Belmont Healthcare Center

Based on observation and staff interviews, the facility failed to store, prepare, and serve food in a safe and sanitary manner by not removing dented cans from service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 60. Findings include: A) Dented cans At approximately 11:50 AM on 10/21/24, during a tour of the kitchen, three (3) dented cans were placed on the shelf alongside cans intended for service. Two (2) cans contained corn and one (1) can contained sliced peaches. At approximately 11:53 AM on 10/21/24, Culinary Aide (CA) #38, stated they were the cook for the day due to the Dietary Manager (DM) being out of the facility, and acknowledged the dents in the cans, and they should have been removed from the shelves with the other cans meant for service.

Based on observation and interview, the facility failed to maintain effective infection control practices in the laundry room. Additionally, facility staff failed to adhere to infection control policies and protocols while providing catheter care. Resident Identifier: #44. Facility Census: 60. Findings included: a) Laundry Room During an inspection of the laundry room with Executive Director (ED) #6 on 10/22/24, at approximately 3:55 PM, discarded mop heads with a brown substance on them, were observed in the laundry sink. Additionally, several towels with brown stains were observed on top of a bin near the sink. Multiple covered, empty bins, for storing soiled items were available and lined up against the opposite wall. ED #6 confirmed soiled items should not be in the sink, or on top of the bins. The presence of uncovered soiled items increases the risk of contamination for all items in the laundry room. b) Resident #44 Catheter care for Resident #44 was observed on 10/23/24 at approximately 1:12 PM. This surveyor had requested Licensed Practical Nurse (LPN) #9's presence during…

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 interview, the facility failed to maintain a correct capacity form for Resident #23 and failed to correctly document dates and times of neurochecks for Resident #13. Resident identifiers: #23 and #13. Census: 60 Findings included: a) Resident #23 A review of Resident #23's records on 10/21/24 at 7:18 PM revealed the following: Physician's Determination of Capacity Form dated 06/05/24 documented the resident did not have capacity to make his own medical decisions with duration being long term due to inability to process information and disorientation caused by a cerebral vascular accident. Physician's Determination of Capacity Form dated 8/30/24 expressed the resident had capacity to make his own medical decisions and was signed by only one physician. During an interview with the Administrator on 10/22/24 at 12:05 PM she acknowledged her understanding in order to restore capacity to a resident who has been deemed incapacitated you must have 2 (two) physician's signatures. She acknowledged, there was only one signature for Resident #23 to restore…

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

Based on observation and interview, the facility failed to ensure that residents had a means of contacting their caregivers through a call system that was accessible to them while in their bed, or other sleeping accommodations within their room. Resident Identifiers: #46 and #38. Facility Census: 60. Findings included: a) Resident #46 During an interview with Resident #46 on 10/21/24 at approximately 1:51 PM, the resident stated she needed to speak to a staff member. She looked around and was unable to locate her call light. Resident then stated, I'll wait for someone to come. Upon being notified the resident needed help, Licensed Practical Nurse (LPN) #51 arrived and confirmed the call light was on the floor below the resident's bed, and inaccessible to the resident. LPN #51 confirmed that the call light was out of the reach of the resident and stated, Well that is a problem! LPN #51 then retrieved the call light and placed it next to the resident, and attended to the resident's needs. b) Resident #38 An observation of Resident #38 on 10/21/24 at 1:45 pm, found the reisdents call…

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 interview the facility failed to implement written policies and procedures that ensured investigations into allegations of abuse and neglect were thoroughly investigated. This failed practice was true for 1 (one) of 6 (six) investigations reviewed. Resident identifiers: #64. Facility census: 64. Findings included: a) Resident #64 On 05/20/24 at 11:30 AM a review of the facility reported incident dated 04/01/24 was performed. It was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room, she requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reports that she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 states that Employee #70 stated she would get her. Employee #56 reports that she also informed Employee #71 and that Employee #71 also stated she would get her. At approximately 01:30 PM, Employees #57 and #42 went into give…

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, staff interview and the facility policy and procedure, the facility failed to provide evidence that all alleged violations were thoroughly investigated and that corrective action was taken. Witness statements and staff education was not thoroughly completed. This was true for one (1) of five (5) facility reported incidents reviewed during the complaint survey. Resident identifier: #64. Census: 65. a) Resident #64 On 05/20/24 at 11:30 AM a review of the FRI complaint and investigation was performed. It was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room, she requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reported she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 stated that Employee #70 said she would get her. Employee #56 reports that she also informed Employee #71 that Employee #70 also stated she would get her. At…

