Fairmont Rehabilitation And Healthcare Center LLC

Based on record review and staff interview, the facility failed to document the vaccination status of each staff member (i.e., immunized or not). This was a random opportunity for discovery. Facility census: 106.During an interview on 07/30/25 at approximately 3:50 PM, the Director of Nursing (DON) reported that the facility only had a total number of staff that received COVID vaccine. The facility did not have any documentation readily available that detailed which staff had received or had not received the COVID vaccine.

Based on observation and staff interview, the facility failed to ensure residents had a dignified existence. Urinary catheter bags were found uncovered.This failed practice was a random opportunity of discovery. Resident Identifier: #115. Facility Census: 106Findings included:a) Resident #115On 07/28/25 at 2:05PM, during a resident interview, it was observed that Resident # 23's catheter bag did not have a bag cover. The uncovered catheter bag was placed on the side but near the foot of the bed which could be seen by any passerby in the hallway. During an interview, on 07/28/25 at 12:10 PM, Licensed Practical Nurse (LPN) #54 acknowledged the catheter bag was not covered.

Based on observation, staff interview, and resident interview, the facility failed to provide reasonable accommodations of needs, by not ensuring Resident #90's call light was within her reach. This failed practice was a random opportunity for discovery.Resident identifier #90. Facility Census: 106.Findings include:a) Resident #90 During an interview with, Resident #90 on 07/30/25 at 12:13 PM, it was observed that Resident #90's call light was not within her reach. She stated she needed to get a nurse to lower the head of her bed and kept asking where her call light was. During an interview on 07/30/25 at 12:15 PM with the Nurse Aide (NA) #63, She acknowledged the call light was hanging on the bed frame behind the resident's mattress where the resident could not see it or reach it.

Based on record review and interview, the facility failed to identify a newly evident diagnosis of Bipolar Disorder on the Preadmission Screening and Resident Review (PASARR). Resident Identifier: Resident identifier: #35. Facility Census:106. Findings Include:a) Resident #35 record review revealed an updated PASSAR dated 03/27/23, which did not identify any diagnosis of mental illness and stated, 'No Level II required.'The resident was diagnosed with bipolar disorder on 05/08/23. The facility failed to update the PASSAR and did not refer the resident for a Level II review, despite the newly evident disorder. During an interview with the Director of Social Services (DSS) #111 on 07/30/25 at 1:55 PM, she confirmed that she was aware that some PASSARs had not been updated. DSS #111 further stated that she was in the process of performing a whole-house review of PASSARs.

Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier: #35. Census 106.Findinbs included: a) Resident #35 During record review on 07/30/25 at approximately 12:10 PM, it was noted that Resident #35's initial PASSAR dated 05/12/22 did not identify any mental illness and stated, No Level II required. However, a review of the resident's diagnoses revealed a diagnosis of Major Depressive Disorder dated 01/27/22. During an interview with the Director of Social Services (DSS) #111 on 07/30/25 at 1:55 PM, she confirmed that she was aware that some PASSARs had not been updated. DSS #111 further stated that she was in the process of performing a whole-house review of PASSARs.

Based on interview and record review, the facility failed to create a comprehensive care plan that addressed the resident's diagnosis of Post Traumatic Stress Disorder (PTSD), failed to incorporate knowledge about PTSD into care plans, failed to identify trauma triggers, and failed to implement interventions and practices to address those triggers and prevent re-traumatization. This was true of two (2) of two (2) residents sampled. Resident Identifiers: #24, #72. Facility Census:106.Findings Include a) Resident #24 Record review 07/29/2025 9:30 AM revealed that Resident #24 has a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 07/10/25. A review of the resident's care plan revealed that PTSD was not addressed. In addition, the care plan failed to identify trauma triggers and failed to implement interventions and practices to address those triggers and prevent re-traumatization. b) Resident #72 During a review of records for Resident #72 on 07/29/2025 10:52 AM, it was noted that the resident had been diagnosed with chronic PTSD on 07/08/25. Further record review 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 interview, and record review, the facility failed to follow a physician's order to administer medications to meet the needs of the resident. This was true for two (2) of seven (7) residents sampled. In addition, the facility also failed to ensure that residents were weighed as per the physician's order. Resident Identifiers: #7, #45, and #103. Facility Census: 106. Findings Include: a) Resident #7 During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, the resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays, Wednesdays, and Fridays. Record review on 07/29/25 at 10:35 AM revealed a physician's order for: Sevelamer Carbonate Oral Tablet (Sevelamer Carbonate) Give 800 mg by mouth with meals every Tue, Thu, Sat, Sun for CKD (chronic kidney disease) Give 800 mg by mouth three times a day every Mon, Wed, Fri - give with meals b) Resident #45 During an interview on 07/30/25 at approximately at approximately 1:22 PM. Resident #45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview, the facility failed to follow currently recognized standards of care in providing assessments and care of a resident's dialysis access. This was true for two (2) of two (2) residents sampled. Resident Identifiers: Resident #7 and Resident #45. Facility Census:106.Findings Included:a) Resident #7Resident #7 had an order dated 06/19/25 by her physician stating, Dialysis: Site of AV shunt Check Bruit and Thrill every shift.During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, the resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays and Wednesdays and Fridays. She also stated that she had never had an Arteriovenous (AV) fistula or graft.Record review on 07/28/25 at approximately 3:30 PM revealed that Resident #7, did not have an AV access shunt. The record review supported the resident's comment 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 facility documentation and staff interview the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 106. Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no sign-in sheets for staff that attended the meeting quarterly. The facility provided copies of meeting signature pages that were copied, and the dates were changed per month. During an Interview 08/04/25, at 1:38 PM the Administrator verified the required members did not sing in for the quarterly QAA meetings. The Administrator said they just copied a page of signatures and changed the date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, The facility failed to maintain all patient care equipment in safe operating condition.This failed practice was a random opportunity for discovery. Resident identifiers : #73 and #18 Facility Census: 106 On 07/28/25 at 3:10 PM, during a resident interview and facility walk through in room [ROOM NUMBER], it was observed that Resident #73 and #18's bathroom had a strong smell of urine with a puddle of water around the toilet base on the floor. On 07/30/25 at 10:29 AM during an interview with the Director of Nursing, and administrator in room [ROOM NUMBER], it was observed that a towel was wrapped around the base of the toilet, they acknowledged the toilet had a leak and caused a puddle of water on the bathroom floor.

Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for residents and staff. A portion of the wall in the laundry room had a black-like substance growing on it. This was a random opportunity for discovery. Facility census: 106.Findings included:a) Laundry Room WallAn observation in the small area behind the dryers, made on 07/30/25 at approximately 10:50 AM, revealed what appeared to be a black-like substance at the bottom of the wall facing the right side of the dryers. On 07/20/25 at approximately 11:52 AM, an interview with Employee #75 verified this finding. This finding was also acknowledged by the facility administrator on 07/30/25 at approximately 11:59 AM.

Based on observation and staff interview, the facility failed to ensure the nurse staffing information was posted in the facility accessible to residents and visitors. This has the potential to affect more than a minimal number of residents. Facility census: 109. Findings include: a) Nurse staffing Observation of the nurse staffing folder at the front hallway with the admissions director (AD) #25 at 10:20 AM on 09/11/23, found there was no information regarding the nurse staff on duty for 09/11/23. At 5:10 PM on 09/11/23, the Director of Nursing (DON) said she had been made aware the staff posting was not completed for 09/11/23.

Based on record review and staff interview, the facility failed to implement the care plans for three (3) of six (6) residents who were care planned for the potential for falls. Facility census: 109. Findings include: At 10:30 AM on 09/11/23, a tour of the 200 hallway with the Housekeeping Supervisor (HS) #52 found three (3) residents on the 200 hallway who's call systems were in the floor and not within reach of the Residents who were in their beds. These three (3) Resident's were care planned for being at risk of falls. Each Resident had an intervention to have call bells within reach. a) Resident's #85 Review of the Residents electronic medical record found a care plan focus: At risk for falls due to poor safety awareness/cognitive deficits, revised on 03/08/23 The goal associated with the focus is: Minimize risk for injury related to falls, revised 03/14/23. Interventions included: Call bell in reach, initiated 03/08/23 b) Resident #9 Review of the electronic medical record found a care plan focus: At risk for falls due to myasthenia gravis, labile personality secondary 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 the call system was accessible to residents while in their bed. This was a random opportunity for discovery. Facility census: 109. Findings include: At 10:30 AM on 09/11/23, a tour of the 200 hallway with the housekeeping supervisor (HS) #52 found six (6) residents on 200 hallway who's call systems were in the floor and not within reach of the Residents who were in their beds. HS #52 confirmed the following residents did not have access to the call light system: #10, #9, #85, #77, #70 and #75. At 5:10 PM on 09/13/23 the above findings were discussed with the Director of Nursing.

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. Five (5) residents eating in their rooms did not have hand hygiene when their lunch trays were served. Proper infection control practices were not followed during medication pass. Additionally, laundry was not processed and transported properly. These were random opportunities for discovery that had the potential to affect all residents residing in the building. Resident identifiers: #69, #83, #74, #48, #2, and #31. Facility census: 105. Findings included: a) Lunch tray distribution On 05/09/23 at 12:35 PM, lunch tray distribution was observed for residents eating in their rooms in the 400 hallway. Prior to the lunch tray service, the surveyor had been observing the residents and did not observe resident hand hygiene being performed. At 12:35 PM PM, Nurse Aide (NA) #200 was observed taking a lunch tray to Resident #69 who was dining in their room. Hand hygiene was not offered to Resident #69.…

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 the resident environment over which it had control was as free from accident hazards as possible. Resident #31 had medication at her bedside. The medication was not secured and could be accessed by any wandering resident. This was a random opportunity for discovery during the care area of medication administration. Resident identifiers: #31, #51, #155, #40, and #156. Facility census: 105. Findings included: a) Medication pass On 05/09/23 at 8:00 AM, medication administration by Licensed Practical Nurse (LPN) #134 to Resident #31 was observed. Resident #31 had an order for Flonase Suspension (Fluticasone Propionate), one (1) spray in both nostrils every 12 hours as needed for congestion. LPN #134 stated Resident #31 kept the Flonase bottle at her bedside. The Flonase spray was located on the resident's bedside table. LPN #134 administered Flonase spray to the resident and returned the bottle to the top of the resident's bedside table. Upon questioning, LPN #134 stated it was the resident's…

