Watertown Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R8) of 1 sampled resident.R8 had a physician order for bronchial hygiene using Cough Assist (a device that clears secretions from the lungs by gradually applying positive air pressure to the airway and then rapidly shifting to negative air pressure, stimulating a deep natural cough to assist with clearing mucus and secretions) treatments twice daily. The treatments were not consistently completed.Findings include: According to the National Institutes of Health (NIH) article PMC7902008 retrieved 5/13/26, .Cough Assist (or Mechanical Insufflator/Exsufflator): The Mechanical Insufflator/Exsufflator (I/E) is a device that produces changes in the airflow inside the bronchial tree in such a way as to vicariate the cough .It is used mainly in patients with neuromuscular pathologies or respiratory muscle deficiency, who have a hypovalid or ineffective cough. An ineffective cough causes…

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 and resident interview and record review, the facility did not assist in making transportation arrangements to and from the source of service for 1 resident (R) (R2) of 1 sampled resident.R2 missed a dentist appointment due to transportation issues on 4/16/26. R2 stated R2 missed other appointments in the past.Findings include:The facility's Transportation for Medical Appointments Policy states in part: .will assist residents with coordinating transportation to medically necessary appointments outside the facility while supporting resident choice and ensuring appropriate communication and documentation .R2 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, anxiety disorder, post-traumatic stress disorder, and contusion of left upper arm.On 5/12/26 at 10:30 AM, R2 indicated R2 missed a dentist appointment on 4/16/26 and had to reschedule due to transportation issues. R2 indicated R2 missed a lot of appointments in the past.Surveyor reviewed R2's progress notes. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure therapy services were provided for 1 resident (R) (R10) of 2 sampled residents.R10 had an order for Speech Therapy evaluation and treatment (dated 4/10/26). R10 was not seen by Speech Therapy while residing in the facility from 4/10/26 through 4/29/26.Findings include:The facility's undated Therapy policy indicates: .Therapy departments will have an established procedure for receiving and responding to requests for therapy services whether it be a referral directly from a physician to assume responsibility for management of one or more of a resident's specified problems, or for consultation or screening to determine if a resident is a candidate for skilled therapy services .The Director of Rehabilitation (DOR) will establish a process for distributing therapy referrals to the appropriate therapy discipline(s) .The DOR will ensure therapists are provided with clear expectations for how quickly therapy responds to all referrals .All referrals…

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 and resident interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 6 residents (R) (R66, R14, R35, R7, R56, and R32) of 34 sampled residents. R66 reported concerns about the laundry process and missing items. R66 stated R66 was missing a sweater and a pair of pajama pants. R14 reported that laundry is frequently lost. R14 stated R14 was missing a nightgown with red cardinals that was reported to staff. R35, R7, and R56 reported concerns about the laundry process and missing items. R32 arrived at the facility in a wheelchair that was borrowed from a friend. R32 reported to staff that the wheelchair went missing approximately 4 days after R32 was admitted . The grievance was not thoroughly investigated or resolved.Findings include: The facility's Grievance policy, dated 9/15/25, indicates: The designated Grievance Official will: receive and track grievances through to resolution; provide written grievance resolutions to residents 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 staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 6 (Certified Nursing Assistant (CNA)-DD, CNA-EE, CNA-FF, Activity Aide (AA)-GG, Maintenance Staff (MS)-HH, and CNA-II) of 10 staff reviewed for caregiver background checks. The facility did not ensure timely completion of CNA-DD's caregiver background check. The facility did not ensure a caregiver background check was completed for CNA-EE. The facility did not ensure timely completion of CNA-FF's caregiver background check. The facility did not ensure a caregiver background check was completed before allowing AA-GG to work with residents. The facility did not ensure a caregiver background check was completed before allowing MS-HH to work in resident care areas. The facility did not ensure timely completion of CNA-II's caregiver background check. Findings include: The facility's undated Abuse/Neglect/Exploitation policy indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by…

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 develop and/or implement an individualized comprehensive care plan for 3 residents (R) (R82, R74, and R72) of 26 sampled residents.R82 reported an allegation of misappropriation. The facility's investigation indicated a safe keeping of valuables care plan would be implemented. The facility did not implement a safe keeping of valuables care plan for R82.R74 received dialysis services. The facility did not implement a dialysis care plan for R74.R72 had a diagnosis of Alzheimer's disease. The facility did not implement an Alzheimer's disease/dementia care plan for R72.Findings include: The facility's Comprehensive Care Plans policy, dated 1/2026, indicates: .3. 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, mental, and psychosocial well-being. The facility's Dementia-Clinical policy, revised November 2018, indicates: .1.…

