Mercer Healthcare Center

b) Resident #56 An observation on 01/22/25 at 11:00 PM, revealed a bottle of Povidone Iodine Prep Solution setting on the dresser in Resident #56's room. During an interview on 01/22/25 at 11:00 PM, Resident #56 stated, They leave all kinds of stuff in here. An observation on 01/22/25 at 11:10 PM, with the Director of Nursing (DON) revealed that Resident #56's room door was shut. The state agency (SA) knocked on the door. A Nursing Assistant (NA) came to the door and stated, We are doing wound care. Give us just a few minutes. During an observation, and interview on 01/22/25 at 11:25 PM, the DON in Resident #56's room showed that the Povidone Iodine Prep Solution was no longer on the dresser. The DON opened the dresser drawers and found the solution in the drawer with 6 bottles of skin prep solution and several unwrapped gauze pads. The DON confirmed that the items should not be in Resident #56's room. c) Material Safety Data Sheet (MSDS) A review of the MSDS for the Povidone Iodine Prep Solution on 01/22/25 at 12:10 PM, under Section 2 {Hazards Identification} reads as follows:…

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, resident interview and staff interview the facility failed to monitor the effectiveness of pain medications in accordance with professional standards of practice. This failed practice was found true for (1) one of (7) seven residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier: #31. Facility census: 120. Findings Include: a) Resident #31 During an interview on 01/28/24 at 9:15 AM, Resident #31 stated, I hurt all the time. They are waiting on something from the pharmacy. A record review on 01/28/24 of Resident #31's current orders revealed an order for Oxycodone-Acetaminophen oral tablet 5-325 to give (1) one tablet by mouth every (8) eight hours as needed for pain. The order had a start date of 11/04/24. Further record review of Resident #31's Medication Administration Reports (MAR's) for the months of 11/2024, 12/2024, and 01/2025 revealed that Resident #31 was given the Oxycodone-Acetaminophen (5) five times without checking the effectiveness of the medication. During an interview on 01/28/24 at 2:00 PM the DON confirmed…

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 store and label medications in accordance with professional standards of care. Multiuse vials of insulin had not been dated when opened. Additionally, multiuse vials of insulin had not been discarded 28 days after opening. These were random opportunities for discovery. Resident identifiers: #83, #85, #80, #62, #51, #61, and #57. Facility census: 120. Findings included: a) Policy review The facility's policy titled Vials and Ampules of Injectable Medications stated as follows: Expiration Dates: Unopened vials expire on the manufacturer's expiration date. When a vial is opened, the nurse records the opened date on the vial. Since opening a vial triggers a shortened expiration date that is unique for that vial, the nurse may record the expiration date on the vial. Triggered expiration dates may be found on the manufacture's [sic] package insert, on the package, or on a reference chart by pharmacy, or by contacting the pharmacist. b) A2 Hallway Cart On 01/22/25 at 9:10 AM, inspection of the A2 hallway…

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 record review the facility failed to ensure food is prepared in a form designed to meet the individual needs of each resident. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #37, #47, #76, #51, #29, #79, #98, and #88. Facility Census: 113. Findings Include: a) On 01/27/25 at 12:37 PM during the noontime meal service it was noted the facility was serving kielbasa sausage. At 12:37 PM on 01/27/25 Employee #162 the district food manager (DFM) was overheard asking [NAME] #146 if she had ground kielbasa. She replied, no. She indicated she thought the kielbasa meet the requirement for the mechanical and advanced diets. Employee #162 advised [NAME] #146 that it needed to be ground. By this point in service the entire A unit of the facility had been served. Employee #162 DFM then indicated to the Dietary Manager (DM) they had run out of ground kielbasa. It was at this time [NAME] #146 was asked by the surveyor if she had ran out of ground kielbasa or had not prepared any. She…

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 the ice machines in the A and B hall pantries were clean and sanitary. In addition, the microwave in the B-hall nutrition pantry was rusted. This failed practice had the potential effect more than an isolated number of residents. Facility Census: 120. Findings Include: a) A and B hall pantries During an observation of the A hall pantry at 11:10 am on 01/20/25, found the ice machine was not clean. The grate were the cups or containers would sit was covered in white scaly substance. The certified dietary manager (CDM) removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. During an observation of the B hall pantry at 11:15 am on 01/20/25, found the ice machine was not clean. The grate where the cups or containers would sit to be filled with ice was covered in a white scaly substance. The CDM removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed…

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 make good faith attempts to correct quality deficiencies related to complete and thorough investigations, despite being cited multiple times in the past and identifying issues related to the investigations. This has the potential to affect more than a limited number of residents. Facility census: 120. Findings include: a) Current survey At approximately 1:00 PM on 01/28/2025, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was that took the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving 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 staff interview, the facility failed to ensure they honored the residents right to receive meal trays in a dignified manner. This was a random opportunity for discovery during the Long-Term Care Survey process. Facility Census:113. Resident identifier: #71. Findings include: a) Resident #71 01/22/25 03:06 PM Resident #71's roommate was served approximately six (6) minutes before Resident #71 was served. During an interview, on 01/22/25 at 3:10 pm with the Administrator, she confirmed Resident #71 should have been served and assisted with eating after the roommates' tray was delivered.

Based on record review and staff interview, the facility failed to thoroughly investigate an allegation of abuse of Resident #319. This was true for one (1) of nine (9) residents reviewed for abuse during the survey process. Resident identifiers: #319, #320, #46, #50, #54, #40, and #8. Facility census: 120. Findings include: a) Resident #319 At approximately 1:00 PM on 01/28/25, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All of the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was taking the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving the statement, however, it was signed by Resident #8. In the initial…

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 ensure Resident #108's Discharge Minimum Data set was coded to accurately reflect the location where the resident was discharged to. This was true for one (1) of 36 sampled residents reviewed during the long-term care survey process. Resident Identifier: #108. Facility Census: 113. Findings include: a) Resident #108 A review of Resident #108's medical record at 10:52 am on 01/27/25 found a Discharge summary dated [DATE] which indicated the resident was transferred to another long-term care facility. A review of the discharge Minimum data set (MDS) with an assessment reference date of 01/08/25 found section A2105 was coded with the number 04 which indicated the resident was discharged to Short Term General Hospital. However, this section should have been coded 02 Nursing home. An interview with the Nursing Home Administrator (NHA) at 2:05 PM on 01/27/25 confirmed this MDS was inaccurate.

