Miletree Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b) Resident #42 On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints. c) Resident #20 On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication 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 record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #10 regarding a diagnosis of diabetes mellitus, Resident #20 for the use of restraints, Resident #52 for fall interventions and meal intake and Resident #47 regarding dental care. This was true for five (5) of 15 residents reviewed during the survey process. Resident Identifiers: #10, #20, #52 and #47. Facility Census: 57. Findings Include: a) Resident #10 On 07/09/24 at 11:15 AM, a record review was completed for Resident #10. The review found the care plan was not developed regarding the diagnosis of diabetes mellitus. On 07/09/24 at 11:50 AM, the Director of Nursing (DON) confirmed the care plan did not include the diagnosis of diabetes mellitus. b) Resident #20 On 07/09/24 at 1:30PM, a record review was completed for Resident #20. The review found the care plan was not developed regarding the use of restraints. On 07/09/24 at 2:00 PM, the DON confirmed the care plan did not include the use of restraints. c1) Resident #52 On 07/12/24 at 12:00 PM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview the facility failed to maintain acceptable parameters of nutrition which are consistent with professional standards of practice. This failed practice was found true for two (2) of (2) two residents looked at for nutrition during the Long-Term Care Survey Process. Resident identifiers #9, and #52. Facility Census 57. Findings Include: a) Resident #9 An initial observation on 07/08/24 at 1:00 PM, of Resident #9 eating lunch revealed, she had only eaten about 25% of her lunch and her tray was away from her. A record review on 07/09/24 at 2:20 PM, of Resident #9's weights read as follows: 7/5/2024 16:23 138.8 pounds (Lbs) 6/4/2024 10:18 140.4 Lbs 6/3/2024 17:02 140.4 Lbs 6/3/2024 10:58 144.4 Lbs 5/4/2024 10:57 148.8 Lbs 4/2/2024 10:20 139.0 Lbs 4/1/2024 15:52 139.0 Lbs 3/1/2024 15:15 155.8 Lbs These weights show a 10.91 percent weight loss in (4) four months and a (6) six percent weight loss in one month. Further record review revealed a Nutritional…

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 record temperatures for the medication refrigerator. This was a random opportunity for discovery. Facility Census: 57. Findings Include: a) Medication Refrigerator On 07/10/24 at 9:25 AM, a tour of the medication room was completed. The tour found one (1) medication refrigerator temperatures were not being documented in June, 2024 and July, 2024. The following dates indicate no documentation had been completed: --07/08/24 PM --06/26/24 PM --06/27/24 PM --06/28/24 PM b) Facility Policy A review of the facility policy entitled, Medication and Vaccine Refrigerator/Freezer Temperatures with a revision date of 07/01/24 was reviewed on 07/10/24 at 9:35 AM. The review found under the heading, Policy, which stated, Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will checked twice a day for proper temperatures. On 07/10/24 at 9:45 AM, the Director of Nursing (DON) confirmed the refrigerator temperatures were not documented.

Based on resident interview, record review and staff interview the facility failed to assist residents in obtaining routine and emergency dental care. This failed practice was found true for (1) one of (1) one residents looked at for dental treatment during the Long-Term Care Survey Process. Resident identifier #47. Facility Census 57. Findings Include: a) Resident #47 During the initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars. During the initial observation on 07/08/24 at 4:55 PM, it was revealed Resident #47 has teeth which are in poor condition with many broken off at the gum line. A record review on 07/09/24 at 3:34 PM revealed, Resident #47 had the following care plan created on 01/14/23 related to dental care: Focus: Resident is at risk for oral health or dental care problems as evidenced by being edentulous. Goal: The resident will maintain intact oral mucous membranes as evidence by the absence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage of a bath basin, bed pan, disposal of soiled linen and transportation of personal belongings. These were random opportunities for discovery. Facility Census: 57. a) room [ROOM NUMBER]A On 07/08/24 at 1:28 PM, an observation was made in room [ROOM NUMBER]A. The observation found a used bath basin and bed pan sitting in the bathtub; a soiled washcloth was on the side of the bathtub as well as a soiled washcloth was hanging on the window seal. Nurse Aide (NA) #58 was notified and removed the bath basin, bed pan, and soiled washcloths from the room. NA #58 stated, let me take care of this. On 07/08/24 at approximately 1:45 PM, the Director of Nursing (DON) was notified and confirmed the bath basin and the bed pan were not stored correctly; and, the soiled linens were not disposed of in the correct manner. The DON stated, Hospice was just in there giving the resident a bath .the items should…

