Arkansas Veterans Home At Fayetteville

Based on observation, interview, and record review, the facility failed to ensure resident individualized care plan was updated to ensure appropriate care was received for 1 (Resident #2) of 1 sampled resident who had a new service or level of care ordered or provided. The findings are: 1. On 01/22/24 at 4:49 PM, surveyor observed R (#2) had oxygen at 3 liters via nasal cannula being administered while resident was lying in his bed. 2. On 01/23/24 at 10:24 AM, surveyor observed R (#2) with oxygen being administered at 3 liters nasal cannula while resident was up in his chair. 3. On 01/23/23 at 2:50 PM, surveyor did a record review of care plan for R (#2) and noted there was no entry in care plan for resident to have oxygen administered. 4. On 01/25/24 at 8:50 AM, surveyor interviewed Minimum Data Set (MDS) coordinator, how do you know when to care plan something when it is added to a resident care. MDS confirmed, in our morning meetings we discuss it also I print out new orders, fall summary and risk data sheet each day. Who is responsible for care planning new interventions, MDS…

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, record reviews, and interviews, the facility failed to ensure Certified Nursing Assistants (CNA's) and Licensed Practical Nurses (LPN's) were able to demonstrate competency in identifying, reporting, and investigating injuries of unknown sources for 1 (Resident #27) of 1 sampled residents; and failure to report injury to residents during care for 1 (Resident #11) of 1 sampled residents, to prevent possible further injury or harm, and to rule out possible abuse. This failed practice had the potential to affect 49 residents. The findings are: Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, specified, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician on call when there has been a (an):…

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 1 (Resident #3) of 1 resident that was reviewed for unnecessary medication did not receive a PRN (as needed) medication pass 14 days without justification, and an evaluation revision by the doctor. The findings are: 1. On 1/25/24 at 10:38 AM, a review of Resident #3 records indicated he had a diagnosis of hypertensive heart disease, diastolic congestive heart failure, Post Traumatic Stress Disorder, and anxiety disorder. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 1/16/24 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact.) A review of the December 2023 physician order documented Haloperidol every 6 hours as needed for agitation, and Lorazepam 0.5mg every 2 hours as needed for anxiety both ordered on 12/28/23. A review of January 2024 Medication Administration Record revealed that Resident # 3 still had order for Haloperidol Lactate 0.5mg every 6 hours as needed for agitation, and Lorazepam 0.5mg every 2 hours as needed for anxiety. 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 Surveyor: [NAME], [NAME] Based on Observation, Interview, and Record Review the facility failed to assure the two medication carts were free from expired medications and that the controlled substances were separately locked in a permanently affixed compartment. The findings are: On 1/24/2024 at 8:50 AM Med Cart 1, LPN #2: Biscadyl sup.10 mg filled 5/17/23 # 6 APAP sup. 650 mg filled 5/17/23 exp. 11/16/23 # 9 Biscadyl sup. 10 mg filled 9/8/22 expired 3/7/23 #5 On 1/24/2024 at 9:01 AM, the medicine room on the 6th floor the narcotic box is behind two locks, but the narcotic containers are not attached to the refrigerator shelf. The Surveyor was able to pick the narcotic boxes up and remove them from the refrigerator. On 1/25/2024 at 9:05 AM, the Surveyor handed the narcotic box to the LPN #2 asked her, what can you do with the narcotic box? The LPN #2 said, I could carry it off. Surveyor asked her if the narcotic box should be attached to the refrigerator shelf. The LPN #2 said, The narcotics are behind two locks,…

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 Surveyor: [NAME], [NAME] Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with a. Infection control procedures, b. with distributing and serving food in a sanitary manner, c. with the resident's being free of accidents/supervision/devices, d. with meeting Pre-admission screening and Resident Review (PASRR) requirements, e. with respiratory care and f. with Quality Assurance and Assessment (QAA) and Quality Assessment and Performance Improvement (QAPI) requirements. These failed practices had the potential to affect all 49 residents who resided in the facility. The findings are: 1. A Recertification and Complaint survey was conducted on 01/26/24 at the facility. During this survey, the team identified concerns with laundry, preparing, and serving food in a safe/sanitary manner, residents being free of accident…

