Hampshire Center

Based on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of Resident #7's bed safety. Resident Identifier: #7. Facility census: 61. a) Resident #7 During an observation of Resident #7's bed, a 6-inch gap was found between footboard & mattress. Resident #7 was observed in bed with a blanket rolled up and put on one side of the footboard and a mattress gap for his feet to rest on. During an interview 12/09/25 at 1:35 PM the DON verified the footboard and mattress gap could cause entrapment. She stated that she would call the maintenance department to get it fixed immediately. No further information was provided prior to the end of the survey on 12/10/25 at 11:30 AM.

Based on observation, resident interview, staff interview the facility failed to ensure diet needs were being provided correctly (1) one of (7) seven reviewed for diets and nutrition. Resident identifier: #49. Facility census: 61. Findings include a) Resident #49 12/07/25 12:30PM, met with Resident #49 during interview, the resident complained of meals not usually being warm, cold at times, and not consistent, Resident #49 said, They do a lot of substitutions Resident #49 informed this surveyor, I received a three week menu but not for my diet, they gave me one for regular diet and I need a consistent carbohydrate Observation of the three week menu revealed it was for a regular diet with Resident #49 name. Observation of the lunch meal ticket for Resident #49 revealed it was for consistent carbohydrate diet, noting certain items: 1/3 cup cornbread dressing and 1/2 cup broccoli florets marked out with cauliflower written, also no stuffing and mashed written. Resident #49 reported Vegetables are always mushy, potatoes too hard, not cooked enough. Sometimes the meat is tough. 12/07/25…

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 provide privacy to residents when providing assistance for showers. This was a random opportunity for discovery during the Survey process. Resident identifier #8. Facility Census 62. Findings Included: a) Resident #8 An observation on 08/12/24 at 9:45 AM, of the shower room located on hall 200 revealed the shower room had no lock or in use signage. Noticing there was no sign or lock the Surveyor knocked on the door. There was no answer, so the Surveyor entered the shower room. Further observation of the shower room revealed Nurse Aide (NA) #38 standing undressing Resident #8, who only had a brief on at this time. During an interview on 08/12/24 at 9:50 AM, NA #59, Stated, We just usually knock. I agree there isn't much privacy. During an interview on 08/12/24 at 10:00 AM, The Administrator stated, Well, us who work here know when shower time is. We just usually know when it is in use. The Administrator confirmed that there was no lock on the door, or in use signage.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #9 and #36, follow a physician's order regarding adaptive equipment for Resident #8, and completing an intervention per the physician for a possible resident to resident altercation for Resident #35. This was true for three (3) of 16 residents reviewed during the survey process. Resident Identifiers: #9, #36, #8 and #35. Facility Census: 62. Findings Included: a) Resident #9 On 08/13/24 at 10:30 AM, a record review was completed for Resident #9. The review found physician's orders were not being followed regarding treatments, including wound care. The following physician's orders were not completed on the following dates: --Clotrimazole-Betamethasone External Cream 1-0.05% apply to affected area topically every day shift for itching. --06/20/24 --07/02/24 --07/10/24 --Hydrocortisone External Cream 1% apply to affected areas topically every day and evening shift 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 staff interview, the facility failed to serve meals at a palatable temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the survey process. Resident identifiers #54 and #60. Facility Census 62. Findings Included: a) Food temperatures Resident #53 and #60 According to the meal timesheet hall 400 trays were brought out to the hallway at 7:45 AM During an observation on 08/13/24 at 8:00 AM, of hallway 400 it was revealed, Resident #54 and #60 were sitting in the hallway in reclining wheelchairs and their breakfast meal trays were still on the food cart. No staff were noted to be nearby and were down hall 200 passing breakfast trays. Further observation at 8:10AM of hallway 400 showed that Residents #54 and #60's breakfast trays were still on the food cart and no staff were present on the hallway. During an interview on 08/13/24 at 8:25 AM, while Residents #54 and #60's food was still on the meal cart, Nurse Aide (NA) #69 stated, We pass all trays on all halls…

