Trinity Health Care Of Logan

Based on record review and staff interview, the facility failed to maintain accurate and complete record for Resident #92. This was true for one (1) of five (5) residents reviewed under the care area of abuse. Resident Identifier: #92. Facility Census: 112.Findings Include:a) Resident #92On 02/03/26 at 12:20 PM, a review of the care plan was completed for Resident #92. The review found under the focus area of the resident uses psychotropic medications, the incorrect dates of an inpatient psychiatric stay. The dates listed were 12/17/25 until 01/10/25. The correct dates should have been 12/17/24 until 01/10/25.On 02/03/26 at 12:58 PM, the Director of Nursing (DON) was notified and confirmed the dates would be corrected on the care plan.

Based on observation and staff interview, the facility failed to maintain an effective infection control program for urinary storage bags. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 112.Findings Include: a) Resident #10 On 02/02/2026 at 2:05 PM, an observation found Resident #10's urinary storage bag on the floor. On 02/02/26 at 2:09 PM, Licensed Practical Nurse (LPN) #53 was notified and stated, it's because it's a low bed. LPN #53 then stated, I'll take care of it. On 02/02/26 at approximately 3:30 PM, the Director of Nursing (DON) was notified and confirmed the urinary storage bags should not be touching the floor.

Based on observation and staff interviews, the facility failed to ensure that residents were free from skin irritation and rashes associated with the use of a laundry detergent known to cause skin irritation. This deficient practice has the potential to affect all residents within the nursing home and was substantiated for 3 of 3 residents reviewed during the long-term care survey process. Findings include: On 10/20/25 record review of complaint filed with the State Agency (SA) reviled residents that the laundry detergent that the facility was using was causing outbreaks for half of residents from neck to feet. No rashes on hands and face. On 10/21/25 at 1:45 PM this surveyor observed blue detergent stored in the laundry area. Hooked up to the laundry machine was a clear detergent. During an interview competed on 10/21/25 at approximately 1:50 PM with Laundry Aide #93 , who stated the facility has been using a hypoallergenic detergent for approximately two years. The laundry aide # 93 explained that the blue detergent is used when the hypoallergenic detergent is out of stock or…

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

Based on observation and staff interview the facility failed to treat residents with respect and dignity during the dining experience and by pulling a resident down the hall backwards. These failed practices were random oppurtunities for discovery and had the potential to affect more than an limited number of residents currently resding in the facility. Resident Identifier # 36 Facility Census 111. Findings Include: a) Resident #36 An observation on 06/04/24 at 11:25 AM, of hall 400, revealed Nurse Aide (NA) # 58 pulling Resident #36 down the hallway backwards in a Geri chair about 30 feet. During an interview on 04/04/24 at 11:26 AM, NA #58 stated, This is the way I always do it. During an interview on 04/04/24 at 1:45 PM, registered Nurse (RN) #4 confirmed, staff should not be pulling residents backwards. b) Main Dining on 05/28/24 An observation of the main dining room for the evening meal on 05/28/24 found there was 24 residents seated in the dining room waiting for their meal at 6:00 PM. At 6:05 PM, Resident #70, #4, # 73, #6, and #59 were all served their meal. The remaining…

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 safeguard the privacy of the back hall of the [NAME] wing resident's medical record. This was a random opportunity for discovery. Resident #83, #108, #97, #65, #60, #35, #98, #44, #45, #66, #68, #94, #66, #69, #30, #19, #58, #18, #3, #35, #96, #86, #80, #57, #10, #79, #53, #512, and #24. Facility Census: 111. Findings Include: a) [NAME] Wing Medication Computer On 05/29/24 at 9:45 PM, a tour of the facility was completed. Upon approaching the [NAME] wing medication computer on the back hall, the computer screen was visible with the resident's pictures and names. On 05/29/24 at 9:48 PM, Licensed Practical Nurse (LPN) #125 approached the cart and stated, I thought I locked the screen. On 06/04/24 at 1:00 PM, Registered Nurse (RN) #4 was notified of the computer screen being visible to anyone passing by the medication cart. RN #4 confirmed the computer screen should have been locked. RN # 4 stated, they told me what happened.