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, and record review the facility failed to ensure staff had on appropriate Personal Protection Equipment (PPE) for 1 (Resident #18) of 4 (Residents #2, #6, #14, #18) sampled residents that were on isolation, and failed to ensure proper signage was posted outside residents rooms to advise or instruct staff and or visitors on appropriate PPE to be worn, and failed to maintain and transport linens properly by staff in the hallway, and failed to ensure clean linen and dirty linen were handled properly in the laundry room to prevent cross contamination. The findings are: 1. On 01/22/24 at 4:04 PM, Resident #18 had red tape on the side of door that had documented, 1/14/24 -1/24/24 Surveyor observed Certified Nurse Aide (CNA) go into Resident #18 ' s room without donning a gown or gloves. Surveyor observed CNA go in and touch resident and ask if he needed changed, and then left the room without washing hands. a. On 01/23/24 at 9:03 AM, the surveyor observed male Certified Nursing…

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

Based on Observation, interview and record review, the facility failed to provide mandatory in-services for the year to all staff. This failed practice had the potential to affect all 49 residents in the facility. The findings are: On 1-25-2024 at 3:03 PM, the Administrator provided proof of the in services that were completed by the staff. It lacked the 12 hours of training in a year that is needed to care for residents. On 1-26-2024 at 9:07 AM, the Surveyor asked the Director of Nursing (DON) how many hours are staff required for in-services yearly. The DON said, twelve hours. The Surveyor asked the DON why are in-services important for the staff. The DON said, Because it is repetitive and helps the staff to remember. On 1-26-2024 at 9:28 AM, the Surveyor asked the Administrator how often in-services should be performed in a facility. The Administrator said, twelve hours for Certified Nursing Assistants, maybe the other staff too. The Surveyor asked the Administrator, why do the staff need in services. The Administrator said, for continuing education and get the new information…

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 ensure a Preadmission Screening and Resident Review (PASRR) was completed before a resident was admitted to the facility for 1 (Resident #3) of 1 (Resident #3) sampled residents who required a PASRR before admission to a skilled nursing facility. The failed practice had the potential to affect 49 residents. The findings are: Resident #3 was admitted on [DATE]. He has active diagnoses of Post Traumatic Stress Disorder and anxiety disorder. A Quarterly Minimum Data Set with an Assessment Reference Date of 1/16/2024 documented the resident scored 14 (indicates cognitively intact) on a Brief Interview for Mental Status. a. On 1/24/2024 at 1:21 PM, the resident's electronic clinical record was reviewed and there was no PASRR Level I noted in record at this time. b. On 1/24/2024 at 2:55 PM, the Administrator confirmed he did not have anything on this resident, after being asked to provide a Level I or Level ll PASRR or a letter from [a screening company] 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 interview, observation, and record review, the facility failed to ensure that an order to administer oxygen was written for 1 Resident (R #2) of 1 sampled resident. Who are receiving oxygen to prevent desaturation. The findings are: 1. On 1/22/24 at 4:49 PM, surveyor observed R (#2) with oxygen via nasal canula at 3 liters per minute. 2. On 1/23/24 at 10:24 AM, surveyor observed R(#2) sitting in wheel chair with oxygen at 3liters per minute. 3. On 1/23/24 at 2:57 PM, a review of R#2 medical record, physician orders revealed there was no order for oxygen to be administered. a. On 1/25/24 at 10:41 AM, surveyor interviewed Registered Nurse (RN)#1, When a resident is receiving oxygen should they have an order. RN#1 said yes, they should. The surveyor asked, who is responsible for making sure an order is placed in the computer. RN#1 said the doctor or the nurse or whoever receives the order should put it in. b. On 1/25/24 at 10:48 AM, the surveyor interviewed Director of Nurses (DON), and asked, when a resident is receiving oxygen should they have an order? The DON said, yes,…

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 interview, the facility failed to ensure food items stored in the refrigerator, freezer, and storage area were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; failed to ensure 1 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and failed to ensure staff fully covered the mouth and nose with their mask while serving a meal. These failed practices had the potential to affect 70 residents who received meals from the kitchen (total census: 71) as documented on a list provided by the Dietary Supervisor on 10/18/2022. The findings are: 1. On 10/17/22 at 10:00 AM, The following were in the walk-in freezer: a. An opened box of sausage. The box was not covered or sealed. b. An opened box of…