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 an accurate and complete record for an acute transfer for Resident #9 and meal intake for Resident #8. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #9 and #8. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 12:00 PM, a record review was completed for Resident #9. The review found the resident had been transferred to an acute care facility on 02/22/24 . The transfer form listed the date as 07/08/23. On 08/12/24 at 12:30 PM, the Director of Nursing was notified of the incorrect transfer date. The DON stated, I will have to look into this. b) Resident #8 During a record review on 08/14/24 at 12:30 PM of Resident #8's meal intake from 06/16/24 to 08/12/24, it revealed that out of a possible 174 meals, 42 of those had no documentation. 0n 08/14/24 at 2:07PM the Nursing Home Administrator confirmed the meal intakes were not documented properly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to do a complete and thorough investigation on a possible resident to resident altercation resulting in death. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #63 and #35. Facility Census 62. Findings Included: a) Resident # 63 A record review on 08/13/24 at 9:00 AM, of Resident # 63's E Interact Change in Condition dated 01/20/24 read as follows: Another resident grabbed at this resident's sleeve and this resident lost balance and fell down. Resident landed on buttocks and the staff member caught head in hands before hitting the floor. Four staff members witnessed the fall. Further record review revealed another E Interact Change in Condition form dated 02/14/24 that read as follows: Found resident on floor in room [ROOM NUMBER], blood noted from back of head. Helmet, elbow pads, and hip pads on. 911 called, neck supported by nurse. Helmet removed. Further Record review revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to implement an intervention regarding pressure ulcers for Resident #54 and implement an intervention of wearing personal protective equipment (PPE) for Resident #50. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #54 and #50. Facility Census: 62. Findings Included: a) Resident #54 On 08/13/24 at 11:00 AM, a record review was completed for Resident #54. The review found the resident was receiving wound care for an unstagable pressure ulcer on the left heel. The care plan was reviewed regarding the wound care and pressure ulcer. The care plan listed an intervention of assist resident in turning and repositioning every 1 (one) hrs (hours) and PRN (as needed). The Director of Nursing (DON) was interviewed regarding this intervention on 08/13/24 at 1:00 PM. At this time, the DON was asked where is the documentation of the one (1) hour turning and repositioning? The DON stated, there is 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 record review and staff interview, the facility failed to update a care plan regarding an actual fall for Resident #42. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #42. Facility Census: 62. Findings Included: a) Resident #42 On 08/14/24 at 9:20 AM, a record review was completed for Resident #42. The review found the resident had an actual fall on 07/10/24 due to the bathroom floor being slippery from powder which is being used with another resident who shares the bathroom. The care plan was reviewed at this time. The care plan focus area stated, Resident is at risk for falls, R/T (related to) Weakness, Osteoarthritis, Chronic Pain, HTN (hypertension). The need for assistance with ADLs, (activities of daily living) use of meds (medications) that could cause drowsiness/dizziness. On 08/14/24 at 9:48 AM, the Director of Nursing was notified the care plan had not been revised to show an actual fall had occurred on 07/10/24. The DON stated, the care plan has not been revised to show an actual fall.

Based on observation, record review, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (4) four residents reviewed for ADL care during the survey process. Resident identifier #50. Facility Census 62. Findings Included: a) Resident #50 During an Observation on 08/14/24 at 5:00 PM, Resident #50's call light came on. Further observation at 5:10 PM, shows Resident #50's call light continues to be on. During an interview on 08/14/24 at 5:15 PM, Resident #50 stated, I need changed, I feel wet. An observation on 08/14/24 at 5:16 PM, shows Nurse Aide (NA) #71 and NA #17 entering Resident #50's room. The NA's asked Resident #50 what he needed. Resident #50 stated, I want changed NA #17 stated, I'll be back in a few minutes with your tray. The call light was then turned off and NA #71 and #17 walked out of the room. At 5:18 PM, the surveyor intervened and asked NA #71 what Resident #50 needed? NA #71 stated, Oh, I didn't hear what he said, he usually wants coffee. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview, the facility failed to provide an ongoing program of activities to meet the needs and interest of the residents. This was a random opportunity for discovery during the survey process. Resident identifier #36. Facility Census 62. Findings Included: a) Resident #36 An observation on 08/12/24 at 12:20 PM, showed Resident #36 eating her lunch in a common area in front of the nurses station. Further observation showed Resident #36 continuing to sit in the common area in front of the nurse's station with no television and/or music on at 1:30 PM, 1:45 PM, 2:25 PM and 3:00 PM. An observation on 08/13/24 at 8:30AM showed Resident #36 eating her breakfast in a common area in front of the nurses station. Further observation of Resident #36 at 10:00AM revealed Resident #36 crying in the common area in front of the nurses station. No Television/music was on at this time. Resident #36 continues to be in the common area at 11:00 AM and still appears to be upset.…

