Arlington Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and the facility's policy titled Behavior Management Program the facility failed to ensure staff implemented Resident Identifier (RI) #3's behavioral care plan approaches. RI #3 had care planned behaviors of being combative and resisting care with an approach to leave the resident alone and return later when the resident resisted care. On 03/31/2023 staff continued to provide care to RI #3 after staff observed the resident was agitated and the resident asked to be left alone. This deficient practice affected RI #3, one of 12 sampled residents whose plan of care was reviewed. Findings include: The facility's policy titled Behavior Management Program with most recent date of 02/2013 documented: .PURPOSE: To provide facilities with a standardized process for identifying, assessing, and managing residents who display mental or psychosocial adjustment difficulties. PROCESS: . II. Behavior Management Programs a) The plan of care should be developed by the interdisciplinary team. e)…

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 interview, record review and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code the resident's status on the completed Minimum Data Set (MDS) Assessment for three (3) residents (Resident #21, #25 and #94) out of 21 sampled residents. The findings include: Interview with the Director of Nursing (DON), on 4/1/21 at 3:00 p.m. revealed the facility did not have a policy to ensure MDS assessments were accurately coded. Review of the CMS RAI 3.0 User's Manual, Version 1.17.1, dated October 2019, Chapter 3, revealed under Section O Special Treatments, Procedures, and Programs, for item O0100C oxygen therapy code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. For item O0100K Hospice care code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation…

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 interview, record review and facility policy review, the facility failed to accurately document the code status of two (2) out of 24 sampled residents (Resident #17 and #94). The facility failed to properly transcribe the correct code status of Resident #17 and #94 to the Physician's Order. The findings include: Review of the facility's policy titled, Advance Directive and Refusal of Treatment, dated 11/2013, revealed the policy did not address the use of the Physician's Order for Life Sustaining Treatment (POLST) as the POLST is not considered an Advance Directive by definition of an Advance Directive. 1. Review of the Face Sheet for Resident #17 revealed admission into the facility on [DATE]. The resident's diagnoses included but were not limited to Hemiplegia following Intracerebral Hemorrhage affecting Left Non-dominant Side, Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Persistent Vegetative State, Type II Diabetes Mellitus, Dysphagia, Contact and Exposure to Other Viral Communicable…

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, interview, record review and review of a facility policy titled, Resident Privacy, the facility failed to ensure Resident Identifier (RI) #147's Foley catheter bag was in a privacy bag and not visible from the hallway on 03/21/19. This deficient practice affected RI #147, one of two residents sampled with a Foley catheter. Findings Include: A facility policy titled, Resident Privacy, dated 12/04, revealed the following: It is the policy of Ball HealthCare Services, Inc. (BHS) . that all residents have the right to personal privacy, including privacy in . medical treatment . RI #147 was admitted to the facility on [DATE] with diagnoses to include Hypertension and Pressure Ulcer of Sacral Region, Unspecified Stage. On 03/21/19 at 9:11 a.m., the surveyor observed RI #147's Foley catheter bag did not have a covering and could be seen from the hallway. RI #147's roommate was observed coming from the bathroom, passing the side of the bed where RI #147's Foley catheter could be observed. Staff 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 observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #146 had a Physician's Order for the use of Oxygen and suctioning. RI #146 was observed utilizing Oxygen at 2 liters via (by way of) nasal cannula and having suction set up at the bedside on three of four days of the survey. This deficient practice affected RI #146, one of 37 sampled residents whose Physician Orders were reviewed. Findings Include: RI #146 was admitted to the facility on [DATE], with a diagnoses of Personal History of Recurrent Pneumonia. RI #146's Problem/Need care plan titled, (RI #1) is at risk for difficulty breathing related to HX (history) of Pneumonia and diagnosis Asthma with a Problem Onset date of 03/07/19, revealed the following approaches: . * O2 (Oxygen) per NC (Nasal Cannula) as ordered *Suction as ordered . A review of RI #146's March 2019 Physicians Orders revealed RI #146 did not have an order for the O2 or suctioning. A review of RI #146's Departmental Notes revealed 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 observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #146's suction machine and Yankauer (oral suctioning tool) were covered while not in use on three of four days of the survey. This deficient practice affected RI #146, one of three residents sampled requiring suctioning. Findings Include: RI #146 was admitted to the facility on [DATE], with a diagnoses of Personal History of Recurrent Pneumonia. On 03/19/19 at 2:27 p.m., the surveyor observed a suction machine on top of RI #146's dresser. A Yankauer, which was connected to the suction machine was observed to be lying on the inside of the dresser drawer. Neither the suction machine nor Yankauer were in a covering. On 03/20/19 at 9:23 a.m., RI #146's suction machine and Yankauer, which remained on the insider of the dresser drawer, remained uncovered. 03/20/19 at 3:42 p.m., RI #146's suction machine and Yankauer remained uncovered. On 03/21/19 at 7:41 a.m., RI #146's suction machine and Yankauer, which…

