated she has had to clean R2's room because the facility does not. On 10/9/24 at 8:30 AM, Surveyor interviewed Hskp BB (Housekeeping) regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge, failed to ensure the written notice contained all pertinent information for a discharge notice including the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman for 2 of 2 facility-initiated discharges reviewed involving 2 Resident (R1 and R2). R1 and R2 received involuntary discharge notices; however, the notices did not contain all necessary information. This is evidenced by: The facility's Transfer and/or Discharge Policy revised 3/2021 states in part: (2) residents are permitted to stay in the facility, and not be transferred or discharged unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . (3) except as specified below, the resident and his or her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 3 of 3 Residents (R1, R2, R3) residing on the Way Unit. Activity staff and staff working on the Way Unit were not providing or offering activities for R1, R2, and R3. There is no documentation of R1, R2, and R3 participating or being offered activities since they were moved to the Way Unit. This is evidenced by: Facility Policy entitled 'Individual Activities and Room Visit program,' states in part: .Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them.1. individual activities are provided for individuals who have conditions 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 failed to assure that there is sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 3 of 3 Residents (R1, R2, & R3). RA (Resident Assistants), who are not Certified Nursing Assistants, were working on the Way Unit alone with R1, R2 and R3 who require increased supervision. This is evidenced by: Facility Employee list shows RA H, RA CC, RA X, and RA AA as being RA's and CNA (Certified Nursing Assistant) Facility staffing schedule indicates the following: On 10/1/24, RA H worked 6:30 AM to 3:00 PM, on the Way Unit and RA CC worked the Way Unit from 3:00 PM to 4:00 PM with another RA training. On 10/2/24, RA CC worked 1:30 PM to 10:00 PM on the Way Unit. No indication on the schedule of a CNA being assigned to the Way Unit during this time. On 10/5/24, RA H worked from 6:30 AM to 3:00 PM, no indication on the schedule who was assigned to the Way Unit or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY UNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID #MK7V11 Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents for 4 of 4 residents (R8, R10, R4, and R7) reviewed for falls/accidents and 4 of 4 residents (R1, R6, R2, and R5) reviewed for resident to resident/supervision. R8 required a two-person transfer with a full body lift, a staff member completed the transfer independently and R8 fell out of the lift. Staff did not follow R10's care plan when they transferred R10 to the restroom. Staff did not have foot pedals on R10's chair and Surveyor observed staff pushing R10 down the hall with his left leg dragging under the wheelchair seat. R7 was observed self transferring without gripper socks. R4 was transferred with the incorrect sling. R1 has the potential to be physically aggressive related to dementia and has a recent history of having resident to resident interactions at the facility. R1's care plan has an intervention that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receive the care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 residents reviewed (R8 and R4). R8 did not have neurological checks completed after a fall per facility protocol. R4 was admitted with orders to weigh daily and update the Physician with a weight increase or decrease by 3 lbs. (pounds) in a day or 5 lbs. in a week. R4's weights were not completed daily, and the physician was not always informed when weights fell outside the given parameters. This is evidenced by: The facility has an Unwitnessed Fall Checklist, undated, which state in part; if resident is unable to tell you if they hit their head, assume they did and do neuro (Neurological) checks with vital signs. Neuro checks are to be completed in PCC (Point Click Care/Electronic Health Record) under the assessment tab. Vital signs/Neuro Checks at time of fall and fifteen minutes after fall,…

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 hand hygiene and infection control practices were performed to prevent the spread of infection for 1 of 4 residents (R11) observed for hand hygiene and infection control opportunities. Staff were observed not completing hand hygiene per standards of practice, placing dirty washcloths in the wash basin, placing dirty washcloths on the bedside table, not disinfecting the bedside table or mechanical lift. This is evidence by: The facility policy titled Handwashing/Hygiene dated revised 8/2019 states in part; the facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 3. Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene polices. 6.…

