Lake Country Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R16) of 16 Residents reviewed had a comprehensive care plan that was reviewed and revised by the interdisciplinary team as determined by the Resident's assessed needs. R16's care plan was not revised to accurately identify R16's at risk for pressure areas/skin impairments, the need for a toileting plan, and discharge planning interventions. Findings Include: 1.) R16's admission Minimum Data Set(MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goal, preparation for transition and reduction in factors leading to preventable readmission for 1 resident (R16) of 1 residents reviewed for discharge planning. * The facility did not complete the admission process for R16 and/or representative including explaining R16's available benefits at time of admission detailing that R16 would either need to private pay as of 10/18/24, or the facility would need to assist R16 with an effective discharge plan for 10/18/24. R16 was notified at 8:45 AM on 10/17/24 the option of private pay or discharge home effective 10/18/24. R16 chose to discharge home on [DATE]. Findings Include: The facility's Transfer and Discharge Policy implemented June 2017 and last revised on 7/15/22 documents: Anticipated Transfers or Discharges-initiated by the Resident a. Obtain physicians' orders for transfer or discharge and instructions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide the necessary ADL (Activities of Daily Living) services for 3 (R7, R11, and R13) of 17 residents who were dependent on staff to provide ADL care. R7 is dependent for bathing and R7 did not receive showers on 9/8/24 and 9/15/24. R11 is dependent for bathing and R11 received 2 showers for the month of September 2024. R13 is dependent for continence care and did not receive continence care multiple times in July 2024. Findings include: 1.) R7 was admitted to the facility on [DATE] with a diagnosis that includes hemiplegia, anxiety, neuromuscular dysfunction of the bladder, dementia, reduced mobility, and speech deficits following cerebral infarction. R7 is dependent on staff for bathing, transferring, and toileting. Surveyor reviewed R7's medical record which documents R7 did not receive a shower on 9/8/24 and 9/15/24. Surveyor could not locate any not documentation of R7 declining a shower on 9/8/24 or 9/15/24. R11 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.

Based on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R16) of 1 Resident reviewed for incontinence. * A bladder assessment and care plan with person centered interventions was not implemented when R16's urinary continence declined from occasionally incontinent to frequently incontinent. Findings Include: 1.) R16's admission Minimum Data Set (MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16…

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 therapy services were provided in a timely manner for 2 (R4 and R16) of 2 residents reviewed for therapy services. *R4 returned to the facility on 7/25/24 after receiving Cortisone (a steroid medication that can help with pain and inflammation) injections to both knees. R4's orthopedic doctor advised that R4 should start Physical Therapy (PT). R4 did not start PT until 9/5/24. *R16 did not receive a home evaluation before discharge. Findings include: 1.) On 10/23/24 at 10:40 AM, Surveyor was informed by Nursing Home Administrator (NHA)-A that the facility does not have a policy for the communication process between staff and the therapy department, for the timing of therapy services, or for the process of home evaluations. R4 was admitted to the facility on [DATE] with diagnosis that includes Stroke, Type 2 Diabetes and Osteoarthritis of the left knee and Bilateral (both sides) knee arthritis. R4's Annual Minimum Data Set Assessment (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not provide a written notice of transfer, including the reason for transfer and appeal rights to the resident, and their representatives, at the time of transfer from the facility. This was observed with 7 (R49, R51, R58, R3, R4, R55, R75) of 7 residents reviewed for transfers. * R49 was transferred to the hospital on 2/3/24 and was not provided a written notice of the transfer including reason for the transfer and appeal rights. * R51 was transferred to the hospital on 4/5/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R58 was transferred to the hospital on 6/15/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R3 was transferred to the hospital on 5/16/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R4 was transferred to the hospital on 5/7/24 and was not provided a written notice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide the written bed-hold requirements to the resident, or their representatives, at the time of transfer from the facility. This was observed with 5 (R49, R51, R58, R55, R75) of 7 resident transfers reviewed. * R49 was transferred to the hospital on 2/3/24 and was not provided the written bed-hold notification. * R51 was transferred to the hospital on 4/5/24 and was not provided the written bed-hold notification. * R58 was transferred to the hospital on 6/15/24 and was not provided the written bed-hold notification. * R55 was transferred to the hospital on 5/4/24 and was not provided the written bed-hold notification. * R75 was transferred to the hospital on 4/21/24 and was not provided the written bed-hold notification. Findings include: On 6/18/24, at 2:09 PM, Surveyor spoke with (Director of Nurses) DON-B. DON-B indicated the facility does not have a policy and procedure for written bed-hold notification requirements. DON-B informed Surveyor 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 the resident's record reflected the accurate resuscitation code status election for 1 (R8) of 18 residents reviewed for code status. R8's hospital discharge paperwork dated [DATE] and facility admission documentation completed on [DATE], indicated R8 elected a full code status. On [DATE] R8's medical record documented a DNR (Do Not Resuscitate) MD (medical doctor) order. After the facility conducted a meeting with R8's POA (power of attorney)-K, R8's code status was changed to a full code and a new full code MD order was placed in R8's medical record on [DATE] per R8's POA-K wishes. On [DATE], R8's code status was changed to DNR. R8's progress notes continue to document R8 is a full code despite the signed paperwork and active MD order for DNR. Findings include: R8 was admitted to the facility on [DATE], and has diagnoses that include Chronic kidney disease, Chronic obstructive pulmonary disease, Type 2 Diabetes, and Dementia. R8's Quarterly…