Based on record review and staff interview, the facility failed to ensure each resident was free from chemical restraint. Resident #27 was given an antipsychotic injection before showers, to prevent the resident from becoming combative during the shower. This was true for one (1) of one (1) residents reviewed for chemical restraints during the survey process. Resident identifier: 27. Facility census: 111. Findings include: A) Record review At approximately 2:22 PM on 05/30/24, a record review was conducted of medication regimen reviews for Resident #27. During this review, the recommendation made on the review for May of 2023 was for Ziprasidone. The recommendation stated the diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance should be changed to be more specific, or the medication should be discontinued. The order for the medication read: Geodon Intramuscular Solution Reconstituted (Ziprasidone Mesylate) Inject 10 mg intramuscularly every day shift every Tue, Thu, Sat for Dementia with psychotic features administer…

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 thoroughly investigate an allegation of sexual abuse involving Resident #91 and Resident #61. This was true for two (2) of six (6) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: 91 and 61. Facility Census: 111. Findings Include: a) Resident #91 and #61 incident date 04/07/24 A review of a Facility Reported Incident which was received by the state agency on 04/07/24 found the following: Type of Incident was a resident to resident incident. The type of abuse was specified as Sexual. The incident form indicated the the staff became aware of the abuse at 9:00 AM on 04/07/24. Resident #91 was listed as the alleged victim. The perpetrator was listed as Resident #61. The reportable listed four (4) staff members as witnesses to the incident. The staff were identified as QA #66, Licensed Practical Nurse (LPN) #105. Restorative Aide #102, and Prior Employee # 1 (Position unknown), The incident report indicated the residents were witnessed in lying in bed in a sexual…

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

Based on record review and resident and staff interview, the facility failed to ensure care plans were developed/implemented for each resident due to hydration interventions not being implemented for Resident #27, Activities visits not being developed for Resident #6, and fall interventions not being implemented for Resident #65. This was true for three (3) of 32 residents reviewed for care plans during the survey process. Resident identifiers: 27, 6, 65. Facility census: 111. Findings include: A) Resident #27 At approximately 2:43 PM on 05/28/24 an interview was conducted with Resident #27. She stated I don't get juice and snacks like I used to. My mouth is so dry, it feels like I'm spitting cotton. Resident #27 was asked if facility staff passed water and ice on a daily basis, to which they stated No, they don't pass it. No water pitcher was witnessed within reach of Resident #27. Upon further investigation, no water pitcher was found in Resident #27's room. Another observation of Resident #27's room at approximately 12:51 PM on 05/29/24 revealed no water pitcher was present 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.

Based on record review and staff interview, the facility failed to follow physician's orders for medication administration. This was true for five (5) of five (5) residents reviewed during the survey process. Resident Identifier: #15, #85, #19, #57 and #361. Facility Census: 111. Findings Include: a) Resident #15 On 06/04/24 at 11:25 AM, a record review was completed for Resident #15. The review found the Medication Administration Record (MAR) for May, 2024 had not been initialed off by the nurse and were left blank, which indicates the medication was not administered as ordered. The following medications are as follows: --Melatonin 3mg (milligram) give two tablets at bedtime was ordered for 05/17/24 at 9:00 PM --Singular 10mg give one tablet at bedtime was ordered for 05/17/24 at 9:00 PM --Mupirocin External Ointment 2% (percent) apply to bilateral nares topically at bedtime was ordered for 05/17/24 at 9:00 PM --Nicotine Transdermal Patch apply one patch transdermally at bedtime and remove per schedule was ordered for 05/17/24 remove at 8:59 PM and apply at 9:00 PM --Seroquel XR…

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 of unnecessary psychotropic medications by prescribing Resident #27 an antipsychotic medication before showers. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 27. Facility census: 111. Findings include: A) Record review At approximately 2:22 PM on 05/30/24, a record review was conducted of medication regimen reviews for Resident #27. During this review, the recommendation made on the review for May of 2023 was for Ziprasidone. The recommendation stated the diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance should be changed to be more specific, or the medication should be discontinued. The order for the medication read: Geodon Intramuscular Solution Reconstituted (Ziprasidone Mesylate) Inject 10 mg intramuscularly every day shift every Tue, Thu, Sat for Dementia with psychotic features administer 10mg injection IM x 1 20…