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 to provide appropriate treatment to prevent further decrease in range-of-motion for Resident #11. This was a random opportunity for discovery. Resident Identifier: #11. Facility Census: 62. Findings Included: a) Resident #11 On 08/14/24 at 3:30 PM, an interview was held with Resident #11. During the interview, Resident #11 stated, I had my shower earlier and they didn't put my splint on my hand (right). On 08/14/24 at 4:00 PM, a record review was completed for Resident #11. The review found a physician's order stating, SoftPro resting hand splint (WHFO) (wrist/hand/finger orthosis) to be applied to right hand in the morning, when patient is in her wheelchair, and to be removed in the evening, at bedtime. Skin checks to be performed pre/post WHFO application two times a day. On 08/14/24 at 5:04 PM, an additional observation of Resident #11 was made. The resident did not have the resting splint on her right hand. On 08/14/24 at 5:07 PM, an interview was held with Nurse Aide (NA) #71. The NA was asked,…

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, resident interview and staff interview, the facility failed to ensure the resident environment, over which it has control, was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 9:00 AM, the initial interview was held with Resident #9. Observations made during the interview, found multiple medications sitting on the over-the-bed table and laying on the resident's bed. Resident #9 was asked, are you allowed to have these medications in your room? The resident responded, it is okay .it is no big deal. On 08/12/24 at 9:28 AM, Registered Nurse (RN) #41 entered into the resident's room. RN #41 was asked, why does the resident have medication laying around his room? RN #41 stated, I don't know why the medication is in here .I didn't know anything about it. On 08/12/24 at 9:40 AM, the Director of Nursing (DON) was interviewed regarding the medication found in Resident #9's room. The DON stated, We don't know what he has .his…

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 interview and staff interview, the facility failed to ensure physician's visits were completed every 30 days for the first 90 days for Resident #9. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Included: a) Resident #9 On 08/12/24 at 9:00 AM, an interview was held with Resident #9. The resident stated, I want to talk to the physician about certain things and I can never see him .it's usually the nurse practitioner .sometimes it's things I want to discuss with a physician. On 08/12/24 at 11:30 AM, a record review was completed for Resident #9. The findings of the review were unclear as to when the facility physician visited the resident versus the nurse practitioner. The DON was asked for a list of the provider's visits to Resident #9. The resident was admitted to the facility on [DATE]. The physician's visits were as follows: --02/22/23 --03/22/23 --05/25/23 --06/22/23 --09/10/23 --11/26/23 --01/21/24 The physician's visits…

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 record review the facility failed to provide an effective infection control program which meets current standards of practice. This failed practice was found true for (3) of (3) residents reviewed for infection control practices during the survey process. Resident identifiers #9, #54, and #50. Facility Census 62. Findings included: a) Resident #9 During an observation on 08/12/24 at 9:45 AM, of Resident #9's bathroom revealed (2) two bed pans were in the bathtub, (1) one of the bed pains had small droppings of a brown substance in it and liquid was in the corners. The commode had Urine in it with a black ring around the top of the urine. Mixed vegetables were found on top of the stopper in the sink. During an interview on 08/12/24 at 9:50 AM, Resident #9 stated, They never clean that stuff up. They just come and do it as fast as they can. During an interview on 08/12/24 at 10:00 AM The Director of Nursing (DON) stated, Yes, this shouldn't be like this. I will get it…

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.This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 59. Findings included: a) Kitchen tour During the kitchen tour on 01/15/24 at 9:13 AM, it was discovered the second-hand washing sink did not have a trash can. The floor under the shelving unit housing the steam table pans was dirty, and the back corner of the walk-in cooler had debris on the floor. An interview with the Dietary Manager on 01/15/24 at 10:25 AM, verified the hand washing sink needed a trash can, the floor beneath the shelving unit needed to be cleaned and the back corner of the walk-in cooler needed to be cleaned.