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

Based on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery and has the potential to affect more than an isolated number of residents. Facility Census: 105. Findings Included: a) Medication Refrigerator On 05/09/23 at 10:25 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator temperature logs were found to be incomplete. The following dates did not have the refrigerator temperatures logged: --03/31/23 AM and PM -- 04/20/23 PM -- 04/21/23 AM and PM -- 04/22/23 AM and PM -- 04/23/23 AM and PM -- 04/24/23 AM and PM -- 04/25/23 AM and PM -- 04/26/23 AM and PM -- 04/27/23 PM -- 04/28/23 AM and PM -- 04/29/23 AM and PM -- 04/30/23 AM and PM -- 05/01/23 AM and PM -- 05/02/23 AM -- 05/03/23 AM -- 05/04/23 AM and PM -- 05/05/23 AM and PM -- 05/06/23 AM -- 05/07/23 AM -- 05/08/23 AM On 05/09/23 at 10:30 AM, Registered Nurse (RN) #22 confirmed the temperature logs for 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 maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered no temperatures were taken on the coolers or freezers, the threshold and freezer door was damaged. Water pitchers were not stored properly and the rice bin was not dated. This failed practice has the potential to affect more than an isolated number of residents. Facility census: 105. Findings included: a) Kitchen tour During the kitchen tour on 05/08/23 at 11:22 AM, it was discovered the temperatures had not been taken on 05/07/23 on any of the freezers or refrigerators. The floor of the freezer and cooler were heavily soiled and needed to be cleaned. The threshold strip and the front of the metal door to the walk-in freezer were damaged and needed to be repaired. The rice bin in the storage room was not dated and pitchers and lids were stored rim down on a soiled shelf. In an interview with the Dietary Manager on 05/08/23 at 11:25 AM, they verified the temperatures were…

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

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete for 16 of 27 residents reviewed in the long-term care survey sample. Additionally, one of these residents also had an inaccurate medical diagnosis recorded in the medical record. Resident identifiers: #72, #2, #24, #32, #355, #357, #64, #10, #4, #59, #80, #36, #37, #93, #38, and #305. Facility census: 105. Findings included: a) 2021 POST form guidance The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated the following: - Complete all sections in the demographic information section with the patient's information. - If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should…

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, family interview, and staff interview, the facility failed to ensure the arbitration agreement was explained to the resident and/or his representative in a form and manner that he or she could understand and decide whether or not to enter into such an agreement. This is true for two (2) of three (3) residents reviewed for the facility task of arbitration during the Long Term Care Survey Process. Resident identifiers: #98 and #205. Facility census: 105. Findings included: a) admission staff interview During an interview on 05/10/23 at 10:47 AM, the Admissions Coordinator (AC)#96 was unable to explain the arbitration agreement. AC #96 stated both parties obtain a lawyer if there is an incident. If resident needs help finding a lawyer, the facility will help. When the surveyor told her this is not the definition of an arbitration agreement, AC #96 stated I am new to this position. The above information was discussed with the Administrator at 11:00 AM on 05/10/23. The facility administrator agreed this was not the definition of arbitration. b) Resident #98…

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 Resident #38's Health Care Surrogate (HCS) the opportunity to participate in a conversation with the Physician Assistant to discuss treatment risks and benefits and to choose the options he would prefer. This was true for one (1) of 27 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #38. Facility census: 105. Findings included: a) Resident #38 Record review, completed on [DATE] at 2:23 PM, identified the following: --Resident #38 lacked capacity to make medical decisions --A Health Care Surrogate (HCS) form was on file and designated Resident #38's son as the legal decision maker. --A Physician Orders for Scope of Treatment (POST) was on file and indicated Resident #38 was to receive CPR [Cardiopulmonary resuscitation], selective treatments, and no artificial means of nutrition. The Certified Physician Assistant had discussed the POST form with Resident's spouse and had accepted verbal consent from 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 reviews, and staff interviews, the facility failed to ensure allegations of serious bodily injuries were reported immediately, but not later than 2 hours after the allegations were made to the administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services, in accordance with State law). The failed practice of reporting was discovered for three (3) of four (4) residents reviewed for falls with major injuries during the Long-Term Care Survey Process. Resident identifiers: #49, #59, and #38. Facility census: 105. Findings included: a) Resident #49 A medical record review on 05/10/23 for Resident #49, revealed on 01/24/23 resident had a fall, which resulted in a major injury. Resident suffered a right distal femoral fracture. The record did not indicate the serious bodily injury had been reported to any of the required State entities. An interview with the Nursing Home Administrator on 05/10/23 at 1:05 PM, confirmed they were unable to locate any Abuse and Neglect reporting made to the State Survey Agency or Adult…

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

Based on record review and staff interview, the facility failed to provide the bed hold policy during two (2) transfers to an acute care facility. This was true for one (1) of two (2) residents reviewed under the care area of hospitalization. Resident Identifier: #94. Facility Census: 105. Findings Included: a1) Resident #94 On 05/08/23 at 1:36 PM, a record review was completed for Resident #94. The review found the resident had been transferred to an acute care facility on 04/05/23 due to nausea and vomiting with a diagnosis of aspiration pneumonia. Upon reviewing the transfer paperwork, the review found no bed hold policy had been given to the resident. On 05/09/23 at 2:19 PM, the Administrator stated we couldn't find the bed hold paperwork. No further information was obtained during the long-term care survey. a2) Resident #94 On 05/08/23 at 2:00 PM, a record review was completed for Resident #94. The review found the resident had been transferred to an acute care facility on 04/20/23 due to an elevated heart rate and low oxygen saturation with a diagnosis of aspiration pneumonia,…