Based upon record review and staff interviews, the facility failed to refer one (1) of eight (8) residents who had a newly evident serious mental health disorder diagnsis for a level II review. This was true for one (1) of eight (8) records reviewed. Resident identifier: #85. Facility census: 120. Findings included: a) Resident #85 Major depressive order was added as a diagnosis in the electronic medical record on 11/04/24, for resident #85. The last PASARR was completed on 06/03/24. During an interview with the Director of Nursing (DON) on 01/23/25 at 12:32 PM the PASARR was reviewed PASARR with her and she acknowledged the error.

Based on observation, record review and staff interview, the facility failed to implement Resident #47's care plan regarding accident hazards in his room and failed to implement Resident #99's care plan in regard to same sex caregivers. This was true for two (2) of 36 resident care plans reviewed during the survey process. Resident identifiers: #47, #99. Facility census: 120. Findings include: a) Resident #47 At approximately 1:18 PM on 01/20/2025, 2:00 PM on 01/21/2025, and 3:30 PM on 01/22/2025, Resident #47's over the bed table was observed sitting on the fall mat to the left side of his bed. The over- the- bed table was placed diagonally, from the top of the fall mat, in a way that exposed the metal bottom, and wheels, of the table, leaving the resident open to landing on them if he were to fall out of bed. Licensed Practical Nurse (LPN) #97 acknowledged the table on the fall mat at approximately 3:35 PM on 01/22/25 and stated the table was usually always on the mat because the resident reaches over and gets his water off of the table. At approximately 4:00 PM on 01/22/25, an…

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 plan after placing resident on a Q one (1) hour checks for three (days). This was a random opportunity for discovery during the Long-Term Care survey process. Facility identifier: #96. Facility Census: 113. Findings include: a) Resident #96 Record review on 01/23/25 at 11:09 AM of Resident #96 care plan, which stated the following Focus -Resident is an elopement risk related to dementia and wandering behaviors. Resident has exit seeking behaviors. Resident has had an elopement. Goal -Resident [NAME] not exit property if unsafe to navigate community. Interventions -Apply secure device. Check placement every shift. check function and door transmitter daily. Document in the order the expiration date of the secured devices. -Assess for hunger, thirst, ambulation/re-admission, quarterly, and PRN(as needed) -Educate resident/resident representative of the need for secure unit/device to maintain resident safety -Evaluate need of secured unit,…

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 failed to ensure they provided an ongoing program of activities of support the needs of each resident. One resident (1) did not have an Activity Preference Assessment (ADA) within in seven (7) Days of Admission. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #368. Facility census: 113. Findings include: a) Resident #368 On 01/27/25 at 01:07 PM during record review it was revealed that Resident #368 was admitted on [DATE]. The activity preference interview was not completed till 11/11/24 On 01/27/25 at approximately 1:30 PM the Director of Nursing (DON) provided a paper stating, When UDA should be completed/How UDA will trigger. On the list it revealed the Activity preference interview triggers to be completed by day seven (7) after admission/re-admission then annually. On 01/27/25 at 2:05 PM the Activity Director (AD) acknowledged the assessment should have been done by day seven (7).

Based on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. A medication dosage was not specified in a physician's order for Resident #42. A physician's order for no straws was not followed for Resident #88. This deficient practice had the potential to affect two (2) of 36 residents reviewed in the long-term care survey sample. Resident identifiers: #42 and #36. Facility census: 120. Findings included: a) Resident #42 On 01/22/25 at 9:31 AM, Licensed Practical Nurse (LPN) #21 was observed administering medications to Resident #42. One of the medications given to Resident #42 was Vitamin D3 1000 international units (IU) or 25 micrograms (mcg). The Vitamin D3 tablet was dispensed from a floor stock bottle of Vitamin D3 located in the medication cart. Review of Resident #42's physician's orders showed an order written on 01/11/25 for Vitamin D3 oral tablet (cholecalciferol) Give 1 tablet by mouth one time a day for vitamins. The dosage of the medication to be given…

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 necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that included the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident 99 had 15 days that he was marked for behaviors. Further record review of Resident #99's Behavior notes from nursing reveal an additional 13 behavior notes since 10/01/24. A record review on 01/27/24 at 10:00 PM, revealed a Care plan for Resident #99 that reads as follows:…

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 medically related social services necessary to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility Census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that include the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident #99 had 15 days marked for behaviors. Further record review of Resident #99's Behavior notes from nursing revealed an additional 13 behavior notes since 10/01/24. A record review on 01/27/24 at 10:00 PM, revealed a Care plan for Resident #99 that read as follows: Focus: 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, record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the medication administration facility task. Resident identifier: #73. Facility census: 120. Findings included: a) Policy Review The facility's policy titled Medication Administration with approval effective date 12/02/24 gave the following procedure: - Read medication label three (3) times before administering medication - First, when pulling the medication from the drawer - Second, when comparing label to MAR [Medication Administration Record] - Third, when preparing to administer the medication b) Resident #73 On 01/22/25 at 8:48 AM, observation was made of Licensed Practical Nurse (LPN) #20 administering medications to Resident #73. Resident #73's medications were dispensed by pharmacy in three (3) plastic packets. One plastic packet was labeled to contain the following medications: - Aripiprazole, 5 milligrams (mg) - Citalopram Hydrobromide, 10…

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 resident interview, record reviews and staff interview's the facility failed to ensure residents were provided with needed dental services. This failed practice was found true for one (1) of four (4) residents reviewed for dental services during the Long-Term Care Survey process. Resident identifier: #55. Facility census: 120. Findings include: a) Resident #55 During an interview with Resident #55 on 01/21/25 at 09:38 AM the resident stated, Don't have upper dentures because it is too expensive for dentures and to have any teeth pulled. Resident #55 went on to state, I am having some pain with my bottom teeth, sometimes it's hard to chew. Record review on 01/22/25, at 2:13 PM, showed the admission [NAME] Data Set (MDS) on 09/19/24 had yes marked for question F} mouth facial pain, or difficulty chewing. On 11/22/24 the administrator was present with the surveyor when Resident #55 stated she had teeth pain and she had not been talked to about coverage for residents in the nursing home. She also said no…