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

Based on observation, record review, and interview, the facility failed to ensure meals were served on regular dinnerware to maintain a homelike environment for all residents. The failed practice had the potential to affect 70 residents who received meal trays from 1 of 1 kitchen, as observed by the Surveyors during the noon meal observation in the Dining Rooms and on room trays on the 500 and 600 Halls on 10/17/2022. The findings are: a. On 10/17/2022 at 12:49 PM, Dietary Employee #3 used paper products to serve lunch to the residents. The Surveyor asked, What was the reason the residents were served their meal in Styrofoam wares? Dietary Employee #3 stated, We have been short of staff. 1. Resident #8 had diagnoses of Type II Diabetes Mellitus and Below the left Knee Amputee. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/22 documented on a Brief Interview for Mental Status (BIMS) a score of 12 (8-12) indicates moderately impaired. The Physician's Order dated, 10/18/2022 documented Resident was to receive Regular texture, Regular consistency.…

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

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of a weight gain of 40.4 pounds to prevent possible complications for 1 (Residents # 33) of 71 residents that the facility was responsible for monitoring their weight according to a list provided by the Administrator on 10/21/2022 and failed to ensure Physician Orders were followed for therapy for 1 (Resident #49) of 6 (Resident #11, R #44, R #49, R #53, R #69, and R #272) sample selected residents with Physician Orders for therapy. The findings are: 1. Resident #33 had diagnoses of Venous Insufficiency, Cognitive Communication Deficit, Malignant Neoplasm of Prostate, and Localized Edema. The annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/11/2022 documented resident scored 7 (0-7 severely cognitively impaired) on the Brief Interview for Mental Status (BIMS), section K documented weight gain of 5% [percent] or more in the last month . 0. No or unknown. The Comprehensive Plan of Care documented, I have bilateral lower extremity localized edema .I will…

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 interview, the facility failed to ensure the resident's environment was free from accident hazards for 3 residents (Resident #9, R #13 and R #16), as evidenced by allowing Resident #13 and R #16 to have a large bottle of (mouth wash) on the countertop in their room, and R #9 had aerosol shaving cream, a bottle of hand sanitizer, and a bottle of lotion in her room, of 8 (Resident #6, R #8, R #9, R #13, R #16, R #31, R #33, and R #68) sampled residents on the Secure Unit 600 Hall who were ambulatory or propel themselves in a wheelchair according to a list provided by the Director of Nursing (DON) on 10/20/22. The findings are: 1. Resident #9 had diagnoses of Vascular dementia, Major Depressive Disorder, Anxiety, and Abnormal weight loss. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/22 documented a Brief Interview of Mental Status (BIMS) score of 0 (0-7 indicates severe cognitive impairment). a. On 10/17/22 at 11:13 AM, during initial screening rounds on the Secure Unit, R #9 was resting with eyes closed in bed with a…

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

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter collection bag was stored in a manner to prevent possible contamination and infections for 1 (Residents #64) of 1 (#64) sampled residents who have indwelling catheters according to a list provided by the Director of Nursing on 10/20/22. The findings are: 1.Resident #64 had diagnoses of Neuromuscular Dysfunction of Bladder, Retention of Urine, Stage 4 Chronic Kidney Disease, Benign Prostatic Hyperplasia and Vascular Dementia. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/23/22 documented resident scored 1 (0-7 severely cognitively impaired) on the Brief Interview for Mental Status (BIMS). Physician's Order documented, Foley Catheter size 16 Frch (French) r/t (related to) urine retention . The Comprehensive Plan of Care documented, The resident has required indwelling Foley catheter r/t (related to) neurogenic bladder and urinary retention . a. On 10/17/22 at 11:13 AM, Resident #64 in his recliner with eyes closed and his Foley catheter…

