Clay Healthcare Center

Based on observation and staff interview, the facility failed to ensure call lights were within reach for residents who had the ability to utilize them to request help. This was true for one (1) of two (2) residents reviewed under the environment pathway. Resident identifier: #16. Facility census: 55. Findings included: a) Resident #16 a) An observation on 10/30/23 at 1:20 PM of Resident #16 revealed the call light was a touch light call pad and was not in reach of Resident #16. The resident was lying in bed. The touch pad call light was on the nightstand. During an observation, on 10/30/23 at 3:30 PM, Resident #16 revealed the call light was not in reach of resident that was lying in bed. The touch pad call light was on the nightstand. During a review, on 10/31/23 at 9:00 AM, of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADLs). The care plan mentioned the resident had a Cognitive Deficit and the care plan indicated the staff needed to place the call light within reach. Observation, on 10/31/23 at 1:30 PM, revealed the call…

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

Based on observation and staff interview, the facility failed to respect residents' right to personal privacy and confidentiality of the medical record. This was a random opportunity for discovery. The failed practice was true for three (3) of 18 sample residents. Resident identifiers: #254, #38, and #34. Facility census: 55. Findings included: a) Resident #254 An in-room observation, on 11/01/23 at 12:29 PM, revealed a print pink sheet of paper pinned to Resident #254's board. The paper had writing on it in a landscape format which read, [Name of Hospice Care Agency] for body mind and spirit. The paper form went on to outline, [First Name of hospice agency staff] will visit me on: and then had a notation that Resident #254 would be visited on 11/01/23 from 11:00 AM - 1:00 PM and would receive social visit, would receive a bed bath, hair would be washed, and clothes would be organized. Additionally, it was noted that Resident #254 would be visited on 11/03/23 sometime between the hours of 11:00 - 3:00 PM. During an interview on 11/01/23 at 1:02 PM, the Administrator confirmed 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 honor the resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure a wall in a resident room was in good repair. Room identifier: 117. Resident identifier: #255. Facility census: 55. Findings included: a) room [ROOM NUMBER] / Resident #255 On 10/30/23 at 1:21 PM observation revealed the wall behind Resident #244's bed was in disrepair. There was an approximate 4 x 2 rectangular scrape/scratch as well as an approximate 2 x 2 rectangular scrape/scratch immediately noticeable to the right of Resident #255's bed. Additionally, there was an approximate 7- 8 scrape/scratch close to the baseboard on the right side of resident's bed. The scrapes had removed the wall paint and left the white drywall exposed. To the left of Resident #255's headboard, there were four (4) round, circular scrapes/scratches approximately the size of a pencil. During an interview, on 10/31/23 at 9:15 AM, the Social Worker 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 policy review, record review, and staff interview, the facility failed to ensure that all alleged violations involving abuse were reported. This was true for one (1) of (2) residents reviewed under the abuse pathway. Resident identifier: #19 . Facility census: 55. Findings included: a) Resident #19 Record review, on 11/01/23 at 9:00 AM, of Resident #19's nursing progress note written on 10/06/23 by the Assistant Director of Nursing (ADON) revealed Resident #19 had filed a grievance. The note read: Resident filed a grievance stating a gray-haired nurse was rude to her. The ADON went on to question the resident further about this. When the ADON asked about the Gray-haired nurse, Resident #19 said, You leave her alone. This person is a Nurse Aide (NA) who provides her care. The ADON investigated further and talked with staff on the floor. All staff stated that the resident gets upset when they attempt to empty the catheter bag. She prefers to empty it herself into the trash. All staff stated that they are not hateful to her, but she gets agitated when anyone attempts to help…

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 new PASARR (Pre-admission Screening) with a new diagnosis. This is true for one )1) of one (1) reviewed for PASARR. Resident identifier: #36. Facility census: 55. Findings included: a) Resident (R) #36 Review of the medical record on 10/30/23 revealed R #36 was diagnosed with schizophrenia in 2023. The annual Minimum Data Assessment with an Assessment Reference Date of 08/03/23 was coded as yes under section I 6000 acknowledging the diagnosis of schizophrenia under the psychiatric/mood disorder. The most recent PASARR dated 10/18/22 was marked as none for mental illness including schizophrenia under section 30. During an interview on 11/01/23 at 8:00 AM, Social Worker #70 confirmed R#36's most recent PASARR is dated 10/18/22. At 8:30 AM on 11/01/23, Regional Director of Clinical Services (RDCS) #100 reported R#2's diagnosis of schizophrenia was dated 1/23/23. The RDCS confirmed the PASARR should have been completed after the new diagnosis of schizophrenia. .