Based on observation, facility record review, Centers for Disease Control and Prevention (CDC) review, and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These failed practices were discovered during observation of medication administration, and review if the Infection Preventionist surveillance had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #39, #43, #165, 38, #6, #113, #5, and #112. Facility census 59. Findings included: a) Medication administration a-1) Resident #39 On 01/17/24 at 8:04 AM, Licensed Practical Nurse (LPN) #59 was observed passing medication. The following medication was adminsitered to Resident #39: Abilify 10 mg Aspirin 81 mg Eliquis 5 mg Fluticasone nasal spray Lidocaine patch Methimazole 5mg Prednisolone eye drops LPN#59 failed to use a barrier when she placed the nasal…

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 record review and staff interview the facility failed to establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was true for six (6) out of nine (9) residents reviewed for antibiotic stewardship. Resident identifiers: Resident #9, #23. #4 #34, #113, and #11. Facility census 59. Findings included: a) Resident #9 A review of the line listing found Resident #9 had onset of symptoms of a Urinary Tract Infection (UTI) on 12/29/23. Resident #9 was given an antibiotic named Cipro which started on 01/02/24. There was no resolution date entered. Also, the were no results listed or if a Urinalysis (UA) was completed. Leaving it unclear if the antibiotic given was needed or the correct one for this infection. On 01/17/24 at 11:35 AM the Infection Preventionist (IP) was asked for the UA and the results. IP stated the resident was sent to the ER (a local hospital) and they are unable to get the results. b) Resident #23 A review of the line listing found Resident #23 had onset of symptoms of a Urinary Tract…

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

Based on observation record review and staff interview, the facility failed to ensure residents were treated with dignity and respect. These failed practices were a random opportunity for discovery and were true for Resident #9. Resident identifier: #9. Facility census: 59. Findings included: a) Resident #9 During the interview process of the survey on 01/15/24 at 8:10 AM. Upon entering the room, it was noted the roommate in the bed beside the window was almost finished with his breakfast. His tray was empty except for a fourth of the egg toast sandwich he was eating. While Resident #9 was trying to blindly reach for food on the tray, because the tray was not placed in front of him and was above his eye level. Resident #9 found a prepackaged cup of juice. Resident #9 was observed trying to open it for eight (8) minutes. He tried to push his finger through the top, he tried to bite it open, and then he used a spoon and finally got a hole in the top of it by using the handle of the spoon. Resident #9 drank the juice from the small hole. On 01/15/24 at 8:48 AM, Resident # 9 had managed…

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 ensure residents were free from physical restraints and evaluate resident's ability to remove physical restraints easily. This was true for two (2) of two (2) residents reviewed for restraints. Resident Identifier: #51 and #49. Facility census: 59. Findings included: a) Resident #51 Observed Resident #51 up in a Broda wheelchair with a thigh strap restraint in place and buckled in the back of the chair, on 01/15/24 at 9:08 AM. A second observation on 01/16/24 at 8:36 AM found Resident #51 up in chair with thigh strap restraint in place. A review of Resident #51's medical record on 01/16/24 at 10:32 AM found no physician's order for a Broda wheelchair with thigh positioning device/restraint. Continued review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 11/20/23. Section P, Restraints and Alarms, indicated no physical restraints were used. The Brief Interview for Mental Status (BIMS) scored a 1, which indicated severely impaired cognition.…