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 interview the facility failed to implement written Quality Assurance and Performance Improvement (QAPI) polices and procedures for data collection and monitoring including adverse event monitoring. This failed practice was true for 6 (six) of 6 (six) investigations reviewed. Resident identifiers: Resident #64, #66. Facility census: 65. Findings included: a) Resident #64 On 05/20/24 at approximately 08:37 PM, a review of the facility policy, [NAME] Virginia Abuse, Neglect and Misappropriation Policy was performed noting the following text on page 19: All investigations of abuse, neglect and misappropriation will be reviewed by the QAPI committee. The committee will determine if the investigation is complete and if the action taken has resolved the issue or if a performance improvement plan is needed. On 05/21/24 at approximately 12:00 PM, a review of the facility policy, QAPI (Quality Assurance Performance Improvement) Plan was performed noting the following text on page 5 (five). ii. The facility will track, investigate and monitor adverse events…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise care plans for one (1) of six (6) residents. Resident #64's care plan was not revised to reflect the resident's ability to use the FreeStyle Libre blood glucose monitoring system. Resident #2's care plan was not revised to reflect her aggression toward other residents. Resident identifiers: #64, #2. Facility census: 65. Findings included: a) Resident #64 On 05/20/24 at 2:23 PM an interview with Resident #64 was conducted. While in Resident #64's room, a beeping sound was noted, a small machine was noted to be on her bedside table, upon observation it was noted to be a FreeStyleLibre blood glucose monitor. The Surveyor questioned Resident #64 about this, she responded, I don't even know where they have that thing on me. The Surveyor told Resident #64 she would get her nurse to help her with it. On 05/20/24 at 2:27 PM Employee #89 was walking down the hallway. The Surveyor asked him if he was Resident #64's nurse, to which he responded, Yes.…

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 interview the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed. This was identified during the extended survey process of the complaint survey. This has the potential to affect a limited number of residents. Identifier: Recreational Director (RD) #60. Census: 65. Findings included: a) On 05/21/24 at approximately 2:30 PM a request to review the Recreational Director (RD) #60's license. This request was made during the facility extended survey process. RD #60 stated she was not yet licensed but was currently in class to obtain her license through the National Certification Council for Activity Professionals. She stated the program had a practicum, and that the Administrator was her preceptor. She further stated that no one was overseeing her work or signing off on it. Record review for the activity preference for Resident #2 revealed it was completed and signed off by RD #60. During an interview with 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 record review and staff interview, the facility failed to maintain accurate medical records as it pertained to behavior monitoring for Resident #1. Resident identifier: 2. Facility census: 65. Findings include: A) Record Review On 05/20/24 at approximately 12:30 PM a review of progress notes for Resident #2 were reviewed as they pertained to behaviors exhibited by Resident #1. The following progress note from 04/20/24 typed as written: 04/20/24 at 3:32 AM - Resident up/out of room, yelling at CNA, cursing. Aggressive behavior. Started to enter another resident's room with this nurse intervening and redirecting back to room. Very irritable and anxious. Asking 'Where's Steve? What the hell are you all doing in my house?' Redirected, reassured resident. Assisted resident back to bed, offered food and fluids. Calmed. Currently lying quietly in bed with 1-1 supervision continued. At approximately 10:00 AM on 05/21/24 a review of the Medication Administration Record (MAR) and behavior monitoring task sheet for Resident #1 was reviewed. According to the MAR and behavior monitoring…

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 medical record review, observation and staff interviews the facility failed to ensure the patient care equipment was in safe operating condition. A concentrator was identified to have overheated and not working for a resident. This was true of one (1) of three (3) residents with oxygen concentrators in use and was identified during the complaint survey. This had the ability to affect a limited number of residents. Resident identifier: #34. Facility census: 65. Findings included: a) On 05/21/24 at approximately 11:15 AM during a medical record review of Resident #34, the resident's oxygen order and care plan identified the oxygen level of 3L (three Liters). An observation of the concentrator in use for Resident #34 was completed at approximately 11:22 AM on 05/21/24. During this time, it was identified that the concentrator oxygen level was at 2. During an interview with the Licensed Practical Nurse #95 she acknowledged the concentrator was reading 2L (two Liters) and that it should be at 3L. She began adjusting the dial, but the concentrator would not adjust up or down 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 medical record review and staff interview, the facility staff failed to accurately complete comprehensive assessments reflecting Hospice services and anticoagulants. This is true for two (2) of two (2) residents reviewed for Hospice and two (2) of two (2) residents reviewed for inaccurate assessments. Resident identifiers: #38, #44 and #46. Facility census: 61. Findings included: a) Resident #38 1. Hospice A review of the medical record revealed Resident (R) #38 was on Hospice services for end of life care. The annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/09/22 was incorrectly coded as no under section J1400. The Resident Assessment Instruction Manual states: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview on 10/19/22 at 12:45 PM, RN MDS Coordinator #65 confirmed R#38's annual MDS assessment dated [DATE] was incorrectly coded under…

