Mulder Health Care Facility

Based on observation, interview and record review the facility did not ensure the environment remained free of hazards for 4 of 4 supplemental residents (R12, R66, R68 and R70) who smoke. R12 was observed outside smoking, on the sidewalk in the front of the facility, with no receptacle to dispose of her cigarette butts in the area. R66 was observed outside smoking, on the patio in the smoking area, with a small receptacle to dispose his cigarette butts. In the same area was a plastic garbage can with a large amount of cigarette butts in it. R68 and R70 are indicated as being smokers and the facility does not have an appropriate receptacle for smoking material to be disposed into. Evidenced by: The facility Smoking Policy, reviewed 01/2024, includes, in part, the following: Purpose: To offer a safe environment to all residents in the facility. 15.2 Procedure. 8. All smoking materials will be disposed of in the proper designated containers that meet NFPA (National Fire Protection Association) standards. On 4/9/25 at 7:00 AM Surveyor observed R12 sitting in her wheelchair, on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a system in place to assess for risk of entrapment between the mattress and side rail and failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 3 of 3 sampled residents (R73, R46 and R25) and 2 of 2 supplemental Residents (R49 and R54) reviewed for bed rails. R73, R46, R54, R25 and R49 all have an air mattress with enabler bars/bedrails. The facility did not complete all requirements as listed in F700 of the State Operations Manual prior to installing bed rails/enabler bars. The facility failed to complete a safety/gap test with the air mattress and provide written documentation of ongoing monitoring of bed rails. Findings include According to the Food and Drug Administration (FDA), The FDA recommends the following actions to prevent deaths and injuries from entrapment and falls from adult portable bed rails: . When installing and using bed rails: *Confirm that the age,…

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 each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect more than a minimal number of residents residing at the facility. Residents voiced concerns with hot foods being served cold. (R45, R25, R14, and R11) 3 of 3 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility Resident Council Minutes included, in part, the following: 3/3/25: Dietary: resident specific requests. Note there was no further explanation what the requests were. 12/2/24: Cold food, has improved. 11/4/24: Food coming cold. Example 1 R45 was admitted to the facility 11/8/24. R45's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/14/25 indicates R45 is cognitively intact. On 4/7/25 at 2:10 PM Surveyor interviewed R45 about his meals. R45 stated the food was often served cold and tasted awful. R45 stated he has told…

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, facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not conduct thorough background checks on 2 of 8 employees that were randomly selected. Findings include The facility's abuse prevention program states, in part: *The facility will conduct thorough investigations of histories of prospective staff, in addition to inquiry of the state, nurse aid registry or licensing authorities prior to employment. *The facility will obtain verification of screening prior to employment or engagement for prospective consultants, contractors, volunteers, caregivers and students and its nurse aid training program and students from affiliated academic institutions, including therapy, social, and activity programs. Screening may be conducted by the facility itself, third party agency, or academic institution. It is recognized that state specific regulatory requirements may require additional limitations to be followed. The…

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

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 22 sampled residents (R45 & R18) reviewed for abuse. Facility did not report an incident of resident-to-resident altercation involving R45 and R18 to the State Agency (SA). Evidenced by: The facility Abuse Prevention Program Policy and Procedure reviewed 01/2025, includes, in part, the following: VII. Reporting/Response. All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required official, including to the State Survey Agency, . and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of 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 interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 22 sampled residents (R45 and R18) reviewed for abuse. Facility did not fully investigate an incident of resident-to-resident altercation involving R45 and R18 to the State Agency (SA). Evidenced by: The facility Abuse Prevention Program Policy and Procedure reviewed 01/2025, includes, in part, the following: V. Investigation. 1. The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days. Example 1 On 4/7/25 at 1:55 PM Surveyor interviewed R45. R45 indicated in early March he had altercation with his former roommate (R18). R45's Resident Progress Notes include, in part, the following: 03/04/2025 08:31 PM Resident and roommate had altercation this shift. Roommate did not like that resident had tv on loud and was speaking on phone on speaker. Roommate started saying negative things…