Based on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan, developed and implemented, with specific interventions of care to address the resident's medical, physical, mental, and psychosocial needs for three (3) of 18 sample residents reviewed. Resident #28's and Resident #104's care plan failed to address specific non-pharmacological approaches to anxiety. Resident #34's care plan failed to have specific Hospice approaches addressed. Resident identifiers: Resident #34, #104 and #28. Facility census: 55. Findings included: a) Resident #28 A record review, for Resident #28, on 11/01/23, revealed a care plan focus area of anxiety medications related to anxiety, with an intervention to encourage the resident to voice feelings and discuss coping skills A discussion of coping skills did not provide for specific direction for staff to assist the resident to alleviate the anxiety. An interview, with the Director of Nursing (DON), on 11/01/23 at 9:13 AM, confirmed the interventions were not written in a manner 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 staff interview, the facility failed to revise a resident's comprehensive care plan based on an identified change in the residents care that was no longer applicable to the plan of care for one (1) of 18 sampled residents reviewed. Resident #28 no longer was receiving oxygen therapy, however, the focus problem with goals and approaches were continued to be included on the the current care plan. Resident identifier: Resident #28. Census: 55. Findings included: a) Resident #28 A record review, on 11/01/23 found current orders contained no order for oxygen therapy. Further review of the record showed the resident had received oxygen therapy, however, the order for oxygen had been discontinued on 09/16/23. A review of the current care plan revision, that was dated 10/12/23, showed a focus area of oxygen therapy with oxygen to be provided at two (2) Liters per minute remained on the care care plan. An interview with the Director of Nursing ( DON), on 11/01/23 at 9:13 AM, confirmed after review of the orders, the order had been discontinued on 09/16/23 and the…

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

Based on observations, record review, and staff interview, the facility failed to provide an activity program that meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was found true for two (2) of (18) residents reviewed during the long-term care survey process. Resident identifiers: #8 and #19. Facility census: 55. Findings included: a) Resident #8 An observation on 10/30/23 at 2:00 PM revealed no stimulation on in Resident #8's room. Resident #8 was fidgeting in bed and repeating staff that was in the hallway. An observation on 10/30/23 at 3:00 PM revealed no stimulation on in Resident #8's room. Resident #8 was lying in bed gripping her blanket. An observation on 10/31/23 at 7:45 AM revealed Resident #8 was in the dining room for morning activities. Resident #8 was placed with her back to everyone else in the room. An observation on 10/31/23 at 8:40 AM Resident #8 was in dining room for scheduled coffee and news activity. The resident was placed with her back to the activity and was not served a drink at this time. 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 ensure each resident's drug regimen was free from unnecessary drugs. A resident was given an antibiotic without adequate indications for its use. This was true for one (1) of two (2) residents reviewed under the antibiotic pathway. Resident identifier: #9. Facility census: 55. Findings included: a) Resident #9 A record review, completed on 10/31/23 at 1:14 PM, revealed the following physician order: Cephalexin Oral Tablet 500 MG (Cephalexin) Give 500 mg by mouth two times a day for infection/ for 7 Days UTI Order Date: 10/24/23 Review of the Medication Administration Record indicated Resident #9 began taking the medication on 10/24/23 and finished on the 10/30/23. Further medical review revealed the following details: -LPN #37 documented, on 10/23/23 at 10:51 AM, Resident #9 was not eating, having periods of lethargy, and a mental status change. At that time the Nurse Practitioner ordered resident to be sent to the emergency room for evaluation and treatment. -On 10/23/2023 at 6:16 PM, the Assistant Director 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 interview, the facility failed to ensure an order for a psychotropic medication included an indication for use. This is true for one (1) of five (5) residents reviewed for medications. Resident identifier: #36. Facility census: 55. Findings include: a) Resident #36 Review of the physician orders on 11/01/23, revealed the following order written on 01/17/23: Risperidone oral tablet 1 milligram (mg). Give 1 mg by mouth two times a day. The order lacked an indication/diagnosis for use or administration. On 11/01/23 at 11:51 AM the Regional Director of Clinical Operations (RDCO) #100 confirmed the Risperidone order for R#36 lacked a diagnosis or indication for administration.

Based on contract review, record review and staff interview, the facility failed to ensure radiology services were available to meet a resident's needs. This is true for one (1) of three (3) residents reviewed for falls. Resident identifier: #2. Facility census: 55. Findings included: a) Resident #2 The (Name of company) portable services agreement dated 04/01/23 states the company agrees to provide portable x-ray services 24 hours a day, seven days a week for STAT emergency requests. A review of the medical record on 10/31/23 found Resident #2 experienced a fall on 10/07/23. A telehealth note written by the Nurse Practitioner on 10/07/23 at 4:55 PM stated resident was now complaining of right hip pain. A STAT x-ray of the hip was ordered and pending. On 10/08/23 at 9:27 AM, telehealth physician assistant wrote .X-rays were ordered however, they will not be done until tomorrow . R#2 was reporting a pain level of 9/10. The resident was sent to the emergency room per family request. The above findings were reviewed with the facility Administrator on 11/01/23 at 09:00 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 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 and/or inaccurate for one (1) of 18 records reviewed for accurate POST forms. Additionally, two (2) nurses signed off the administration of a medication which was not available in the facility. This was true for two (2) of five (5) scheduled medication times. Resident identifiers: #47 and #43. Facility census: 55 Findings included: a) Resident #47 Review of Resident #47's Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on 07/06/23. However, the resident representative's actual signature was never obtained. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals states, The patient (or incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA…