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 deficiencies cited, resident interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental, and psychosocial well-being. Facility census: 61. Findings Included: a) Citations During the facility's long-term care survey the following citations are cross referenced for F725: -See F550 Resident Rights / Exercise of Rights -See F0641 Accuracy of Assessments -See F0677 ADL Care Provided for Dependent Residents -See F0693 Tube Feeding Management -See F0695 Respiratory Care -See F0761 Label / Store Drugs and Biologicals -See F842 Accurate Medical Record -See F0880 Infection Prevention and Control b) Resident Interviews During an interview on 10/17/22 at 12:02 PM, Resident #12 stated, At times they get short, they have call offs, and care is late at times. Observation 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.

Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored and administered in accordance with current accepted professional practices to ensure the safety and efficacy of medications administered. Medications stored in one (1) of two (2) medication carts inspected, had medication that was being administered after the manufacturer use by date. Temperatures were not obtained for the medication room refrigerator to ensure proper storage of medications requiring refrigeration. This practice had the potential to affect more than a limited number of residents. Resident Identifier: Resident #1. Facility census: 61. Findings included: a) Medication cart An observation of the Blue Hall medication cart , on 10/18/22 at 08:49 AM, revealed a Humalog insulin quick pen for Resident #1. Further observation revealed the insulin pen had a date of 09/17/22 written on the outside of the pen. An interview with Licensed Practical Nurse (LPN) # 26, on 10/18/22 at 09:07 AM, verified the date of 09/17/22 was the date the Humalog Insulin…

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, policy review, and staff interview, the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility census 61. Findings Included: A review of the facility policy entitled HCSG 016 Food: Preparation with an effective date of 05/2014 and revision date of 09/2017 stated: .13. All foods will be held at appropriate temperatures, greater than 135 degrees F (Fahrenheit) (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding . a) Tray Line On 10/18/22 at 11:25 AM, Food Services Director #56 obtained temperatures from the tray line prior to the meal service. The following foods did meet the temperature guidelines: --puree corn 96.0 degrees F --cottage cheese 45.3 degrees F --shredded cheese 44.7 degrees F During an interview on 10/18/22 at 11:55 AM, the Food Services Director #56 confirmed the temperatures were incorrect. We will get this corrected immediately. b) Lunch Tray Temperature On 10/18/22 at…

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

Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. The facility also failed to accrue dishwasher, refrigerator, freezer and resident refrigerator temperature logs. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census: 61. Findings included: a) Kitchen Tour On the initial tour of the kitchen on 10/17/22 at 10:45 AM, the following food was found in the walk-in refrigerator in a Ziploc baggies with the date but were not labeled: --Angel Food Cake --American [NAME] Cheese Also, on 10/17/22 10:49 AM, the following food was found in the walk-in refrigerator labeled but not dated: --An opened bag of hash browns --An open bag of ravioli --An open bag of chicken tenders. The Food Services Director #56 confirmed the above items should have been labeled and dated once they were opened. b) Resident Pantry A review of the facility policy titled Use…

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 interview, the facility failed to maintain an accurate medical record for one three (3) of 20 sample residents reviewed during the Long-Term Care Survey process. Resident identifiers: #48, #111, and #20. Facility census: 61. Findings included: a) Resident #48 An electronic medical record review, completed on 10/17/22 at 1:38 PM, revealed the following details: -A hospice discharge form, dated 09/02/22, providing resident/resident's representative a notice of non-coverage and stating that hospice services were ending. -A Physician Order for Scope of Treatment (POST) Form was on file. The second page of the POST form noted, Patient is enrolled in hospice. During an interview, on 10/18/22 at 2:05 PM, the Assistant Director of Nursing (ADON) acknowledged the POST form was not accurate and needed updated. b) Resident #20 An electronic medical record review, completed on 10/18/22 at 9:22 PM, revealed the following physician order: Every day and evening shift, check for residual q shift [every shift] and note any amount in ml (milliliters). If residual is…