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 permit a resident to return to the facility following a hospitalization for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed. R11 was not permitted to return to the facility following an emergency facility-initiated transfer to the hospital. The facility discharged R11 and stated they would not allow R11 to return. R55 was not permitted to return to the facility following an emergency facility-initiated transfer to the hospital. The facility discharged R55 and would not allow R55 to return. It should be noted R55's guardian wished for R55 to return to the facility and R55 was pending Medicaid approval at the time of discharge. Example 1 R11 was admitted to the facility on [DATE], with diagnoses that include: type 2 diabetes with diabetic polyneuropathy (damage to multiple peripheral nerves causing pain, tingling, burning, numbness or sensitivity to touch), acquired absence of limb (amputation), phantom limb syndrome with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge, failed to ensure the written notice contained all pertinent information for a discharge notice including the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge. The facility failed to notify R11 and R55 in writing prior to a facility-initiated discharge, did not give R11 or R55 a chance to appeal the facility-initiated discharge, and did not appropriately prepare R11 or R55 for the facility-initiated discharge. This is evidenced by: The facility policy titled, Resident Transfers and Discharge Notification, dated 1/2025, states in part: . Procedure: Facility-initiated transfer or discharge - Involuntary Discharge 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 provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge. The facility failed to notify R11 and R55 in writing prior to a facility-initiated discharge, and did not appropriately prepare R11 or R55 for the facility-initiated discharge. This is evidenced by: The facility policy titled, Resident Transfers and Discharge Notification, dated 1/2025, states in part: . Procedure: Facility-initiated transfer or discharge - Involuntary Discharge The facility will provide written notice in a language the resident or resident's representative can understand. The notice must also be provided to an immediate family member or legal representative. Written notice will be given at least 30 days before the proposed discharge. In specific circumstances written notice may need…

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 written information to the resident or resident representative regarding the bed hold policy for 1 (R55) of 1 supplemental resident's reviewed for facility-initiated discharge R55 is not his own person and has two guardians. Neither guardian was provided with a written bed hold prior to R55 being transferred to the hospital on 4/10/24. This is evidenced by: The facility policy entitled, Bed Hold, dated, 1/2025, states, in part: . Policy: Our facility allows residents to hold or reserve a bed while absent from the facility due to hospitalization or therapeutic leave. This policy applies to all residents regardless of payment source and will be provided to the resident or resident's representative at the time of admission and again with any emergency transfer from the community . Procedure: 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission…

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 permit 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge to return to the facility after a hospitalization and the ability to return to the facility. R11 and R55 were not allowed to return to the facility following an emergency facility-initiated transfer to the emergency room. The facility stated they would be discharging R11 and R55 due to inability to provide the staffing level needed to care for R11 and R55. It should be noted R11 signed a bed hold and the facility had a bed hold for R55 that stated the family gave verbal consent to hold the bed and would pay the bed hold charges. Example 1 R11 was admitted to the facility on [DATE], with diagnoses that include: type 2 diabetes with diabetic polyneuropathy (damage to multiple peripheral nerves causing pain, tingling, burning, numbness or sensitivity to touch), acquired absence of limb (amputation), phantom limb syndrome w/pain (sensation…

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 is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 22 residents reviewed for ADLs (Activities of Daily Living) (R34). R34 requested to use the bathroom. CNA EEE (Certified Nursing Assistant) told R34 she is on a two (2) hour toileting schedule and will need to wait. R34 was waiting approximately 1 hour and 20 minutes before being assisted to the bathroom. Evidenced by: The facility's policy, Activities of Daily Living, dated 3/2023, includes, in part, as follows: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are…

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 resident receives care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 2 residents reviewed for pressure injuries (R73). R73 had a pressure reducing air mattress for pressure injury healing and was observed laying on the mattress with multiple layers under R73. Findings include A study published on the National Library of Medicine titled The Effect of Multiple Layers of Linens on Surface Interface Pressure: Results of a Laboratory Study concluded that excessive linen usage for patients on therapeutic support surfaces (such as air mattresses) should be discouraged. https://pubmed.ncbi.nlm.nih.gov/23749661/ R73 was admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of bone (bone cancer) and an unstageable pressure ulcer of sacral region (resident's bottom). R73 was admitted to the facility with orders for an air mattress. Surveyor confirmed this air mattress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 sampled resident (R11) and 1 of 1 supplemental resident (R55). R11 stabbed himself with a pair of scissors after experiencing uncontrolled phantom limb pain. Prior to this, R11 had expressed suicidal ideations related to his chronic pain multiple times in the two months prior to this event. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. Following this incident, the resident returned to the facility and continued to express suicidal ideation and uncontrolled pain. No trauma assessment was completed or PHQ-9s (depression screening) following suicidal statements. R55 expressed suicidal ideations multiple times between his admission date of 8/5/24 and his discharge date of 4/10/25.…