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

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service in the main dining room and for Resident #36. This was a random opportunity for discovery. Resident Identifier: #36. Facility census: 57 Findings included: a) Main Dining Room During an observation of meal services on 07/09/24 at 12:15 PM, dependent resident's trays being placed in front of them at the same time as table mates without dining limitations. The dependent resident was not assisted until all trays were served in the dining room and there was an available staff member to assist them. An interview took place at 1:36 PM with the Director of Nursing (Don). The Director of Nursing was present throughout the serving process and verified that all residents at a table should be serve at the same time and dependent residents should be assisted when their tray is placed in front of them. b) Resident #36 On 07/09/24 at 11:40 AM, an observation of Resident #36 was made during the noon meal. Occupational Therapist Aide (OTA) #71 was standing while…

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 notify the ombudsman of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 Findings Include: On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the notifications to the Ombudsman, the Director of Nursing (DON) stated, we don't have anything .the person doing the notifications didn't know it included transfers .they thought it was only discharges.

Based on record review and staff interview, the facility failed to provide bed hold notices of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the bed hold notices , the Director of Nursing (DON) stated, we don't have anything .they weren't done.

Based on record review and staff interview, the facility failed to transmit a Minimum Data Set (MDS) upon discharge of Resident #22. This was true for one (1) of one (1) residents reviewed under the care area of resident assessment. Resident Identifier: #22. Facility Census: 57. Findings Include: a) Resident #22 On 07/10/24 11:10 AM, a record review was completed for Resident #22. The review found the MDS Discharge Return Not Anticipated dated on 03/01/24 was completed but not transmitted within greater than 120 days. On 07/10/24 at 12:10 PM, an interview was held with Clinical Reimbursement Coordinator (CRC) #5. CRC #5 was notified and acknowledged the discharge MDS was completed but was not transmitted. CRC #5 stated, I don't know why it wasn't transmitted .I'll have to look into this.

Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents. This is true for 0ne (1) of three (3) residents reviewed for ADL care. Resident Identifiers: #49. Facility census: 57. Findings included: a) Resident #49 During an observation 07/08/24 at about 12:19 PM Resident #49 appeared to be unkept, with oily hair and facial hair. A continued record review of Resident #49's Significant Change, 04/18/24 Minimum Data Set (MDS), MDS Section E (Behaviors) also indicated Resident #49 does not reject care. A review of Resident #49's ADL documentation found, only two (2) showers noted in the last 30 days. On 07/10/24 at 10:03 AM the Director of Nursing verified Resident #49 did not receive all showers as scheduled.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, record review, and staff interview the facility failed to provide an ongoing activity program which meets the physical, mental and psychosocial well-being of each resident. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #13. Facility Census 57. Findings Include: a) Resident #13 During the initial interview on 07/08/24 at 3:05 PM, Resident #13 stated, I used to attend activities, I just don't anymore. I don't know why. I sometimes don't know what is going on. A record review on 07/09/24 at 9:30 AM, of Resident #13's medical record revealed, she was admitted to the facility on [DATE]. Further record review of Resident #13's Activity participation record shows during her 48 days at the facility she participated in 8 out of room group activities. A record review on 07/09/24 at 10:00 AM, of Resident #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24,…

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 follow physician's orders regarding the release of restraints. This was true for two (2) of two (2) residents reviewed under the care area of restraints. Resident Identifiers: #42 and #20. Facility Census: 57. Findings Include: a) Resident #42 On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) On 07/09/24 at 1:10 PM, a review of the Treatment Administration Record (TAR) was reviewed for June, 2024. The review found the TAR was missing documentation for the following dates: --06/18/24 2:00 PM --06/18/24 4:00 PM --06/30/24 4:00 PM On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed there was no documentation on the TAR for 06/18/24 at 2:00 PM, 4:00 PM and 06/30/24 at 4:00 PM. b) Resident #20 On 07/09/24 at 1:30 PM, a record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, staff interview and record review the facility failed to provide pain management consistent with professional standards of practice. This failed practice was found true for (1) one of (3) three residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier #43. Facility Census 57. Findings Include: a) Resident #43 During an initial interview on 07/08/24 at 2:09 PM, Resident #43 stated, My pain is an 8 or above all the time. I want a different doctor but no more are available. They won't give me pain meds to help. Resident states his pain is an 8 or above all the time. A record review on 07/09/24 at 11:37 AM, of Resident #43 orders revealed the following pain medications ordered for Resident #43. Ordered on 04/24/24 : Acetaminophen Tablet 325 milligrams (MG) Give 2 tablets by mouth every 6 hours as needed for General Discomfort Notify physician/midlevel provider if discomfort persists. Do not exceed 3g/day Ordered on 05/29/24: Naprosyn Oral Tablet 500 MG…