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 to ensure an allegation of neglect was reported when Resident #55 was burned from an e-stim patch. This was a random opportunity for discovery. Resident identifier #55. Facility Census 59. Findings included: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM revealed a scabbed area to her right lower leg. She stated, It got burnt from a E-stim patch in therapy that was defaulted. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 12/26/23 --Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to right lower leg topically everyday shift for wound for 14 Days cleanse wound, apply Silvadene and optifoam dated…

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

Based on resident interview, staff interview, and operation policy the facility failed to take actions to thoroughly investigate an alleged neglect when Resident #55 received a burn from an e-stim unit. This was a random opportunity for discovery. Resident identifier #55. Facility census: 59. Findings included: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM, revealed a scabbed area to her right lower leg. She stated, it got burnt from an E-stim patch in therapy that was defective. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score on the Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 12/26/23 --Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to right lower leg topically every day shift for wound for 14 Days cleanse wound, apply…

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 reviews and staff interviews, the facility failed to capture diagnoses upon admission and complete an updated Preadmission Screening and Resident Review (PASARR) This was true for three (3) of three (3) residents reviewed for the area of PASARR. Resident identifiers: #112, #51, and #39. Facility census: 59. Findings included: a) Resident #112 During a medical record review on 01/16/24, it was discovered the PASARR was not updated with the admission diagnosis of major depressive disorder. In an interview with the Director of Nursing (DON) on 01/16/24 at 9:37 AM, verified a new PASARR had not been completed to include the admission diagnosis of major depressive disorder. b) Resident #39 On 01/16/24, a record review of the resident's electronic medical record (EMR), the resident's most recent PASARR, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated no diagnosis of Major Depression. The record also revealed the resident had a diagnosis of Major Depression…

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 develop a person-centered 48 hour baseline care plan for urinary tract infection (UTI). This was true for one (1) of one (1) reviewed for the care area of UTI during the Long-Term Care Survey Process. Resident identifier: #56. Facility census: 59. Findings included: a) Resident #56 During a medical record review, on 01/17/24, it was discovered the baseline care plan completed within 48 hours of Resident 56's admission did not communicate the admission diagnosis of a UTI. In an interview, on with the Assistant Director of Nursing (ADON) on 01/17/24 at 03:20 PM, they verified the 48 hour baseline care plan did not include the diagnosis of UTI.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for each resident. This was true for three (3) of 17 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: Resident #58, Resident #49, and Resident #40. Facility Census: 59 Findings Include: a) Resident #58 On 01/15/24 at 10:10AM during a tour of the facility, Resident #58 was seen to in a wheelchair with a chair alarm. A review of the medical record on 01/16/24 at 8:54 AM, found Resident # 58 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 06 and lacked capacity long term. The residents comprehensive care plan review did not identify a person centered comprehensive care plan per the standards of practice for the use of the chair alarm. On 01/16/24 at 11:36AM the Director of Nursing (DON) reviewed the care plan and acknowledged the chair alarm was not included 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 revise the residents care plan in regard to tube feeding. This failed practice was true one (1) out of one (1) reviewed for tube feeding. Resident identifier: #45. Facility census 59. Findings include: a) Resident #45 During the interview process on 01/15/24 at 9:07 AM it was noted a tube feeding pump was at bedside. Record review found the tube feeding had been on hold since 11/15/23. The current care plan still contains the following: *Enteral Feed up/on at 7PM down/off at 7 AM. *Glucerna 1.5 CAL. administer Continuous via Pump 35/ml/hour for 12 hours a day if less than 75% of meals consumed. Interview on 01/17/24 at 2 PM with the Director of Nursing (DON) confirmed the enteral feeding has been on hold since 11/15/23 and agreed the care plan has not been revised to the current plan of care.