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 have an accurate Minimum Data Set (MDS) for Resident #51 regarding an active diagnoses. This was true for one (1) of 27 residents reviewed during the long-term survey process. Resident Identifier: #51. Facility Census: 105. Findings Included: a) Resident #51 On 05/08/23 at 2:06 PM, a record review was completed for Resident #51. The record review found the resident had a fall with a major injury resulting in a right femur fracture. The MDS with an assessment reference date (ARD) of 03/22/23 modification of a significant change did not list the right femur fracture as a diagnosis. On 05/10/23 at 3:00 PM, the Administrator stated, the diagnosis has been corrected 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 implement the care plan for one (1) of 27 residents reviewed in the long-term care survey sample. Resident identifier: #102. Facility census: 105. Findings included: a) Resident #102 Review of Resident #102's comprehensive care plan showed the following focus written on 04/14/23, Has/At risk for respiratory impairment related to trach [tracheostomy], respiratory failure, pulmonary emboli, pneumonia. An intervention was added on 04/17/23 for Additional same size/type trach #6 and obturator at bedside at all times. Ambu bag, suction canister and catheters in room at all times. On 05/09/23 at 1:30 PM, Registered Nurse (RN) #22 was asked to locate the emergency equipment in Resident #102's room. RN #22 could not locate an Ambu bag in Resident #102's room. An Ambu bag is a device that provides ventilation for a resident with a tracheostomy who is not breathing or not breathing adequately. RN #22 stated there was an Ambu bag on the emergency cart, but she would obtain one specifically for Resident #102's room…

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 revise a person-centered, comprehensive care plan, to include changes in respiratory care. This was true for one (1) of 27 residents' care plans reviewed during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105. Findings included: a) Resident #19 A medical record review on 05/09/23 revealed orders for oxygen to be received at two (2) liters per minute (lpm) via a nasal cannula, with a start date of 12/13/22. The current care plan had not been revised and indicated Resident #19 was receiving oxygen at four (4) lpm as needed since 12/01/21. An interview with the Nursing Home Administrator (NHA) on 05/10/23 at 12:31 PM, confirmed Resident #19 was now receiving two (2) lpm of oxygen via nasal cannula and the care plan had not been revised. .

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain medication was correctly followed for Resident #37. This failed practice was true for one (1) of one (1) residents reviewed for pain. Additionally, the facility to ensure a medication patch was dated and signed when applied to Resident #27. Resident identifiers: #37 and #27. Facility census: 105. Findings included: a) Resident #37 A medical record review, completed on 05/09/23 at 11:27 AM, revealed the following physician order, dated 02/28/23 at 1:00 PM, HYDROcodone-Acetaminophen Oral Tablet 5-325 MG. Give 2 tablets by mouth every 4 hours as needed for pain 5-10. Review of the March 2023, April 2023, and May 2023 Medication Administration Records (MARs) revealed the following dates and times the medication was not given in accordance with the physician's order: --03/06/23 at 5:17 PM the medication was given with a pain level of 0. --03/07/23 at 10:37 AM the…

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

Based on observation, record review, and staff interview, the facility failed to ensure eternal feeding care was provided according to professional standards of practice. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #357. Facility Census: 105. Findings Included: a) Resident #137 Upon the initial interview on 05/08/23 at 11:50 AM, Resident #357's bottle of Glucerna was found not dated upon administration. On 05/08/23 at 11:53 AM, Registered Nurse (RN) #22 confirmed the Glucerna bottle was not dated upon administration. On 05/09/23 at 10:14 AM, the Administrator was notified and confirmed the Glucerna bottle should have been dated upon administration. No further information was obtained during the long-term survey process. .

Based on observations and staff interviews the facility failed to provide respiratory services in accordance with professional standards of practice. This was true for three (3) of four (4) residents reviewed for respiratory care services. Resident #19 and #355, did not have respiratory equipment stored properly and Resident #4's oxygen tubing was not dated. Resident identifiers #19, #355, and #4. Facility census: 105. Findings included: a) Resident #19 During an observation on 05/08/23 at 1:45 PM, it was discovered the mask for the Average Volume Assured Pressure Support (AVAPS) Trilogy machine was not bagged properly after using. Licensed Practical Nurse (LPN) #99 on 05/08/23 at 1:45PM, verified the AVAPS Trilogy mask was not stored properly. b) Resident #355 Upon the initial interview with Resident #355 on 05/08/23 at 1:18 PM, the bilevel positive airway pressure (BIPAP) mask was found laying on the night stand without being stored in a respiratory bag. On 05/08/23 at 1:20 PM, Registered Nurse (RN) #22 confirmed the BIPAP mask was not stored correctly in a respiratory bag. On…

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

Based on record review and staff interview the physician and or designee failed to respond to a Medication Regimen Review (MRR). This was discovered for one (1) of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105. Findings included: a) Resident #19 During a medical record review on 05/10/23, it was discovered the MRR completed by the pharmacist on 11/25/22 recommended a pulse be taken before Metoprolol was to be administered. A review of the order on 05/10/23 at 10:33 AM, revealed Metoprolol Tartrate 25 milligrams (mg), give 12.5 mg two (2) times daily for hypertension, had no reference for a pulse to be taken before administering the medication. An interview with the Assistant Director of Nursing (ADON) on 05/10/23 at 10:33 AM, verified the recommendation by the pharmacist on 11/25/22, had no response from the physician and or designee. .