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, the 2013 Food Code, and the facility's policy on Waste Disposal, the facility failed to ensure the area around the outside oil refuse receptacle was free from food related garbage and trash, so as to discourage attracting vermin. This had the potential to affect all residents in the facility, 109 of 109 residents. Findings Include: 2013 Food Code by the United States Public Health Service and Food and Drug Administration documented the following: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area . for REFUSE . shall be maintained free of unnecessary items, as specified under . 6-501.114, and clean. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: . (B) Litter. The facility's policy and procedure for Waste Disposal, last revised 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and review of a facility policy titled, Resident Privacy, the facility failed to ensure licensed staff provided privacy during suctioning and Tracheostomy care for Resident Identifier (RI) #89. This deficient practice affected RI #89, one of one resident observed during Tracheostomy care. Findings Include: A review of a facility policy titled, Resident Privacy, revealed: It is the policy .that all residents have the right to personal privacy, including privacy in accommodations, medical treatment . RI #89 was admitted to the facility on [DATE] with diagnoses including, Respiratory Failure Unspecified With Hypoxia or Hypercapnia and Tracheostomy Status. On 03/15/18 at 10:45 a.m., Employee Identifier (EI) #2, a Respiratory Therapist, was observed suctioning and providing Tracheostomy care for RI #89. The privacy curtain was not pulled and the door remained open during RI #89's medical treatment. On 03/15/18 at 2:11 p.m., an interview was conducted with EI #2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and review of facility documents titled, ADMINISTRATIVE POLICY, the facility failed to ensure a care plan was developed for the use of a psychoactive medication for Resident Identifier (RI) #16. This deficient practice affected one of 28 residents reviewed for care plans. Findings Include: A review of a facility document titled, ADMINISTRATIVE POLICY with a revised date of 09/2009, revealed: SUBJECT: Care Plans PURPOSE: Plans of Care are developed . to coordinate and communicate the plan of care for the resident. A review of a facility document titled, ADMINISTRATIVE POLICY with a revised date of 02/2013, revealed: SUBJECT: Psychoactive Medications . PROCESS: I. Unnecessary Drugs . (f)Nursing service, social service and other members of the interdisciplinary team will address behavior symptoms . in the plan of care . According to record review, RI #16 was readmitted on [DATE] with the diagnoses including, Cognitive Communication Deficit, Alzheimer's Disease 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, review of a facility policy titled, Oral and Nasal Inhalation Administration and Fundamentals of Nursing the facility failed to ensure: 1.) a Licensed Nurse remained with Resident Identifier (RI) #53 during administration of a nebulizer treatment, and 2.) Licensed Nurses followed physician's orders for flushes between medications for Resident Identifier (RI) #3 and RI #25. These deficient practices affected RI #53, RI #3 and RI #25, three of eight residents and three of seven nurses observed during medication administration observation. Findings Include: A review of a facility policy titled, Oral and Nasal Inhalation Administration, dated 8-2007 revealed: PURPOSE: To administer oral, nasal and aerosol inhalation medications in a safe and accurate manner. .III. Aerosol/Hand Held/Mask Nebulizer Therapy .d. Monitor delivery of medication until completely delivered. A review of Fundamentals of Nursing Ninth Edition, 2017, by [NAME] Stockert and Hall, Page 632…

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 observations, interviews, medical record reviews and review of a facility document titled, Standard Precautions, the facility failed to ensure licensed staff: 1. changed gloves after gastrostomy tube medication administration for Resident Identifier (RI) #3 before rinsing, drying and storing RI #3's syringe, 2. did not manipulate a paper towel dispenser lever while wearing gloves during RI #3's medication administration, and 3. rinsed and dried both pieces of RI #25's piston syringe before storing them in a plastic bag, These deficient practices affected RI #3 and RI #25, two of eight residents and two of seven nurses observed during medication pass observations. Findings Include: A review of a facility document titled, Standard Precautions revised 12/2009 revealed: Standard Precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status.POLICY INTERPRETATION AND IMPLEMENTATION: 1. Hand Hygiene .b. Wash hands immediately after gloves are removed, between…

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.