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

Based on record review and staff interview, the facility failed to ensure a resident's antibiotic was the appropriate one for the infection it was being used to treat. A resident was given an antibiotic without adequate indications for its use. This was true for one (1) of two (2) residents reviewed under the antibiotic pathway. Resident identifier: #9. Facility census: 55. Findings included: a) Resident #9 A record review, completed on 10/31/23 at 1:14 PM, revealed the following physician order: Cephalexin Oral Tablet 500 MG (Cephalexin) Give 500 mg by mouth two times a day for infection/ for 7 Days UTI Order Date: 10/24/23 Review of the Medication Administration Record indicated Resident #9 began taking the medication on 10/24/23 and finished on the 10/30/23. Further medical review revealed the following details: -LPN #37 documented, on 10/23/23 at 10:51 AM, Resident #9 was not eating, having periods of lethargy, and a mental status change. At that time the Nurse Practitioner ordered resident to be sent to the emergency room for evaluation and treatment. -On 10/23/2023 at 6:16 PM,…

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 residents who required respiratory care, was provided that care in accordance with professional standards of practice. Orders for oxygen flow rates did not include a specific rate for providing oxygen to the resident. This was true for four (4) of five (5) residents reviewed for oxygen therapy during the Long-term survey process (LTCSP). Resident identifiers: Residents #21,#9, #101, and #8. Census: 52. Findings included: a) Resident #9 A review of the medical record for Resident #9, noted an order for oxygen and included the direction that staff may titrate oxygen from 2-4 Liters per min ( L/min )via nasal cannula (NC) to maintain an oxygen saturation (O2Sa) of 90% or greater. The order did not contain a specific flow rate of oxygen to administer to Resident #9. b) Resident #21 A review of the medical record for Resident #21, noted an order for oxygen and included the direction that staff may titrate oxygen from 2-4 L/min via NC to maintain an O2Sa of 90% or greater. The order did not contain a specific flow…

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 anonymous resident and family interviews, anonymous staff interviews, feedback in the Resident Council meeting, review of staffing sheets, review of the facility assessment, and staff interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights and physical, mental, and psychosocial well-being. Facility census: 52 Findings included: a) Anonymous Resident and Family Interviews On 06/27/22 at 1:21 PM, an anonymous resident interview was completed. The resident stated the staff members were slow on answering lights because of low staffing. On 06/27/22 at 1:33 PM, an anonymous family interview was completed. The family member stated, There is not enough staff. One Sunday they only had 3 aides for the entire building. Staffing has gotten progressively worse over the last 6 months. Residents don't get to the bathroom in time. Some don't receive feeding assistance. Staff will say they need to find someone once…

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 review of facility documentation, and staff interview , the facility failed to have the required members attend the Quality Assessment and Assurance (QAA) meetings at least quarterly. The facility failed to ensure the Medical Director or designee attended the QAA meetings at least on a quarterly basis. This practice had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: Sign in sheets for QAA meetings were reviewed from July 2021 through June 2022. The sign in sheets for the meetings showed no attendance, by signature, of the Medical Director or designee for the quarter for July through September 2021 and no attendance by signature of the Medical Director or designee for the quarter of April through June 2022. An interview on 06/29/22 at 1:21 PM, with the Administrator and Registered Nurse (RN) #75, revealed after the Administrator had reviewed the minutes for the months where no signatures were found for the Medical Director attendance. There was no verification in the minutes for those meetings the Medical Director was…

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 and resident interview, the facility failed to provide care that promoted dignity for Resident #16. During a random opportunity for discovery, a sign was observed above a resident's bed noting the resident had an incontinent appliance. Resident identifier: Resident #16. Facility census: 52 Findings included: a) Resident #16 An observation, on 06/27/22 at 12:55 PM, revealed a sign over Resident #16's bed, attached to the overhead light, that read white briefs. During an interview with Resident #16 at this time, confirmed she did not know why a sign like that would be over her bed and preferred something like that to not be there. A staff interview on 06/28/22 at 1:30 PM, with Registered Nurse #5 (RN #5) verified there was a sign above the bed of Resident #16. RN #5 stated that the sign noting the need for Resident #16 to have white briefs was a dignity issue and removed the sign from the light where the sign was located. .