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 maintain an accurate and complete record regarding a transfer for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalizations. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 On 07/11/24 at 1:00 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility on 10/09/23. The transfer form indicated the resident was transferred on 10/01/23. On 07/11/24 at 1:30 PM, the Director of Nursing (DON) confirmed the date was incorrect on the transfer form. The DON stated, there was a corporate call discussing this issue .it does have the incorrect date.

Based on observation and staff interview, the facility failed to honor resident privacy when leaving an elopement binder containing resident pictures and elopement risk identification forms in the front lobby accessible to any passerby. This was a random opportunity for discovery and was true for 18 residents. Resident identifiers: #26, #51, #6, #54, #2, #53, #37, #39, #49, #34, #45, #46, #43, #111, #211, #40, #24, and #13. Faciity census: 61. Findings included: a) Elopement Binder Observation, on 03/06/23 at 10:38 AM, found the facility's elopement binder in the front lobby accessible to any passerby. The elopement binder contained resident pictures and an elopement risk identification form completed for each resident who had been deemed an elopement risk. The resident picture and the elopement risk identification form were to be provided to law enforcement and search party at the time of any resident elopement. The elopement risk identification forms included resident information like date of birth , distinguishing characteristics like colostomy bag, last known address in 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 review of facility grievances, facility reportables, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state agencies as required. This had the potential to cause more than minimal harm. This was a random opportunity for discovery. Resident identifiers: #8, #32, #44, and #56. Facility census: 61. Findings included: a) Resident #8 On 03/07/23 at 2:04 PM, a review of the facility grievance log from September 2022 through March 2023 found the following resident complaint: -On 10/13/22, Resident #8's family member asked how often resident should be being showered. She was told at least twice a week and bed baths in between those times. Resident #8's family member reported, Well, that isn't happening. The family member also reported Resident #8's teeth are not getting cleaned. During an interview on 03/08/23 at 10:10 AM, Social Worker #6 agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state…

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 monthly pharmacy medication reviews were completed by the consulting pharmacist and reviewed by the physician. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #38, #30, and #4. Facility census: 61. Findings included: a) Resident #38 A record review, completed on 03/08/23 at 3:02 PM, found the following progress notes from the consulting pharmacist: -Drug Regimen Review Documentation, dated 10/20/2022 at 6:07 PM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted. -Drug Regimen Review Documentation, dated 12/16/2022 at 10:17 AM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted. -Drug Regimen Review Documentation, dated 02/20/2023 at 10:29 AM, revealed A medication regimen review was performed- see report for comments/recommendation(s) noted. The pharmacist reports for the months of October 2022, December 2022, and February 2023 were not scanned into…

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 maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifier: #41. Facility census: 61. Findings included: a) Resident #41 On 03/08/23 at 11:00 AM observation of Licensed Practical Nurse (LPN) #83 opened the sterile tracheostomy (trach) care kit and proceeded to put on sterile gloves. After pouring hydrogen peroxide into two (2) of the sections in the trach care kit, LPN #83 removed the soiled trach dressing and proceeded to take sterile swabs, dipped into the peroxide solution and clean around the trach stoma. After removing the sterile gloves, performed hand washing and put on unsterile gloves, removed the inner cannula and placed into one of the sections…