Based on observation, record review and staff interview, the facility must provide special eating equipment for residents who need special equipment. This deficient practice was true for one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #2. Facility census: 105. Findings included: a) Resident #2 Review of Resident #2's physicians' orders showed an order written on 02/22/23 for a two-handled cup with flat lid with meals. On 05/10/23 at 7:55 AM, Resident #2 was observed eating breakfast in her room. Her tray had a cup with no handles. Nursing Aide (NA) #27 confirmed Resident #2 was supposed to have a two-handled cup and went to the kitchen to get one for the resident. No further information was provided through the completion of the survey. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, resident interview, and staff interview, the facility failed to ensure residents' dignity. The residents' indwelling urinary catheter bedside urine collection bags did not have privacy covers for Resident #260, Resident #55, and Resident #102. Additionally, Resident #55 was left in a bed in the hallway without being covered. Resident identifiers: #260, #55, #102. Facility census: 108. Findings included: a) Resident #260 During observation on 02/14/22 at 12:00 PM, Resident #260 was noted to be resting in bed. An indwelling urinary catheter bedside urine collection bag was noted to be hanging on the bedside rail. The catheter collection bag did not have a privacy cover, which allowed the urine to be viewed by anyone walking past the room. During a second observation on 02/14/22 at 4:02 PM, Resident #260's indwelling urinary catheter urine collection bag continued to be uncovered. Licensed Practical Nurse (LPN) #38 stated Resident #260 was admitted to the facility with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure three (3) of twenty-six (26) residents advance directives were communicated to staff in a clear and concise manner to allow staff to immediately determine the resident's code status in the event of an emergency. Resident identifiers: #411, #44, and #106. Facility census: 108. Findings included: a) Resident #411 On [DATE] at 3:02 PM, observation with Licensed Practical Nurse (LPN) #38, found two (2) pink sheets of paper in the front of the paper chart; one (1) which said Do not Resuscitate (DNR) and one (1) that said full code. LPN #38 confirmed there was no indication the resident or a resident representative had completed any paperwork to determine if the resident wished to formulate an advance directive or had an existing advance directive. LPN #38 said usually there is an orange card in the chart signed by the physician after discussion with the resident or responsible party. There was no information in the medical record indicating…

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, resident interview, and staff interview, the facility failed to ensure Residents #106 and #107 had a clean, safe and well maintained bathroom. In addition, Resident #106's bed linens were not clean, and the facility did not have an adequate number of wash clothes for daily use. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #106, #107. Facility census: 108. Findings included: a) Resident #106 During an interview on 02/14/22 at 2:22 PM, Resident #106 stated, They [facility staff] need to fix the toilet sprayer, it leaks, and the bathroom floor is always wet that's why we have the towels laying there in front of the toilet. The Resident further stated, And look here [resident pointed to bed sheet] this hasn't been changed in a week. The Resident's bottom bed sheet was visibly soiled with a dark brown dried substance. On 2/14/22 at 2:30 PM, the Assistant Director of Nursing (ADON)…

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, resident review, and staff interview, the facility to develop and implement the comprehensive care plan for three (3) of 26 residents reviewed during the long-term care survey process. The facility failed to develop the comprehensive care plan in the area of anxiety and anti-anxiety medications for Resident #93 and in the area of pain for Resident #42. The facility failed to implement the care plan in the area of non-pressure wound treatments for Resident #410. Resident identifiers: #93, #410, #42. Facility census: 108. Findings included: a) Resident #93 Review of Resident #93's medical records revealed a diagnosis of anxiety disorder. The resident was receiving two (2) medications, Trazodone and Buspar, for anxiety. Review of Resident #93's comprehensive care plan did not show a focus related to anxiety and anti-anxiety medications. During an interview on 02/15/22 at 2:52 PM, Social Worker (SW) #36 confirmed the resident was not care planned for anxiety. SW #36 stated she would develop…

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, medical record review, resident interview, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Resident (R) #212's antibiotic was not administered for three days. The interdisciplinary team failed to coordinate services for R #49 between the facility and contracted Hospice services and ensure Hospice visitation records were included in the medical record. Physician orders for specialized treatments and lab work were not completed for Residents #55, #410 and #90. This is true for five (5) of 26 sampled residents reviewed during the long term care survey process. Resident identifiers: #212, #49, #55, #410, and #90. Facility census: 108. Findings included: a) Resident (R) #212 During an interview on 02/14/22 at 1:45 PM, R #212 reported she did not receive her antibiotics the first three days in the facility. A review of the medical record on 02/14/22, confirmed R #212 was admitted to the facility from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on staff interview, resident interview, and observation, the facility failed to have sufficient nursing staff to ensure call lights were answered timely and room changes were completed in a timely manner. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Resident identifiers: #107, #55, #212, #69. Facility census: 108. Findings included: a) Resident #107 During an interview on 02/14/22 at 12.25 PM Resident # 107 stated the nighttime staff has smart mouths and they have a hard time answering bells, its worse at night, especially on the weekends. The Resident stated, I help my roommate to the rest room because they won't. Then they get hateful with me and tell me to get out of bathroom and leave. b) Resident #55 On 02/15/22 at 10:20 PM, Resident #55 was observed to be laying in a hospital bed, in the North side of the building at the end of the 400-hallway facing the exit door. The hospital gown only came down to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, and staff interview the facility failed to ensure staff possessed the appropriate competencies and skills sets to provide nursing and related services at a professional standard of care. Medications were not administered as scheduled. This was a random opportunity for discovery and had the potential to affect more than a limited number of staff. Resident identifiers: #76, #8, #44, and #83. Facility census 108. Findings included: a) Resident #76 Resident #76 was located behind the double zipper wall in the COVID-19 unit. A review of the facility, Medication Admin Audit Report dated 02/13/22 revealed the following medications were administrated five hours late by Licensed Practical Nurse #2. The scheduled time was for 9:00 AM and was administration time was 2:00 PM: *Risperdal, give 1 tablet two times a day for anxiety, paranoid schizophrenia. *Carvedilol, give 1 tablet two times a day for Congestive heart failure. *Eliquis, give 1 tablet two times a day for atrial flutter (an irregular…