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 food prepared in a form designed to meet individual needs for 1 of 1 sampled resident (R48). The facility has not reassessed R48's swallowing ability after she was unable to wear her lower denture due to an abscess to ensure she receives food prepared in a form that meets her needs. As evidenced by The facility's policy, Diet Order, revised 1/2025, documents, in part, as follows: During the course of the resident's stay, any diet change as recommended by the Dietician, Diet Technician, Speech Language Pathologist, or Nurse should be communicated to the attending M.D. (Medical Doctor). for consideration. Nursing may downgrade a diet texture temporarily for example: oral problems, difficulty swallowing/chewing, mouth sores, etc. R48 was admitted to the facility on [DATE] with diagnoses including, but not limited to, as follows: diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar which also impedes…

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

Based on record review and interview, the facility did not immediately consult with the resident's physician when 1 of 3 sampled residents (R1) experienced a significant change or required a change in treatment. R1's physician was not consulted when R1's oxygen saturation and pulse fell below the desired range. This is evidenced by the following: The facility policy and procedure Notification of Change, last reviewed 1/24, states, in part: Introduction: The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change of condition, potential discharge, room transfer for death. Notification Parameters: [Facility] has adopted the current INTERACT Tools Change of Condition: When to report to the MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant). The INTERACT program is an evidence-based program that may be utilized by the nurse when needed and does not supersede the clinical judgement of the licensed nurse. A Physicians personal request for notification of a condition may supersede…

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 all incidents involving potential abuse were thoroughly investigated for 1 of 4 residents (R) 6. R6 swung arm out and hit R5 in the chest as R5 came by in R5's wheelchair. Facility did not interview other residents in the facility for potential abuse. Findings include: The facility's Abuse Prevention Program Policy and Procedure, revised 06/2023, states: Intent: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Resident-to-Resident Abuse A resident-to-resident altercation should be reviewed as a potential situation of abuse. The facility Administrator and/or Director of Nursing will initiate an investigation of a potential allegation of abuse between residents. V. Investigation: 1. The Administer and/or Director of Nursing are to initiate and coordinate completion of a thorough investigation. The…

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

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect 75 of 76 residents residing in the facility. Findings include: On 02/19/24 at 8:55 AM, Surveyor toured the kitchen with Dietary Supervisor (DS) M and asked their qualifications they held that allowed them to assume the role of Dietary Supervisor. DS M indicated DS M started in the position the end of December 2023 and was not enrolled in any classes and was unaware when DS M would be. DS M indicated DS M did not have a certification to be a dietary manager. On 02/20/24 at 2:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the dietician was full time and provided oversight of the kitchen. NHA A indicated the dietician was there 2 days a week and they have a regional dietician that is available by phone. Surveyor asked when the dietician is at the facility if the dietician conducts kitchen supervision and completes…

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 and interview, the facility did not prepare and distribute food under sanitary conditions. Dishwasher temperatures did not reach correct levels, staff did not perform hand hygiene with glove use, and staff with a beard did not wear a beard net. This has the potential to affect 75 of 76 residents. Findings include: The facility policy, entitled Glove Usage By Dietary Staff, revised 8/23, reads in part Never handle food with your bare hands or gloved hand while serving. The facility policy, entitled Dietary Dress Code, revised 8/23, reads in part [NAME] covers must be worn by staff presenting with facial hair. Example 1 On 02/20/24 at 11:05 AM, Surveyor observed dish machine wash and rinse temperature log. On the bottom of the log it says, High Temp Machine: wash/rinse 160, Sanitize 180. Surveyor asked Dietary Supervisor (DS) M about the dishwasher temperatures not always making it up to 180. DS M indicated they didn't know it needed to get to that. Surveyor pointed out to DS M that on the…

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

Based on observation and interviews, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used a clothing protector to wipe R37 and R35's face during dining. Facility staff were heard sharing R30, R54, R1, and R24's personal information in public areas of the facility. Facility staff did not respond in a respectful manner to R14. This occurred for 7 of 76 residents. This is evidenced by: The facility policy, entitled Dignity, dated reviewed on 01/24, states in part: Dignity means that in their interactions with residents . Demonstrating courtesy, patience, and friendliness in all interactions . Provision of care instruction in privacy . Promoting residents' independence and dignity in dining. The facility policy, entitled Privacy, Dignity, and Confidentiality dated reviewed 01/2024, states in part: Reporting of care and services of any resident between staff should be done in a private manner that cannot be overheard by others. Example 1 On 02/19/24 at 11:51 AM, Surveyor observed…

