Salem Center

Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for 0ne (1) of one (1) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #72. Facility census: 84. Findings Included: a) Policy review Record review of the facility's policy titled, grievance /concern, showed: -Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern. -Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log. - Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. -Notify the person filing the grievance of resolution in a timely manner. b) Resident #72 On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated that she made a complaint about another Resident peering in her room, a…

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 have cans with uncompromised seals, dishware stored inverted or covered, supplies stored off the floor, and clean sanitized mobile utility food carts. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census. 84. Findings included: a) Kitchen tour During Initial tour on 10/23/23 at 10:44 AM found: 1- two (2) food #10 cans with dented compromised seals. 2- two (2) mobile utility carts with food on them, having old food and other debris on all three (3) shelves. 3-dish stored inverted with dust and debris in bowls and cups. 4- Items such as open paper towels in the dry storage, stored on the floor. An Interview with the Dietary Manager during initial tour verified all issues noted. She stated that she was unaware of the issues, and she would fix the issues.

Based on observation, and staff interview, the facility failed to ensure personal privacy and confidentiality of personal and medical information contained in the electronic health record. This deficient practice was based on a random opportunity for discovery for Resident #17, whose Medication Administration Record (MAR) was not secured but left open and visible for all who passed by the area to view. Resident identifier: Resident #17. Census: 84. Findings included: a) Resident #17 A review of Policy 0PS209 Privacy Rights :Patient, dated 11/28/16. noted the patient has a right to personal privacy and confidentiality of there personal and medical records. An observation of medication administration, on 10/24/23 at 08:25 AM, revealed Registered Nurse (RN) #74 prepared the medications and entered Resident #17's room to administer the medications. RN #74 failed to secure the computer screen before leaving the cart, leaving the medical and personal information of Resident #17 available to view by any passerby. The information that was in plain view, included the resident's name and room…

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

Based on record review and staff interview, the facility failed to identify a psychiatric diagnosis of depression for Resident #78. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #78. Facility Census: 84. Findings Included: a) Resident #78 On 10/24/23 at 9:43 AM, a record review was completed for Resident #78. The review found the resident was prescribed Cymbalta (antidepressant) 30mg (milligram) daily for depression with a start date of 09/22/23. The Minimum Data Set (MDS) with the assessment reference date (ARD) of 09/27/23 was reviewed and section I (psychiatric/mood disorder) found a no which indicates the resident did not have a diagnosis of depression. On 10/25/23 at 11:04 AM, an interview was held with the Director of Nursing (DON). The DON stated, there is no documented diagnosis of depression listed on the MDS. No further information was obtained during the long-term survey process.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #77. Census 84. Findings Included: a) Resident #77 On 10/16/23, a record review of the resident's electronic medical record (EMR), found the resident's admission PASARR, dated 06/09/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of schizoaffective disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 10/24/23 at 1:24 PM, an interview with the Administrator confirmed the admission PAS presented to the surveyor did not indicate a diagnosis of schizoaffective disorder and a new PAS was not completed for schizoaffective disorder upon…

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 develop and/or implement a care plan regarding refusal of care for Resident #82 and the use of a right hand splint for Resident #76. This was true for two (2) of 18 residents reviewed during the survey process. Resident Identifiers: #82 and #76. Facility Census: 84. Findings Included: a) Resident #82 On 10/23/23 at 11:15 AM, the resident was observed and appeared to be somewhat disheveled. A record review was completed on 10/23/23 at 12:16 PM. The review found multiple refusals of showers and bed baths documented. The resident had only two (2) showers documented in September, 2023 and one (1) shower and two (2) bed baths documented in October, 2023. The following dates of refusals are as follows: --09/18/23 --09/21/23 --09/27/23 --09/29/23 --09/30/23 --10/02/23 --10/03/23 --10/06/23 --10/09/23 --10/11/23 --10/16/23 --10/18/23 The care plan indicates the resident needs extensive assistance of one (1) staff member for bathing. However, the care plan does not list refusals of care under…

