Complete Care at Ridgewood LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *R4 had unwitnessed falls on 1/17/2025, 1/19/2025, 2/4/2025, and 2/13/2025. The facility did not thoroughly investigate the falls to determine a root cause of each fall and develop personalized interventions to prevent future falls. *R2 had two unwitnessed falls on 1/17/2025 and 2/7/2025. The facility did not thoroughly investigate these falls. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and a thorough investigation to determine a root cause to determine necessary preventative interventions. Findings include: The facility policy and procedure titled Fall Prevention Program dated 4/2024 documents: Policy Explanation and Compliance…

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 a sanitary environment was maintained to help prevent the development and transmission of infections during wound care for 1 (R7) of 1 residents observed during wound care. *R7 had a treatment to the right calf pressure injury and hand hygiene was not performed between dirty and clean aspects of the treatment. Findings include: The facility policy and procedure titled Hand Hygiene dated 4/2024 documents: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The attached Hand Hygiene Table…

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 policy review, record review and interview, the facility failed to ensure the family member and Activated Responsible Party (FM1) of one Resident (R1) out of nine residents reviewed in the sample was provided with information required to make informed decisions about the residents health care. FM1 was not notified prior to rehabilitation services being discontinued for R1. This failure created the potential for the resident's rehabilitation services to be unnecessarily and/or prematurely discontinued. The findings include: Review of the facility's policy titled, Notification of Changes dated 01/2024 read, in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Review of R1's admission Record, dated 12/06/24 and found in the Electronic Medical Record (EMR) under the Profile Tab, indicated 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 reviews, interviews, and facility policy review, the facility failed to ensure one of nine sample residents (Resident (R) 6) had her preferences honored. Findings include: Review of the facility's policy titled, Accommodation of Needs, provided by the facility, with a revised date of 02/24, revealed The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The policy further revealed Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible. Review of R6's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) revealed R6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated her cognition 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 observation, interview, record review, and review of the facility policy, the facility failed to ensure one comprehensive care plan for enhanced barrier precautions (EBP) was implemented for one of nine sample residents (Resident (R) 4) reviewed for care plans. This failure had the potential to put R4 and other residents at risk for infections. Findings include: Review of the facility's policy titled, Comprehensive Care Plans provided by the facility with a revised date of 02/24, revealed It was the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical,…

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, interviews, and review of the facility policy, the facility failed to follow enhanced barrier precautions (EBP) and infection control for one of nine sample residents (Resident (R) 4) reviewed for infection control precautions. The failure had the potential to put the residents at risk for the spread of an infection. Findings include: Review of the facility's policy titled, Clean Dressing Change, provided by the facility, with an implemented date of 11/23 and reviewed/revised on 09/24, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physicians' orders will specify type of dressing and frequency of changes. The policy further revealed to set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used…

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 ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment was not sanitized between resident use potentially affecting 3 (R36, R15, and R86) of 3 residents reviewed for monitoring of blood sugars and the handling of dirty laundry was not kept separate from the clean laundry potentially affecting all 92 residents in the facility. *An observation was made of Registered Nurse (RN)-K wiping off an EvenCare glucometer with an alcohol wipe. RN-K did not use a disinfectant wipe to clean the glucometer. RN-K had checked blood sugars on R36, R15, and R86 without disinfecting the glucometer between residents potentially exposing those residents to blood borne pathogens. *Observations were made of Laundry Aide-M handling dirty laundry while wearing a gown. The gown was not removed before Laundry Aide-M handled clean linen from the dryer. Findings include: 1.) The facility policy and procedure entitled Blood Glucose Monitoring dated 1/2024…