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 maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 76 residents (R). (R52, R28, R60, R233, and R70) Staff observed passing medication without proper hand hygiene. Staff observed rinsing a urine soiled commode bucket in the resident's bathroom sink. Findings: The facility policy entitled, HAND WASHING/HAND HYGIENE, last reviewed 01/2024, stated in part: .Wash hands and other skin surfaced when: .2. After removing gloves or other personal protective equipment; 3. After care of each resident; 4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.) . Example 1 On 02/20/24 at 7:06 AM, Surveyor observed medication pass with Licensed Practical Nurse (LPN) I. LPN I performed no hand hygiene before entering room of R52 after touching the medication cart, computer mouse and computer keyboard.…

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 complete the required Preadmission Screen and Resident Review (PASRR) screens for 1 of 2 residents reviewed, (R18). This is evidenced by: The facility policy, entitled Resident Assessment PASRR Requirements, dated 11/28/17, states: .To ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs .If the resident meets criteria for a level II review (mental illness, developmental disability, antipsychotic medication use, or any state requirements), the Level II request must be submitted to the State assigned entity for decision of placement prior to admission .Significant change in condition Level I requests must be completed and submitted to the State entity when a resident has a change in their mental health status, antipsychotic…

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 develop comprehensive person centered care plans for 3 of 21 sampled residents. (R1, R30, and R7) This is evidenced by: The facility policy, entitled Resident Assessment Care Plan Development, dated updated on 05/24/2022, states in part: Reflect changes in the residents' preferences and goals as they change throughout their stay .The comprehensive care plan will be developed and maintained .Updates will be made to the comprehensive care plan as needed. Example 1 R1 was admitted to the facility in October 2023 and has diagnoses that include chronic respiratory failure, obstructive sleep apnea, type 2 diabetes mellitus, obesity, and schizophrenia. R1's care plan dated 10/26/23 document, goal resident will be clean/well-groomed daily approaches include. POSSIBLE .EXAMPLES .LIKES TO WEAR JEWELRY, LIKES TO WEAR A HAT, LIKES TO WEAR MAKEUP, LIKES TO WEAR SUSPENDERS LIKES TO HAVE A LAP BLANKET ON WHEN UP. DELETE IF NOT APPLICABLE. Observations 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 record review and interview, the facility did not revise or update resident (R) care plans for 1 of 21 sampled residents (R35). This is evidenced by: The facility policy, entitled Resident Assessment Care Plan Development, updated on 05/24/2022, states in part: Reflect changes in the residents' preferences and goals as they change throughout their stay .Updates will be made to the comprehensive care plan as needed. R35 was admitted to the facility on [DATE], with diagnoses including Parkinsonism, adult failure to thrive, and R35 is currently on hospice. R35's care plan lists approaches under activities; including: Visitors: Family window visits. R35's care plan lists goals; including: Will not deteriorate in ability to ambulate AEB: ability to ambulate 50 feet independently with walker. The Short Term Goal Target Date: 05/07/2024 On 02/21/24 at 10:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA) W and asked if R35 could walk independently. CNA W confirmed R35 does not have the ability 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 residents with a pressure injury (PI) or at risk for PIs received necessary treatment and services, frequent repositioning, pressure relieving interventions that are consistent with professional standards of practice, to prevent the development of PIs and to promote healing for 3 of 6 residents (R) reviewed for PIs. (R74, R23, and R25) Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, .Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved .Reposition the individual to relieve or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure to obtain rationale for catheter use and physician's order for a catheter for 1 of 4 sampled residents (R)7. Finding include: R7 was admitted to the facility on [DATE] and has diagnoses that include acute and chronic respiratory failure with hypoxia, dysphasia, type 2 diabetes mellitus with diabetic neuropathy, and hypertension. The diagnosis list did not have a diagnosis related for the use of a catheter. Surveyor reviewed R7's physician orders. The physician orders did not have an order for the size of the catheter and balloon, when the catheter could be changed, and diagnosis. On 12/12/23, R7 was discharged from the hospital back to the facility with a catheter for urinary retention and orders to follow up with urology. Surveyor was unable to locate documentation in the medical record that a follow up appointment was done. On 02/22/24 at 12:39 PM, Surveyor interviewed Director of Nursing (DON) B and Regional Clinical Director (RCD) C and asked…