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 medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was kept on Resident #30's medical chart. This was true for one (1) of 22 sample residents. Resident identifier: #30. Facility census: 61. Findings included: a) Resident #30 An electronic medical record review, completed on 03/06/23 at 3:14 PM, indicated that Resident #30 was admitted to the facility on [DATE]. It also identified the following details: -A Physician Determination of Capacity was on file and indicated Resident #30 had capacity to make her own medical decisions. -A WV Physician Orders for Scope of Treatment (POST) form was on file and indicated Resident #30 had reported there was a family member who had been appointed as Resident #30's Medical Power of Attorney (MPOA) in the event the resident lost capacity and could no longer make her own medical decisions. The professional who assisted in completing the form was identified as the facility's Social Worker. -There was no copy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment. This is true for two (2) of 21 sample residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #41 and #59. Facility census: 61. Findings included: a) Resident #59 A discharge medical record review of Resident #59's revealed a progress note on 1/14/23 at 9:56 AM that stated that the Resident left Against Medical Advice (AMA) with her responsible party. According to the Annual Minimum Data Set (MDS) Discharge assessment for Resident #59, with an Assessment Reference Date (ARD) 01/14/23, Section A (Identification information) was not accurately assessed for discharge return not anticipated, unplanned to an acute hospital. During an interview on 03/08/23 at 9:58 AM the Clinical Reimbursement Coordinator (CRC) Nurse confirmed Resident #59's Discharge MDS was incorrect. She stated that Resident #59 was discharged to home. b) Resident #41's History of Trauma…

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

Based on resident interview, record review, and staff interview, the facility failed to ensure a resident with decision-making capacity was informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This was true for one (1) of one (1) residents reviewed for care plans. Resident identifier: #41. Facility census: 61. Findings included: a) Resident #41 During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings or receiving a copy of the initial baseline care plan. A record review, completed on 03/07/23 at 7:45 PM, revealed: -Resident #41 had decision-making capacity. -Licensed Practical Nurse (LPN) #95, on 12/12/2022 at 9:37 AM, documented Resident #41 was out of the facility at the hospital -Social Worker #6 documented in the Post admission Patient/Family Conference Note, dated 12/12/22 at 9:46 AM, The following were in attendance: Patient, Social Services, and CRC [Clinical Research Coordinator]. Expectations: Patient's stay is expected to be Short Term.…

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 interview, the facility failed to develop and/or implement a person-centered comprehensive care plan for one (1) of 22 sample residents reviewed during the long term care survey process. A history of trauma/Post-Traumatic Stress Disorder (PTSD) was not addressed for Resident #41. Resident identifier: #41. Facility census: 61. Findings included: a) Resident #41 During an interview, on 03/06/23 at 11:26 AM , Resident #41 reported she had a history of trauma in early life affecting privacy concerns and would like to have counseling. A record review, completed on 03/07/23 at 7:45 PM, revealed: -Resident #41 was admitted to the facility on [DATE]. -A Social Services Assessment, dated 11/23/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when 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.

c) Resident #41 During an interview on 03/06/23 at 11:01 AM, Resident #41 reported she could not recall being invited to care plan meetings. A record review, completed on 03/07/23 at 7:45 PM, revealed: -Resident #41 had decision-making capacity. -LPN #95, on 12/12/2022 at 9:37 AM, documented Resident #41 was out of the facility at the hospital -Social Worker #6 documented in the Post admission Patient/Family Conference Note, dated 12/12/22 at 9:46 AM, The following were in attendance: Patient, Social Services, and CRC [Clinical Research Coordinator]. Expectations: Patient's stay is expected to be Short Term. Patient/family and IDT agree upon projected length of stay. Advance Directives not yet in place. The role of each IDT member was discussed. Discussed rehospitalization and the clinical capabilities of Center if the patient's condition changes, and the benefits of staying at the Center for treatment. Additional Information Discussed: Prior living situation, Prior level of function, Current level of function, Recent losses/traumatic events, Behavior symptoms/successful approaches,…

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 policy review, record review and staff interview, the facility failed to provide care and services in a timely fashion in accordance with acceptable standards of practice. The facility failed to obtain a resident's weight upon admission. This was true for one (1) of 22 sample residents during the annual recertification survey. Resident identifier: #261. Facility census: 61. Review of the facility's Weights and Heights Policy, with a review date of 06/15/22, instructed, Patients are weighed upon admission and/or re-admission . Findings included: a) Resident #261 On 03/06/23 at 2:29 PM, an electronic health record review revealed: -Resident #261 was admitted to the facility on [DATE]. -Resident #261's first weight was documented on 03/04/23. -A physician order, dated 03/06/24 at 1:08 PM, Weigh every day shift every Wed [Wednesday] for four (4) Weeks AND every day shift on the 1st and ending on the 5th every month. During an interview, on 03/08/23 at 8:59 AM, Licensed Practical Nurse (LPN) #58 confirmed…