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 serve food and drink that was palatable, attractive and at a safe and appetizing temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 111. Findings Include: A) Dining Room evening time meal. During an observation of the evening meal on 05/28/24 beginning at 6:00 PM it was noted staff from the units were bringing trays into the dining room and placing them in a meal cart that was in the dining room. This continued until the dining room meal cart arrived from the kitchen at approximately 6:20 PM. At this time they began serving 19 residents who had been waiting on their meal. At 6:30 PM when the last tray off the meal cart which was parked in the dining room at the beginning of the observation was served the Certified Dietary Manager was asked to obtain the temperature of the last tray.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards for medication administration, disposal of soiled linen and dinner service. These were random opportunities for discovery. Resident Identifiers: #512, #85, and #13. Facility Census: 111. Findings Include: a) Resident #512 On 05/28/24 at 5:45 PM, observation of the dinner service was observed on the [NAME] wing. The dinner tray was removed from food cart without a lid to cover food. Nurse Aide (NA) #110 realized the plate did not have a cover and placed the contaminated tray back on the cart with clean trays. On 05/28/24 at 5:50 PM, Assistant Nurse Aide Supervisor #31 verified the tray should not have been placed back on the cart. On 05/28/24 at 6:00 PM, Licensed Practical Nurse (LPN) #34 was notified of the infection control breach during the dinner service. On 05/28/24 at 6:04 PM, the Administrator was notified of the infection control breach during the meal service. 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 report an allegation of verbal abuse for Resident #22 and a bruise on Resident #93. This was a random opportunity for discovery. Resident Identifier: #93 and #22. Facility Census: 111. Findings include: a) Resident #93 On 06/03/24 at 12:22 PM a record review of Resident #93's progress notes found the following note: 5/16/2024 08:14 Nurses Note Note: This nurse entered the resident's room to medicate the resident with her morning meds. When the resident turned around to face this nurse, a bruise under her eye was noticed. When asked what happened the resident explained that, I bumped it off the cabinet when I bent over to put my things away. This nurse asked the resident if she felt any pain of discomfort to which the resident reported she wasn't hurting and she did not know she was bruised until this nurse asked about it. Physician Notified If Needed: Physician Orders if Needed: Responsible Party Notified If Needed: first name (Emergency Contact-daughter-in-law) was contacted, first name (Son) is unavailable at work…

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 the resident and/or responsible party an accurate bed hold policy upon discharge from the facility. This was true for one(1) of six (6) residents reviewed for the care area of hospitalizations during the long term care survey. Resident Identifier: #57. Facility Census: 111. Findings Include: A) Resident #57 A review of Resident #57's medical record found she went to the hospital on [DATE] at which time the facility was at bed hold capacity. The resident returned to the facility on [DATE]. She used a total of three (3) of her 12 medicaid bed hold days for this hospital stay. Resident #57 was again discharged to the hospital on [DATE] at the time of this discharge the facility issued a bed hold notice the residents responsible party which indicated they were at bed hold capacity and Resident #57 still had 12 medicaid bed hold available for the year. An interview with the business office manager at 1:44 PM on 06/04/24 confirmed the resident…

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

Based on observation, staff interview, and record review the facility failed to provide activities of daily living (ADL) to dependent residents to maintain good personal hygiene. This failed practice was found true for (1) one of (6) six residents looked at for ADL care area during the Long-Term Care Survey Process. Resident identifier #45. Facility Census 111. Findings include: An observation on 06/03/24 at 11:48 AM, revealed Resident #45 had chin hair that was approximately 3 centimeters long and covered most of her chin. During an interview on 06/03/24 at 12:12 PM, with Resident #45 she stated, These chin hairs bother me sometimes, They don't always shave them. My nails were really long and they just cut them the other day. During an interview on 06/03/24 at 12:20 PM, Nurse Aide (NA) #110 stated, I did her care today, sometimes she refuses some of her care. I don't know when the last time she had her chin hair shaved. A record review on 06/03/24 at 12:48 PM, of Resident #25's task titled {AM CARE} revealed that residents scheduled shower days are Monday, Wednesday and Friday. For…