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

Based on observation, staff interview and resident interview the facility failed to serve food at palatable temperatures. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #29. Facility census: 120. Findings include: a) Resident #29 During an observation on 01/22/25 at 12:55 PM, Resident #29 was served a lunch tray. The light was turned on in his room. The tray was set on his bedside table and the lid was taken off. Resident was asleep. Constant observation from 12:55 PM to 1:50 PM showed that no staff members entered Resident #29's room and that Resident #29 continued to be asleep. At 2:10 PM a Nursing assistant (NA) entered Resident #99's room. During an interview on 01/22/25 at 1:50 PM, NA #49 stated, We usually leave them in there for about an hour if they don't eat. I was getting ready to take his. At this time Resident #29 woke up and said I am hungry. He grabbed the butter knife out of his bag and stuck it in his dessert. With the SA in the room NA #49 gave him a spoon. An observation on 01/22/25 at 2:30 PM, revealed…

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, resident interview, record review, and staff interview, the facility failed to provide ordered assistive eating devices. This was a random opportunity for discovery. Resident identifier: #51. Facility census: 120. Findings included: a) Resident #51 Resident #51 was observed in his bed on 01/20/25 at 1:33 PM and was noted to have food on his clothing. His lunch tray was on the bedside table in front of him. There was also food on the bedside table. His plate did not have a plate guard. Review of Resident #51's physician's orders showed an order written on 01/06/25 for regular diet, dysphagia advanced texture, thin liquids consistency, regular utensils and plate guard. The resident had a diagnosis of contracture to his right hand, which was his dominant hand. On 01/22/25 at 12:50 PM, Resident #51 was observed eating in his bed from the tray on his bedside table. His meal ticket stated he was to have ground roast turkey, poultry gravy, cornbread dressing, honey roasted carrots, buttered dinner roll/bread, margarine, brown sugar glazed angel food cake, and a plate…

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 upon record review and staff interviews, the facility failed to accurately record the DNR status of Resident #32, in the electronic medical record. This was a random opportunity for discovery. Resident identifier: #32. Facility census: 120. Findings include: a) Resident #32 Resident #32's POST form signed and dated on [DATE] was for Do Not Resuscitate (DNR) with Selective Treatments. The physician orders and dashboard in the electronic health care record and document CPR. During a staff interview with LPN #21, she was asked where she would look to find the resident's lifesaving preferences. She stated either the POST form or the dashboard in the medical record. Record review revealed the dashboard, and the POST form do not match. On [DATE] at 10:56 AM, an interview with Unit Charge LPN #21 was held. The LPN was asked the question, If residents were to be found not breathing, how would you know what care to provide, i.e. CPR or DNR? LPN #21 stated since she does some of the admissions, she knew which one…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure Enhanced Barrier Precautions (EBP) were appropriately initiated. This was a random opportunity for discovery. The facility also failed to ensure appropriate hand hygiene was performed during pressure ulcer dressing changes for one (1) of one (1) residents observed for pressure ulcer dressing changes. Resident identifiers: #51 and #31. Facility census: 120. Findings included: a) Policy Review - Enhanced Barrier Precautions The facility's policy and standard procedure titled Enhanced Barrier Precautions with approval effective date 04/01/24 stated Enhanced Barrier Precautions (EBP) are indicated for residents with indwelling medical devices, including urinary catheter. A sign was to be posted on the resident door to indicate EBP was required. b) Resident #51 On 01/20/25, Resident #51 was noted to have an…

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

Based on staff interview and record review the facility failed to ensure two (2) of five 5 residents resident received treatment as ordered by their physician. The facility failed to follow physician's orders for wound treatments for Resident #54 and #66. Resident identifiers: #54 and #66. Facility Census: 104. Findings included: a) Resident #66 On 06/11/2024 at approximately 11:00 AM during a medical record review for Resident #66, it was identified with reviewing the Treatment Administration Record (TAR) that the physician's orders were not followed daily for the following days and treatments. 05/15/25 - Wound care: cleanse left posterior thigh with wound cleanser; dry, apply calcium alginate and foam dressing daily and as needed daily on day shift for wound healing (written as ordered). Order not completed. 05/07/24- Oxygen at two (2) via nasal cannula (NC) every shift (written as ordered). The night shift order was not completed. 05/07/24- Sacral Ulcer Stage IV apply silver alginate in wound covered by sacral foam dressing each shift. every day and night shift for sacral ulcer…

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 maintain appropriate infection control standards for foley catheter care storage and/or disposal of a bed pan and timely removal of a meal tray. These were random opportunities for discovery. Resident identifier: #8, #37. Room identifier: #A19. Facility Census: 104. Findings included: a) Resident #8 On 06/11/24 at 10:30 AM, foley catheter care was observed which was performed by Nurse Aide (NA) #32. While performing the care, NA #32 placed soiled linen directly on the floor. Upon completion of the foley catheter care, NA #32 was emptying the urinary drainage bag. NA #32 did not place a barrier between the graduated cylinder and the floor. When NA #32 had completed emptying the urinary drainage bag, a wet substance was observed on the floor. NA #32 was asked, what is the wet substance on the floor? NA #32 stated, it's urine .I should have put something on the floor. On 06/11/24 at 10:48 AM, the Director of Nursing (DON) was notified of the infection control breaches regarding the lack of using barriers…

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 resident and staff interview, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure the availability of clean washcloths. This has the potential to affect more than a limited number of residents. Resident identifier: 57. Facility census: 107. Findings include: a) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them out. Once she got rags, they got Resident #57 up at 9 AM. Resident #57 had a BM and CNA told resident that she's gonna put her feet…

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 that all alleged violations involving abuse and neglect were reported, to the appropriate state agencies as required. This was a random opportunity for discovery and a deficient practice identified during complaint investigation. The deficient practice was true for five (5) out of five (5) resident records sampled under the abuse/neglect category. Resident identifiers: #73, #77, #10, #57, and #112. Facility census: 107. Findings included: a) Resident #73 Record review, completed on 05/07/24 at 8:00 AM, revealed a facility reportable dated 01/19/24 describing an alleged incident of facility neglect. The facility had erroneously served Resident #73 pureed Shrimp and Sausage Jambalaya for dinner despite the fact she had a known shrimp allergy. There was no evidence the facility had shared the five (5) day follow-up investigative details with Adult Protective Services (APS). b) Resident #77 Record review, completed on 05/07/24 at 8:10 AM, revealed a facility reportable dated 01/31/24 describing an alleged incident…

