Diversicare Of Oneonta

Based on interviews, record review, and facility policy review, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I after the resident was diagnosed with a new mental illness for one (Resident #80) of three residents reviewed for PASARR completion. Findings included: A review of the facility's undated policy titled, PASRR [PASARR] Requirements, revealed, .3. In the event a resident is discharged to a 'mental health or psychiatric hospital' and returns with a new mental illness diagnosis, a new PASRR must be completed prior to or immediately upon readmission. A review of Resident #80 admission Record revealed the facility admitted Resident #80 on 10/29/2020 with diagnoses that included Depressive Disorders. Per the admission Record, on 04/29/2022, the resident received a diagnosis of Paranoid Schizophrenia and on 05/04/2022, a diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 04/13/2023, indicated Resident #80 had a Brief…

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 interviews, record review, and facility policy review, the facility failed to ensure a level I Preadmission Screening and Resident Review (PASARR) was updated with a newly developed mental illness for one (Resident #14) of three residents reviewed for PASARRs. Findings included: A review of the facility undated policy titled, PASRR (Preadmission Screening and Resident Review) [PASARR] Requirements revealed, .Guidelines: In an effort of the Health Information Management Coordinator to obtain a completed record, all patients [residents] must have a Pre-admission Screening and Resident Review prior to or immediately upon admission as required by Federal and/or a patient/resident specific review process as defined by local State guidelines. The PASRR is completed to determine provision of appropriate and needed serviced [sic] to individuals who have been diagnosed with MI/MR [mental illness/mental retardation]. Process: 1. Upon admission a PASRR must be completed timely for patients by qualified individuals . A review of Resident #14's admission Record revealed the facility…

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 interviews and record review, the facility failed to ensure treatment was provided per physician's orders for a resident who required their legs to be wrapped with a compression bandage daily due to edema for one (Resident #45) of 27 sampled residents. Findings included: A review of Resident #45's admission Record revealed the facility admitted Resident #45 on 07/16/2022 with diagnoses that included Heart Failure, Weakness, and Type Two Diabetes Mellitus. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 06/16/2023, indicated Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #45 required limited assistance with dressing and personal hygiene. A review of Resident #45's physician's orders revealed an order dated 06/15/2023 for the resident to have both of their legs tightly wrapped with a compression bandage in the morning for edema and remove at bedtime. In an interview 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 interviews, record review, and document review, the facility failed to ensure one (Resident #90) of one resident reviewed for vision/hearing was seen by the in-house optometrist as ordered by the physician. Findings included: A review of Resident #90's admission Record revealed the facility admitted the resident on 03/17/2023 with a principal diagnosis of Parkinson's Disease. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/2023, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had adequate vision. A review of Resident #90's Order Summary Report indicated a physician's order dated 06/12/2023 for an Optometrist consult for right eye for in house MD [medical doctor]. A review of a document titled [Name] Final Appointment Listings in Alabama indicated an optometrist would be in the facility on 06/23/2023 to see 19 residents. Per…

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 interview, the facility failed to ensure the physician documented a clinical rationale for continuing a psychotropic medication ordered on an as-needed (PRN) basis beyond 14 days and failed to indicate a duration on the PRN order for one (Resident #63) of five residents reviewed for unnecessary medications. Findings included: A review of Resident #63's admission Record indicated the facility admitted Resident #86 on 03/19/2021 with diagnoses that included Major Depressive Disorder, Panic Disorder, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2023, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident had Anxiety Disorder, Depression, Post-Traumatic Stress Disorder, and received antianxiety medication. A review of Resident #63's care plan, revised on 04/07/2023, indicated the resident had diagnoses that included PTSD,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interviews, and review of a facility policy tilted Specific Medication Administration Procedures Administration Procedures For All Medications the facility failed to ensure Resident Identifier (RI) #20 was provided privacy during medication administration by a licensed nurse. This affected RI #20, one of four residents observed during medication administration, and one of four licensed nurses observed during medication administration. Findings Include: A review of a facility policy titled, Specific Medication Administration Procedures Administration Procedures For All Medications, with a date of 06/15, revealed, . Procedures: . 2. Provide privacy for resident during administration of medications, . RI #20 was admitted to the facility on [DATE] with diagnoses to include Acute Respiratory Failure with Hypoxia, Other Pneumonia, Unspecified Organism, Chronic Atrial Fibrillation. On 12/09/19 at 7:15 a.m., Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), 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 observation, interviews, a review of a document provided by the facility titled Perry.[NAME] Clinical Nursing Skills & Techniques 8th Edition, the facility failed to ensure a Licensed Practical Nurse (LPN) removed her gloves and washed her hands or used an alcohol-based hand rub between giving Resident Identifier (RI) #61's oral medications and a nebulizer breathing treatment. This affected RI #61, one of four residents observed during the medication pass, and one of four licensed nurses observed during the medication pass. Findings Include: A review of a document provided by the facility titled Perry.[NAME] Clinical Nursing Skills & Techniques 8th Edition, with a copyright date of 2014, revealed . Hand Hygiene . The most important and basic technique in preventing and controlling transmission of infections is hand hygiene . If hands are not visibly soiled, use an alcohol-based hand rub . a . after having direct contact with patients . f. After contact with inanimate objects (e.g., medical equipment) in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of the facility's document titled, Peri Care Audit Tool, the facility failed to ensure peri-care was provided in a manner to prevent the potential for cross contamination when a staff wiped Resident Identifier (RI) #42 from the back to the front when providing incontinent care. This resident also has a history of urinary tract infections (UTI). This affected one of two residents observed during incontinent care. A facility document titled, Peri Care Audit Tool, revealed, Action .3.wash front to back . RI #42 was admitted to the facility on [DATE]. A record review revealed, RI #42 had diagnoses of urinary tract infection, site not specified, and dementia. Peri Care was observed on RI #42 on at 10/24/18 at 7:19 PM, with Employee Identifier (RI) #3. EI #3 wiped back to front, in the perineal area. He then went to wash his hands and placed a brief on the resident. An interview with EI #3 was conducted on 10/24/18 at 7:50 PM. EI #3 was asked, which way 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of a facility policy titled, Handwashing/Hand Hygiene, and a document titled, Peri Care Audit Tool , the facility failed to ensure: 1. Staff members did not turn the faucet off with their bare hands, and 2. Staff members wiped front to back while providing peri care. This had the potential to effect Resident Identifier (RI) #78, one of 6 residents observed during med pass and RI #42, one 2 residents observed during peri care. Findings include: A facility policy titled, Handwashing/Hand Hygiene, revised August 2015, revealed Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . Procedure . Washing Hands . 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel. RI #78 was admitted to the facility on [DATE] with diagnosis to include Type II Diabetes Mellitus. 1. A observation was made on 10/24/18 at 03:13 PM, 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.