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

Based on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Control program. Staff failed to wear a face shield during tracheostomy (trach) care and maintain sterile technique during trach cleaning and care. In addition, kitchen staff failed to perform hand hygiene and residents hand hygiene was not performed prior to eating. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #41, #161. Facility census: 61. Findings included: a) Resident #41 On 03/08/23 at 11:00 AM observation of Licensed Practical Nurse (LPN) #83 opened the sterile tracheostomy (trach) care kit and proceeded to put on sterile gloves. After pouring hydrogen peroxide into two (2) of the sections in the trach care kit. LPN #83 removed the soiled trach dressing and proceeded to take sterile swabs, dipped into the peroxide solution and clean around the trach stoma. After removing the sterile gloves, performed hand washing and put on unsterile gloves, removed the inner cannula and placed into one of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure a resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #41. Facility census: 61. Findings included: a) Resident #41 A medical record review, completed on 03/08/23 at 8:45 AM, revealed the following: -Resident #41 was admitted to the facility on [DATE]. -A Social Services Assessment, dated 11/23/22, revealed Resident #41 reported a history of trauma and/or Post-Traumatic Stress Disorder (PTSD). Resident answered, Quite a bit when asked in the past month, if she had repeated, disturbing memories, thoughts or images of a stressful experience from the past. Resident answered, Moderately when asked in the past month…

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, staff interview, the facility failed to have an accurate diagnosis for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for Unnecessary medications. Resident identifier: #12. Facility census: 61. Findings included: a) Resident #12 A medical record review for Resident #12 found, Physician orders: --Celexa Oral Tablet 20 MG (Citalopram Hydrobromide) Give 1 tablet by mouth one time a day for depression, with an order date 12/23/2022. --Seroquel Oral Tablet 100 MG (Quetiapine Fumarate) Give 100 mg by mouth two times a day for mood and behaviors. Order date 12/23/2022. --Seroquel Oral Tablet 200 MG (Quetiapine Fumarate) Give 200 mg by mouth at bedtime for mood and behaviors. Order date12/23/2022 --Buspirone HCl Tablet 15 MG Give 2 tablet by mouth two times a day for anxiety Give two tablets (30mg), Order date 12/23/22. Continued medical record review of Resident #12's active diagnosis list did not find diagnoses for Depression or Anxiety. On 03/08/23 at 1:25 PM during an Interview the Administrator verified Resident #12 did not…

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

Based on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 61. Findings included: a) Kitchen On 03/08/22 at 2:00 PM a review of training certificate for food handlers found: Dietary [NAME] #38 - No documentation of Food Handlers Training prior to 03/06/23. During an Interview with the District Manager on 03/08/23 at 2:20 PM, verified the staff in question did not have Food Handlers Training until this date. .

Based on observation and staff interview, the facility failed to complete labeling and dates on refrigerator items in accordance with professional standards for food service safety related to storage. This has the ability to affect a limited number of Residents that get their nutrition from the kitchen. Facility Census: 61. Findings Included: a) Kitchen During the initial kitchen tour on 03/06/23 at 11:00 AM., an observation found: --Walk-in refrigerator -a container with 3 cabbage heads, and a large container of wilted loose-leaf lettuce was not labeled or dated. During an interview on 03/06/23 at 11:12 AM., the Account Manager, confirmed the items were not labeled. She removed the lettuce at this time and labeled the container of cabbage. .

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. A Physician Order for Scope of Treatment Form (POST Form) was not filled out and the hard medical chart did not contain the updated POST form. This practice affected one (1) of (22), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #21. Facility census: # 61. Findings included: a) Resident #21 A electronic medical record review on 03/07/23 at 9:14 AM revealed, Resident #21's Post form Section D did not contain the required physician's full name , date signed, phone number or License number. A review of Resident #21's active hard chart did not contain the active/revised POST form. During an interview on 03/07/23 at 10:49 AM, the Social Worker verified the wrong POST form was on Resident #21's hard chart and the revised Post did not contain all required information in section D. .