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 medical record review, the facility failed to provide routine and prescribed pharmaceuticals for residents during the daily medication administration and failed to maintain complete and accurate narcotic records. This was found for two (2) of five (5) residents reviewed during medication pass but has the potential to affect all residents. Resident identifiers: #39 and #95. Facility census: 108. Findings include: a) Resident (R) #39 During an observation of medication administration on 02/15/22 at 8:10 AM, Registered Nurse (RN) #27 and Licensed Practical Nurse (LPN) #6 were unable to find a multi-dose vial of Calcium Carbonate - Vitamin D 500-200 milligrams (mg) per unit to match the physician's order. LPN #6 stated the facility does not normally carry the dose ordered and RN #27 reported she would hold the medication until she could clarify the order. A follow up interview with RN #27 at 12:00 PM on 02/15/22 confirmed the physician was contacted and the order was changed to match the facility stock. A review of the medical record on…

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

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. The initial kitchen tour found a dirty drip pan, food debris on the floor of the walk-in cooler and freezer, and missing floor tiles along the wall in the dish room. The flour in the flour bin was not dated after opening. These failed practices had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 108. Findings included: a) Kitchen tour During a kitchen tour on 02/14/22 at 11:30 AM, it was discovered the stove drip pan was dirty and the walk-in cooler/freezer had food debris on the floors. There were missing floor tiles along the wall in the dish room and the flour in the flour bin was not dated after opening. An interview with the Dietary Manager (DM) on 02/14/22 at 11:40 AM, verified the floors of the walk-in cooler and freezer were dirty and needed to be cleaned. In addition, the DM also agreed the drip pan needed to be cleaned, the missing floor tiles…

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 policy review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee had a system for monitoring departmental performance data routinely in order to identify deviations in performance and adverse events. The facility failed to identify quality deficiencies of which they should been aware of, related to antibiotic stewardship. This had the potential to affect all resident who resident at the facility. Facility census: 108. Findings included: Quality Assurance and Performance Improvement Plan Review of the facility's Quality Assurance and Performance Improvement Plan found the following: Elements of the QAPI design and scope include: Clinical care - monitoring and evaluating performance and opportunities for improvement in areas such as Quality Measure performance, incidents/accidents, infection control and antibiotic stewardship, metric analysis. etc . Antibiotic Stewardship Facility Policy, Antibiotic Stewardship revision date: 12/2016. *Orientation, training and education of staff will emphasize the importance of antibiotic…

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 establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Appropriate hand hygiene was not performed during medication administration. Additionally, proper infection control practices were not followed when emptying a urine collection bag. Resident identifiers: #102, #52, #46, #39, #95. Facility census: 108. Findings included: a) Residents #52 and #46 On 02/15/22 at 8:26 AM, medication administration by Licensed Practical Nurse (LPN) #37 was observed. LPN #37 administered medications to Resident #52. LPN #37 prepared the medications at the medication cart in the hallway and carried the medications into the resident's room for the resident to take. After leaving Resident #52's room, LPN #37 then prepared Resident #46's medications at the medication cart in the hallway and carried the medications into the resident's room for the resident to take. LPN #37 did not perform hand hygiene between medication…

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

Based on policy, record review, and staff interview the facility failed to implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for seven (7) of seven (7) residents reviewed. Seven (7) residents received antibiotics in absence of the appropriate screening criteria need to determine the effectiveness of antibiotic therapy. Resident identifiers: #317, #38, #49, #314, #45, #315, and #27. Facility Census 108. Findings included: Facility Policy, Antibiotic Stewardship revision date: 12/2016. *Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. *Appropriate indications for use of antibiotics include: -Minimum criteria met for clinical definition of active infection or suspected sepsis -Pathogen susceptibility, based on culture and sensitivity, to antimicrobial. -The staff and practitioner will document the criteria that support the suspicion in the resident's…

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

Based on staff interview and record review the facility failed to designate an infection preventionist who has completed specialized training in infection prevention and control. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 108. Finding included: During an interview on 02/14/2022 at 12:05 PM, Infection Preventionist (IP) #26 stated he completed the training from the Center for Medicare and Medicaid Services (CMS) models. IP #26 was asked for proof of certification of completion. IP #26 was asked to provide the certificate of training multiple times: On 02/15/22 at 9:30 AM. On 02/15/22 at 3:22 PM. On 02/16/22 at 4:10 PM. At the conclusion of the survey IP #26 had not provided a Certificate. On 02/16/22 at 3:33 PM, the Administrator was aware IP #26 needed to provide a copy of his infection prevention certificate. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to vaccinate eligible residents with the influenza and/or the pneumococcal vaccine(s), for five (5) of five (5) residents reviewed. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #102, #3, #313, #8 and #24. Facility census: 108 Findings included: a) Policy Review Record review of the facility's policy titled, Influenza Vaccine, revised October of 2019, showed that between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. b) Resident #102 Review of Resident #102's medical record showed it did not contain documentation to show the Resident was offered the required vaccinations for pneumonia and/or influenza. Resident #102 was admitted to the facility on [DATE]. During an interview at 11:00 AM on 02/15/2022, the Infection Preventionist (IP) was asked for the documentation regarding the pneumonia and/or influenza vaccine. On 02/15/22 at 1:53 PM, IP…