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

Based on observation, and interviews the facility faild to provide an activity program calendar that is clearly visible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111 Resident identifier: #16 Findings include: On 06/03/24 at 1:04 PM two surveyors observed the May activity program calendar hanging on the wall near the main dining room and activity office. The activity program calendar was observed to be written in the following colors; bright orange, lime green, hot pink, and purple, the activities scheduled was not easily read due to the bright/neon colors by either surveyor making this observation. An interview with Resident #16 on 06/03/24 at 1:30 PM revealed the rsident could not make out what was on the calendar stating them colors are bright aint they, glasses or no glasses you couldn't read that. On 06/03/24 at 1:40 PM, the Activity Director stated oh ok I will get this changed confirming the colors were bright and making the activity program's schedule not easily read.

Based on record review and resident and staff interview, the facility failed to ensure each resident received proper hydratio, due to no water being passed to Resident #27. This was true for one (1) of two (2) residents reviewed for hydration during the survey process. Resident identifier: 27. Facility census: 111. Findings include: A) Resident #27 At approximately 2:43 PM on 05/28/24 an interview was conducted with Resident #27. She stated I don't get juice and snacks like I used to. My mouth is so dry, it feels like I ' m spitting cotton. Resident #27 was asked if facility staff passed water and ice on a daily basis, to which they stated No, they don ' t pass it. No water pitcher was witnessed within reach of Resident #27. Upon further investigation, no water pitcher was found in Resident #27 ' s room. Another observation of Resident #27 ' s room at approximately 12:51 PM on 05/29/24 revealed no water pitcher was present in the room. At approximately 10:00 AM on 05/30/24 another observation of Resident #27 ' s room revealed no water pitcher was present in the room. At…

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

Based on record review and staff interview, the facility failed to ensure that yearly performance evaluations were completed for each nurse aide. This was true for two (2) of five (5) nurse aide performance evaluations reviewed during the survey process. Facility census: 111. Findings Include: A) Incomplete Evaluations At approximately 11:30 AM on 06/05/24, a review was conducted of nurse aide performance evaluations completed by the facility for the last year. During review, it was determined that two evaluations were incomplete. The evaluation for Nurse Aide (NA) #49 was filled out but there was no date indicating when the performance evaluation was completed. The evaluation for NA #48 did not have a complete characteristics portion of the evaluation. Under the characteristics portion, there are four (4) choices, unsatisfactory, satisfactory, good, excellent. None of the options were selected for that portion of the evaluation. The evaluation was also not dated to indicate when it was completed. At approximately 12:00 PM on 06/05/24 an interview was conducted with the Nurse Aide…

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

Based on observation, record review and staff interview, the facility failed to maintain an accurate and complete medical record for Resident #85, #95 and #58. This is true for three (3) of 32 residents reviewed during the survey process. Resident Identifier: #85 and #95. Facility Census: 111. Findings Include: a) Resident #85 On 06/04/24 at 9:13 AM, while observing medication administration, Resident #85 stated, I want my medication now. LPN #26 stated, (Name of Resident) let me get them for you. Upon opening the Medication Administration Record (MAR) in the computer, the medications were noted to be given at 9:09 AM. LPN #26 was asked, why does the computer show the medication has already been given? LPN #26 stated, I haven't given his medication this morning .I don't know why it is checked off. LPN #26 stated, let me look and see who documented them. It was me. stated LPN #26. I know how I can check .let me look at the narcotic book and see if the Klonopin has been signed out. Upon reviewing the narcotic book, the Klonopin had not been signed out and the narcotic count 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 and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The signage for residents on transmission-based precautions (TBP) did not indicate the specific type of precaution and the personal protective equipment (PPE) needed. Additionally, PPE was not readily available at the entrance to the room of a resident in TBP. Also, the facility failed to have a water management program designed to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These deficient practices had the potential to affect all residents residing in the facility. Resident identifiers: #46, #52, #32. Facility census: 98. Findings included: a) Water management program During an interview on 12/07/22 at 12:25 PM, the Director of Nursing (DON) was asked for a copy of the facility's water management program designed to prevent the growth of Legionella and other opportunistic waterborne pathogens…