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, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 9 residents (R) (R71, R13, R66, R67, R14, R15, R23, R58, and R63) of 9 sampled residents. R71 had an order for acetic acid that was unclear regarding application and use. R71 was not administered 11 of 44 doses. R13's methenamine hippurate for frequent urinary tract infections (UTIs) was not restarted timely after a hospital stay. Medications for R66, R67, R14, R15, R23, R58, and R63 were not administered timely or in accordance with physician orders. n 3/9/26. Findings include: The facility's Medication Administration policy, dated 10/25/14, indicates: Medications are administered as prescribed in accordance with good nursing principles and practices .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. A schedule of routine dose administration times is established by 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, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 77 residents residing in the facility. Certified Nursing Assistant (CNA)-NN did not complete appropriate hand hygiene during cares for R72. R13 was on contact precautions. Assistant Administrator (AA)-M entered R13's room without completing hand hygiene or donning appropriate personal protective equipment (PPE). Registered Nurse (RN)-Y did not complete appropriate hand hygiene during medication preparation and administration for R14, R15, R23, and R58.Hand hygiene was not offered to multiple residents prior to dining, including R73 and R66.Findings include: The facility's hand hygiene policy, dated 2023, indicates: Bedrock Healthcare facilities recognize hand hygiene as the primary measure to prevent the transmission of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R71 and R84) of 26 sampled residents were free of significant medication errors. R71 was admitted to the facility with a diagnosis of osteomyelitis. R71 did not receive three doses of intravenous (IV) antibiotics as ordered. R84 was admitted to the facility with sepsis from a soft tissue infection and right calf cellulitis and abscess. R84 did not receive two scheduled doses of IV antibiotics. R84 requested to go to the hospital so R84 would not miss another dose. Findings include: The facility's Medication Administration policy, dated 10/25/14, indicates: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system .Preparation: .4. Five Rights - Right resident, right drug, right dose, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not have reliable transportation to and from the source of service for 1 resident (R) (R13) of 2 sampled residents. R13 had a baclofen pump that needed to be changed. R13 had multiple missed appointments due to transportation issues prior to getting the pump changed.Findings include: Between 3/9/26 and 3/12/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including paraplegia, unspecified injury at T1 level of thoracic spinal cord, anxiety, and depression. R13's Minimum Data Set (MDS) assessment, dated 1/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. On 3/9/26 at 8:19 AM, Surveyor interviewed R13 who indicated there were concerns with transportation when R13 needed to get R13's baclofen pump changed. R13 stated R13 made it to the appointment on the fourth try. R13 stated the first time, the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy, the facility failed to ensure the results of an abuse investigation were submitted to the State Agency (SA) within five working days for 1 resident (R) (R4) of 2 sampled residents reviewed for allegations of abuse.The facility submitted an initial report to the SA on 11/22/25 for an allegation of abuse involving R4. The final investigative report report was due on 12/1/25. The facility did not submit the final investigative report until 12/3/25.Findings include:Review of the facility's undated Abuse/Neglect/Exploitation policy indicates: The Administrator should/will follow up with government agencies during business hours to confirm the initial report was received and to report the results of the investigation when final within 5 (five) working days of the incident, as required by state agencies.Review of R4's admission Record revealed R4 was admitted to the facility on [DATE]. Review of R4's admission Minimum Data Set (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.

Based on staff and resident interview, the facility did not ensure there were sufficient supplies for 1 of 4 Residents (R2).R2 indicated the facility ran out of the brief size R2 needed and R2 had to wear two briefs instead of one. Staff interviews verified the facility frequently ran out of wipes, briefs, and wash cloths used for resident care. Findings include:On 9/24/25, Surveyor observed the facility's supply closets which contained brief and wipes. Staff interviews indicated the supplies will be gone by the end of the week. On 9/24/25 at 9:02 AM, Surveyor interviewed R2 who indicated the facility runs out of the briefs that R2 uses and staff have to use two different briefs to make one brief. R2 stated the facility also runs out of wipes and staff don't cleanse R2 when they change R2. R2 indicated it occurred at least five or six times since R2 was admitted in April. (R2's medical record indicated R2 was dependent on staff for toileting and required partial/moderate assistance with hygiene. R2 was alert and oriented and did not have an activated Power of Attorney (POA).) 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 observation and staff and resident interview, the facility did not provide adequate privacy during cares in a double occupancy room for 1 of 4 Residents (R2).R2 reported a concern with a male visitor in the room while staff provided care for R2. Findings include:On 9/24/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnosis including muscle wasting, atrophy (is the partial or complete wasting away of a part of the body.), osteoarthritis, pain syndrome, dysthymic disorder (persistent depressive disorder (PDD), is a chronic form of depression characterized by a low mood lasting for at least two years), and anxiety disorder.R2's Minimum Data Set (MDS) assessment, dated 7/15/25, indicated R2 was dependent on staff for toileting and transfers, required substantial/maximal assistance with dressing, and required partial/moderate assistance with hygiene. R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 1 residents (R6) reviewed for tracheostomy (an opening surgically created through the neck into the trachea in which a tube is inserted to provide an airway to allow air to fill the lungs) care.During R6's tracheostomy care, facility staff did not maintain sterile technique.This is evidenced by:The facility's policy Tracheostomy Care, dated 10/23, includes: The purpose of this procedure is to guide tracheostomy care. General Guidelines 1. Aseptic (the practice of using methods to prevent contamination) technique must be used; c. during tracheostomy tube changes. Sterile gloves must be used during aseptic procedures.The facility's policy Infection Prevention and Control Program, revised 7/25, includes: standard precautions: Hand hygiene shall be performed in accordance with our facility's established hand hygiene…