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 provide reasonable accommodation in regards to a call light being out of reach. This was a random opportunity for discovery. Resident Identifiers: #1 and #65. Facility Census: 107 Findings included: a) Resident # 1 An observation and interview on 05/07/24 at 9:58 AM, with Resident #1 found the resident lying in her bed without a call light in sight. Upon being asked about her pain level, and how she would notify staff if she needed assistance, the Resident stated that she would use her call light, but couldn't locate it. The call light was observed on the floor near her bed. On 05/07/24 at 10:05 AM, Nurse Aide (NA) #80 confirmed that call light was on the floor, and not within the residents reach. b) Resident #65 An observation on 05/07/24 at 10:13 AM found Resident #65 laying in her bed with no call light in sight. The call light was observed on the floor near the bed's wheels. On 05/07/24 at 10:21 AM, Registered Nurse (RN) #65, confirmed that the call light was on the floor, and not within reach. RN # 65 stated that…

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

Based on record review and resident and staff interview, the facility failed to ensure allegations of neglect were thoroughly investigated by concluding personal care was provided to a resident in a timely manner, but failing to establish how long the resident waited to receive care. This was true for one (1) of three (3) residents reviewed for allegations of neglect during the survey process. Resident identifier: 57. Facility census: 107. Findings include: A) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them…

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 resident and staff interview, the facility failed to ensure personal care was provided to a resident in a timely manner, by making a resident wait to be cleaned and assisted out of bed because there were no clean linens. This was true for one (1) of one (1) residents reviewed for ADL care during the survey process. Resident identifier: 57. Facility census: 107. Findings include: A) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them out. Once she got rags, they got Resident #57 up at 9…

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 the Daily Staffing Posting information was accurate and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all residents. Facility Census: 97. Findings included: a) Accurate and Current Data On 1/31/24 at 8:00 AM the 1/06/24, 1/07/24, 1/27/23 and 1/28/24 Staffing Posting Forms were reviewed and the total number of Direct Care staff for each Direct Care department per shifts was not identified. On 1/31/24 at 8:10 AM the Administrator acknowledged that the Staffing Posting Forms reflect FTE's (full time equivalent's) and not the actual total number of Direct Care staff for each Direct Care department per shift as required. b) Maintain the daily Staffing Posting Form a minimum of 18 months On 1/29/24 at 3:06 PM a review of the Staffing Posting Form and the Punch Detail Report was completed for 1/06/24, 1/07/24, 1/27/23 and 1/28/24. The Staffing Posting Forms for 1/06/24 and 1/07/24 had handwritten…

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, policy review, resident interview and staff interview, the facility failed to ensure three (3) of three (3) residents and/or residents representatives reviewed were afforded the right to participate in the care planning process. Resident identifiers: #6, #12 and #69. Facility Census: 97. Findings included: A review of the facility policy titled Plan of Care Overview with no effective date is read as follows. 1. General Care Planning (PoC) Goals and Guidelines. .c. Resident/representative will have the right to participate in the development and implementation of his/her own PoC including but not limited to : .vi. Right to be informed, in advanced, of changes to the PoC d. The facility will: .iii. Review care plans quarterly and/or with significant changes in care. .v. support the residents rights to participate in treatment and care planning During an interview, on 01/31/24 at 9:05 AM, Regional Registered Nurse (RRR) (RN) #224 stated the facility policy titled Plan of Care Overview had no effective date or revision date. a) Resident #6 During an…

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.

Findings Included: c) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' wound care orders and review of the Treatment Administration Report (TAR) for Resident #11 for the last three (3) months shows the following treatments orders were not completed: 11/04/23 - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift, left buttock #2 -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Stage III -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #1 I-cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #2 - cleanse pressure area to right buttock with wound cleaner, dry, supply…

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 establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Resident identifier: #100. Facility census 97. Findings included: a) Gabapentin A review of the medical records for Resident #100, found they were ordered to receive Gabapentin (used for relieving pain for certain conditions in the nervous system) 900 milligrams (mg) to be administered three (3) times a day. The order date was 07/12/23. On 01/29/24 at 2:40 PM the Director of Nursing (DON) was asked why did the Controlled Substance Record (CSR) had two (2) separate pages with the same medication and same dose. DON verified both pages were the same as follows: (named Resident #100) Gabapentin tab 600 mg Give 1 and ½ tabs by…

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

Based on record review and staff interview the facility failed to ensure the dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This was a random opportunity for discovery. Facility Census: #97 Findings include: a) On 01/29/24 at 10:58 AM the Dietary Director was unable to provide the required state food handlers cards for eight (8) of the fourteen (14) staff members in the kitchen area. This was confirmed with the Administrator on 01/29/24 at 1:30 PM at which time she stated she would see if there were any that were missing in the Human Resource file. However, on 01/31/24 at 11:10 AM, she was only able to provide an additional two (2) food handler cards. Therefore, six (6) of the fourteen (14) staff kitchen staff's food handler cards were not available.

Based on observation and staff interviews the facility failed to ensure menus were followed and residents received the correct serving of food items. This has the potential to affect all residents who receive nutrition from the kitchen. Facility census: 97 Findings included: a) On 1/29/24 at 12:06 PM, kitchen line staff were observed plating resident trays for the noon meal. The meal consisted of kielbasa, capri vegetable blend, and baked beans. Staff were using a scoop #12 which held 2.66 ounces to serve the kielbasa for the pure and ground diets. According to the Diet Guide Sheet, the #10 scoop should have been used. The #10 scoop held 3.25 ounces. Residents received a pureed and ground diet received .59 ounces less than the required serving size. Further observation on 01/29/24 at 12:10 PM, found the ground and pureed capri vegetable blend was also being served with scoop #12 which held 2.66 ounces when the Diet Guide Sheet showed the pureed and ground capri vegetable blend should have been served with #10 (3.25) ounce scoop. Residents receiving a pureed and ground diet received…

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

Based on observation, staff interview and resident interview, the facility failed to serve and prepare food in a palatable, attractive, and appetizing manner. This had the potential to affect more than a minimal number of residents at the facility. Resident identifiers: #50 and #68. Facility Census: 97. Findings included: a) Resident #50 On 01/24/24 at 12:40 PM, observation found the resident in her room with her lunch meal tray. The resident was not eating the meal. When asked how her meal was, the resident stated, this food is crap, this is hard. The resident picked up a chicken tender and tapped it on her plate to demonstrate how hard the chicken tender was. The chicken tender did make a noise when tapped on the plate. The resident also said the chicken tenders were burnt on the edges. Observations found the chicken tenders were dry and crusty with dark brown discoloration around the edges. The resident added she didn't even order the chicken tenders because the menu said the meat was kielbasa. She said, I never order the chicken tenders because they are always hard and dried…