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

Based on observation, record review, and interview, the facility failed to ensure the licensed nurse checked for tube placement according to standard nursing practice prior to administering medications and scheduled feeding through a PEG (Percutaneous Endoscopic Gastrostomy) tube for 1 (Resident #55) of 1 sampled resident (Resident #55) who had a Peg Tube per a list provided by the Administrator on 10/19/22 at 11:47 AM. The findings are: Resident #55 had diagnoses of Dysphagia, Hemiplegia and Hemiparesis following Cerebral Infarction, Gastrostomy and Vascular Dementia. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/19/2022 documented the resident scored 3 (0-7 severely cognitively impaired) on the Brief Interview for Mental Status (BIMS), section K documented Feeding tube. a. The Physician's orders documented, . Flush PEG tube with 100 ml [milliliter] water AC PC [before and after medication administration before meals . give 300ml Jevity via PEG tube four times a day. May use Glucerna 1.5 if jevity 1.5 is not available four times a day . NPO…

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 interview, the facility failed to ensure respiratory care was consistent with professional standards of care to prevent potential complications for three (Resident #6, #53, and #270) of 10 (Resident #6, #8, #9, #23, #30, #53, #55, #69, #270, #272) sample residents as evidenced by oxygen tubing and humidity bottles not dated, oxygen tubing not being stored in a bag or other closed container when not in use to prevent potential contamination and not having a physician order for oxygen flow rate. This failed practice had the potential to affect 29 residents who had Physician Orders for oxygen, according to a list provided by the Director of Nursing (DON) on 10/20/22 at 1:24 PM. The findings are: 1. Resident #6 had diagnosis of Hypertension, Post-Traumatic Stress Disorder, Allergies and required Oxygen for therapeutic purposes. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/07/22 documented Resident #6 scored 9 (8-12 indicates moderately…

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 of the 8:00 AM medication pass on 10/19/22, record review and interview, the facility failed to ensure a medication error rate of less than 5% [percent] was maintained to prevent potential complications for 2 (Residents #8, and #28) of 4 residents (Resident #8, #28, #55, #60) observed during the medication pass, which resulted in medication errors. This failed practice had the potential to affect 38 residents who received medications from Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1 according to a list provided by the Administrator on 10/20/22 at 2:04 PM. The error rate was 14.29 % based on observation of 35 medications administered, with a total of 5 errors. The findings are: 1.On 10/19/22 The Surveyor observed LPN #2 on the 8:00 AM medication pass. Prior to starting, LPN #2 was instructed to let the Surveyor know if he was holding any medication or if he had already given a medication when we got to their medication pass. LPN #2 voiced understanding. a. On 10/19/22 at 8:14 AM, LPN #2 began to place medications into a pill cup for Resident #8.…

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, and record review, the facility failed to ensure the Quality Assessment and Assurance Committee (QAA) put forth good faith attempts to correct and reassess its own quality deficiencies for a homelike environment by providing meals using Styrofoam plates, bowls and cups, and plastic silverware for 70 residents who received meals from the kitchen, for proper respiratory care for 27 residents who were on oxygen therapy according to the oxygen list provided on 10/20/22 from the Director of Nursing (DON), and for timely assessments for 44 residents who had a significant change due to hospice per a list provided by the DON on 10/20/22. The findings are: a. On 10/17/22 at 12:32 PM, all residents who received meals in the dining room and in their rooms on the 500 floor and 600 floor were served in Styrofoam containers, Styrofoam bowls, Styrofoam cups and given plastic utensils. b. From 10/17/22 to 10/19/22, there were observations made of oxygen tubing and humidity bottles not dated,…

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

Based on observation, interview, and record review, the facility failed to ensure a glucometer was cleaned between residents per manufacture's recommendations for 1 (Residents #8) of 2 (#8, #13) sampled residents that the nurse on the 600 hall used the multi-use glucometer to monitor their Capillary Blood Glucose (CBG) according to a list provided by the Administrator on 10/19/22, failed to ensure clean linens and personable were covered and always kept separate from potentially contaminated linen to prevent the potential for cross contamination, and failed to ensure staff handling dirty laundry disposed of Personal Protective Equipment (PPE) immediately after completing task to help prevent the potential of cross contamination and spread of infection for 71 residents who receive their linens laundered by the facility and 68 residents who receive their personable laundered by the facility per laundry list received from Director of Nursing (DON) 10/20/22. The findings are: Resident #8 had diagnoses of Type 2 Diabetic Mellites with a recent Below the Knee Amputation, and Chronic…