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, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 of 1 Residents (R2).During the provision of peri-care for R2, staff did not properly change gloves and complete hand hygiene. Findings include:The facility's Infection Prevention and Control Policy Program, dated 7/2025, indicates: The facility has established and maintains 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 disease and infection as per accepted national standards and guidelines .5. Standard precautions: .b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. (Of note: A…

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

Based on interview and record review, the facility did not ensure that a resident, with a personal fund deposited with the facility, had conveyance of the resident's funds within 30 days of discharge and a final accounting of those funds to the individual or probate administering the resident's estate, in accordance with State law for 1 of 1 resident reviewed (R1) for trust accounts. R1 discharged from the facility on 3/25/24. R1's account was still active at facility with a balance of $2520.00. There was no conveyance of R1's account after resident discharged and no final accounting of those funds to R1's Health Care Power of Attorney (HCPOA). This is evidenced by: Facility's admission packet, dated 3/2020, includes: . Payment Policy- Payment is required one month in advance and the Facility's Business Office can provide information as to when payment is due each month. A one-month deposit of the daily rate is due upon admission. This deposit will be held in an interest-bearing account and may be applied to outstanding balances with resident and/or legal representative. If 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 implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for residents; and did not ensure the staff responsible for the arbitration agreement had complete understanding of an arbitration agreement and was able to thoroughly explain the agreement for complete resident/reasonable party understanding. This deficient practice had the potential to affect all 71 residents who resided in the facility and went through the admission process as arbitration agreements is part of the facility's admission process. R25, R12, R128, R129 and R72's resident representative voiced concerns regarding not fully understanding the arbitration agreement they signed upon admission to the facility. R25, R128, and R129 indicated they wanted to revoke their arbitration agreement. RR OO indicated the arbitration agreement was not explained to him fully and he would not have wanted to sign 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 failed to ensure residents (R) received adequate supervision to prevent accidents for 2 of 2 sampled residents (R57 and R56) and 3 supplemental residents (R36, R63, and R35) reviewed for the charging of their electric wheelchairs. R57's electric wheelchair was plugged in and charging in his room. R35's electric wheelchair was in her room along with her charging cord for her electric wheelchair. Surveyor observed R56's power wheelchair charger plugged into the wall in room. Surveyor observed R36's power wheelchair charger plugged into the wall in room. Surveyor observed R63's power wheelchair charger plugged into the wall in room. This is evidenced by: The facility policy Electric Wheelchair Policy, implements 3/8/20, states, in part: Due to the potential for fire or explosion, all electric wheelchairs will be recharged in an area which is not used by the residents for sleeping and which has no oxygen in the vicinity. Example 1 On 11/5/24 at 11:34…

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 policy review, the facility did not ensure that all residents receive food at a palatable temperature for 1 of 4 hallways and 1 of 1 test trays. Residents voiced concerns with receiving hot foods cold. Surveyor requested test tray. Hot foods temped cold and cold foods temped warm. R39 and R32 stated the food is cold. Evidenced by: The facility policy, Record of Food Temperatures, with no date, states, in part; .2. Hot foods will be held at 135 degrees or greater .11. No food will be served that does not meet the food code standard temperatures . Example 1 On 11/5/24 at 11:40AM, Surveyor requested a meal tray down the 100 hallway. Pork with gravy temped at 114.2 F, potatoes 124.7 F, and red juice temped at 50.1 F. Hot foods were cold and drink was warm. On 11/6/24 at 4:58PM, DM R (Dietary Manager) indicated DM R completes weekly audits on room meal trays. DM R indicated the food temperatures really depend on the resident's personal preference. DM R indicated understanding when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents were treated with respect and dignity and cared for in a manner to enhance their quality of life for 1 (R5) of 3 residents reviewed for resident rights. R5 voiced concern with staff not assisting her out of bed after using the bed pan. R5 indicated the interactions with staff make her feel like a child. R5 was admitted to the facility on [DATE] with a diagnoses including stroke, anxiety disorder, major depressive disorder, pain, adult psychological abuse, kidney failure, muscle wasting, vascular disease, and need for assistance with personal cares. R5 most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/8/24, indicates R5 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R5 is cognitively intact. R5 is own person. R5's Comprehensive Care Plan, states, in part; .Focus R5 has a physical functioning deficit related to left side hemiparesis. Date initiated: 2/16/23 .Toileting: R5 uses the bedpan…