Based on observation and staff interview the facility failed to ensure the resident was correctly positioned to maximize eating abilities. These failed practices were a random opportunity for discovery and was true for Resident #9. Resident Identifier: #9. Facility census 59. Findings included: a) Resident #9 Observation on 01/15/24 at 8:10 AM, found Resident #9 was trying to blindly reach for food on his tray, because his tray was not placed in front of him and was above his eye level. Resident #9 found a prepackaged cup of juice. Resident #9 was observed trying to open it for eight (8) minutes. He tried to push his finger through the top, he tried to bite it open, and then he used a spoon and finally got a hole in the top of it by using the handle of the spoon. Resident #9 drank his juice from the small hole. On 01/15/24 at 8:48 AM, Resident # 9 had managed to move the plate cover enough to get what appeared to be scrambled eggs with his fingers. On 01/15/24 at 8:51 AM, Nurse Aide #75 was asked if Resident #9 was positioned correctly to eat. NA #75 stated no he was not and walked…

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, family interview and staff interview the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the care area of bathing/showers and assisting during mealtime. This was true for two (2) out of two (2) residents reviewed for ADLs. Resident identifiers: #45, and #9. Facility census 59. Findings Include: a) Resident #45 A medical record review found Resident #45 suffered a Cerebral Infarction, which left her totally dependent for ADL care. During a family phone interview on 01/15/24 at 12:03 PM, with the husband of Resident #45, he stated he often must bush her hair and when she was first admitted he had to cut the hair on the back of her head almost to the scalp because it was so matted up. He also stated she did not have dandruff before coming here. He went on the say many times he felt like his wife had not been showered in a while and hair is rarely washed or brushed. A review of the facility ADL sheet called the, Documentation Survey Report v2, dated for the month of January, had the following information:…

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, resident interview and staff interview, the facility failed to ensure one (1) resident received treatment and care in accordance with professional standards of practice. The facility failed to ensure a change in condition was completed or a skin issue was monitored for progression. This was a random opportunity for discovery. Resident Identifier: Resident #55. Facility Census: 59. Findings Include: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM, revealed a scabbed area to her right lower leg. She stated it got burnt from an Electrical Stimulation (E-stim) patch in therapy which was defective. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score on the Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A medical record review found it was void of information from the incident mentioned in the interview. A review of the Physician's Order Summary revealed from: 11/26/23…

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 use a psychotropic medication to treat a specific, diagnosed, and documented condition. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #58. Facility Census 59 Findings include: a) Resident #58 A review of the medical record on 01/16/24 at 8:54 AM, found Resident # 58 was admitted to the facility on [DATE] with a Brief Interview of Mentals Status (BIMS) score of six (6) and lacked capacity to make medical decisions. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/30/23 identified the resident suffering from disorganized thinking behavior, which fluctuates (comes and goes, changes in severity). Resident #58's diagnosis include: -- Alzheimer's disease -- unspecified dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, -- psychotic disturbance -- mood disturbance, and --anxiety -- cognitive…

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 a complete order for hospice services for Resident #40. This was true for one (1) of one (1) resident reviewed for the care area of hospice, during the Long-Term Care Survey Process. Resident #40 did not have a complete order for hospice. Resident identifier: 40. Facility census: 59. Findings included: a) Resident #40 During a medical record review, on 01/16/24, it was discovered the order for hospice services was incomplete. It did not include the phone contact for the hospice service provider. In an interview with the Director of Nursing (DON) on 01/16/24 at 1:30 PM, the DON verified the order for hospice was incomplete. It did not include the phone contact for the hospice provider.

Based on observation and staff interview, the facility failed to ensure the call light system device was accessible for a resident while in bed. This was a random opportunity for discovery and was true for Resident #30. Resident identifier: #30 Facility census: 59. Findings included: a) Resident #30 On 1/15/24 at 8:07 AM during a tour of the facility, Resident #30 was seen in his bed with oxygen half off his face and he was very agitated and cursing asking to see a nurse. When asked if he had called for assistance with the use of his call light, he stated it wasn't working. The call light was lying on the floor under his bed at this time. TLSH #19 was asked to come to the room for Resident #30. Team Lead Skin Health (TLSH) #19 confirmed the resident was able to operate the call light and acknowledged Resident #30's call light was lying on the floor, out of the residents reach. TLSH #19 stated Resident #30 was very agitated about some family issues which had recently occurred and because his call light was not working and on the floor. TLSH #19 stated she had called maintenance 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.

