Country Lane Manor

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interviews, the facility failed to ensure resident free from financial exploitation when a staff member didn't return change from a purchase made on behalf of a resident for 1 of 10 (Resident #3) reviewed. The facility reported a census of 46 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to follows safe sanitation and food handling practices to prevent cross contamination and foodborne illness. The facility reported a census of 51 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to prevent three deficiencies identified in the 2024 recertification from being cited again during the current recertification survey. The facility reported a census of 51 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility policy review, the facility failed to attempt to designate resident representation for 1 of 1 residents (Resident #23) with a moderate cognitive impairment and intellectual disability, to ensure medical and financial decisions were made with informed consent. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview, the facility failed to complete a self-medication assessment for 1 of 1 residents (Resident #9) who self-administered insulin. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interviews, the facility failed to allow 1 of 1 residents (Resident #28) reviewed for smoking, to choose to continue smoking after the facility changed their smoking policy to be a smoke free campus. The facility reported 51 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interview, the facility failed to notify the physician of low blood pressure results, and of persistent coughing despite a change in diet order and the administration of an as needed cough syrup for 2 of 2 residents (Resident #17 and #46) reviewed for physician notification. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, clinical record review and staff interviews the facility failed to include the use of an indwelling catheter prior to admission on the care plan for 1 of 1 residents (Resident #49) reviewed for care plans. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview, the facility failed to clarify orders for indwelling catheter care and follow up on an order for a urinalysis in a timely manner for 1 of 2 residents (Resident #49) reviewed for urinary catheters. The facility reported a census of 51 residents.

Inspectors wroteBased on attendance record review and interview, the facility failed to have the minimum required members in attendance at their Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to follow infection prevention protocols for 2 of 3 residents (Resident #9 and Resident #14) reviewed with indwelling urinary devices. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to initiate treatment for an eye infection timely and in accordance with professional standards of practice for 1 of 5 residents reviewed. (Resident #3) The facility reported census was 53.

Inspectors wroteBased on observations, food temperatures during food services, and resident interview, the facility failed to serve food in an attractive and palatable manner for 1 of 2 meals. The facility reported census was 59.

Inspectors wroteBased on clinical record review, policy review, provider and staff interviews the facility failed to implement a physician order to change a type of wound dressing for 1 of 3 residents (Resident #6) with a wounds. The facility reported a census of 57 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews the facility failed to have a consistent plan and procedure for advance directives for 6 of 25 residents reviewed. (Resident #9, #17, #19, #34, #42, and #60). The facility reported a census of 56 residents.

Inspectors wroteBased on record review, facility provided documents, and interviews the facility failed to provide sufficient qualified nursing staff to provide nursing services that meet the residents' needs safely and in a timely manner and promotes each resident's rights, physical, mental, and psychosocial well-being The facility reported a census of 56 residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide Monthly Drug Regimen Reviews for the month of July. The facility reported a census of 56 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to prevent potential for contamination when gloves were not changed at appropriate times during meal service for 1 of 1 meal services observed. The facility failed to ensure resident food had been stored at appropriate temperatures and expired food had been removed when 1 of 1 resident food refrigerators lacked a thermometer, temperature log, labels, and opened dates of food or drinks. The facility further failed to ensure dish sanitation when the dishwasher log lacked entries for safe wash and rinse temperatures and the cups used for service appeared to have a coating of white film for 1 of 1 facility dishwashers. The facility reported a census of 56 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last six months. The facility reported a census of 56 residents.

Inspectors wroteBased on observation, resident and staff interview, and clinical record review, the facility failed to ensure resident choice of caregivers had been respected for 1 of 3 residents (Resident #18) reviewed for dignity, when a caregiver continued to assist with cares following resident request otherwise. The facility reported a census of 56 residents.

Inspectors wroteBased on observation, resident and staff interview, clinical record review, and facility policy review, the facility failed to ensure accessibility of a hand washing sink and working overhead lamp in resident room for 1 of 2 residents (Resident #18) reviewed for choices. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure basic nursing principles were followed for 2 of 24 residents reviewed (Resident #9 and Resident #20). The facility readmitted Resident #9 from a hospital stay and did not ensure that the primary provider was aware of her readmission therefore this resident did not receive a number of her medications. The facility obtained an order of liquid morphine (narcotic) for Resident #20 who was on Hospice Care and actively dying. The facility did not obtain a bottle of liquid morphine for Resident #20 and gave her the medication from another resident's bottle. The facility reported a census of 56 residents.