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

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 69 residents. Staff returned to work to soon after signs and symptoms of GI (gastrointestinal illness). Surveyors observed R24 reach in the kitchenette's ice machine with her bare hands. The facility policy entitled Communicable/Contagious Diseases, Employee, with a revision date of 1/24, states in part: . Policy Statement: Personnel with active communicable infections may not be in contact with residents, resident-care items and equipment, or resident environments (e.g., common areas or resident rooms) until they are no longer clinically infectious or contagious. Work restrictions and return to work criteria for specific illnesses are determined by the infection preventionist based on the risk of transmission. Policy Interpretation and Implementation: . 2. Personnel may 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 interview and record review the facility did not ensure prompt resolution of all grievances for 3 of 14 residents reviewed (R2, R40, and R59) for grievances out of a total sample of 17 residents and 5 of 5 supplemental residents reviewed for grievances (R31, R6, R10, R39 and R50). R31, R39, R10, R40 voiced concerns at the Resident Council Meeting regarding the facility not following up on concerns/grievances. R2, R6, R50, and R59 voiced concerns during individual interviews regarding the facility not following up on voiced concerns/grievances. Staff reported they were aware of concerns voiced by R2, R50, R59, R40, R10, R39, R6, and R31 and did not report to the Grievance Official and did not follow the facility's grievance process. Evidenced by: Facility policy, entitled Grievance/Complaint Filing, revised 4/2017, includes, in part: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that all medications were stored and labeled in accordance with standard of practice for 3 of 3 (R25, R8, and R422) supplemental resident's, 2 of 4 medication storage rooms, and 3 of 5 medication carts reviewed. Surveyor observed expired eye drop administration to R25 during medication pass. Surveyor observed expired facility stock supply of acetaminophen 325 mg (milligram) tablets of the 300 wing medication cart during the medication storage task on [DATE]. This medication was previously administered to R8 and R422 on [DATE] morning doses. Surveyor observed an opened multidose vial of Tubersol in the medication room refrigerator located on the 300 wing with an unreadable partial date of unknown identification if the partial date is for the date of opening the vial or the expiration date. Evidenced by: The facility policy Administering Medications, revision date [DATE], states in part, . 12. The expiration/beyond use date on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents choices were honored in meal substitutions and an environment that promotes an enhanced quality of life which affected 1 of 1 resident (R59) out of a total sample of 17 residents. R59 voiced concerns her bed was not always made and her choice to have her bed made was not always honored. R59 also expressed concerns her meal choices were not honored. As evidenced by: Example 1 R59 was admitted to the facility on [DATE] with a diagnosis including paresthesia of skin, which is a tingling or prickly sensation in the arms, hands, legs, or feet. R59's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/4/24, indicates R59 has a BIMS (Brief Interview for Mental Status) score of 9 out of 15 indicating R59 is moderately cognitively impaired. R59's MDS indicates the need for some help with self-care and mobility, as well as partial/moderate assistance with all ADLs (Activities of Daily Living). R59's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident's (R30) out of a total sample of 17 residents observed for self- administration of medications. R30 was observed to have medications on the floor and an empty medication cup on her bedside table. This is evidenced by: The facility's policy titled Administering Medications dated April 2019, states in part, .27. Residents may self- administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team has determined that they have the decision-making capacity to do so safely . The facility policy titled Self-Administration of Medications dated February 2021, states in part, .1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self- administration of medications is safe and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility did not ensure adequate indications for use prior to the administration of a high-risk medication for 1 resident of 5 residents reviewed for unnecessary medications out of a total sample of 17 residents (R40). R40 receives Lemborexant (sedative/hypnotic) for insomnia. The facility failed to complete a sleep assessment for R40 prior to prescribing and administering a hypnotic medication. Evidenced by: Facility policy, entitled Psychotropic Medication Use, dated July 2022, states: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy interpretation and implementation: A psychotropic medication is any medication[sic] that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. anti-psychotics; b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 1 of 5 residents (R40) reviewed for immunizations. R40 was not offered pneumococcal vaccines. Facility does not have a declination or consent for the pneumococcal vaccine. The facility policy entitled Pneumococcal Vaccine, revised 5/22/24, states, in part: . Policy…

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's assessment, last reviewed/updated on 8/18/23, does not address the competencies to care for residents with behaviors or what the facility is doing to work with residents with behavioral needs. The facility assessment does not address the number of residents with traumatic brain injuries (TBIs), the resources required for those residents, or the number of staff necessary to care for these residents. The deficient practice has the potential to affect 19 of the 20 residents with dementia on the View Unit. Findings include: NHA A (Nursing Home Administrator) provided Surveyor a copy of a document titled, Facility Wide Resource Assessment, which states in part . Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The assessment will be used to make decision about the direct care staff needs, as well as the capabilities to provide services to the residents at [Facility Name] Nursing Home. Using a competency-based approach…

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 changed R1's living area for staff convenience and did not ensure that R1's representative was notified in writing of the room change for 1 of 1 residents (R1) out of a total sample of 7 residents. R1 was moved back and forth on the View unit and the Dementia Stabilization Unit (DSU) for staff convenience and without giving written notice of the change to R1's representative. This is evidenced by: Facility Policy entitled Room Change/Roommate Assignment, revised March 2021, states, in part: . Policy Statement: Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Policy Interpretation and Implementation: 2. Room changes initiated by the facility are limited to moves within the same building in which the resident currently residents, unless the resident voluntarily agrees to move to another building within the same facility (composite distinct part). 4. Prior to changing room or roommate…