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 treat residents with dignity when administering insulin for 2 (R33 and R55) of 2 residents observed receiving insulin. Licensed Practical Nurse (LPN)-G administered insulin to R33 in the hallway by the nurses' station with other residents present. LPN-G checked R55's blood sugar and then administered insulin to R55 in the TV room with another resident present. No privacy was provided to R33 or R55. Findings include: The facility policy and procedure entitled Timely Administration of Insulin dated 1/2024 states: Policy Explanation and Compliance Guidelines: . 5. d. Explain procedure and provide privacy. On 5/1/2024 at 8:22 AM, Surveyor observed LPN-G standing at the medication cart next to the nurses' station. LPN-G dialed up the dose on the insulin pen for R33. R33 was in a wheelchair in the middle of the hallway next to the medication cart. Other residents were in the hallway and dining room getting ready for breakfast. The dining room was located across from the nurses' station. LPN-G administered R33's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 2 (R188 and R190) of 2 residents reviewed with non-pressure injuries. R188's non-pressure injuries were not comprehensively assessed on admission. R190's non-pressure injuries were not comprehensively assessed on admission. Findings include: The facility policy and procedure entitled Skin Assessment dated 10/2023 states: Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions,…

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 with pressure injuries received care consistent with professional standards of practice to promote healing for 4 (R188, R62, R14, and R12) of 5 residents reviewed with pressure injuries. *R188 was admitted to the facility with pressure injuries that were not comprehensively assessed on admission and the air mattress was observed to be not set according to R188's weight. *R62, R14, and R12 had pressure injuries and observations were made of their air mattresses not to be set according to their weight. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Management dated 10/2023 states: Policy Explanation and Compliance Guidelines: . 3. Assessment of Pressure Injury Risk . c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. 4.…

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, interview and record review, the facility did not ensure that 1 (R29) of 1 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R29 has limitations in range of motion to R29's left upper extremity. The facility did not apply R29's left hand splint as per R29's Care Plan. Findings include: The Facility policy, entitled Prevention of Decline in Range of Motion, dated 2/2023, states, in part: Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning and preventative care . 3. Appropriate Care planning. A. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy…

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 (R75) of 6 residents reviewed for weight received the necessary services to assist with nutritional maintenance. * R75 had a significant weight loss of 23 pounds (LBS) or 10.7% in 8 days which was not addressed by the Dietician or notification given to R75's physician. Findings include: On 5/6/24 the facility's policy titled, Weight Monitoring dated 1/24 was reviewed and read: A significant change in weight is defined as a 5% change in weight in 1 month (30 days). The physician should be informed of a significant weight change. The Registered Dietician should be consulted to assist with intervention: actions are recorded in the nutrition progress notes. R75 was admitted to the facility on [DATE] with diagnoses that included Diabetes Type 2, Dysphasia and Dementia. R75's quarterly Minimum Data Set (MDS) dated [DATE] indicated R75 did not have significant weight loss or gain during the assessment reference period. On 5/5/24 R75's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure the accurate administration of all drugs and biologicals to meet the needs of each resident for 1 (R15) of 5 residents reviewed for medications. R15 has a Medical Doctor (MD) order for a daily Lantus injection (Lantus is a long-acting insulin used to control blood sugar). Registered Nurse (RN)-K did not follow the MD order on 4/10/24, 4/18/24 and 4/24/24 and the Lantus injection was not given by RN-K. Findings include: The facility policy, entitled Medication Administration, dated April 2024, states, in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . R15 was admitted to the facility on [DATE] and has diagnoses that include: Type 2 Diabetes Mellitus. R15's Minimum Data Set (MDS) assessment, dated 2/24/24, indicates that R15 is cognitively intact and that R15 receives insulin injections…

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 safe, clean, comfortable, and homelike environment. This deficient practice was noted for 7 (R61, R52, R18, R26, R90, R32, and R199) of 22 Resident rooms reviewed for cleanliness. Findings include: On 1/26/23 at 12:40 PM, Surveyor interviewed Housekeeping/Laundry Supervisor (HLS)- I in regards to the observations of environmental concerns. HLS-I stated that a daily clean consists of emptying the garbage, wiping down the garbage can, cleaning all touch points like knobs, sweeping and mopping the room floor, cleaning the bathroom including sink and toilet and mopping the bathroom floor. HLS-I stated each Resident room gets a deep clean 2 times per month by moving all the furniture out, windows, and baseboards. HLS-I explained that each housekeeper has 28 Residents they are responsible for housekeeping for plus med rooms and bathrooms in the common area. Surveyor asked HLS-I if the department has been adequately staffed in order to keep the Resident rooms clean and comfortable. HLS-I stated that staffing has been colorful…