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 revise a care plan for one (1) of 18 sampled residents, when an assessment was made with additional information obtained regarding resident's care and or behavior. Resident #47 was known by staff to adjust/alter oxygen flow rates but this behavior was not included in the resident's care plan revision. Resident identifier: Resident #47. Census: 84. Findings included: a) Resident #47 An observation, on 10/22/23 at 12:22 PM, showed oxygen was being administered to Resident #47 at a rate of 4.5 liters/minute (L/min). During the observation, the resident's spouse revealed, Resident #47 would adjust the flow rate depending on how he was feeling. Resident #47 confirmed this. A record review revealed Resident #47 was to receive oxygen at 3.0 L/min via nasal cannula continuously as resident will allow every day and night shift. A review of the current comprehensive resident centered care plan, last review of 08/11/23, showed the resident was diagnosed with Chronic Obstructive Pulmonary Disease, and was to be…

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 follow a physician's order regarding right hand splint application for Resident #76 and complete neurological (neuro) checks after a fall for Resident #17. This was true for two (2) of 18 residents reviewed during the long-term survey process. Resident Identifiers: #76 and #17. Facility Census: 84. Findings Included: a) Resident #76 On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded, I haven't worn it since I've been out of therapy. On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on night stand. The resident was again asked, have you worn your hand splint? The resident responded, nope .they haven't put it on me. On 10/24/23 at 12:42 PM, a physician's order dated 09/06/23 was found. The physician's order stated, Patient to donn R (right) hand splint for up to 6 (six) hr/day (hours per day) or as…

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 each resident received care consistent with professional standards of practice following physician's orders to treat pressure sores. This was true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Protocol for the care area of pressure ulcers. Resident #17 was not provided the treatment in accordance with physician's orders. Resident identifier: Resident #17. Census: 84. Findings included: An interview, with Resident #17, on 10/23/23 at 1:27 PM, revealed the resident was receiving cream to an area on the back and buttocks due to having had problems with pressure ulcer development. An observation of the treatment , performed by Registered Nurse (RN) #74 on 10/24/23 at 12:30 PM, revealed RN #74, cleansed the area on Resident #17's back and buttocks with Wound cleanser and applied and Optifoam dressing to both areas. A record review , of the treatment orders, did not include an order for wound cleanser and an Optifoam dressing. for the area treated on the back 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 and staff interview, the facility failed to complete an annual performance review for Nurse Aide (NA) #66. This was true for one (1) of five (5) employees reviewed under the care area of sufficient and competent staffing. Facility Census: 84. Findings Included: a) Nurse Aide (NA) #66 A review of nursing aide requirements was completed on 10/24/23 at 1:00 PM. The review found NA #66 did not have a current performance evaluation. The last documented performance evaluation was completed in 2019. An interview with the Director of Nursing (DON) on 10/24/23 at 1:50 PM was completed. The DON stated, NA #66 has not had a performance evaluation since 2019 .she worked infrequently while going to nursing school and she was prn (as needed), now she is back. On 10/24/23 at 2:00 PM, the Administrator confirmed a performance evaluation should have been completed. No further information was obtained during the long-term survey process.

Based on record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the drug was medically necessary to treat a specific condition with behaviors monitored to ensure effectiveness of the medication prescribed. Resident #6 and Resident #78 were receiving an anti-psychotic medication, however, behavior monitoring did not contain a documented specific behavior to be observed and monitored. This failed practice was identified in two (2) of five (5) residents reviewed for unnecessary medications during the LTCSP. Resident identifier: Resident #6 and #78. Census: 84 Findings included: a) Resident #6 A record review was completed for Resident #80 on 10/25/23 at 9:54 AM. The review found the resident was taking an anti-psychotic medication (Abilify) for Schizo-affective disorder. The Medication Administration Record (MAR) was reviewed and found a physician's order for Abilify (Aripiprazole) 0.5 mg. Give 0.5 tablet by mouth one time per day for Schizoaffective. 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 medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a grievance that was reported. This practice affected one (1) of one (1), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #72. Facility census: # 84. Findings Included: a) Resident #72 On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated, she made a complaint about another Resident peering in her room, a month ago. Resident #72 stated that nothing was ever done about the issue. 10/23/23 a record review of the grievances log revealed no issues were documented for Resident #72. A continued record review of Resident #72's Quarterly 09/07/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #72 has capacity. 10/25/23 at 9:29 AM during an Interview the Social Worker (SW) #67 stated she was aware of the concern, and she stated she educated the male resident #11 and followed up with resident #72 at the time of…