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 self-administration of medications was determined to be clinically appropriate for 1 of 1 supplemental residents (R1) investigated for self administration of medication. Surveyor observed R1 to have medication at bedside. R1 did not have a self-administration of medication assessment completed. Evidenced by: The facility policy, entitled, Resident Self Administration Medication, dated 3/1/20, states, in part: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; . g. The resident's ability to ensure 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 did not ensure grievances were documented and thoroughly resolved for 2 of 23 sampled residents (R5 and R29.) R5 voiced concern regarding staff not assisting her in getting back up after she uses the bed pan. R5 indicated this makes her feel like a child and staff will say, We aren't playing the up and down game. R29 voiced a concern regarding being left on the commode and filed a grievance. Staff did not follow-up with R29 regarding the resolution of the grievance. Evidenced by: The facility policy Grievances dated 3/1/19, states in part: .The facility will ensure prompt resolution to all grievances, keeping the resident and the resident representative informed throughout the investigation and resolution process .G. Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority .As necessary, the Grievance Official and facility leadership will take immediate action to prevent further…

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 Example 2 R10 admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, dementia with psychotic disturbance, and anxiety disorder. R10's quarterly MDS (Minimum Data Set) dated [DATE], question section N0450 B: Has a gradual dose reduction been attempted is marked NO, indicating a GDR (Gradual Dose Reduction) has not been attempted. Section N0450 C: Date of last attempted GDR: was not answered. On [DATE], R10's Risperdal oral tablet 0.5 mg was reduced from four times a day to three times a day. R10's physician orders dated [DATE] include Risperdal oral tablet 0.5mg three times a day. On [DATE] at 3:21 PM, Surveyor interviewed DON B (Director of Nursing) regarding the MDS process. DON B indicated the facility follows the Resident Assessment Instrument (RAI) Manual for completing the MDS. DON B indicated the [DATE] quarterly MDS should have been completed correctly to include R10's GDR that was completed on [DATE]. Based on interview and record review, the facility did not ensure…

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 medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 2 of 22 sampled residents (R56 and R68). Surveyor observed R56's Medtronic to be unplugged rendering it unable to transmit data timely to the cardiac clinic that monitors R56's pacemaker. R68 was not weighed daily per physician order. Evidenced by: The facility policy, Weight Monitoring, no date, states, in part; .Based on 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 .5. A weight monitoring schedule will be developed upon admission for all residents: .d. If clinically indicated- monitor weight daily . Example 1 R56 admitted to the facility on [DATE] with diagnoses including presence of cardiac pacemaker. On 11/4/24 at 2:04 PM facility staff unplugged R56's Medtronic/pacemaker monitoring system from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for 1 of 5 residents (R10) reviewed for unnecessary medications. R10 does not have a timely Abnormal Involuntary Movement Scale (AIMS) test. This is evidenced by: The facility policy Use of Psychotropic Med implemented 4/24/24, states, in part: 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 resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics .Residents who receive an antipsychotic medication will have an AIMS test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN (As Needed) or as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 31 opportunities that affected 1 out of 3 residents (R1) included in the medication pass task, which resulted in an error rate of 6.45%. LPN N (Licensed Practical Nurse) did not prime R1's insulin pens before administration. (Of note, if insulin pens are not primed the resident may not receive the correct dose of insulin.) This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/19, 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 . (Of note, the facility policy did not contain information on priming of insulin pens) The facility policy entitled, Medication Errors, dated 3/1/19, states, in part: .1. The facility shall ensure medications will be…