Based on record review and staff interview, the facility failed to have a Preadmission Screening and Resident Review (PASARR) Level II evaluation completed on a resident living in the facility. Resident identifier: #43. Facility census: 52. Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR 483.100-483.138. The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders (MD), intellectual disabilities (ID) and related conditions. This initial screening is referred to as Level I identification of individuals 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.

Based on observation and staff interview, the facility failed to initiate a care plan for recent treatment with psychologist. This was a random opportunity for discovery. Resident identifier: #19. Facility census 52. Findings included: a) Resident #19 On 6/28/22 at 4:00 PM a review of residents consultation reports Resident #19 had been seen by (name of psychiatric group) on 06/20/22 with a diagnosis of Adjustment Disorder and made the following recommendations: - work on transferring resident to a facility closer to home - resident practices prayer at certain times of the day. These times should be posted in order to reduce interruptions. - Resident likes to be included in decision making. - See next visit. Care Plan was not initiated in regards to psychologist visit and treatment with recommendations. On 6/29/22 at 3:00 PM, an interview with Registered Nurse (RN) #71 and Registered Nurse Assessment Coordinator (RNAC) #40 were asked if a care plan was initiated for Resident #19 regarding the psychologist recommendations. After looking at the records RNAC #40 stated, I did not even…

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 revise a care plan in a timely manner. This was true for one (1) of 20 sample residents. Resident identifier: #19. Facility census 52. Findings included: a) Resident #19 On 06/28/22 at 7:00 PM, a review of residents care plan and orders found resident had an anti-anxiety medication, Ativan care planned. In review of current and discontinued orders for Resident #19 found no order for Ativan. On 6/29/22 at 12:25 PM, interview with Registered Nurse (RN) #71 why resident has a care plan for Ativan that she is not currently receiving. RN #71 reviewed residents care plan and orders and stated, I do not know why there would be a care plan in place if she was not receiving Ativan. RN #71 also looked at discontinued orders as well and found no Ativan order. On 6/29/22 at 12:45 PM, an interview with the Registered Nurse Assessment Coordinator (RNAC) #40 stated I need to look under completed orders which resident was only on Ativan for 14 days when newly admitted in April 2022 . RNAC #40 stated, no, care plan was not revised…

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 review of medical records and staff interview, the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not administering an antibiotic medication as ordered by a physician. This was true for one (1) of 20 residents reviewed in the annual long-term care survey process. Resident identifier: #28. Facility census: 52. Findings included: a) Resident #28 During an interview, on 06/27/22 at 3:09 PM, Resident #28 stated she had just gotten over a urinary tract infection (UTI). A record review was completed on 06/28/22 at 10:43 AM. The record review demonstrated that Resident #28 had a physician order, dated 06/08/22, which read, Cephalexin Tablet 250 mg. Give 500 mg by mouth two times a day for UTI for 19 Administrations. Review of the June 2022 medication administration record (MAR) revealed the facility failed to administer a dose of the antibiotic on the evening of 06/14/22. This resulted in Resident receiving the antibiotic 18 times instead of the 19 doses ordered by her attending physician. 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.

Based on record review and staff interview, the facility failed to obtain accurate weights and verify weights as needed. This was true for one (1) of 20 residents sampled during the annual long-term care survey process. Resident identifier: #49. Facility census: 52. Findings included: a) Resident #49 On 06/27/22 at 2:07 PM, a brief electronic medical record review revealed Resident #49 had experienced weight loss. Resident #49's weights were: -167.1 lbs taken on 06/07/22 via a mechanical lift (initial weight upon admission) -165.2 lbs. taken on 06/25/22 via mechanical lift -132.5 lbs. taken on 06/26/22 via mechanical lift -134.4 lbs. taken on 06/27/22 standing The facility's Nursing Policy, with an effective date of 11/18/2019, entitled: Weighing and Measuring the Resident gave the following directives: --Report any significant weight loss/weight gain. --Reweigh if the weight increases or decreases by 5 pounds During an interview on 06/28/22 at 2:47 PM, the Director of Nursing (DON) explained it was the facility's belief that the original weights taken with the mechanical lift may…

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 treatment / to intervene and seek psychologist consult in a timely fashion. This is true for one (1) of 20 residents reviewed in sample. Resident identifier: #19. Facility Census 52. Findings included: a) Resident #19 During an interview on 06/28/22 at 9:24 AM, Resident #19 was very displeased with the facility, Resident #19 stated, Prior to coming to the facility a representative from Clay Center came to speak with me telling me that a facility would be found for her to be close to home. Resident #19 stated, I did not realize it was going to be Clay Center so far from [NAME] and not close to my home. My husband and son both work and then drive 100 miles round trip to come and visit me. Resident #19 stated, I was promised a private room and that did not happen until just recently, promised to be placed in a facility close to home and that did not happen. Resident #19 also stated, The staff at Clay Center and therapy are not always 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.