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 residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 4 of 7 (R34, R61, R8, and R90) residents reviewed for pressure injuries. *R34 developed a blister on their right heel that was identified on 12/8/2022. There was not a comprehensive assessment completed on R34's right heel pressure injury until 12/20/22. *R61 was identified to be at high risk for developing pressure injuries. R61 was observed without a cushion in their wheelchair during survey. *R8 was observed without their heels floated during survey per their plan of care. R8's air mattress was not being checked for function per shift. *R90 was identified to be at risk for developing pressure injuries. R90 was observed with their heels not floated off the mattress during survey per their plan 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, facility policy and procedure review, and interview, the facility did not ensure a safe smoking environment for residents and visitors. This had the potential to effect all 7 (R150, R55, R300, R42, R29, R17 and R54) of 7 assessed resident smokers. This also had the potential to effect anyone that utilized the designated smoking area for the facility. The facility designated smoking area did not include a fire extinguisher, nor did the facility lobby area. There were observations of individuals smoking in the designated area and in front of the facility entrance. Findings include: The facility policy and procedure for Smoking, dated 10/10/22, was reviewed by Surveyor. This procedure includes that there is to be a fire extinguisher in the designated smoking area; and there is to steps to minimize second hand smoke to families, staff, and other residents. On 1/24/23 at 11:29 AM Surveyor observed the designated smoking area. Surveyor did not observe a fire extinguisher. On 1/24/23 at 12:03 PM Surveyor observed a resident and visitor smoking in the designated area.…

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 medications requiring refrigeration were stored at the appropriate temperature for 2 of 3 medication room refrigerators reviewed. This has the potential to affect 9 (R74, R17, R15, R85, R82, R11, R67, R8, and R39) of 9 residents observed to have medications stored in medication room refrigerators. *Observation of the second-floor east medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was not completed for 5 days in the month of January. Surveyor also observed 8 cans of alcoholic beverages being stored in the medication room refrigerator with medications labeled for resident use. *Observation of the first-floor west medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was 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 observation, record review and interview, the facility did not ensure residents were treated with dignity and care that promotes their quality of life. This was observed with 2 (R26 and R151) of 22 residents reviewed. * R26 was observed with their Foley drainage bag uncovered. * R151 was observed with their Foley drainage bag uncovered and did not have their personal clothes to wear for days. Findings include: The facility's policy and procedure for Catheter Care, revised 10/1/22, was reviewed by Surveyor. The policy indicates: Privacy bags will be available and catheter drainage bags will be covered at all times when in use. The facility's policy and procedure for Resident's Personal Inventory, revised 5/2022, was reviewed by Surveyor. The policy indicates the facility will do an inventory list when a resident is admitted and ongoing to protect personal property and prevent loss. 1. On 1/23/23 at 10:03 AM Surveyor observed R26 in their room. R26 had a Foley drainage bag hanging on their nightstand…

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 promote or facilitate the residents choice for sleep schedules and health care. This was observed with 2 (R39 and R85) of 22 residents reviewed. * R39 gained weight in the facility and was not offered any alternate dietary diet to assist with weight control and/or loss. * R85 sleep preferences were not implemented by staff. Findings include: 1. On 1/23/23 9:54 AM, Surveyor spoke with R39 in their room. R39 indicated they just do jigsaw puzzles in their room and watches television. R39 is in a wheelchair and indicated they have gained a lot of weight while residing in the facility. On 1/24/23 at 10:59 AM, Surveyor conducted a Resident Group. R39 expressed they have gained a lot of weight in the facility. Their knees hurt and they just eat and sleep here. Surveyor reviewed R39's medical record. R39's Plan of Care for Potential for Weight Change dated 5/21/2020 is related to obesity with unplanned weight gain. The Interventions include:…