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

Based on interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 resident's (R329). R329 had an order for Novolin 70/30 FlexPen (Insulin) and Metoprolol Tartrate 25 MG (Lowers blood pressure), that was not administered on 10/12/24 and 10/13/24, missing a total of two doses of his daily insulin and four doses of his blood pressure medication. This is evidenced by: The facility policy titled, Medication Administration, dated 3/1/19, 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 . Policy Explanation and Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders . 10. Review MAR (Medication Administration Record) to identify medication to be administered . 14. Administer medication as ordered in accordance with manufacturer specifications . 17. Sign MAR after administered. For those medications requiring vital signs, record…

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 Example 3 R32 admitted to the facility on [DATE], with diagnoses that include, in part: other chronic pancreatitis, pseudocyst of pancreas, personal history of other diseases of the digestive system. R32's MDS (Minimum Data Set), dated [DATE], indicates BIMS (Brief Interview of Mental Status) score of 15, indicating R32 is cognitively intact. On [DATE] at 8:34 AM, Surveyor observed resident taking Creon (a prescription medication used to treat pancreatic insufficiency) out of her bedside cabinet, top drawer. LPN N (Licensed Practical Nurse) indicated that the medication was supposed to be locked in a lock box/bag and would need to be removed from R32's room. R32 indicated that staff had never discussed the need to keep medication locked up. On [DATE] at 11:13 AM, Surveyor interviewed DON B (Director of Nursing), DON B indicated that self-administered medications kept in a resident's room are to be stored in a locked drawer or a lock box. Based on observation, interview and policy review the facility did not…

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

Based on interview and record review the facility did not ensure that their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 2 supplemental residents (R64 and R35). R64 was treated with an antibiotic when she didn't meet the facility's standard of practice (McGeer). R35 was treated with an antibiotic when she didn't meet the facility's standard of practice. This is evidenced by: The Facility's Policy and Procedure entitled Antibiotic Stewardship Program undated, documents in part: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR (Situation, Background, Assessment, and Recommendation) form prior to notifying the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility use McGeer Criteria to define infections. iv. Criteria specific to each state are used to determine whether or not 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 did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 4 of 4 halls and has the potential to affect all 72 residents (R) residing at the facility. R5, R7, R9, R4, and R2 voiced concerns regarding not having enough staff to meet their basic needs. Residents also voiced long call light wait times. Facility staff stated there are tasks that they are not able to get done due to not having enough staff per shift. Evidenced by: The Facility Assessment Tool, dated, 8/18/17, states, in part: .Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents .The purpose of the assessment is to determine what resources are necessary to care for residents .The intent of the facility assessment is for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a dignified existence and self-determination in choices which affected 1 of 9 resident (R4) out of a total sample of 9 residents. R4 voiced concerns that she was forced to wear a nightgown because she had no clean clothes. As evidenced by: R4 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Kidney Disease, Type II Diabetes with Diabetic Neuropathy, Dehydration, Major Depressive Disorder, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Unsteadiness on feet, Weakness. R4's admission Minimum Data Set (MDS) with a target date of 7/18/24, indicates, in part: Brief Interview of Mental Status (BIMS) of 14, indicating cognitively intact. On 8/6/24 at 9:34 AM, Surveyor observed R4 sitting in a wheelchair in her room, dressed in a nightgown. R4 expressed concerns to Surveyor that she had no clean clothes, that they were all in the laundry. R4 stated that she stays in her room because it makes 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.

Based on record review, and staff and vendor interview, the Bedrock Corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 72 residents in the facility. The Bedrock Corporate governing body failed to maintain current payment status with several service providers and vendors that resulted in vendors refusing to provide further service until payment is received, the facility is delinquent in their property taxes and utilities, the governing body has not paid State bed tax or federal Civil Money Penalties (CMPs), the facility pharmacy provider was abruptly terminated after a past due notice was issued including potential of disruption of service. The failure of the Bedrock governing body to maintain current contract payments has resulted in loss of service and notice of disruption of service. Bedrock's corporation's failure to provide sufficient funding to maintain service/vendor…