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 procure, store, prepare, and serve food in a sanitary manner, by failing to store food containers in a sanitary manner, and by failing to record refrigerator temperatures. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility Census: 97. a) Kitchen observation At approximately 1:07 PM on 01/29/24, a plastic food container was removed from the dishwasher and placed on the drying rack in the dish room. The container was sealed with the lid, with water inside, failing to allow it to properly air dry. Culinary Director (CD) #98 and Regional Dietary Manager (RDM) #220 witnessed the container on the drying rack, sealed with water inside, unable to properly air dry. b) On 01/29/24 at 08:25 PM, observation of the refrigerator in the warming kitchen off the dining room on the B hall temperature log posted on the refrigerator shows the last refrigerator temperature was checked on 08/16/23 morning shift According to the facility Policy for #…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 97. Findings included: a) Isolation Caddie At approximately 11:36 AM on 01/29/24, an observation was made of an isolation caddie on the door of room A14. The top right pocket contained candy, empty candy wrappers, and used medical gloves. Nursing Staff Scheduler (NSS) #24 witnessed the condition of the isolation caddie on the door of room A14. b) Clean linen cart At approximately 8:09 PM on 01/29/24, an observation was made of a clean linen cart on the A Hall of the facility, between rooms A5 and A7. This linen cart was uncovered, with the linens exposed, a jacket sitting on top of the cart, an…

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 notice for resident room changes, including the reason for the change, before the resident's room or roommate in the facility is changed. This is true for four (4) of five (5) residents reviewed for room changes during a complaint survey. Resident Identifiers: #29, #10, #84 and #101. Resident Census: 97. Findings included: a) Resident Room Changes On 01/30/24 a review of resident room changes revealed: 1. Room changes were completed for Resident #29 on 01/15/24 and 01/08/24 with no room move assessments completed. 2. A room change completed for Resident #10 on 01/25/24 with no room move assessment completed. 3. A room change was completed for Resident #84 on 01/18/24 with no room move assessment completed. 4. A room change was completed for Resident #101 on 01/07/24 with no room move assessment completed. During an interview on 1/30/24 at 1:20 PM the Director of Nursing (DON) stated that she was unable to locate documentation for Residents #29, #84, #10, and #101's room changes.

Based on observation and staff interview the facility failed maintain the residents right to personal privacy and confidentiality of their personal and medical records. This was a random opportunity of discovery. Resident Identifiers: #69 and #95. Facility Census: 97 Findings Included: a) Resident #69 On 01/29/24 at 08:09 PM it was observed that Licensed Practical Nurse (LPN) #122 had left the computer screen opened on the medication cart. The LPN was in a residents' room and the medication cart and computer screen were left unattended. The personal and medical records for Resident #69 were exposed and available to anyone walking past the medication cart. This was confirmed with LPN #122 on 01/29/24 at 8:13 PM and the Administrator at 8:28 PM. b) Resident #95 On 01/29/24 at 08:20 PM it was observed that Licensed Practical Nurse (LPN) #71 had left the computer screen opened on the medication cart. The LPN was in a resident's room and the medication cart and computer screen were left unattended. The personal and medical records for Resident #95 were exposed and available to anyone…

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 complete a thorough investigation of a verbal abuse allegation and report the results to the appropriate State Agencies within a five (5) day follow up of the incident in accordance with State law. Resident identifier: Resident #67. Facility Census: 97. Findings Include: a) Resident #67 A review of the facility reportable log on 01/29/24 at 2:25 PM, revealed the following verbal abuse allegation: The alleged victim (Resident #67's name) Alleged Perpetrator name: Housekeeper #12 name Date of incident: 10/16/23 Brief description of the incident: Resident reported that when she ask for a roll of toilet paper (Housekeeper #12 name) replied hell, I gave you two (2) rolls yesterday. The reporting forms were void of any documentation that a thorough investigation of the verbal abuse allegation had occurred. The forms were also void of any documentation of a five (5) day follow up report completed and sent to the appropriate state agencies in accordance with the State Law. During an interview, on 01/29/24 4:00 PM, 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 implement a comprehensive person-centered care plan for wound care treatments. This was found for one (1) of three (3) respidents reviewed for pressure ulcers. Resident Identifiers: #11 and #63. Facility Census: 97 Findings Included: a) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' comprehensive personal-centered care plan: Focus: .has impaired skin integrity related to limited physical mobility, incontinence, morbid obesity, has pressure ulcers to left posterior thigh X 3 areas, sacrum and right buttock. Intervention/tasks: Administer treatments as ordered by medical provider. Apply barrier creams post incontinent episodes. Complete skin at risk assessment upon admission, quarterly, and as needed, complete weekly skin checks, Resident #11 had Physician orders for multiple pressure ulcer wound care. There is a care plan for the wound care, however, the facility failed to implement the care plan as written. Review of the Treatment Administration Report for Resident #11 for the last three (3)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This was a random opportunity for discovery. Facility census: #97 Findings Included: a) B1 Hall medication cart On 01/29/24 at 08:09 PM observation of the medication cart on B1 hall was unlocked and left unattended by Licensed Practical Nurse (LPN) #122. There were six (6) residents sitting near the medication cart. According to a Resident Response Analyzer report of wandering residents provided by the Director of Nursing on 01/29/24, there were sixteen (16) residents that wandered throughout the facility. The LPN was away from the medication cart for four (4) minutes. According to the facility Policy # NS-1197-02 Nursing mediation Safety Precautions: c. Lock medication cart when not in the immediate vicinity of the cart . which she failed to do. This was confirmed 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 observation, record review and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This failed practice was found true for (1) one of (3) three residents reviewed for hydration. Resident identifier: #91. Facility census: 97. Findings include: a) Resident #91 During an observation on 01/29/24 at 11:00 AM and 2:00 PM, Resident #91's pink water pitcher at her bedside was found to be empty. A record review on 01/29/24 at 2:00 PM of Resident #91's hospitalizations revealed that Resident #91 had been hospitalized on [DATE]. One of her admitting diagnoses was dehydration. Resident #91's last Dietary Nutritional assessment dated [DATE] shows that her estimated fluid needs are 1200-1400 milliliters (ml) per day. She is also to use a (2) two handled cup for fluid consumption. A record review on 01/29/24 at 2:30 PM of Resident #91''s fluid intake for the month of 01/2024 after she returned from the hospital, reveals the following daily total fluid intakes:…

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 that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan. The facility failed to follow the physician's order and the comprehensive care plan intervention to document the post-dialysis weight provided by the dialysis center weekly. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for receiving dialysis treatments. Resident identifier: #4. Facility census: 97. Findings included: a) Resident #4 Review of Resident #4's physician's orders showed the following order written on 09/28/23, Document dry weight (post-dialysis weight) provided by dialysis center weekly, every day shift, every Thursday. Resident #4's comprehensive care plan had the following intervention implemented on 07/03/23 and revised on 01/18/24, Obtain weight as ordered. Report abnormal fluctuations to medical provider, nephrologist/ dialysis center, resident, resident representative. Document dry weight…