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

Based on resident interview and staff interview, Resident Council grievances were not addressed timely. This is true for five of 27 reviewed. Resident identifiers #77, #63, #42, #44 and #64. Facility Census 82 Findings included; a) Resident Council On 05/17/22 02:00 PM, residents #77, #63, #42, #44 and #64 voiced that meeting after meeting the issues brought up from previous meetings are the same issues that are never addressed or resolved. Resident Council President #77 stated, for example snacks not always provided, showers not give on days assigned, foods not always hot, beds not always made timely or sheets changed after showers, water not always passed and shower rooms only has a couple showers that actually work. On 5/19/22 at 12:45 PM, interview with Activity Director (AD) concerning resident council meeting for 5/10/22 meetings under administration stated, don't feel issues get resolved timely, or they come back again later in time. AD stated, yes the residents who attended resident council on 5/10/22 meeting did voice concerns about issues not getting resolved when brought…

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

Based on record review and staff interview the facility failed to implement a care plan to address residents' medical needs for pressure ulcer care, eye eversion and the use of an anticoagulant. This was true for three (3) of 27 care plans reviewed. Resident identifiers #50, #41 and #26. Facility census: 82. Findings included: a) Resident #50 A review of Resident #50's medical record showed a diagnosis of Pressure Ulcer of right buttock, stage two (2). A physician order dated 04/01/22 stated, Cleanse stage 2 pressure ulcer of right upper buttock with wound cleanser. Pat dry. Apply thin layer of Chamosyn cream. Complete at least 2 times daily and as needed during turning and repositioning. Skin Check assessments dated 04/16/22 through 05/13/22 stated Resident had a stage 2 right upper buttocks. The care plan was reviewed with no pressure ulcer care or treatment addressed. During an Interview on 05/18/22 at 10:30 AM, Center Reimbursement Coordinator (CRC) #49 stated the pressure ulcer was not addressed on the current care plan as it appeared to have been resolved by accident 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 and record review the facility failed to ensure all resident are offered an evening snack. This failed practice has the potential to affect all residents who receive snacks from the kitchen. resident identifiers #77, #63, #42, #44 and #64. Facility Census 82 Findings included; a) Snacks On 05/17/22 2:00 PM resident council meeting concerning snacks not always being offered or being available. Resident Council President #77 stated, for example, one evening there were no snacks at all in the pantries and the kitchen was locked up so, no snacks could be obtained. There are usually no snacks for diabetics to consume. Resident Council #77 stated, around the first week of May 2022 there we no snacks available and the nursing staff put their money together to go purchase snacks at the local grocery store and spend $145.00 worth of snacks so residents could have snacks. Residents #63, #42, #44 and #64 all agreed. On 05/18/22 at 9:00 AM, interview with Dietary Manager (DM) regarding snacks and how many snacks are taken to pantry on units and how often. DM stated,…

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 policy review the facility failed to properly label and date food items stored in the refrigerators in accordance with the professional standards for food service safety. The facility failed to complete daily temperature checks for the kitchen area reach-in refrigerator. The failed practice had the potential to affect more than a limited number of residents. Facility census: 82. Findings included: A record review of the facility's policy titled Food and Nutrition Services Policies and Procedures revised date 06/15/18 stated, All foods are labeled with name of product and the date received and use by date once opened. Food and nutrition services employees observe and record equipment temperatures daily according to the Refrigerator/Freezer Temperature Standards. a) Walk-in Refrigerator An observation of the walk-in refrigerator, on 05/16/22 at 11:10 AM, showed food items that were opened or pre-made with no labels or dates. The food items were as followed: - One (1) opened container of Beef Base with no receive or use by date - One (1) metal…