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 and record review, the facility failed to ensure all aspects of Antibiotic Stewardship were conducted which included periodic review of antibiotic use by prescribing physicians was for true infections. This failed practice had the potential to affect 5 residents currently prescribed antibiotics per list received from Director of Nursing (DON) on 10/21/22. The findings are: 1. On 10/19/22 at 01:38 PM, The Surveyor conducted an Antibiotic Stewardship interview with the Infection Control and Preventionist (ICP). The ICP had an Infection Control Certificate dated 2/17/21. The Surveyor asked the ICP her process for checking and verifying antibiotics. The ICP stated the following: a. Every morning I go to report and check each antibiotic type and run the report. The ICP ran the report on her computer and the Surveyor chose R #272's antibiotic for UTI [Urinary Tract Infection] dated 10/18/22 to review. ICP tried to pull up R #272's information but could not find any. The ICP checked another location…

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 Pneumococcal Immunizations were administered to eligible residents in a timely manner and immunization records documented accurately in electronic system for 2 (Resident #31 and R #64) of 5 (R #31, R #47, R #62, R #64 and R #66) sample selected residents. This failed practice had the potential to affect the 78 residents admitted since the facility's last survey per the admission list provided by the Administrator on 10/21/22. The findings are: a. On 10/18/22 at 09:11 PM, The Surveyor reviewed five residents Immunization records in electronic records and found the following: 1. R #31 had diagnoses of Alzheimer's and Parkinson's and Electronic Records had a Pneumococcal consent signed 5/5/21 no signed Pneumococcal declination and a Pneumococcal Conjugate Vaccine (PCV13) 10/17/16 with no 2nd vaccine from the series. 2. R #64 had diagnoses of Vascular Dementia and Type 2 Diabetes Mellitus and electronic records had a Pneumococcal consent signed 5/26/22 no signed Pneumococcal declination and a PCV23 given 5/15/07 with no…

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 and record review, the facility failed to ensure COVID-19 vaccinations were provided to eligible residents and accurate immunization records were kept for consents and declinations for COVID-19 vaccinations for 3 (Resident #31, R #62, R #64) of 5 (Resident R #31, R #47, R #62, R #64, and R #66) sample selected residents. This failed practice had the potential to affect the 78 residents admitted since the facility's last survey per the admission List provided by the Administrator on [DATE]. The findings are: 1. On [DATE] at 10:15 AM, The Administrator provided the resident COVID-19 Vaccination List. 2. On [DATE] at 09:11 PM, The Surveyor reviewed five residents Immunization Records in the electronic medical records and found the following: a. R #31 had diagnoses of Alzheimer's and Parkinson's. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a SAMS (Staff Assessment of Mental Status) summary score of 3 (Indicating Severe Cognitive Impairment).…

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 proper documentation and tracking of COVID-19 vaccination status for all staff, failed to ensure the accuracy of data entered into the National Healthcare Safety Network (NHSN), and failed to ensure accuracy of COVID-19 vaccination status of staff was given to surveyors. This failed practice had the potential to affect 71 residents residing in the facility per the Census and Conditions received from the Administrator on 10/18/22. The findings are: a. On 10/17/22 at 10:15 AM, the Administrator provided a list of the staff who had COVID-19 vaccinations. b. On 10/18/22 at 9:11 PM, the Surveyor reviewed the staff COVID-19 vaccination list and found one staff with NA listed for the 2nd [second] dose of the Pfizer Vaccine series, five staff with None listed, one staff with NA in each column, and two staff listed with Pfizer or Moderna and no dates documented. c. On 10/18/22 at 2:40 PM, the Surveyor met with the Infection Control & and Preventionist (ICP) in the library, near her office on the 6th [sixth] floor and 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.