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

Based on resident interviews, observation and staff interview the facility failed to provide the appropriate nutritive content as prescribed for a renal diet. This was a random opportunity for discovery. Facility Census: 97. Findings included: a) Resident #50 During an observation, on 01/29/24 at 12:37 PM, of Resident #50's tray, the diet ticket on the tray had Parsley pork chops, Herb Noodles, Capri Vegetable Blend, Dinner Roll, and Carrot cake. The Parsley Pork Chop was marked through, and tenders were written on the ticket. Resident #50 said she did not order any chicken tenders. She added that a staff member took her order this morning and she was told Kielbasa was the meat for the meal and this was what she ordered. Resident #50 stated, the lunch is crap, this is hard. The Resident demonstrated by tapping the chicken tender on her plate. A clicking noise could be heard when the resident tapped the chicken on the plate. The Resident stated she never ordered chicken tenders because they were always hard. The administrator entered the room during the interview. The resident showed…

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 facility documentation and staff interview the facility failed to have the minimum quarterly Quality Assessment and Assurance (QAA) meetings to identify and correct Quality deficiencies. This had the potential to affect more than an isolated number of residents that reside at the facility. Facility census: 71. a) QAA meetings Record review of the facility's undated policy titled, Quality Assurance performance Improvement (QAPI),showed the facility will have a QAPI meeting every month. On 08/22/23 at 9:45 AM a review of QAPI plan, policy and meeting sign in sheets revealed no documentation for QAA / QAPI meetings were available from 02/28/23 through 07/11/23. On 08/22/23 at 9:51 AM the Administrator stated that they don't have documentation of a QAA / QAPI meeting from 2/28/23 until 07/11/23.

Based on observation, record review, resident interview and staff interview, the facility failed to thoroughly investigate allegations of abuse and/or neglect for four (4) of four (4) residents reviewed for the care area of abuse. Resident #51's elopement, Resident #3's wound care not being provided, missing rings for Resident #10 and allegations of verbal and physical abuse by a nursing assistant (NA) during repositioning of Resident #229 were not thoroughly investigated. Resident identifiers: #51, #3, #10 and #229. Facility Census: 71. Findings Included: a) Resident #51 On 08/21/23 at 3:00 PM, the facility reportable log was reviewed. Resident #51 was listed as an elopement from the facility on 07/28/23. The immediate reporting of allegations stated, SW (Social Worker) and DON (Director of Nursing) alerted to resident elopement by staff on the floor. Staff searched rooms and door/outside areas for resident. A staff leaving the facility saw her and stayed with her alerting DON that she was with the resident at the bottom of the hill. Staff member stayed with (Name 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise a care plan for Resident #51's actual elopement, discontinuation of fall precautions for Resident #50, current diagnoses for Resident #31, discontinuation of a urinary catheter for Resident #329 and an accrual of actual falls for Resident #278. This was true for five (5) of 24 residents reviewed during the long-term survey. Resident Identifiers: #51, #50, #31, #329 and #278. Facility Census: 71. a) Resident #51 On 08/21/23 at 9:00 AM, the care plan was reviewed for Resident #51. The resident was noted with an actual elopement on 07/28/23. However, the care plan listed risk for elopement on the care plan. The care plan had not been revised to reflect an actual elopement had taken place. On 08/21/23 at 11:45 AM, Corporate Nurse #158 confirmed the care plan had not been revised to reflect the actual elopement which occurred on 07/28/23. b) Resident #50 On 08/21/23 at 9:30 AM, the care plan was reviewed for Resident #50. A progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and staff interview the facility failed to follow physicians orders. This was true in the care areas of late medication administration, missed medications, following orders for fall precautions, rechecking blood glucose level, performing neurological checks and reviewing laboratory results. Resident Identifiers: #20, #32, #38, #50, #51, #229, #278, #329. Facility Census: 71 Findings Included: a) Resident #38 1. Missed order to recheck blood glucose On 05/12/23 at 12:00 noon, the blood glucose level read HI on the glucometer. Indicating the blood glucose was over 500. According to the progress note on 05/12/23 at 13:48 PM, the provider was notified with a new order to administer 16 units of Novolog and recheck in 1 hour. The Novolog was administered as ordered, however there was no recheck on the blood glucose in one hour. This was confirmed with the Director of Nursing on 08/16/23 at 11:10 AM. No further documentation was provided. 2. Late administered medications Scheduled…

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, Resident interviews, staff interviews, and record reviews the facility failed to ensure all staff had appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. These findings were true for one (1) out of one (1) in the care area of parenteral care, one (1) out of two (2) in the care area of dialysis, one (1) out of one (1) reviewed for Activities of daily Living (ADL), three (3) out of three (3) reviewed for abuse, five (5) out of five (5) reviewed for arbitration agreements, one (1) of one (1) reviewed for laboratory services, drug regimen reviews, medication error rate greater than five (5) percent, Quality Assurance and Assessment (QAA) meetings, Quality of care areas included: incomplete neurological assessments, late medication administration, not administering antibiotic and treatment timely and missed medications, and infection control. These practices have the potential to affect all residents…

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 maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the walk-in cooler had debris on the floor. The threshold seal was missing to the walk-in cooler and the serving lids for the steam table were stored on a dirty shelf, and the ice machine was not draining properly. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 71. Findings included: a) Kitchen tour During the kitchen tour on 08/14/23 at 11:50 AM, it was discovered the floor to the walk-in cooler was dirty and needed to be cleaned and the threshold rubber sealing was missing to the walk-in cooler. The serving lids for the pans on the steam table were stored rim down on a dusty shelf and the ice machine drain lines were in direct contact with the floor drain, with no stop gap to prevent back flow. In an interview with the acting Dietary Manager (DM), on 08/14/23 at 12:01 PM, the DM verified the walk-in cooler needed 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 staff interview and facility documentation the facility failed to explain the arbitration agreement to residents or their representatives to understand the terms of the agreement. This has the potential to affect all residents residing in the facility. Facility census: 71. Findings included: a) Binding Arbitration Agreement A review of the facility Arbitration Agreement found: Right to Resend- -The Resident or his or her representative has the right to resend this Arbitration Agreement within thirty days after signing it. Arbitrator Appointment and Neutrality- -Under the Arbitration Agreement, disputes or claims arising between the parties will be resolved through binding arbitration and shall be conducted by one or more neutral arbitrators. If the parties are unable to agree on the appointment of a single arbitrator, each party shall appoint one arbitrator and the third arbitrator shall be appointed by the other two arbitrators. During an interview on 08/16/23 at 11:05 AM with Social Services Designees (SSD) #92 and #93, SSD #92 explained to this surveyor that she informs…