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 (R1) resident observed for self-administration of medications out of a total sample of 3 residents. R1 was observed to have medications at her bedside and had not been assessed to self-administer medications. Evidenced by: The facility policy entitled, Resident Self Administration of Medication, dated 3/1/23, states in part, Policy Explanation and Compliance Guidelines: 1. Each resident has the opportunity to self-administer medications during the routine assessment. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safer for self-administration . d. The resident's capability to follow directions . g. 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 2 of 2 residents (R1 and R5) reviewed were able to choose their physician. R1 during an interview indicated that she has not been allowed to see her primary care physician and instead is only allowed to see the in-house physician and Nurse Practitioner (NP) R5 was not aware she is able to select her own physician instead of being followed by the Medical Director. Evidenced by: The facility's policy titled Resident Rights implemented 10/01/22, states in part: .Policy: The facility will inform the resident both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Policy Explanation and Compliance Guidelines: 1. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights 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 observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents from occurring for 1 of 3 residents reviewed for accidents/supervision (R1). R1 was admitted following hospitalization for an intentional overdose with Potassium (Electrolyte that affects heart rhythm) and Amlodipine (Calcium-channel blocker, decreases blood pressure by widening blood vessels) and staff failed to maintain adequate supervision of the resident while R1 was in possession of these medications. Evidenced by: The facility policy entitled, Accidents and Supervision Policy, dated 3/1/23 states, in part: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s) . 1. Identification of Hazards and Risks- the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents. The facility was under a tornado warning and staff failed to follow the facility's policy and procedure to ensure resident safety for 4 or 4 residents (R1, R2, R3, and R4) interviewed. This has the potential to affect more than a limited number of residents residing in the home. R1, R2, R3, and R4 reported that facility staff did not move them into the hallway during a tornado warning. Evidenced by: The facility's policy Tornado dated 10/1/23, states in part, .7. Emergency procedures for tornado warning: a. Make announcement that the facility is under a tornado warning. b. Implement take cover procedures immediately. i. Relocate residents to designated safe areas. ii. Close doors. iii. Provide pillows and blankets to protect head/ body from debris. c. Staff take cover in designated safe areas. Perform emergency tasks only. d. Remain in safe areas until tornado…

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 all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 of 4 sampled residents (R1) reviewed for abuse. R1 received a life-threatening letter from a facility Certified Nursing Assistant (CNA), the facility failed to report the incident to the State Agency (SA) This is evidenced by: The facility's policy titled Abuse, Neglect, and Exploitation dated 10/1/22, states in part .Definitions: .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance…

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 medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 3 sampled residents (R1). The facility was aware of R1's history of having a small bowel obstruction and did not thoroughly assess R1 when he presented with symptoms of nausea and vomiting, did not provide continued monitoring every shift by obtaining vitals and observing/monitoring for continued emesis and describing appearance and amount. The facility failed to monitor R1's condition every shift by obtaining vitals and observing/recording the appearance of R1's urine when they suspected he had a Urinary Tract Infection and while waiting for the Urine Analysis results. The facility failed to monitor R1's intake every shift and failed to notify R1's Medical Doctor of his low fluid intakes. Evidenced by: R1 admitted to the facility on [DATE] with the following diagnoses: Paraplegia, Spinal Stenosis of lumbar region with neurogenic…

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 report 1 of 4 incidents to the State Survey Agency timely. R4 reported that R2 came in to R4's room on 4/8/24 and R2 touched R4 on the buttock and pulled his pants down. R4 reported this to facility staff on 4/8/24. The facility failed to report non-consensual sexual touching to state agency timely as the facility reported to state agency on 4/10/24. Evidenced by: The facility policy, Abuse, Neglect, And Exploitation, dated 10/01/22, states, in part; .Sexual Abuse is non-consensual sexual contact of any type with a resident .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (R1). R1 has known self-injurious behavior and the facility did not ensure measures were in place to protect him from further accidents and self-injurious behavior. Findings include R1 was admitted to the facility on [DATE] and has diagnoses that include anxiety, depression and quadriplegia. R1's most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 is cognitively intact. R1 was discharged from a local hospital to the facility. His discharge diagnoses include Polysubstance abuse, history of cocaine abuse and marijuana use. R1's care plan states, Focus: .has been intoxicated from alcohol and cannabis during stay here .has tested positive for Fentanyl (Narcotic) and THC (Tetrahydrocannabinol/Marijuana) on a drug screen .Interventions: Attempt interventions before…

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 behavioral health services to ensure the highest practicable mental and psychosocial well-being for 6 residents (R7, R5, R3, R4, R6, and R8) of 10 sampled residents. R7 admitted to the facility with a history of substance abuse. The facility failed to offer R7 services related to this diagnosis and failed to create a care plan with how staff will monitor R7's visitor from bringing medications and alcohol into the facility. R5 admitted to the facility with a history of alcohol dependency with intoxication and alcohol abuse. The facility failed to offer R5 services related to these diagnoses and failed to create and implement a care plan that includes what staff should monitor R5 for, a goal related to R5's alcohol use, and interventions related to R5's alcohol use. R5 was found to be in possession of alcohol on multiple occasion, noted to have alcohol odor on his breath, and eventually received his 4th OWI (Operating While Intoxicated) ticket…