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 interview, the facility failed to keep an accurate antibiotic line listing and failed to discard biohazard materials appropriately. This failed practice had the potential to more than a limited number of residents. Resident identifiers: #11, #49, and #50. Facility Census: 82 Findings included: a) Resident #11 and #49 Based on record review the antibiotic line listing was not completed in its entirety. This was confirmed with Registered Nurse (RN) #32 on 05/19/22 at 2:25 PM. On the March Line List and the 2022 Running list there are two Residents that are currently on antibiotics that are not on the line listing. They are Resident #11 and #49. Both orders are prophylactic. Resident #11 had Augmentin started on 01/10/22 with no stop date and Resident #49 had Macrobid started on 01/13/22 with no stop date. b) Resident #50 An observation on 05/16/22 at 12:52 PM showed a clear bag of brown substance laying on the floor by Resident #50's bathroom door. During an interview on 05/16/22 at 12:52 PM, Resident #50 stated that the bag was trash. 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 record review and staff interview, the facility failed to ensure one (1) of 27 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident #49 did not have a Physician Orders for Scope of Treatment (POST) form signed by the individual making decisions on behalf of the resident. Resident identifier: #49. Census: 82. Findings included: a) Resident #49 A record review showed a POST form, dated 01/14/2022. The form contained verbal consent by Resident #49's decision maker. No other update with the resident representative's signature was found. An interview, with Social Services employee #3, (SS#3) on 05/17/22 at 11:45 AM, revealed the facility had no signed POST form for Resident #49. SS #3 stated the facility felt it was adequate to obtain verbal consent and no other signature was required. An interview with the Director of Nursing (DON), on 05/18/22 at 11:57 AM, verified only verbal consent was obtained for Resident #49's POST form. It was stated further by the DON, the facility would use verbal consent…

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 random observation and interview, the facility failed to ensure a Resident's medical information was secured in a manner that protected personal, medical and health information. This was a random opportunity for discovery. Resident identifier #73. Facility census: 82. Findings Included: A review of the facility's policy titled privacy rights: Patients. Effective date 06/01/96 with revisions 11/28/16 revealed the following: --The patient has a right to personal privacy and confidentiality of his/her personal and medical records. a) Resident #73 On 05/19/22 at 10:40 AM, an observation of the computer monitor displaying an electronic medical record for Resident #73. The medication cart was left unattended, on top of the Hilltop-hall. The cart was in a place easily accessible to residents, visitors, or other unauthorized persons. On 05/19/22 at 10:42 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the information was in view. The ADON stated that resident information should never be in view of guests or visitors. She closed and locked…

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

Based on resident interview, facility documentation review and staff interview the facility failed to make efforts to resolve a resident's grievance as indicated by the actions taken to investigate the concern on the grievance form. This was a random opportunity for discovery. The failed practice was true for one (1) of one (1) grievance forms reviewed. Resident identifier: #34. Facility census: 82. Findings included: a) Resident #34 During an interview on 05/16/22 at 2:45 PM, Resident #34 stated that currently there was a grievance made against Nurse Aide (NA) #45. Resident #34 stated a grievance form was completed because NA #45 documented assistance was given to Resident #34 for a shower however Resident #34 was adamant that NA #45 did not assist with showering on two (2) separate occasions. Resident #34 stated that information on the results of grievance was wanted. Resident #34 stated the only knowledge available was Residents are only allowed two (2) showers per week. Review of the facility's grievance logs verified a grievance form dated 04/27/22. The grievance form completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, record review, facility documentation review and staff interview the facility failed to provide a resident with Activities of Daily Living (ADL) care in the form of a shower. This was true for one (1) of four (4) Residents review for ADL care. Resident identifier: # 34. Facility census: 82. Findings included: a) Resident # 34 During an interview on 05/16/22 at 2:45 PM, Resident #34 stated that currently there was a grievance made against Nurse Aide (NA) #45. Resident #34 stated a grievance form was completed because NA #45 documented assistance was given to Resident #34 for a shower however Resident #34 was adamant that NA #45 did not assist with showering on two (2) separate occasions. Resident #34 stated that information on the results of grievance was wanted. Resident #34 stated the only knowledge available was Residents are only allowed two (2) showers per week. Review of the facility's grievance logs verified a grievance form dated 04/27/22. The grievance form completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to follow physicians orders in accordance with professional standards of practice. Resident identifiers: #67 and #49. Facility Census: 82 Resident #67 a) Resident #67 has a current order for HYDROcodone-Acetaminophen Tablet 7.5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 related to PAIN, UNSPECIFIED (R52) For pain 6-10, using pain scale 0-10. According to the Medication Administration Report (MAR) he was administered the HYDROcodone-Acetaminophen Tablet 7.5-325 MG twenty one (21) times in April 2022 and May 2022 for a pain level less than six (6). This was confirmed with the Director of Nursing during an interview on 5/18/22 at 12:30 PM b) Resident #49 A record review for Resident #49 showed the resident was admitted to the facility on [DATE] with a diagnosis of Idiopathic constipation. Physician's orders included the following protocol to administer in case of Resident #49 not having bowel movement (BM)…