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 a person-centered comprehensive care plan was developed for oxygen therapy and smokeless tobacco. This was true for three (3) of 24 sampled residents reviewed during the long term care survey process. Resident Identifiers: Resident #94, #60 and #8 . Facility Census: 98. Findings Included: a) Resident #94 On 12/06/22 at 9:00 AM, a review of the current physician's orders found an order for O2 (oxygen) at 2 (two) L/M (liters per minute) NC (via nasal canula) PRN (as needed) dyspnea (shortness of breath) dated 11/30/22. (Typed as written.) On 12/06/22 at 9:58 AM, a record review was completed for Resident #94. Upon completion of the review, the care plan did not list the oxygen therapy as a focus area. On 12/06/22 at 12:56 PM, the Director of Nursing (DON) confirmed oxygen therapy was not listed on the care plan. b) Resident #8 On 12/05/22 at 12:53 PM, during the initial phase of the long term survey process Resident #8 asked me if I could…

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.

B. ased on observation, medical record review, and staff interview the facility failed to ensure residents' received treatment and care in accordance with professional standards. This was a failed practice in the care areas of not following physician's orders to elevate the head of bed, failing to have a physician order for hospice care, and incomplete neurological checks after an unwitnessed fall. This was true for three (3) of 24 sampled residents. Resident Identifiers: #69, #76, and #72 Facility Census: 98 Findings Included: a) Resident #69 On 12/06/22 at 11:50 AM, while reviewing the medical records, it was noted Resident #69 was under hospice care for renal cancer. This is reflected on the matrix and the residents care plan. A review of his current physician orders found no order for hospice care. This was confirmed with the Director of Nursing on 12/06/22 at 11:55 AM. b) Resident #76 During a medical record review on 12/06/22, the physician's order revealed the head of bed was to be always elevated at 30-40 degrees with a start date of 11/21/22. On 12/06/22 at 9:48 AM, during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for pneumococcal immunizations. This deficient practice had the potential to affect any resident who had not had pneumococcal immunizations but wanted to receive them. Facility census: 98. Findings included: a) Pneumococcal immunizations The facility's policy and procedure titled Immunizations: Pneumococcal Vaccination (PPV) of Residents was reviewed. No implementation date was specified in the policy. The revision date of the policy was 03/02/2018. The policy did not specify which pneumococcal vaccinations would be offered to the residents. However, the policy stated CDC guidelines would be followed for pneumococcal vaccinations. The facility's immunization acknowledgement and consent form contained information and consent regarding the pneumococcal vaccinations PCV 13 (pneumococcal conjugate vaccine) and PPSV 23 (Pneumococcal polysaccharide vaccine). During an interview 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 resident interview, staff interview, and observation, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents. The hot water temperature in the sink was not comfortable for one (1) resident who received bed baths. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 98. Findings included: a) Resident #46 During an interview on 12/05/22 at 12:05 PM, Resident #46 stated she recieved bed baths with cold water. She stated the water for the bed baths were filled from the sink in the room. On 12/05/22 at 11:45 AM, this surveyor turned on the hot water spigot on the sink in the room. On 12/05/22 at 11:48 AM, the water had not warmed up from when it was initially turned on at 11:45 AM. At this time, the maintenance supervisor entered the room because he heard the sink running. He confirmed the water was not warm. He allowed the water to run another minute and then confirmed that it had still not warmed up. On 12/05/22 at 12:15 PM, the Director of Nursing (DON) was informed about the situation. She stated no…

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

Based on observation, resident interview, medical record review and staff interview the facility failed to revise the care plan in a timely manner. This was true for three (3) out of 24 care plans reviewed during the survey. Resident Identifiers: #69 and #8. Facility census: 98 Findings Included: a) Resident #69 On 12/06/22 at 9:00 AM, a review of Resident #69's care plan found, a care plan with with an initiated date of 11/23/22, which read as follows: #16 french urinary catheter to bedside drain with a thirty (30) milliliter balloon. Change as needed for occlusion/leakage/sediment. During an observation and interview with Resident #69 on 12/06/22 at 10:08 am, it was discovered he no longer has a urinary catheter. He stated, I did not have it long and I insisted they remove it. On 12/06/22 at 12:42 pm, the Director of Nursing confirmed the care plan needs to be revised to reflect no urinary catheter. b) Resident #8 On 12/06/22 at 2:40 PM, during the medical review for unnecessary medications, it was noted that Resident #8 has a current order for Lamictal 25 milligrams twice a day…