Based on interview and record review, the facility failed to ensure Significant Change Minimum Data Set (MDS) Assessments were completed for residents on hospice in the required timeframe for 1 of 1 (Resident #44) sample selected residents receiving hospice services per the Resident Matrix provided by the Administrator on 10/18/22. This failed practice had the potential to affect 44 residents that received hospice services since the facility's last survey per the hospice list provided by the Director of Nursing (DON) on 12/20/22. The findings are: Resident #44 had diagnoses of Malignant neoplasm of brain, Malignant Neoplasm of Sigmoid Colon, and Secondary malignant neoplasm of bone. Significant (Sig) (MDS) with Assessment Reference Date (ARD) of 10/3/22 scored a 13 (13-15 indicates cognitively intact). a. On 10/18/22 at 03:48 PM, the Surveyor requested a Hospice Care Plan (CP) from the Administrator. b. On 10/19/22 at 08:06 AM, The Administrator provided the Surveyor with (Named) Hospice Care Plan from the. The Care Plan documented hospice started care on 9/16/22. c. On 10/20/22 at…

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 the Preadmission Screening and Resident Review (PASRR) II evaluation process was completed in accordance with the State PASRR process for 1 (Resident # 66) of 15 (Resident #6, R #8, R #9, R #11, R #13, R #16, R #23, R #30, R #31, R #49, R #53, R #62, R #64, R #66, and R #68) sample selected residents who had a diagnosis of a Serious Mental Health Disorder and/or Intellectual Disability (ID) to ensure the resident received appropriate care and services per a list provided by the Director of Nursing (DON) on 10/20/22. The findings are: Resident #66 had diagnoses of Post-Traumatic Stress Disorder and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/22 scored a 13 (13-15 indicates cognitively intact). a. On 10/18/22 at 08:42 AM, The Surveyor reviewed electronic records, and PASRR II was not found. The Surveyor requested PASRR II from the Administrator. b. On 10/18/22 at 01:57 PM, The Administrator provided a State Designated Professional Associates letter dated 4/12/22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure a Baseline Smoking Assessment and Care Plan was completed for safety and appropriate care for 1 new admission resident (Resident #270) of 1 new admission sampled resident reviewed who smoked. This failed practice had the potential to affect eleven residents admitted since 06/26/21 who smoked according to a list provided by the Director of Nursing (DON) on 10/20/22 at 1:24 PM. The findings are: Resident #270 was admitted to the facility on [DATE] with Diagnoses of Chronic Obstructive Pulmonary Disease, Malignant Neoplasm of Unspecified part of Unspecified Bronchus, Moderate Protein-Calorie Malnutrition, and Chronic Pain Syndrome. An admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/07/22 documented a Brief Interview for Mental Status (BIMS) of 15 (Cognitively Intact), was independent for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Current tobacco use documented yes. a. On…

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

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 11 residents on mechanical soft diets and 25 residents on regular diets who received meals from the kitchenette on 500 Hall and 19 residents on regular diets and 8 residents on pureed diets who received meals from the kitchenette on 600 Hall, according to a list provided by the Dietary Supervisor on 10/18/22 at. The findings are: 1. The facility menu for week 4 Day 22, specified for the residents on mechanical soft and regular diets 3 ounces (Oz). a. On 10/19/22 at 12:26 PM, Dietary Employee (DE) #1 gave 2 small slices of ham to the residents who received regular diets on 600 Hall and the residents that received regular diets on Hall 600. At 1:12 PM all residents on 600 Hall, who received regular diets were served 2 small thin slices of ham. The menu specified for each person on regular diets to receive 2 oz.…

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 Care Plans for residents on hospice included a description of the care and services provided by hospice and the facility for 1 of 1 (Resident #44) sample selected residents receiving hospice services per the Resident Matrix provided by the Administrator on 10/18/22. This failed practice had the potential to affect 44 residents that received hospice services since the facility's last survey per the Hospice List provided by the Director of Nursing (DON) on 12/20/22. The findings are: 1. Resident # 44 had diagnoses of Malignant Neoplasm of brain, Malignant neoplasm of sigmoid colon, and Secondary malignant neoplasm of bone. Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/3/22 scored a 13 (13-15 Indicates Cognitively Intact). a. On 10/18/22 at 03:48 PM, an electronic record review of R #44's Care Plan (CP) there was no Hospice services, contract company, or services provided by hospice and facility. The Surveyor requested a Hospice CP from the Administrator. b. On 10/19/22 at 08:06…

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.