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 implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to provide activities according to their interest for Resident #47 and Resident #48 and failed to develop a care plan in a timely manner for Resident #110. This practice was found true for three(3) of five (5) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #47, Resident #48 and Resident #110 Facility Census: 62 Findings Included: a) Resident #47 During the initial tour of the facility on 10/03/22 at 10:21 AM observed Resident # 47 laying in the bed, in the dark with the privacy curtain pulled, window blinds closed, and no over bed light on. Resident #47 was holding her bed comforter tag in her hand rubbing it. There was no TV/music or other sensory…

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

Based on record review, resident interview and staff interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being in accordance with the facility assessment. This failed practice has the potential to affect more than an isolated number of residents currently resding in the facility. Resident Identifiers: Resident #53. Facility census: 62 Findings Included: a) Resident Council meeting During a resident council meeting held on 10/04/22 at 10:02 AM the following concerns were presented: Confidential interviews with the Resident group found the following concerns related to call lights: -Depends on how many is working how long it takes them to answer the call lights. -There can be one (1) Nurses Aide to a hallway or one (1) to the whole building. -Sometimes we wait up to an hour. -They turn off the call light then you wait a long time before they return if they come back at all.…

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

Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to accurately record dishwasher and resident refrigerator temperature logs. The facility also failed to keep the kitchen equipment sanitary. The facility also failed to have a one (1) inch space between the floor and ice machine drain in the kitchen and nourishment room ice machines. These failed practices had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and nourishment room. Facility census: 62. Findings Included: The Food Service Director (FSD) was not present upon entering the facility. The [NAME] was in charge of the kitchen at the time of the initial tour. a) Pantry A review of a facility policy titled Food Storage: Receiving with a revision date of 09/17 found the following. .5. All food will be appropriately labeled and…

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

Based on record review, resident and staff interview, the facility failed to ensure a resident was included in all aspects of person-centered care planning, which supported the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines. This was true for one (1) of 22 residents reviewed for care plan involvement during the survey process. Resident identifier: Resident #15 Census; 62 Findings included: a) Resident #15 An interview, with Resident #15, on 10/03/22 at 9:53 AM, revealed the resident was not aware of the care that had been planned and stated he/she had not been invited to attend any care plan meeting. A record review , showed a Minimum Data Set (MDS), completed 08/08/22, assessing the resident to have a BIMS (Brief Interview for Mental Status) to be at a score of 11, which would indicate mild impairment. Further review of the record showed two (2) care plan meeting notices had been provided to family members on 05/26/22 and 08/25/22, but there was no evidence the resident had been invited to attend or was involved…

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, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice was clinically appropriate. This deficient practice was identified during a random opportunity for discovery when Resident #53 was observed in the resident's room with an inhaler on the bedside table. Resident identifier: Resident #53. Census: 62. Findings included: a) Resident #53 A review of Policy NSG 309 Medications: Self-administration, revision date of 03/01/22, showed if a resident requests to self-administer medications they would be evaluated for safety and appropriateness. If it was determined the resident could self-administer medications, an order would be obtained , self administration and self-storage would be care planned, and capability re-evaluated initially , quarterly and with any change of condition. An observation on 10/03/22 at 10:17 AM, revealed an inhaler laying on the bedside table, in the resident's room, belonging to Resident #53. An interview with 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 resident interview, record review, and staff interview the facility failed to provide showers according to the residents preferences. This failed practice was true for one (1) of twenty-two (22) sampled residents. Resident Identifier: #26 Facility Census: 62 Findings Included: a) During the initial interview phase of the long term survey process Resident #26 complained of getting bed baths instead of showers as she preferred. According to her care plan, it is important for her to choose between a shower or a bed bath and she prefers a shower. Records indicate that she is schedule for a shower every Monday, Wednesday and Friday. Documentation shows she received seven (7) out of fourteen (14) showers schedule for the last thirty-four (34) days. She received twenty-seven (27) bed baths during this time. This was confirmed with the Director of Nursing during an interview on 10/04/22 at 4:45 PM. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview, the facility failed to assist residents to carry out Activities of Daily living (ADL's) including grooming and eating , when the resident was assessed to require assistance. This was true for one (1) of nine (9) residents reviewed for ADLs during the Long Term Care Survey Process (LTCSP). Resident #50 did not receive assitance with grooming as required. Resident identifier : Resident #50. Census: 62. Findings included: a) Policy review A review of Policy : NSG 200 Activities of Daily Living (ADLs). with a revision date of 06/11/21, showed the facility must provide the necessary care and services when a resident was unable to carry out this function, to ensure a residents ADLs, including grooming and eating, were maintained. Documentation was required every shift when ADL assistance was provided and was to be made in the medical record. b) Resident # 50 An observation of Resident #50, on 10/03/22 at 01:38 PM, revealed the resident to have an excessive…