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, medical record review, and staff interview the facility failed to provide the proper assistive device required to maintain the Resident's ability to communicate effectively. This was true for one (1) out of one (1) residents reviewed for communication. Resident Identifier: #25 Facility Census: 98. Findings Included: a) Resident #25 On 12/06/22 at 11:40 AM, a review of Resident #25's medical record showed a current order dated 6/23/21 which read as follows : Resident may use pocket-talker hearing amplifier device as tolerated. On 12/06/22 at 11:45 AM, Licensed Practical Nurse (LPN) #127, stated she hasn't seen him with it for a while. It also could not be located in the residents room. This was confirmed with the Director of Nursing on 12/06/22 at 1:30 PM. .

Based on observation, resident interview, medical record review, and staff interview the facility failed to ensure Resident #69 who was receiving oxygen therapy had a physicians order. This was a random oppurtunity for discovery. Resident Identifier: # 69. Facility Census: 98. Findings Included: a) Resident #69 On 12/05/22 at 1:30 PM during the interview phase of the long term survey process, Resident #69 was observed with oxygen in use and states he needs it at times due to shortness of breath. On 12/05/22 at 1:55 PM upon review of the current orders for Resident #69, found no current order for oxygen therapy. On 12/05/22 at 2:55 PM, the above information was confirmed with the Director of Nursing. .

Based on medical record review, observation and staff interview the facility failed to provide hemodialysis services consistent with professional standards of practice. This was discovered for one (1) of one (1) resident reviewed for dialysis services during the Long-Term Care Survey Process. Resident identifier: #76. Facility census: 98. Findings included: a) Resident #76 During a random opportunity for discovery on 12/06/22 at 9:10 AM, it was discovered there were no hemostats (a clamping device used to stop bleeding for the perma catheter), readily available at bedside for Resident #76 who has a perma catheter. On 12/06/22 at 9:20 AM, the Director of Nursing (DON) was unable to locate any hemostats in Resident #76's room. The DON reported the hemostats were not readily accessible at bedside for the perma catheter for Resident #76. .

Based on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) nurses during shift change. This was a random opportunity for discovery. Facility Census: 98. Findings Included: a) Medication Administration On 12/06/22 at 8:00 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change and the narcotic count was not completed: --11/22/22 day shift not signed by the on coming nurse. --11/22/22 evening shift not signed by the off going nurse. --11/28/22 day shift the number of narcotic pages were not counted. On 12/06/22 at 8:10 AM, the Director of Nursing (DON) confirmed the above dates were not signed by two (2) nurses at the end of each shift and the number of pages was not complete. b) Facility Policy On 12/07/22 at 11:15 AM, the facility policy for Controlled Substances was reviewed. Under the heading Procedure section C states .a physical inventory of that medication will be made at the change of each shift by two (2)…

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 complete an accurate medical record in the care area of showers for Resident #46. In the area of tobacco use for Residents #26. This deficient practice had the potential to affect two (2) of 24 sampled residents during the long-term care survey process. Resident identifiers: #46, #26. Facility census: 98. Findings included: a) Resident #46 Review of Resident #46's medical record showed the resident's days to receive showers were Monday, Wednesday, and Saturday. Review of Resident #46's nurse aide task reports for the last 30 days showed the following bathing activities for Mondays, Wednesdays, and Saturdays: - On 11/7/22, a shower was given. - On 11/09/22, no shower was given. - On 11/12/22, no shower was given. - On 11/14/22, no shower was given. - On 11/16/22, a shower was given. - On 11/19/22, no shower was given. - On 11/21/22, a shower was given. - On 11/23/22, no shower was given. - On 11/26/22, a shower was given. - On 11/28/22, no…

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