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 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 a medication cart unlocked and unattended. Facility Census: 82. Findings Included: A review of the facility's policy titled Storage and Expiration Dating of Medication, Biologicals. Effective date 12/01/07 with revisions 01/01/22 revealed the following: --Facility should ensure that all medications and biologicals are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. a) Hilltop Hall Medication Cart On 05/19/22 at 10:40 AM, An observation of an unlocked, unattended medication cart on the Hilltop Hall. The cart was in a place easily accessible allowing access to these medication by residents, unauthorized persons, or visitors. On 05/19/22 at 10:42 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the Medication cart was unlocked. The ADON verified that the medication cart…

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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this not possible or resident preferences indicate otherwise for 1 of 3 residents reviewed during the Long-Term Care Survey Process (LTCSP) for the area of nutrition. Resident identifiers: #49 and #9. Census: 82 Findings included: a.) Resident #49 A record review for Resident #49 showed the weight for Resident #49 on 01/13/22 to be 189.3 lbs and the resident's weight to be 170.3 lbs on 04/13/22, indicative of a 10.4 percent weight loss. The resident also had a weight of 175.5 lbs on 04/05/22 and a weight of 164.6 lbs recorded on 05/05/22 indicating a significant weight loss of 6.21 percent in one (1) month. Further review of the medical record showed a nutritional assessment noting the resident required increased nutritional needs and the facility would offer alternate food choices if less than 50%…

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 nursing assistants (NA's) received 12 annual hours of training a year including dementia training and abuse prevention. This was true for two (2) of five (5) employee files that were reviewed. Employee Identifiers: #26 and #57. Facility census: 82. Findings include: a) Employee #26 On 05/19/22 during a review of Employee #26, nursing assistant (NA), personnel record found she was hired 08/26/14. Further review of her personnel record found her list of trainings for the past 12 months found no dementia training or abuse prevention training. On 05/19/22 at 10:04 AM, during an interview with the Director of Nursing (DON), was asked if all employee training were contained within their employee file. The DON Verified that NA #26 did not have the required trainings for dementia or abuse. b) Employee #57 On 05/19/22 during a review of Employee #57, nursing assistant (NA), personnel record found he was hired 12/01/12. Further review of her personnel record found his list of trainings for the past 12 months found…

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, interview and policy review, the facility failed to ensure medications and biologicals used in the facility were stored in accordance with currently accepted professional principles. The Hilltop medication room refrigerator and medication cart was not locked and unattended. This is true for one (1) of two (2) units. Facility Census 82. Findings included: A review of the facility's policy titled Storage and Expiration Dating of Medication, Biologicals. Effective date 12/01/07 with revisions 01/01/22 revealed the following: -- Facility should ensure that all medications and biologicals are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. -- Controlled Substances stored in the refrigerator must be in a separate container and double locked. a) Hilltop Hall Medication Cart On 05/19/22 at 10:40 AM, An observation of an unlocked, unattended medication cart on the Hilltop Hall. The cart was in a place easily accessible allowing access to these medication by residents, unauthorized persons, or visitors. On…

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

Based on observation, staff interview and resident interview the facility failed to provide food preferences in a timely manner. This failed practice has the potential to affect all residents who receive nutrients from the kitchen. resident identifier #12. Facility Census 82 Findings included; a) Resident #12 food preferences On 05/16/22 at 11:20 AM interview with Resident #12 revealed the menu is not always correct and they do not always get what is on their ticket. Resident also stated they were suppose to receive tomato soup with lunch and did not receive any soup. They further stated their dislikes and likes are not on the ticket. On 05/16/22 at 11:40 AM, interview with Regional Dietary Manger (RDM) asking to see preference sheet for Resident #12 and RDM stated after looking, there is not a preference sheet for the resident. Asked when preference sheets are obtained once admitted and how often are the preference sheets updated. RDM stated, within 5 (five) days of admission and then after every 6 (six) months at the minimum. The goal is to try and update quarterly. Resident 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.