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 with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R7) of 8 residents reviewed for pressure injuries. R7 was re-admitted to the facility from the hospital on 7/19/2023, with a stage 2 pressure injury to the coccyx. The facility did not complete a comprehensive assessment of the pressure injury including measurements and a description of the wound bed documented upon re-admission. R7 had 2 additional re-admissions to the facility from the hospital on [DATE] and 10/12/2023. The facility did not complete a comprehensive assessment of the pressure injury with measurements and description of the wound bed documented upon readmission for these two additional re-admissions. Findings include: The facility policy, titled Pressure Injuries and Non pressure Injuries, dated 7/20/2022 documents: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the environment remained free of accident hazards for 1 (R3) of 6 residents reviewed for accidents. * R3 fell from bed while receiving cares due to bed frame not being extended to accommodate mattress size. R3 has bed rails attached to frame but there is no maintenance plan in place by facility for inspection after installation. Findings include: The Facility Policy and Procedure titled, Bed Maintenance and Inspections Policy Date Implemented: 6/16/2022, states in part: Policy Explanation and Compliance Guidelines: 1. The Maintenance Director, or designee, is responsible for keeping records of bed inspections and maintenance. 2. Bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each . 3. The Maintenance Director shall review each manufacturer's recommendations and requirements for maintenance and bed inspections, and shall establish a maintenance and inspection schedule accordingly . 6. Bed frame, mattress,…

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 ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight for 1 of 2 (R69) residents reviewed for weight loss. R69 was not weighed as ordered. R69 sustained severe weight loss over a period of less than 2 months. Neither the Physician, nor the Dietician was notified and no new interventions were implemented. R69 continued to lose weight with no Physician or Dietician notification and no new interventions were implmented until an additional month later. Findings include: R69 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following Cerebral Infarction, Aphasia, Dysarthria, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea and Hyperlipidemia. The facility policy titled Weight Monitoring revised 12/21/22 documents (in part) . . The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R27) of 3 residents was provided with pain management consistent with professional standards of practice. R27 reported being in constant pain. The facility did not identify R27 was assessed to have a significant worsening of pain effecting R27's quality of life while conducting R27's Minimum Data Set (MDS) Pain assessments on 5/13/24. R27 was hospitalized on [DATE] and was readmitted to the facility on [DATE]. R27 did not have an order for scheduled Tylenol order from 5/9/2024 through 6/3/2024 or Tramadol which was in place prior to R27's hospitalization. The facility did not address the potential for R27 to experience increased pain with the change in pain medication orders. R27's Physician Assistant's (PA) documentation indicated R27 was getting Physical therapy (PT) and Occupation therapy (OT) to help with pain management. R27 was not receiving PT or OT to help with pain management. Findings include: The facility policy, entitled Pain…