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 and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed with to maintain a separation between the clean and soiled area of the laundry room to prevent contamination of airflow. This practice had the potential to affect more than an isolated number of residents. Facility census: 71. Findings included: a) Laundry Room During tour of the laundry area on 08/15/23 at 3:12 PM an observation found the door between clean and dirty laundry area open. This exposed clean clothes and linens being folded to soiled clothing and linens being sorted and washed. A continued observation revealed the door to outside from the dirty laundry opened. During an interview, on 08/15/23 at 3:20 PM, the laundry supervisor verified the doors were open. He verified the doors should not be propped open. He stated they were all the time telling laundry aides to…

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

Based on observation and staff interview, the facility failed to ensure each resident received privacy during care. This was based on a random opportunity for discovery and was true for Resident #37, who was not provided privacy during an injection. Resident Identifier: Resident #37. Census: 71. Findings included: a) Resident #37 An observation, on 08/15/23 at 08:22 AM, revealed Licensed Practical Nurse (LPN) #22 administered two (2) injections to Resident #37, at a site located on the resident's abdomen. Prior to administering the injections, LPN #22 did not provide privacy for Resident #37, who was seated in a chair at the foot of the bed. LPN #22 lifted the resident's gown to chest level exposing the resident's undergarments and abdomen. The resident's roommate was in bed at this time, eating the breakfast meal. Resident #37's roommate had a direct view of the procedure being conducted. An interview, with LPN #22, on 08/15/23 at 08:24 AM, confirmed privacy had not been provided to the resident receiving the injections and should have been. An interview with the Administrator, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, observation, staff interview the facility failed to Promptly resolve a grievance concerning a non-working television (TV.) This was a random opportunity for discovery. Resident identifier: #229. Facility census: 71. Findings included: a) Resident #229 While observing a dressing change on 08/16/23 at 3:20 PM, Resident # 229 stated in the presents of RN #18 and RN#19 that her TV had not worked since she has been here. Resident #229 was admitted on [DATE]. RN #19 picked up the TV remote and turned the TV on. A blue screen came on saying no channels were available. Resident #229 said that was all it did and that she had asked for someone to fix it several times and was told they would let someone know; however, no one ever came to her room to look at the TV. Resident #229 was in a room alone due to being placed in Transmission Based Precautions (TBP). On 08/21/23 at 12:12 PM, a follow-up visit with Resident #229 found the TV was fixed the following day the resident spoke to this…

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

Based on resident interview, facility documents review, and staff interviews, the facility failed to implement written policies and procedures for reporting an allegation of abuse in a timely manner. This was true of one (2) out of three (3) residents reviewed in the care area of abuse and misappropriation of property. Resident Identifiers: Resident #229, #10. Facility census 71. Findings included: a) Policy The facility policy titled, [NAME] Virginia Abuse, Neglect, and Misappropriation. The accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incident. Immediate reporting: not later than two (2) hours after the allegation is made if the events involve abuse or result in serious bodily injury. The resident's condition will be stabilized by nursing, if appropriate. 1. A physical examination (head-to-toe) will be performed by Director of Nursing or nurse…

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, facility documentation of reportable occurrences review, resident and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, and failed to ensure the results of an investigation was reported within five (5) working days of the occurrence, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of three (3) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported, in a timely manner, involving Resident #229. An allegation of misappropriation of personal items, the facility had knowledge of, was not reported in a timely manner, for Resident #10. There was no evidence the results, of a five (5) day investigation, were reported in a timely manner involving Resident #10 and #229. Resident identifiers: Resident #10 and Resident #229. Census: 71. Findings…

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 provide an accurate and complete Minimum Data Set (MDS) assessment for Resident #31. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #31. Facility Census: 71. Findings Included: a) Resident #31 On 08/15/23 at 12:53 PM, the MDS modification of admission MDS dated [DATE] was reviewed. Under section I Active diagnoses, two (2) diagnoses were not indicated under the psychiatric/mood disorder section. The two (2) diagnoses that were not listed were anxiety disorder and depression. On 08/15/23 at 1:18 PM, MDS Registered Nurse (RN) #86 confirmed the diagnoses of anxiety disorder and depression were not included on the MDS. No further information was obtained during the long-term survey process. .

Based on observation, record review, and staff interview, the facility failed to develop and/or implement the care plan with fall and pressure ulcer precautions for Resident #50 and dialysis instructions for dialysis for Resident #11. This was true for two (2) of 24 residents reviewed during the long-term survey. Resident Identifiers: #50 and #11. Facility Census: 71. Findings Included: a) Resident #50 On 08/14/23 at 3:07 PM, a record review was completed for Resident #50. A physician's order dated 05/13/23 stated, heel protectors when up every shift and a physician's order dated 08/13/23 also stated, resident to have elastic tubular stockings to BLE (bilateral lower extremities) as tolerated every shift. The care plan pressure ulcer precautions were reviewed and did list the intervention of tubular stockings to BLE as tolerated. However, the care plan did not list heel protectors when up every shift. On 08/14/23 at 1:15 PM, the resident was observed sitting in a scoot chair with no stockings to the bilateral lower extremities. The resident was observed with bare feet. This…

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 and staff interview the facility failed to have a complete discharge plan / recapitulation of stay. This is true for 1 of 3 Residents reviewed for discharge. Resident identifier #76. Facility census 71. Findings Included: a) Resident #76 Medical record review of Resident #76's discharge from the facility on 06/09/23 Revealed a Discharge summary / Recapitulation of stay completed 06/09/23 at 9:12 AM. Continued review found section D. Activities Director was incomplete. Section C. Dietary Services final summary was completed and signed by the Culinary Director 07/05/23. No Resident or Representative Signature in section E. Subsequent review of Resident #76's medical record showed no further information on the discharge / discharge planning. During an interview with the Director of Nursing on 08/15/23 at 1:48 PM, she stated that she would provide a copy of the summary with the Resident Signature. On 08/15/23 at 2:23 PM a second copy of the Discharge Summary / Recapitulation of stay completed 06/09/23 was provided. Section C Dietary Services final summary…