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 and safe administration of medication for 1 resident (R5) of 10 sampled residents. The facility did not ensure R5's medications were given per Physician orders as he left the facility without his medications. The facility did not update R5's Medical Doctor (MD) when his medications were omitted. The facility did not hold all R5's medications and consult with R5's MD when he was found to have alcohol odor on his breath. Evidenced by: Facility policy, entitled Medication Administration, implemented 3/1/20, includes, 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 . Facility policy, entitles Medication Errors, undated, includes: The facility shall ensure medications will be administered as follows: according to physician orders . per manufacturer's specifications regarding 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 observations, interviews and record reviews, the facility failed to ensure a medication error rate of 5% or less. LPN H and LPN I (Licensed Practical Nurse) were late administering medications to R19, R20, R21, R1, and R22. This resulted in 29 errors out of 34 opportunities which calculates to an 85.2% error rate. Findings include: Review of the facility policy titled Medication Administration, dated 03/01/19, showed: Policy: 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, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . 1. During a medication administration observation on 01/17/24 at 9:34 AM, LPN H provided R19's medications of vitamin D, bupropion (antidepressant), memantine (NMDA receptor antagonist), glimepiride (antidiabetic), Miralax (osmotic laxative), Trajenta…

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 2 of 2 residents (R16 and R17) and/or their representatives reviewed for facility initiated emergent hospital transfer, from a total sample of 33 residents, were provided with written transfer/discharge notice that included the reason for transfer, the place of transfer, and other information regarding the transfer. Findings include: Review of the facility policy titled, Transfer and Discharge (Including AMA [Against Medical Advice]), dated 10/01/22, showed: Policy Explanation and Compliance Guidelines: . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if 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 failed to ensure 2 of 2 residents (R16 and R17) and/or their Resident Representative (RR) received written notification of the facility's bed-hold policy. Findings include: Review of the facility policy titled Bed Hold Notice Upon Transfer, implemented 03/01/19, showed: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed . Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed…

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 62 residents residing in the facility. Dietary Manager (DM)-G did not wear a hairnet that fully covered DM-G's hair. The kitchen and food preparation areas were unclean. The facility did not ensure warewasher (dishwasher) surface temperatures reached an appropriate temperature to ensure sanitization. The facility did not have a practice to monitor and document cooling temperatures. Cook (CK)-H and CK-I did not obtain temperatures of microwave reheated food to ensure the food was heated evenly. Findings include: On 8/1/23, DM-G verified the facility followed the FDA (Food and Drug Administration) Food Code as their standard of practice. Hairnet: The FDA Food Code 2022 documents at 2-402.11 Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively to keep their hair from contacting exposed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff and resident interview, the facility did not ensure dignity was maintained for 1 Resident (R) (R57) of 2 residents reviewed for indwelling urinary catheters. During multiple observations, R57's catheter drainage bag was uncovered and visible to others. Findings include: On 8/1/23, Surveyor reviewed R57's medical record. R57 was admitted to the facility on [DATE] with diagnoses that included heart failure, muscle weakness, and reduced mobility. R57's most recent MDS (Minimum Data Set) assessment indicated R57 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R57 had moderate cognitive impairment. R57 required up to extensive assistance with activities of daily living (ADLs). On 7/31/23 at 11:35 AM, Surveyor observed R57 in a common area in a wheelchair. Surveyor noted R57's uncovered catheter drainage bag contained urine, was anchored below the wheelchair, and was visible to others. Another resident was in the same common area sitting across from…

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 resident and staff interview, the facility did not ensure a safe, clean, comfortable and homelike environment for 1 Resident (R) (R57) of 3 residents reviewed. On 7/31/23 at 11:35 AM, Surveyor observed R57 in a common area in a wheelchair. Surveyor noted R57's wheelchair had hardened white matter on the front left seat and a hole in the right armrest that measured 1 x 1 cm (centimeter). The seat cushion, metal bars and plastic parts of the wheelchair were soiled with dried hard matter. The left armrest was cracked and peeling. The right outer metal part of the side of the wheelchair contained brownish dried matter. R57 stated, I think this chair is a hundred years old and It really needs a good cleaning. R57 indicated R57 was unsure if the wheelchair was cleaned on a regular basis and indicated the wheelchair was in the current condition for a while. On 8/1/23 at 10:05 AM, Surveyor observed R57's wheelchair in the same condition. On 8/1/23 at 10:16 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated resident equipment is cleaned weekly…