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 Registered Pharmacist consult recommendations were acted upon promptly, and relayed to the required staff. This was observed with 2 (R58 and R3) of 5 resident medication reviews. * R58 and R3 had Registered Pharmacist (RPH) medication regimen review recommendations that were not relayed to the Physician, Medical Director and Director of Nurses, promptly. Findings include: The Facility policy titled Consultant Pharmacist Services Provider Requirements dated 01/23 documents (in part): Procedures 4 . c. Review and follow-up to previous month's pharmacy recommendations with the nursing care center staff d. Medication Regimen Reviews (MMR) for each Skilled Nursing (SNF) resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. e. Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related 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 and interview the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and including labeling drugs and biologicals with the expiration date when applicable. This was observed with 2 (R45 and R55) of 2 residents reviewed who receive insulin. R45 and R55 each had 2 open insulin pens in their respective medication cart that were not labeled with an open or use by date. Findings include: The Facility policy titled Medication Administration Subcutaneous Insulin dated 01/23 documents (in part): Procedures .Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. 6. Date vial or device after first use . On 06/19/24, at 12:56 PM, Surveyor was completing a review of the medication cart located on the 100 hallway east. R55 had insulin pens of insulin glargine and latanoprost of which neither had an open date 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, record review, and policy review, the facility failed to ensure one of 10 sampled residents (Resident (R) 1) was fully informed of the risks and benefits of proposed care and treatment options and was given the right to choose her preferred option when her antibiotic regimen was altered. Findings include: Review of R1's electronic medical record (EMR) Medical Diagnoses tab revealed R1 was initially admitted to the facility on [DATE] and discharged from the facility on 02/12/24. Review of R1's discharge Minimum Data Set (MDS), with an Assessment Reference Date of 02/12/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Review of R1's EMR Orders'' tab revealed an order for vancomycin hydrochloride (HCL), an antibiotic, oral capsule 125 milligrams (mg) by mouth one time every other day for Clostridioides difficile (C. diff) for 14 days. It was recorded that the antibiotic was started on 01/29/24 and discontinued 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the physician was notified when multiple administrations of antibiotics and probiotics to treat a recurrent Clostridioides difficile [C. diff, a bacterial infection known to cause diarrhea and colitis (inflammation of the colon)] were not available for administration for one of 10 sampled residents (Resident (R) 1). This delayed the physician from altering R1's course of treatment when a new antibiotic course was not initiated. Findings include: Review of R1's electronic medical record (EMR) Medical Diagnoses tab revealed R1 was initially admitted to the facility on [DATE] and discharged from the facility on 02/12/24. Review of R1's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Review of R1's EMR Progress Notes tab revealed: 1. On 12/13/23 at 3:47 AM, R1 had tested…