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, interviews, and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when COVID precautions of appropriate Personal Protective Equipment (PPE) were not followed and employee fit testing for N95 masks were outdated. This has the potential to affect all 76 residents residing in the facility at the time of survey. This is evidenced by: The facility policy entitled, Covid-19 Prevention, Response and Reporting, dated 05/2023, states: .HCP [Health Care Provider] who enter the room of a resident with suspected or confirmed SARS-CoV-2 [COVID] infection should adhere to standard precautions and use a NIOSH [National Institute for Occupational Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (contact and droplet precautions) . Upon entrance of the complaint survey on 12/14/23, 42 of the 76 residents were positive for COVID. On 12/14/23 at 8:10 AM,…

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 5 residents (R) of 5 sampled residents (R3, R4, R5, R6, R7) were provided the most recent covid booster, the covid booster was not offered or provided to any residents in the facility having the potential to affect all 76 residents that reside in the facility. This is evidenced by: The facility policy entitled Covid-19 Vaccine Program, dated 09/2023, states: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .Covid-19 vaccinations currently in use include the updated (2023-2024 Formula) mRNA COVID-19 vaccines .People ages 65 years and older are recommended to receive 1 dose of updated (2023-2024 formula) mRNA vaccine .COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines .The facility will educate and offer the COVID-19 vaccine to…

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

Based on record review, interviews, review of Facility Reported Incident (FRI), and policy review, the facility failed to ensure that one resident (Resident (R) 3) of three residents reviewed for abuse was free from physical abuse. Findings include: Review of the facility provided Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report (initial report) dated 05/07/23 revealed R3 was hit on the arm by fellow resident [R2] with a roll of toilet paper. Residents were separated to ensure safety. Family and police notified. Investigation initiated. Review of the Misconduct Incident Report (5-day report) dated 5/12/2023 revealed R2 hit R3 in the head with a roll of toilet paper. R3 did not have any pain or injury. Residents were immediately separated by staff. R3 was assisted back to room for a skin and pain assessment. R3 zero pain, injury, and redness. No other residents were affected by this incident. Residents separated immediately. R2 put on checks while in the dining room. Doctor, family, Director of Nursing (DON), Administrator notified. Care plan reviewed 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, record review, and facility policy review, the facility failed to report timely, within two hours and not later than 24 hours, for initial notification to the state survey agency (SSA), for three of three sampled residents (R2, R3, and R5) which included an allegation of an injury of unknown origin for R5 and a resident-to-resident incident for R2 and R3 reviewed for facility reported incidents (FRIs). Failure to report allegations of injuries of unknown origins and/or resident-to-resident incidents could potentially lead to abuse and neglect. Findings include: 1. Review of a FRI for R5, dated 06/28/23 revealed .Nurse Practitioner ordered an x-ray due to a change in condition with increased confusion. Chest Xray results indicate right shoulder dislocation. The origin of this injury is unknown. Resident is being kept safe with increased monitoring. Resident has chronic Right shoulder pain admitted with. No increase in pain. No redness or swelling. No additional signs and symptoms . Continued…

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, staff interview, and policy review, the facility failed to ensure food was prepared, stored, and served in a sanitary manner. This had the potential to affect all residents of the facility. Findings include: Example 1: On 12/27/22 at 9:05 AM, the sanitizer in the red sanitizer bucket with wiping cloths was measured using a test strip by the DM M (Dietary Manager). The quaternary sanitizer in the solution measured 0 parts per million (ppm). The DM stated she had prepared the solution that morning to keep the wiping cloths in and to sanitize the food contact surfaces. The DM verified it was not at the correct concentration to sanitize the food contact surfaces. She stated it should have been 150 to 400 ppm. The facility policy titled Sanitation Terminology with a revised date of 07/2016 stated the quaternary solutions should be at 150 to 400 ppm in order to sanitize food contact surfaces. Example 2: On 12/27/22 at 9:15 AM, a one-half gallon carton of strawberry lemonade juice was in the medication room nourishment/resident refrigerator located in the medication…