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 inform residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of each a single confirmed infection of COVID-19. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 108. Findings included: During an interview on 02/14/22 at 12:05 PM, the Infection Preventionist (IP) #26 when asked how the residents/responsible parties was notified about the new positive cases of COVID-19? The most recent outbreak began on 01/04/22 with the most recent positive case occurring on 02/13/22. IP #26 said the social worker handled that and he was not sure how the notification was completed. On 02/15/22 at 11:30 AM, Social Worker (SW) #36 said she calls the families to let them know if their family member test positive for COVID-19. SW #36 confirmed other residents/families were not notified of each new positive case. SW #36 said that if she talked to a family member, she would write a note about it in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, staff interview and resident interview, the facility failed to ensure reasonable accommodations of needs for Resident #55 during a room change. Resident #55 was left in the hallway for an extended period of time without a call light and bed linens. This failed practice was a random opportunity for discovery. Resident identifiers: #55. Facility census: 108. Findings included: a) Resident #55 Resident #55 On 02/15/22 at 10:20 PM, Resident #55 was observed to be laying in a hospital bed, in the North side of the building at the end of the 400-hallway facing the exit door with only a hospital gown on that came down to Resident's mid-thigh. The Resident had no blanket or sheet covering him. The Resident's Foley catheter was hanging from the bottom of the bed without a dignity cover with the tubing running parallel between both legs. Resident #55 was not placed in room [ROOM NUMBER] until 11:04 PM. Licensed Practical Nurse (LPN) #4 was asked why the resident was in hallway? LPN #14 said they…

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 display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection survey was placed in an area not easily accessible to residents. This had the potential to affect more than a limited number of residents. Facility census: 108. Findings included: a) Accessible survey results During an observation on 02/16/22 at 10:50 AM, it was discovered the State inspection was not located in an area easily accessible to residents. An interview with the Nursing Home Administrator on 02/16/22 at 10:50 AM, verified the Survey book was not located in an area easily accessible to residents. .

Based on record review and staff interview, the facility failed to ensure prompt efforts were made to resolve a residents grievance/concern. This was a random opportunity for discovery. Resident identifier: #86. Facility census: 108. Findings included: a) Resident #86 On 02/14/22 at 1:22 PM, the resident said nursing assistant (NA) #76 is very bossy to her. She tells me the room is too hot and she turns off my heat. She only works when, the State comes in. She wants to boss everybody including me. I have been in many disagreements with her. She talks too loud and I tell her, Don't talk so loud to me, I can hear. She said, I have told other people about her, and nothing is done although everyone agrees she's a problem. Due to her position here, she can't be fired. Review of the grievance/concern forms on 02/15/22 at 12:05 PM, found no written verification the resident had voiced any concern regarding NA #76. On 02/15/22 at 12:18 PM, the resident's concerns with NA #76 were communicated to the administrator. On 02/16/22 at 2:25 PM, the administrator said she had not talked to the…

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

Based on record review, facility policy, and staff interview, the facility failed to implement their policy and procedure for reporting potential allegations of abuse and or neglect. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108. Finding included: a) Resident #261 Review of the facility's, Abuse Policy, found The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate correct, remedial or disciplinary action occurs, in accordance with applicable local, state or federal law . On 02/16/22 at 8:39 AM, while reviewing another complaint, a copy of an email was found from a Department of Health and Human Resource (DHHR) worker, emailed to the Director of Nursing (DON) at the facility on 10/05/21 at 7:31 AM, regarding Resident #261. The email is as follows: Good morning (Name of DON.) Here is the intake as received by my office. Please respond and provide any documents to discount these contentions- care plan for falls etc. Reporter states that (name of Resident #261) is in the Fairmont Nursing…

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 policy review, record review, and staff interview, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation is made. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108. Findings include: a) Resident #261 Review of the facility's, Abuse Policy, found The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate correct, remedial or disciplinary action occurs, in accordance with applicable local, state or federal law . On 02/16/22 at 8:39 AM, while reviewing another complaint, a copy of an email was found from a Department of Health and Human Resource (DHHR) worker, sent to the Director of Nursing (DON) at the facility on 10/05/21 at 7:31 AM, regarding Resident #261. The email is as follows: Good morning (Name of DON.) Here is the intake as received by my office. Please respond and provide any documents to discount these contentions- care plan for falls etc. Reporter states that (name of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the timely completion and transmittal of a discharge Minimum Data Set (MDS) Assessment. This was a random opportunity for discovery. Resident identifier: #2. Facility census: 108. Findings included: a) Resident #2 Review of Resident #2's medical record showed the resident was discharged home on [DATE]. Further review of the medical record, showed an Entry MDS assessment with Assessment Reference Date (ARD) 10/05/21, an admission MDS assessment with ARD 10/11/21, and a Five (5) Day Medicare Assessment with ARD 10/11/21. No Discharge MDS was located in the medical record. During an interview on 02/15/22 at 1:37 PM, the MDS Coordinator confirmed Resident #2 did not have a Discharge MDS completed. On 02/15/22 at 2:05 PM, the MDS Coordinator stated she completed a Discharge MDS for Resident #2 today. No further information was provided through the completion of the survey. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the comprehensive care plan was revised when changes occurred or additional information should have been elicited. This had the potential to affect two (2) of 26 residents reviewed in the long-term care survey process. Resident identifiers: #5, #90. Facility census: 108. Findings included: a) Resident #5 On 02/14/22 at 1:39 PM, Resident #5 was observed following staff members and visitors down the hallway, asking them to take her with them. The resident was repeatedly saying, What are we going to do? Review of Resident #5's comprehensive care plan showed the following focus, Repetitive physical movements related to cognitive impairment /dementia. The focus was initiated on 09/10/2018. An intervention initiated on 09/10/2018 was to Illicit [sic] family input for best approaches. During an interview on 02/16/22 at 11:17 AM, the Minimum Data Set (MDS) Coordinator agreed Resident #5's comprehensive care plan had not been revised since 2018…