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 (R62) of 4 Residents reviewed for weight loss received the necessary care and services to assist with nutritional maintenance. *R62 was admitted on [DATE] and the first weight obtained on R62 was 10/2/22. Further, R62 has a physician's order as of 11/11/22 to obtain daily weights and this was not completed by the facility. Findings Include: Surveyor reviewed the facility weight monitoring policy and procedure dated 10/2022 and noted the following: .Policy: Based on the Resident's comprehensive assessment, the facility will ensure that all Residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the Resident's clinical condition demonstrates that this is not possible or Resident preferences indicate otherwise. Compliance Guidelines: Weight can be useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious…

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 ensure a resident with a gastrostomy tube received the appropriate care and services for a resident with a gastrostomy tube. This was observed with 1 (R90) of 2 residents with a gastrostomy tube. R90 has a gastrostomy tube that was not flushed or care planned after feeding was discontinued. Findings include: The facility's policy and procedure for Care and Treatment of Feeding Tubes, dated 10/2022, was reviewed by Surveyor. The policy includes: the resident's plan of care will address the use of feeding tube, including strategies to prevent complications; Directions for staff for providing care, including water flushes and skin care. On 1/23/23 at 11:31 AM Surveyor observed R90 in their bed. Surveyor observed on the over bed table there are 2 large Styrofoam cups with straws. Surveyor observed there was a large, tan colored and moist appearing area on R90's blanket by their upper abdomen area. There was a tube feeding syringe with a container on the bed side table. Surveyor reviewed R90's medical record and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not have evidence of ongoing communication and collaboration between the facility and the dialysis center for the care and services of 1 of 1 Residents (R62) reviewed who was receiving dialysis. *R62 did not always have evidence of assessment of R62's condition and monitoring for complications before and after dialysis, specifically obtaining R62's pre-weight by the facility staff and did not have ongoing communication and collaboration with the dialysis center. The form contains documentation from the dialysis center and serves as a communication tool between the facility and the dialysis center. Findings include: Surveyor reviewed the facility's Hemodialysis policy and procedure reviewed/revised 10/2022 and notes the following: .Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person centered-care plan, and the Resident's goals and preferences, 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 record review and interviews, the facility did not ensure residents receiving psychotropic medications had indications for use, adequately monitored administration and comprehensively assessed need for the medication. This was discovered with 3 (R39, R58 and R32) of 5 resident medication reviews. -R39's psychotropic medication did not indicate the individualized use with non-pharmacological interventions. -R58's psychotropic medication was not comprehensively assessed to identify their individual use and non-pharmacological interventions. -R32's psychotropic medication did not have a definitive stop date and was not discontinued when ordered by the physician. Findings include: The facility's policy and procedure Use of Psychotropic Medication, dated 10/10/22, was reviewed by Surveyor. The policy indicates: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial 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 observation, record review and interview, the facility did not implement isolation measures with a resident with potential symptoms of an infection. This was observed with 1 (R39) of 1 residents observed with loose stools that were to be assessed for potential (clostridium difficile) C-Diff. R39 had noted to be experiencing recurring loose stools/diarrhea. The physician was called and ordered testing for C-Diff with an antibiotic based upon test results. R39 was not placed in contact isolation when C-Diff was suspected. Findings include: On 1/23/23 at 9:55 AM Surveyor spoke with R39 in their room. R39 did not have any indications they were on any isolation for infection. R39 indicated the facility just had Covid here and there are just germs everywhere. R39 indicated they caught something with loose stools. Surveyor reviewed R39's medical record. The Progress Notes indicate the following: - 1/22/2023 at 21:56 (9:56 PM) R39 complained of loose stools, per R39 loose stool started a week ago. Writer informed on call Physician of the change in condition. Per Physician start 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.