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 respiratory care was provided in accordance with professional standards of practice for one (1) of three (3) residents who was reviewed for oxygen therapy. Physician's orders for the oxygen administration flow rate was not followed for Resident #53. Resident identifier: Resident #53. Census: 62 Findings included: a) Resident #53 Review of the Policy, titled : Oxygen Concentrator, revision date of 06/15/22, showed, under section 2. (10), the liter flow would be set per order. A record review, showed a current physician's order, dated 9/22/22, for Resident #53 to receive oxygen at one (1) Liter per minute via Nasal Cannula continuously. An observation was made of the flow rate of oxygen Resident #53 was receiving on 10/04/22 at 09:06 AM, in the presence of Director of Nursing (DON). The DON verified at this time the flow rate was set on three (3) liters per minute, when the order was for the resident to receive one (1) liter of oxygen per minute. .

Based on record review and staff interview, the facility failed to ensure a Registered (RN) was present at the facility for at least eight (8) consecutive hours a day seven (7) days a week. This had the potential to affect a limited number of residents residing at the facility. Facility census: 62. Findings Included: a) Registered Nursing hours During a review on 10/05/22 of the daily nurse staffing hours revealed on 10/02/22 there was no RN scheduled for that date. A review of the payroll time sheet for RN #64, revealed on 10/01/22 clocked in at 10:45 PM and clocked out at 7:30 AM. During an interview on 10/05/22 at 2:37 PM the Scheduling and Payroll Manager #68 stated there was no RN scheduled for Sunday because the RN # 64's name worked Saturday 11 PM to 7:15 AM. She acknowledged it was not 8 consecutive hours on Sunday 10/02/22. .

Based on observations, resident interview and staff interview the facility failed to provide menu items according to resident preference and the facility also failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: Resident #13, and Resident # 18. Facility Census: 62 Findings Included: a) Resident #13 During an interview on 10/03/22 at 10:39 AM Resident #13 stated We get a lot of soup and sandwiches, the food is never good. We never receive what we are supposed to. If the menu says chicken noodle soup we get tomato soup. The menu might say hamburger and we get a ham sandwich. During a main dining room observation on 10/03/22 at 12:22 PM the Residents' meal tray tickets stated the following: Harvest Soup Egg salad sandwich lettuce and tomato Watermelon Pasta Salad During an interview on 10/03/22 at 12:53 PM the [NAME] stated there were no tomatoes or lettuce…

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 accurately document the percentage of meal intake for the Resident. This was true for one (1) of twenty-two (22) records reviewed. Resident Identifier: #30 Facility Census: 62 Findings Included: a) According to Resident #30's care plan she is independent to extensive assistance with eating. The care plan also has interventions for participation in the restorative feeding program twice (2) a day, three (3) times a week as well as monitor intake of all meals. On 10/04/22 this surveyor witnessed Restorative Aid (RA) #9 attempt to feed Resident #30. The Resident would not wake up enough to eat. After attempting to feed the Resident for approximately fifteen (15) minutes the RA took the resident back to her room. The Resident did not eat anything. Restorative Aide #9 did not provide any documentation concerning the lunch meal However, Certified Nurse Aid (CNA) #34 documented that the resident feed herself and ate 100% of the meal. This was incorrect. CNA #34 was not in the dining room during the lunch meal and…

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.