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 permit 1of 1 residents (R1) reviewed for transfer and discharge to stay in the facility and did not transfer a resident from the facility unless the transfer was necessary and the residents needs could not be met by the facility. R1 was transferred to and from the skilled nursing facility to the community based residential facility within the facility campus without giving R1's family proper notice and without proper documentation justifying the transfer. Findings include: The facility policy titled, Transfer or Discharge, Preparing a Resident for, states in part . Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification to the resident, resident representative and the Office of the State Long-Term Care Ombudsman of a transfer for 1 of 1 residents (R1) reviewed for transfer/discharge out of a total sample of 7. The facility failed to notify R1's representative and the Ombudsman in writing of the reason for transfer to the Dementia Stabilization Unit (DSU). This is evidenced by: The facility policy titled, Transfer or Discharge, Preparing a Resident for, states in part . Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for 1 (R1) of 1 resident reviewed for discharge. Evidenced by: The facility policy titled, Transfer or Discharge, Preparing a Resident for, states in part . Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 3. Nursing services is responsible for: a. obtaining orders for discharge or transfer, as well as recommended…

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 staff interviews, the facility did not provide evidence that Certified Nursing Assistants (CNAs) had 12 hours of in-service training per year for 1 of 5 CNA's reviewed for in-service training. The survey team randomly selected five (5) facility CNAs who have been employed at the facility for longer than one (1) year. CNA W did not have 12 hours of in-service training. Findings include: Surveyor provided NHA A (Nursing Home Administrator) with a list of five CNA names the Surveyor had randomly selected and requested their in-service records. PAA Y (Payroll/Accounting Assistant) stated that Facility Educator X is out today and they do not have access to her files. PAA Y stated, she has only access to Relias training but no other training files. Surveyor reviewed the in-service records and noted the following: Surveyor reviewed CNA W's in-service records from 1/20/22 - 1/20/23. During this time, CNA W completed zero (0) hours of in-service for the year 1/20/22 - 1/20/23. The facility did not provide any documentation for training hours 1/20/23 - 1/20/24. CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 supplemental resident's (R26) observed during medication pass. R26 was observed to have her medications left at bedside. This is evidenced by: The facility's policy titled Medication Administration Policy dated 9/6/19, states in part, .10. Self- Administration of Medications .a. For a resident to administer their own medications, the resident needs to have completed and passed a nursing assessment that will aid in determining if this resident is capable of self- administering their own medications including leaving medications to be taken at their own determined time, completing their own nebulizer treatments, and applying an ointment or cream where and when ordered. b. A medical provider will need to order meds to be at bedside or to administer own medications. The resident must provide ability to self- administer their own medications prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 2 of 5 residents reviewed for restraints (R35 and R29). R35 had a pommel cushion without an assessment for its use. The facility did not consider this device a restraint. R29 had a wheelchair seatbelt she could not be easily removed by the resident. The facility did not consider this device a restraint. Evidenced by: The facility's policy titled Use of Restraints last revised April 2017, states in part: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time…

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 resident (R1) of 1 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R1 was at risk for pressure injury (PI) development. R1 developed a deep tissue injury (DTI) to the left heel. Facility staff did not ensure PI interventions were in place and did not implement an appropriate offloading device for the left (L) heel. Treatment orders were not completed as ordered. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, chronic kidney disease stage 4, Alzheimer's, and osteoporosis. R1's Minimum Data Set (MDS) with an Assessment Reference Date of 3/14/23 indicates a Brief Interview of Mental Status score of 00 indicating severe cognitive impairment. Section G of the MDS indicates R1 requires extensive assistance of 1 staff for bed mobility and transfers. Section M…

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 staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 2 residents reviewed (R42) out of a total sample of 21. R42 had an order for scheduled and PRN (as needed) pain medication. R42 has chronic pain and feels pain is not controlled. Facility had not been assessing pain with scheduled pain medication to track effectiveness of medications. Evidenced by: The facility policy, entitled Administering Pain Medications, with a revision date of March 2020, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication . General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined…

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 of 4 residents (R64) of a total of 21 residents reviewed had a drug regimen free from unnecessary drugs. R64 did not meet criteria for antibiotic therapy. As evidenced by The facility policy, Antibiotic Stewardship & MDROs (Multi Drug Resistant Antibiotics), dated 2020, indicates in part, the following: Antibiotic stewardship refers to systemic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The CDC (Centers for Disease Control) indicates that antibiotics are among the most frequently prescribed medications in nursing homes with up to 70% of residents receiving at least one antibiotic when followed for over one ear. The CDC defines Antibiotic Stewardship as a set of commitments and actions designed to optimize the treatment of infections…

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

Based on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the influenza and/or pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal, this affected 3 of 5 residents (R10, R44, R59) reviewed for immunizations. R10 had no documentation of pneumococcal immunizations in their medical record. R44 had no documentation of pneumococcal immunizations in their medical record. R59 had no documentation of pneumococcal immunizations in their medical record. The facility has not updated their pneumococcal policy to reflect the Centers for Disease Control's (CDC) recommendations to include PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance) and PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20). The facility has not been…

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.