Inspectors wroteBased on interview, clinical record review, and facility policy review, the facility failed to follow Provider's orders for indwelling catheter balloon size for 1 of 2 resident (Resident #43) reviewed for bowel and bladder incontinence. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a Gradual Dose Reduction (GDR) was trialed for 1 of 5 residents reviewed (Resident #38). A Consultant Pharmacist recommended a GDR for Duloxetine (antidepressant medication)from 40 mg (milligrams) to 30 mg for Resident #38 in November of 2023. The primary provider for Resident #38 agreed to the GDR in January of 2024. The Duloxetine was not decreased per the recommendation and approval of the provider. The facility reported a census of 56 residents.

Inspectors wroteBased on staff interview, clinical record review, and Pre-admission Screening Resident Review (PASRR) level 2 review, the facility failed to resubmit short stay approval PASRR level 2 within the appropriate time frame for 1 of 2 residents (Resident #16) reviewed for PASRR. The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, policy review, resident interview and staff interviews, the facility failed to carry out assessments and interventions for 2 of 5 residents reviewed for a change in condition (Resident #10, and #209). The facility failed to carry out assessments/interventions for a resident with a low blood sugar (#10), and failed to carry out interventions after a resident did not have a bowel movement for multiple days (#209). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews, resident interview, provider interview and clinical record review, the facility failed to implement timely interventions for residents identified at high risk for pressure ulcer development and to prevent worsening of wounds, perform thorough and consistent assessment which included wound measurements and wound description, and coordinate which staff from the clinical team staged and measured wounds for two of three residents reviewed for pressure ulcers (Resident #20, Resident #208). Resident #20 developed a deep tissue injury to the right heel and stage two pressure ulcer to the coccyx, and Resident #208 admitted with wounds not thoroughly assessed by the facility on admission, nor consistently monitored, staged, or measured following the resident's admission. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews, the facility failed to ensure an environment free of accidents and hazards for 4 of 6 residents reviewed for supervision. The facility failed to provide adequate supervision to prevent falls for Residents #42 and #18, and #19, and failed to utilize both foot pedals during wheelchair locomotion for Resident #211. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, clinical record review, policy review, staff interviews, family interview and resident interviews, the facility failed to develop and implement interventions to prevent/treat weight loss for 2 of 5 residents reviewed for nutrition (Residents #13 and #52) and failed to provide ordered supplements for 2 of 5 residents reviewed for nutrition (Residents #18 and #34). The facility reported a census of 58 residents.

Inspectors wroteBased on facility document review, staff interview and facility policy review, the facility failed to ensure a process in place to allow consistent access to resident funds outside of business hours for five of five residents who participated in the trust fund (Resident #11, #12, #27, #28, and #40). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, and the facility policy, the facility failed to provide adequate staffing to prevent a fall with injury; answer call lights in a timely manner; provide feeding and bathing assistance; and provide a bed pan to a resident before an incontinent accident for 6 of 19 residents (Residents #10, #12, #19, #28, #46, #207). The facility census 58 residents.

Inspectors wroteBased on observations, menu review, policy review, and staff interviews, the facility failed to ensure 18 of 18 residents receiving a mechanical soft diet received the correct meal portion and failed to ensure 6 of 6 residents receiving a pureed diet received food in accordance to the menu. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, facility document review, policy review, and staff interviews, the facility failed to maintain adequate kitchen sanitation and failed to follow infection control measures to prevent cross contamination during food service for 1 of 1 meal observed. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interview, and clinical record review, the facility failed to ensure a dignified dining experience when a resident was not provided assistance timely during two meal observations and was not assisted timely after the resident spilled water on themselves for one of two residents reviewed for dignity (Resident #12). The facility reported a census of 58 residents.

Inspectors wroteBased on observation, clinical record review, policy review, resident interview and staff interview, the facility failed to individualize the physical space of a resident's bathroom in order to ensure the resident maintained independent functioning, dignity, and well-being for 1 of 1 residents reviewed for accommodation of needs (Resident #16). The facility reported a census of 58 residents.

Inspectors wroteBased on resident interview, staff interviews, clinical record review, and the facility policy, the facility failed to supply the resident with a menu that provided him options for the meals for 1 of 3 residents reviewed for choices (Resident #10). The facility reported a census of 58 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to notify 1 of 3 Medicare Part A beneficiaries of coverage ending (Resident#8). The facility reported a census of 58 residents.