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

Based on resident interview, staff interview and record review the facility failed to provide a service for daily oral care for a dependent resident. This failed practice was true for One (1) out of one (1) reviewed for ADL care. Resident identifier: # 229. Facility census 71. Findings included: a) Resident #229 During an observation of a dressing change on 08/16/23 at 3:20 PM, Resident # 229 stated in the presents of Registered Nurse (RN) #18 and RN#19 that she has not had any oral care since she has been there. During a follow-up visit with Resident #229 on 08/21/23 at 11:52 AM, revealed Resident #229 stated she still had not received any oral care. She was asked if she had a toothbrush. Resident # 229 responded with; they have never given me one. During an interview, on 08/21/23 at 12:16 PM, Nurse Aide (NA) #11, was asked if she provided oral care for Resident #229 today. She replied yes, I did. NA #11 was asked if she could show the surveyor where the oral care supplies were kept in the room. NA #11 went in Resident #229's room and began looking in the drawer of the nightstand…

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

Based on resident interview, staff interview and record review the facility failed to recognize, evaluate, and address the needs of a resident to ensure the resident was provided a bag lunch prior to going to dialysis three (3) days a week. This was true for two (2) of two (2) residents reviewed for dialysis services. Resident Identifier: #11 Facility Census: 71 Findings included: a) Resident #11 During an interview, on 08/14/23 at 1:52 PM, Resident #11 stated she has dialysis three days a week with a pickup time of 11:40 AM. She stated she did not get lunch prior to leaving. Breakfast was served at approximately 7:00 AM and therefore she did not eat again until dinner which was approximately 5:00 PM. Resident #11 stated she was getting a sandwich but had not received anything for lunch for the last month. She said she would like lunch prior to leaving the facility for dialysis because she was a diabetic and gets hungry. Review of documented weight does not reflect a weight loss. Record review shows the order to read Dialysis: (name of center) . Dialysis days are Tuesday, Thursday,…

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, Centers for Disease Control and Prevention (CDC) website review, and staff interview the facility failed to provide dressing changes that meet the professional standards of care. This was true for one (1) out of one (1) resident observed for peripherally inserted central catheter (PICC). Resident identifier: #229. Facility census 71. Findings included: a) Resident #229 During an observation of a PICC dressing change on 16/23 at 2:10 PM, for Resident # 229 with Registered Nurse (RN) #18 and RN#19 the following was observed: RN #18 removed the transparent dressing covering, donned sterile gloves, and tried to use a Chlorhexidine sponge (this type of sponge is on the end of a plastic handle filled with the Chlorhexidine and to be activated you have to squeeze the two (2) smaller tabs on the sides. Squeeze the tabs together and hold the sponge down to fill with the Chlorhexidine. RN #18 failed to hold the sponge pointing downward to fill with the cleanser. There was a large amount dried blood on and around the insertion site. RN #18 tried to take the catheter out…

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, policy review and staff interview the facility failed to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This was true for one (1) of two (2) residents reviewed for dialysis services. Resident identifier: #11 Facility Census: 71 Findings Included: a) Resident #11 On 08/16/23 at 11:55 AM record review found several Pre and Post Dialysis Evaluations were missing. This was confirmed with the Regional Director of Clinical Operations (RDCO) #159 at this time. According to the facility Hemodialysis Care and Monitoring Policy and Procedure the facility will provide a method for on-going communications and collaboration for the development and implementation of the dialysis care plan. VIII Pre Dialysis a. Evaluation will be completed within four (4) hours of transportation to dialysis to include but not limited to: i. Accurate weight. ii Blood pressure, pulse, respirations and temperature. b. Medications administered or medication(s) withheld prior to dialysis. c. Provide meal or snack prior to leaving…

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 complete the monthly medication reviews for Resident #51. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident #51. Facility Census: 71. Findings Included: a) Resident #51 On 08/16/23 at 10:30 AM, a review of the monthly medication reviews from the pharmacy was completed. The review found a monthly review dated 05/07/23 recommending a gradual dose reduction (GDR) for Melatonin 3mg (milligrams) at HS (hours of sleep) was not completed or signed by the physician. On 08/16/23 at 12:10 PM, the Director of Nursing (DON) stated, May's was not done .I'm not sure why. No further information was obtained during the long-term survey process.

Based on observation, record review, facility documentation review and staff interview, the facility failed to ensure the facility provided medications with an error rate of five (5) percent or less. This was found true for one (1) of four (4) residents observed during the medication administration task of the Long Term- Care Survey Process (LTCSP). The facility medication error rate was 7.69. Resident identifier: Resident #48. Census: 71 Findings included: a) Resident #48 An observation, of the medication pass for Resident #48, on 08/15/23 at 08:39 AM , showed a physician's order on the medication administration record, for Nasacort 1 spray in each nostril to be administered at 09:00 AM. Licensed Practical Nurse (LPN) # 39, stated at this time, the Nasocort was not in the medication cart. LPN #39, went on to prepare the oral medications for the resident. LPN #39 was observed to crush Keppra 750 mg. When questioned, LPN #39 stated if the medication was to be crushed there would be an order not to crush. The surveyor requested to see a Do Not Crush list , however, LPN #39 could not…

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

Based on record review and staff interview the facility must obtain laboratory services to meet the needs of the residents. The facility was responsible for the quality and timeliness of the laboratory services. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order…

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 physician was promptly notified of laboratory results that fell outside of clincial reference ranges. This resulted in a delay of treatment for a resident who had a urinary tract infection. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of…

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

Based on medical record review and staff interviews the facility failed to ensure documentation was accurate and correct. This was true for one (1) out of two (2) reviewed for dialysis. Resident identifier: #229, Facility census 71. Findings included: a) Resident #229 weights While reviewing the medical records for Resident #229 for the care area of dialysis it found in the weight file it was documented Resident #229 weighted 182.2 pounds on 08/05/23 and on 08/12/23 Resident #229 weighted 79.2 pounds. After a review of the dialysis communication sheet, it was found the 79.2 was supposed to be kilograms not pounds. The above information was shown to the Director of Nursing (DON). The DON agreed the weight was entered wrong on 08/15/23 02:54 PM. The DON agreed this was an inaccurate medical record. b) Resident #229 Chest x-ray A review of the Treatment Administration Record (TAR) found that Resident had an order to have a two (2) view chest x-ray every shift until 08/14/23. May DC (discontinue) order once obtained. Start date 08/11/23. On 08/11/23 from 7a to 7p shift Licensed…

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.