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

Based on observation and staff interview, the facility failed to ensure care was provided in a manner to promote the resident's dignity. A sign was posted in Resident #46's room noting direction for care or treatment. This failed practice was based on a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident identifier: Resident #46. Facility census: 61 Findings included: a) Resident #46 An observation, on 10/17/22 at 11:45 AM, revealed a sign posted on the wall, above the resident's chair in Resident #46's room. The sign read as follows: When (Resident #46) is in chair do not let her have the remote. She will put herself on the floor. Put her in her chair and hide the remote. An interview, with Registered Nurse (RN) #65, on 10/17/22 at 11:48 AM, verified no sign should be above the resident's chair, showing resident information and stated it should be removed .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for two (2) of two (2) residents reviewed for Hospice. Resident identifiers: #38 and #44. Facility census: 61. Findings included: a) Resident #38 Review of the medical revealed Resident (R) #38 is on Hospice services for end of life care. The annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/09/22 is incorrectly coded as no under section J1400. The Resident Assessment Instruction Manual states: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview on 10/19/22 at 12:45 PM, Registered Nurse (RN) MDS Coordinator #65 confirmed R#38's annual MDS assessment dated [DATE] was incorrectly coded under section J1400. b) Resident #44 On 10/19/22 at 10:00 AM, a record review was completed for Resident #44. The Annual 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 observation, record review, and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of dressing and personal hygiene. This was true for nine (9) of 20 residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifiers: #1, #47, #31, #112, #28, #27, #22 and #8. Facility census: 61. a) Resident #1 On 10/18/22 at 8:55 AM, an interview with Resident #1 was completed. Resident #1 stated I'm supposed to get my showers Monday, Wednesday and Fridays .There was a new girl and she didn't know anything about it. She said we don't give showers on evening shift anymore. On 10/18/22 at 3:24 PM, an interview with the Administrator regarding the shower schedule was held. The Administrator stated, they can have showers whenever they request them .we do showers on evening shift .here is a copy of the new shower schedule .we will go talk to her and if she wants a shower she can have one. A review of the new shower schedule dated…

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

Based on record review and staff interview, the facility failed to provide the necessary treatment and services to promote healing of pressure ulcer. This failed practice was true for one (1) of four (4) residents reviewed for pressure ulcer care. Resident identifier: #55. Facility census: 61. Findings included: a) Resident #55 A record review, completed on 10/18/22 at 7:54 PM, found the following physician order, Cleanse right heel unstageable pressure ulcer with wound cleanser. Apply Silver Hydrogel to wound bed, no sting skin prep to peri wound. Cover with dry dressing. Change qd [every day]. Every day shift for Wound Care. Diabetic Ulcer. The physician order had a start date of 10/02/2022. Review of the October 2022 Medication Administration Record (MAR) revealed the following dates that were left blank: -10/15/22 -10/17/22 -10/18/22 During an interview, on 10/19/22 at 8:45 AM, the Director of Nursing (DON) confirmed the three (3) above dates on the October 2022 MAR were left blank and undocumented. The DON further stated all nurses are trained to document accurately in the MAR…

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 interview, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feeding. The facilty failed to ensure the residual amounts were obtained in accordance with the physician's orders. This was true for one (1) of two (2) residents reviewed who was receiving a tube feeding during the Long Term Care Survey Process. (LTCSP). Resident identifier: #111. Facility census: 61. Findings included: a) Resident #111 A record review, for Resident #111, showed a physician's order, dated 10/16/22, for staff to check for residual daily , every shift, before reconnection of the tube feed and note any amount in milliliters (ml). If the residual was greater than 100 ml, staff were to hold the feeding for one (1) hour and recheck. If residual remained greater than 100 ml , the staff were to notify the physician. Further record review, showed no evidence the residual was being checked every day, during every shift, in order to…

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

Based on observation, record review and staff interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was administered in accordance with physician's orders. This failed practice was true for one (1) of two (2) residents receiving oxygen therapy, reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: Resident #111. Facility census: 61. Findings included: a) Resident #111 A record review for Resident #111, showed a physician's order, dated 10/16/2022, for the resident to receive oxygen therapy at a flow rate of two (2) liters per minute (L/min), related to a diagnosis of Chronic Obstructive Pulmonary Disease. An observation, on 10/17/22 at 12:50 PM, revealed the oxygen was being administered to Resident #111 at a rate of 1.5 L/min. An interview, with Registered Nurse (RN) #65, on 10/17/22 at 12:53 PM, confirmed Resident #111 was receiving oxygen at 1.5 L/min and verified the oxygen was not being administered in accordance with physician's orders. RN…

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

Based on observation and interview, the facility failed to keep waste properly contained when the dumpster was overfilled and uncovered. This failure had the potential to result in unpleasant odors and harboring of pests. Facility census: 61. Findings included: A review of the food code by the Food and Drug Administration (FDA), dated 2017, section 5-501.113 indicated outside receptacles must have tight-fitting lids or covers. a) Dumpster During an observation on 10/17/22 at 10:35 AM, the dumpster was overfilled. Garbage bags were observed approximately 12 inches above the top edge of the dumpster. The lid was flipped behind the dumpster. During an interview with the Dietary Services Supervisor (DSS) on 10/17/22 at 10:37 AM, the DSS acknowledged the dumpster was overflowing and the lid was not closed. He went on to state, All staff use this dumpster for disposal of garbage. I will also address this with the Director of Housekeeping. .