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, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R72) of 2 residents who received medication through a peripherally inserted central catheter (PICC) was monitored or assessed for complications. R72 was admitted to the facility with a PICC line (a soft, thin flexible tube inserted in a vein used to administer IV (intravenous) medication and fluid). R72's PICC line was not monitored or flushed for 25 days. Findings include: The facility's Central Line Care policy, dated 10/1/19, indicated: Policy: It is the policy of this facility to ensure that central venous access catheters are flushed, locked and removed consistent with current standards of practice .Central venous access devices or catheters that are placed into the central circulation with the tip located in the superior vena cava or the inferior vena cava depending upon location. These are commonly known as central lines. These devices may be used for longer durations of time but are 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 staff interview and record review, the facility did not ensure 2 Residents (R) (R46 and R77) of 5 sampled residents prescribed high-risk medications had a plan of care that addressed use of the medications and contained interventions to monitor for possible adverse reactions. R46 was prescribed antihistamine medication for anxiety and opioid (narcotic pain relief) medication for pain. The facility did not develop a plan of care that addressed the use of both medications and contained interventions to monitor for adverse reactions to the high risk medications. R77 was prescribed opioid medication for pain. The facility did not develop a plan of care that addressed the use of opioid medication and contained interventions to monitor for adverse reactions to the high risk medication. Findings include: 1. On 8/2/23, Surveyor reviewed R46's medical record. R46 was readmitted to the facility on [DATE]. R46 had diagnoses that included major depressive disorder, anxiety, insomnia, asthma, and cellulitis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not offer or administer Pneumococcal vaccines for 3 Residents (R) (R45, R53, and R57) of 5 residents reviewed for immunizations. R45 received the Pneumococcal 23 vaccine on 7/18/16. R45 was not offered or administered the Pneumococcal 15 or Pneumococcal 20 vaccine. R53 received the Pneumococcal 13 vaccine on 4/8/15 and the Pneumococcal 23 vaccine after the age of 65 on 11/16/17. A discussion with R53, R53's provider and the facility did not occur regarding R53's eligibility to receive the Pneumococcal 20 vaccine. R57 received the Pneumococcal 13 vaccine on 10/14/15 and the Pneumococcal 23 vaccine after the age of 65 on 5/2/18. A discussion with R57, R57's provider and the facility did not occur regarding R57's eligibility to receive the Pneumococcal 20 vaccine. Findings include: The facility's Pneumococcal Vaccine (Series) policy, dated 3/1/19, contained the following information: It is our policy to offer our residents, staff, and volunteer workers…

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 a written notificatoin of transfer was provided to a Resident (R) transferred to the hospital for care for 2 (R2 and R49) of 3 sampled residents reviewed for hospitalizations. Additionally, the facility did not notify the State Long-Term Care Ombudsman of hospital transfers for R2. The facility did not provide R2 and/or R2's resident representative and the Ombudsman with a written transfer notice when R2 was transfered to the hospital on 5/10/22. The Facility did not provide R49 and/or R49's resident representative with a written transfer notice when R49 was transfered to the hospital on 5/19/22 Findings include: 1. From 7/11/22 through 7/13/22, Surveyor reviewed R2's medical record which documented the facility transfered R2 to the hospital on 5/10/22. Surveyor noted R2's record did not contain a written transfer notice. On 7/12/22 at 1:22 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not provide a written notification of transfer to residents and/or resident…

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 resident and staff interviews and record review, the facility did not provide proper assistance in maintaining hearing ability for 1 Resident (R) (R7) reviewed for assistive hearing devices. Surveyor noted during initial tour that R7 was very hard of hearing and required talking very loudly and close to residents ear. R7 had a history of hearing impairment for which the facility did not address by thorough assessment and intervention. Findings include: The Facility's admission agreement indicated, 1. Definitions. For the purposes this Agreement the following terms are defined and incorporated: 2. Care and Services .Consent. Resident consents to admission to and treatment by our Facility and health care providers .Ancillary .In accordance with the Resident's plan of care, the facility will arrange for ancillary services which may include rehabilitation, podiatry, ophthalmology, audiology, dental, laboratory and diagnostic, hospice and pharmacy services. The Resident agrees to the conducting of diagnostic tests for the provision of ancillary services as ordered by 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 staff interview and record review, the facility did not ensure that residents were free from unnecessary antipsychotic medications by monitoring for adverse reactions for 1 Resident (R) (R39) of 5 residents reviewed for unnecessary medications. R39 was prescribed Risperidone (also know as Risperdal, an antipsychotic medication). The facility did not complete a TD (Tardive Dyskinesia) assessment to monitor for side effects of the medication. Findings include: The National Alliance on Mental Illness (NAMI) documented in a web-based article dated 2022, Tardive dyskinesia (TD) is a movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs. TD symptoms are beyond a person ' s control. These symptoms can make routine physical functioning difficult, significantly affecting quality of life .TD primarily occurs as a side effect of long-term use of certain medications. It can become a permanent condition even after a person stops taking the medication .TD symptoms…

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.