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 interviews, record review, and facility policy review, the facility failed to ensure 1 of 19 sampled residents (R230) was provided admission paperwork which included residents' rights and responsibilities. Findings include: Review of a document provided by the facility titled admission Policy, undated indicated .Prospective residents will be given a copy of [NAME] information Regarding Payment, Rights & Responsibilities, Services & Limitations, and all other applicable policies, prior to signing the Consent to Treat and admission Agreement, whenever practical . R230 was admitted to the facility on [DATE]. R230's admission Packet dated 12/23/22 indicated the resident's representative signed the admission paperwork, which included rights and responsibilities of the resident. There was a hand-written note at the top of the cover sheet which stated, None of this was filled out or signed until 12/27/22 I was asked to date it at 12/23/22. There was no name at the end of this hand-written statement nor were…

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, staff interviews, and review of facility policy, the facility failed to ensure 1 of 6 residents (R38) reviewed for abuse remained free from physical abuse. R38 was physically assaulted by R15 on 3 separate occasions. Findings include: The facility policy titled Abuse Prevention Program Policy and Procedure with a revised date of 01/22 stated Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. R15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated no problems with her long-term and short-term memory; requiring modified independence with daily decision making; and being independent with bed mobility, transfers, walking, and locomotion. According to the assessment she exhibited verbal behaviors directed to others (threatening, screaming at others, cussing at others) during the 7 day look back period. Review of R38's annual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility did not ensure that further potential abuse did not occur for 1 of 6 sampled residents (R38). R38 was physically assaulted by R15 on multiple occasions. Following each incident, the facility did not take action to ensure R38 was not further abused in the future. Findings include: Review of R15's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed R15 had no problems with her long-term and short-term memory; requiring modified independence with daily decision making; and was independent with transfers, walking, and locomotion. According to the assessment, R15 exhibited verbal behaviors directed to others (threatening, screaming at others, cussing at others) during the 7 day look back period. R15's plan of care has a problem start date of 09/14/21 stating, resident has had altercations with another resident. Staff updated on whom. The approach dated of 09/14/21 stated to Attempt to keep residents separated if able. Redirect when needed. Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility pharmacy policy review, the facility did not ensure that 1 of 6 residents' (R13) medication regimens was free from medication irregularities. R13 had an order for as needed lorazepam (a psychotropic medication). There was no 14 day stop order. This irregularity was not identified during 5 monthly reviews. Findings include: Review of a document provided by the facility titled Drug Regimen Review for [NAME] Health Care Facility dated 02/01/21 indicated .To ensure timely pharmacist conducted drug regimen review (DRR) for every resident, including guidelines for documentation and communication to nursing, practitioners, and administrative team .Irregularities and recommendations identified during DRR will be printed, including date, resident name, medication name, and irregularity, by the pharmacist and provided to the charge nurse for distribution to practitioners for review at their next scheduled visit . R13 admitted to the facility on [DATE]. R13's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents and policy, the facility failed to ensure 1 of 6 residents (R13) reviewed for unnecessary medications did not receive an as needed psychotropic medication for greater than 14 days. R13 had 2 orders for as needed lorazepam. There were no stop orders for either order. R13 received the as needed lorazepam for greater than 14 days without the prescriber evaluating and documenting the clinical indications for the continued use and duration of therapy out of a total sample of 19 residents. Findings include: Review of a document provided by the facility titled Psychotropic Medication Use, dated 09/22 indicated .PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she must document their rationale in the resident's medical record and indicate the duration for the PRN order. The attending physician 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 observation, and staff interviews, the facility failed to follow appropriate infection control practices for 1 of 4 residents (R180) observed during medication administration. Nursing staff placed medications directly on an unclean surface. Findings include: On 12/30/22 at 7:46 AM, LPN O (Licensed Practical Nurse) administered medications to R180. LPN O poured R180's pills out of the medication cup and on to the bedside table. LPN O did not clean the table or place a barrier before pouring out the pills. R180 then picked up each medication one at a time until she had taken them all. During an interview on 12/30/22 at 8:03 AM, LPN O was asked if the bedside table where he poured R180's pills was clean. LPN O stated probably not, to be quite honest with you. LPN O stated further that R180 lacked the finger dexterity to handle pills from the medication cup, and that he let R180 pick up the pills herself to preserve her independence. During an interview with DON B (Director of Nursing) on 12/30/22 at 12:18 PM, DON B was told of the foregoing observations. The DON stated that it…

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.