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 and staff interview the facility failed ensure the resident environment remains as free of accident hazards as is possible. Medications were left unattended on a bedside table belonging to Resident # 313. This was a random opportunity for discovery. Resident identifier: #313. Facility census 108. Findings included: a) Resident #313 On 02/14/22 at 1:57 PM, an observation revealed medications were left unattended on a bedside table belonging to Resident #313. There was a green paste like substance in a medication cup. Resident #313 said it was Icy Hot. (The manufactures guidelines for Icy Hot note: may cause harm if swallowed, call the poison control center or doctor), Two (2) bottles of eye drops for glaucoma Pilocarpine HCL Solution. (The side effects could chest pain, diarrhea, fast slow or irregular heartbeat, headache, nausea or vomiting, shortness of breath and stomach aches). Dorzolamide (Side effects: bloody nose, burning, crawling, itching, numbness, prickling.) Nasal spray- Oxymetazoline (overdose symptoms may include drowsiness, slow…

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 with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. This failed practice was true for two (2) out of two (2) residents reviewed for catheter care. Resident identifiers: #102 and #260. Facility census: 108. Findings included: a) Resident #102 During the initial tour on 02/14/22 at 12:26 PM, it was noted the collection Foley bag and tubing were lying on the floor under the wheelchair of Resident #102. Licensed Practical Nurse #14 came in room and adjusted the collection bag to the back of the wheelchair. In addition, the Foley collection bag did not have a privacy cover. Observation of catheter care with Nurse Aide #47 on 02/16/22 at 2:30 PM, revealed the following: NA #47 prepared a pan of water, obtained two wash cloths and one towel. NA #47 did not use the folding technique with the washcloth. NA#47 initiated peri care by wiping down the right side of the groin then initiated a downward stoke on the left side of the groin,…

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 one (1) of four (4) residents reviewed for the care area of nutrition maintained acceptable parameters of nutritional status. Facility staff incorrectly documented the percentage of food consumed for meals. Resident identifier: #692. Facility census: 108. Findings included: a) Resident #692 Observation on 02/14/22 at 1:39 PM, found the resident was in her room, up in her wheelchair with the noon meal on the bed-side table in front of her wheelchair. The residents' fork was lying on her plate with a small corner (one bite) of lasagna cut off, still on the plate. The residents' tray also contained a vegetable blend, bread, and strawberry shortcake. None of the other items on her plate had been touched. When asked, the resident said she did not want to eat and didn't want anything else because she wouldn't eat it either. I'm just not hungry. The residents' tray was picked up from her room and placed on the dirty food cart. On 02/15/22 at…

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

Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of dialysis was monitored for any possible complications after receiving dialysis treatments at an outpatient certified dialysis facility. Resident #86. Facility census: 108. Findings included: a) Resident #86 During an interview with the resident about dialysis care and treatments on 02/14/22 at 1:26 PM, the resident said facility staff don't always check on her after she returns from dialysis. She stated staff don't take her vital signs when she returns. She said, just like today, I came back and handed my papers to the nurse at the desk and nothing has been done yet. (Resident stated name of Licensed Practical Nurse #38) and said the nurse still hasn't taken my blood pressure, temperature or pulse and I have been back for an hour now. Record review found an order dated 10/17/21 for: Dialysis Days M-W-F (Monday, Wednesday, and Friday) at (Name of dialysis center, telephone number, and address); pickup time 7 am for chair time 740 am…

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

Based on observation, resident interview, staff interview and record review, the facility failed to ensure staff have the basic competencies needed to provide care to a resident with psychosocial disorders. This was true for one (1) of two (2) residents reviewed for choices. Resident identifier: #22. Facility census: 108. Findings included: a) Resident #22 On 02/14/22 at 12:27 PM, the resident was in her room crying. When asked why she was tearful, the resident said, Everything has been taken away from me. The resident was unable to state specifics, she just kept crying and saying when she came here she doesn't have any say into what happens to her. In addition, the resident said a nurse that works here said, I probably don't have long to live anyway. Record review found the resident does have a diagnosis of depression and receives Lexapro Tablet, 10 MG, an antidepressant, daily. Review of the most recent Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/21/21 noted the resident scored 10 on her brief interview for mental status (BIMS). A score of 10 indicates the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide a safe, clean environment. A broken outlet cover in a resident room with visible wiring showing and large hole in a over-the-bed table were observed . This was a random opportunity for discovery and has the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #8. Facility census: 89. Findings included: a) wall outlet On 02/14/2022 at 11:45 AM, it was observed in room [ROOM NUMBER] there was a broken outlet cover on the wall between the two beds, without any furniture in front of the outlet. The outlet had visible wires showing and was approximately 12 inches from the floor and easily accessible. This was verified with Nurse Aide #45. b) Resident #8 On 02/14/22 at 1:44 PM, observation revealed a large hole measuring approximately 5 inches by 4 inches on the right corner of the over- the- bed table. This was verified with Nurse Aide #45.