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

Based on interview, record review, and policy review, the facility failed to ensure one of 10 sampled residents (Resident (R) 6) who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when R6 missed four of five showers during her admission to the facility. Findings include: Review of R6's undated Medical Diagnoses tab, located in the electronic medical record (EMR), revealed R6 was admitted to the facility from 11/13/23 to 11/29/23 with diagnoses including generalized muscle weakness and muscle wasting and atrophy, not elsewhere classified. Review of R6's admission Minimum Data Set with an Assessment Reference Date of 11/20/23, located in the EMR MDS tab, revealed R6 was assessed as requiring partial to moderate assistance with showers, having a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (indicating moderately impaired cognition), and no rejections of care during the lookback period. Review of R6's Documentation Survey Report v2 [version 2], provided by the facility for November 2023 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 record review, interview, and policy review, the facility failed to ensure medications were available for administration for one of 10 sampled residents (Resident (R) 1). R1 missed multiple administrations of antibiotics and probiotics to treat a recurrent Clostridioides difficile [C. diff, a bacterial infection known to cause diarrhea and colitis (inflammation of the colon)]. Findings include: Review of R1's electronic medical record (EMR) Medical Diagnoses tab revealed R1 was initially admitted to the facility on [DATE] and discharged from the facility on 02/12/24. Review of R1's discharge Minimum Data Set (MDS) with an Assessment Reference Date of 02/12/24 and located under the MDS tab of the EMR, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Review of R1's EMR Progress Notes tab revealed: 1. On 12/13/23 at 3:47 AM, R1 had tested positive for C. diff. R1 was started on vancomycin, an antibiotic, four times a day for 10 days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medical record accurately reflected the resident's refusals to be weighed and physician notification of weight changes for one of 10 sampled residents (Resident (R) 5). Findings include: Review of R5's Medical Diagnoses tab in the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] and discharged on 02/27/24 with diagnoses including chronic diastolic (congestive) heart failure. Review of R5's care plan, provided by the facility, revealed a focus for rejections of care, initiated on 02/07/24, with interventions including use consistent approaches when given care. Review of R5's EMR Orders'' tab revealed an order dated 02/08/24 for daily weights to be completed and for the physician to be notified of a weight gain of more than two pounds in 24 hours or more than five pounds in one week related to congestive heart failure. Review of R5's EMR Medication Administration Record (MAR), from the Orders tab for January…

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 staff interview, the facility did not ensure allegations involving potential abuse were thoroughly investigated for 3 Residents (R1, R7, and R10) of 3 Residents reviewed for allegations of abuse. * On 9/29/23, an allegation of abuse involving R1 was reported to Director of Nursing(DON-B), but was not thoroughly investigated by the facility. * Certified Nursing Assistant(CNA)-E reported to nurses that R7 was upset and tearful because R7 was being forced to go to bed when R7 did not want to and the facility did not thoroughly investigate the allegation. The accused CNA-C was allowed to continue to work with other residents with no provision as to how the facility would protect other residents from potential further abuse. *On 9/3/23, an allegation of abuse involving R10 was reported to DON-B and Administrator(NHA-A), but was not thoroughly investigated by the facility. Findings Include: Surveyor reviewed the Abuse, Neglect, and Exploitation policy and procedure revised 7/15/22 and notes…

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 allegations of mistreatment or abuse involving 3 Residents (R1, R7, and R10) were reported immediately to the State Survey Agency. * On 9/29/23, an allegation of abuse involving R1 was reported to Director of Nursing (DON-B), but was not reported to the State Survey Agency. * Certified Nursing Assistant (CNA-E) reported to nurses that R7 was upset and tearful because R7 was being forced to go to bed when R7 did not want to. * On 9/3/23, an allegation of abuse involving R10 was reported to DON-B and Administrator (NHA-A), but was not reported to the State Survey Agency. Findings Include: Surveyor reviewed the Abuse, Neglect, and Exploitation policy and procedure revised 7/15/22 and notes the following in regards to reporting: .IV. Identification of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility did not maintain records that were complete and accurately documented for 1 (R9) of 2 residents reviewed who received cardiopulmonary resuscitation (CPR) in the facility. * R9 received CPR after a cardiac arrest on [DATE] and nothing about the event was documented in R9's medical record. Findings include: R9 was admitted to the facility on [DATE] with diagnosis that included Malignant Neoplasm of the Pancreas. On [DATE] Director of Nurses (DON)-B provided a list of residents who received CPR in the facility that included R9. On [DATE] R9's medical record was reviewed and no entries regarding R9's change of condition or need for CPR were documented in the medical record. On [DATE] at 9:00 AM DON-B was interviewed and indicated on [DATE] at about 2:30 PM R9 stopped breathing and Registered Nurse (RN)-J called a code and started CPR. CPR was continued until paramedics got there and paramedics were able to get a pulse and transferred R9 to the hospital where…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 70 residents residing in the facility. The facility did not have a practice of monitoring and documenting food holding temperatures. Findings include: The FDA (Food and Drug Administration) Food Code 2022 documents at section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding .Time/Temperature Control for Safety Food shall be maintained: (1) At 57°Celsius (C) (135°Fahrenheit (F) or above, except that roast cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54°C (130°F) or above; (2) At 5°C (41°F) or less. In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended the minimum hot holding temperature specified in the Food Code: Be greater than the upper limit of the range of temperatures at which Clostridium perfringens (C. perfringens) 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 observation and staff and resident interview, the facility did not ensure food was served at a palatable temperature and was appetizing for 9 Residents (R) (R8, R17, R1, R54, R56 R175, R176, R24, and R15) of 12 residents. R8, R17, R54, R56, R1, R176, R24, and R15 stated their meals were not served at a palatable temperature and/or the food was not appetizing. In addition, R175's lunch meal contained items that were warm, lukewarm and cool to taste. Findings include: On 4/10/23 at 10:15 AM, Surveyor interviewed R8 who stated the food is not always hot and appealing. R8 further stated that even when sitting in the dining room, the food is served lukewarm, the vegetables are often mushy and the coffee is served cold. R8 verified dining staff reheat the food if asked; however, R8 stated R8 no longer asks because when the food is reheated, it doesn't come back as hot and is just as cold. On 4/10/23 at 11:31 AM, Surveyor interviewed R17 who stated the food is bad. R17 stated R17 does not always receive foods that are requested, the food is not served hot, and R17 is served menu…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure accurate administration of medication for 3 Residents (R) (R15, R7 and R21) of 5 residents reviewed. R15 did not consistently receive pain medication timely as ordered by R15's physician. R7 did not consistently receive medication timely as ordered by R7's physician. R21 did not consistently receive medication timely as ordered by R21's physician. Findings include: The facility's Medication Administration General Guidelines policy, dated 1/2023, contained the following information: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices .14. Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . 1. On 4/10/23, Surveyor reviewed R15's medical record. R15 was admitted to the facility with diagnoses to include recent right…