Inspectors wroteBased on personnel record review, staff interview, and facility policy review the facility failed to ensure staff's background checks completed prior to hire date for 1 of 5 staff; and failed to ensure the dependent adult abuse mandatory reporter training current for 1 of 5 staff reviewed (Staff C, and Staff D). The facility reported a census of 58 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) coding for 3 of 7 residents reviewed for medications (Residents #3, #18, #46) and for 1 of 1 residents reviewed with a catheter (Resident#11). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility policy review the facility failed to ensure medications were administered per physician order, failed to ensure parameters present for insulin administration for when to hold scheduled insulin dosage, failed to ensure medication dosages consistently included as part of medication orders, and failed to ensure rinse and spit following administration of a steroid inhaler for three of five residents reviewed for professional standards (Resident #11, Resident #18, Resident #50). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews, resident interviews, clinical record review, and facility policy review the facility failed to ensure activities of daily living (ADL) including eating assistance, nail care, shaving, and showers consistently completed for three of four residents reviewed for ADLs (Resident #12, #28, and #29). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review and facility policy review the facility failed to ensure catheter tubing remained off the floor, failed to accurately assess a resident for the presence of a catheter, and failed to ensure timely orders for an indwelling catheter for two of two residents reviewed for catheters (Resident #11, Resident #19). The facility reported a census of 58 residents.

Inspectors wroteBased on staff interviews, clinical record review, and the facility policy, the facility failed to ensure the resident didn't have two active orders for the same opioid medication for 1 of 1 residents reviewed for pain (Resident #208). The facility reported a census of 58 residents.

Inspectors wrote2. The MDS assessment dated [DATE] revealed Resident #13 scored a 6 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS revealed the resident received an antidepressant. The MDS revealed a diagnosis of depression. The Care Plan revealed a focus area revised on 10/27/23 for a diagnosis of depression and resident received medication for the disease process. The interventions dated 2/3/22 revealed administration of an antidepressant medication as ordered by the primary care provider (PCP). The interventions dated 1/22/24 revealed antidepressant medication decreased by PCP/GDR (gradual dose reduction); observe for signs/symptoms of increased depression and notify PCP as needed. The Physician Orders revealed the following orders: a. Duloxetine 20 mg (milligram)- give 2 tablets- ordered on 5/8/23 and discontinued on 1/20/24 b. [...]

Inspectors wroteBased on clinical record review, policy review, resident interviews and staff interviews, the facility failed to offer bedtime snacks to 2 of 2 residents who desired bedtime snacks (Residents #28 and #46). The facility reported a census of 58 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility QAPI (Quality Assurance and Performance Improvement) Plan, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last 19 months. The facility reported a census of 58 residents.

Inspectors wroteBased on facility document review, staff interview and facility policy review, the facility failed to ensure a surety bond in place to cover the total amount of personal funds in the resident trust account for five of five residents who utilized the trust fund (Resident #11, #12, #27, #28, and #40). The facility reported a census of 58 residents.

Inspectors wroteBased on observations and provider interview, the facility failed to pay it's waste management providers resulting in delayed and absent pick up. The facility reported census was 50 residents.

Inspectors wroteBased on record review, staff interviews, facility policy review, and Centers for Disease Control information the facility failed to follow proper infection control practices to mitigate the risk for the spread of infectious disease. The facility reported a resident census of 50 residents.

Inspectors wroteBased on observations, food temperatures during food services, and resident interviews, the facility failed to serve food within appropriate temperature ranges, with consistently adequate flavoring and in an attractive and palatable manner throughout 4 observed meals. Facility reported census was 50 residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents treated in a dignified manner and value the resident's right to choose to stay in bed for breakfast and still be allowed to go outside and smoke for 1 of 3 residents reviewed for resident's rights (Resident #8). The facility reported a census of 60.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to update the Care Plan and fall interventions for 3 of 3 residents reviewed for falls (Resident #2, Resident #4, and Resident #5). The facility reported a census of 60.

Inspectors wroteBased on interview, record review, and the facility policy review, the facility failed to adequately supervise a resident in a shower chair after transferred to his room which lead to the resident falling out of the shower chair for 1 of 3 residents reviewed for falls (Resident #2). The facility reported a census of 60.

Inspectors wroteBased on interview, the plan of correction and review of CMS-2567 reports, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in repeat deficiencies identified on the facility's current revisit and complaint survey previously identified during surveys completed in the last fourteen months. The facility reported a census of 60 residents.