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

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R45) of 5 residents was monitored for the effectiveness and potential side effects of psychotropic medications. R45 was admitted with diagnoses that required use of multiple psychotropic medications. The facility did not monitor for the effectiveness or potential side effects of the medications. Findings include: The facility's Medication Error Reporting and Adverse Drug Reaction Prevention and Detection document, dated January 2023, contained the following information: The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis .refer to State regulations if medication error and adverse reaction reporting programs are legislated .Facility staff monitor the resident for possible medication-related adverse consequences .Evaluation of resident's side effects of medications, including sedation, lethargy, agitation, mental status changes or behaviors .The facility staff monitors residents for possible adverse consequences and/or the need to modify the dose of 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.

Based on observation, staff and resident interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 4 errors occurred during 28 opportunities which resulted in a 14.29% medication error rate affecting 2 Residents (R) (R7 and R21) of 3 residents observed during medication pass. R7 had physician orders for Baclofen (a muscle relaxant) 10 mg (milligram) tablet four times a day scheduled at 7:00 AM, 11:00 AM, 3:00 PM and 7:00 PM, Tizanidine (a muscle relaxant) 3 mg tablets three times a day scheduled at 8:00 AM, 12:00 PM and 8:00 PM, and Eliquis (used to prevent blood clots) 5 mg tablet two times a day scheduled at 8:00 AM and 7:00 PM. During an observation of medication administration, Surveyor noted R7's AM medications were not administered until 11:20 AM. R21 had a physician order for Eliquis 5 mg tablet two times a day scheduled at 7:00 AM and 7:00 PM. During an observation of medication administration, Surveyor noted R21's 7:00 AM dose of Eliquis was not administered until 11:26…

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 staff interview, the facility did not staff performed appropriate hand hygiene during a care observation for 1 Resident (R) (37) of 2 sampled residents with an indwelling catheter. Staff did not perform appropriate hand hygiene during an observation of care for R37. Findings include: The facility's Hand Hygiene policy, dated 11/2/22, contained the following information: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). When to wash or sanitize hands. * Before applying and after removing personal protective equipment (PPE), including gloves. * After handling contaminated objects. * Before performing resident care procedures. * After assistance with personal body functions (e.g. elimination). R37 was admitted to facility 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.