Woodland Hills Healthcare And Rehabilitation

Based on observation, interview, and record review, the facility failed to provide consistent bathing and personal hygiene for 4 (Residents #1, #3, #4, and #5) dependent residents to maintain hygiene, prevent infection and possible skin issues. The findings are: 1. Review of Medical Diagnoses revealed Resident #1 had diagnoses of neoplasm of uncertain behavior of the brain, contracture of muscle multiple sites, and dementia. a. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2024 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 08 (08-12 indicates moderately impaired mental status) and dependent for bathing. b. Resident #1's Care Plan with a revision date of 04/23/2023 documented, .BATHING/SHOWERING: The resident requires assistance by (1-2) staff with bathing/showering 3 times weekly and as necessary . c. Resident #1's Monthly Summary dated 05/11/2024 documented Resident #1 was dependent for bathing. d. On 05/23/2024, Resident #1's Task Sheet documented Resident #1 was to have a shower every Monday, Wednesday, 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.

Based on observation, interview, and record review, the facility failed to maintain a safe and palatable food temperature for trays served to residents who receive meals in their room. The findings are: On 05/22/2024 at 11:50 AM, the temperatures of the food items on the steam table prior to lunch service were checked by the dietary staff. The following temperatures were documented: Regular and Mechanical Soft: Lasagna - 175 degrees Fahrenheit Tossed Salad - 40 degrees Fahrenheit. Garlic Bread - 160 degrees Fahrenheit Cheesecake - 40 degrees Fahrenheit Pureed: Lasagna - 170 degrees Fahrenheit Greens - 170 degrees Fahrenheit Garlic Bread - 170 degrees Fahrenheit Cheesecake - 40 degrees Fahrenheit On 05/22/2024 at 12:15 PM, during the lunch meal service, lunch trays were observed being loaded onto an open sided cart to transport to the residents on the 300 Hall who eat meals in their room. At 12:30 PM, the Dietary Manager accompanied this Surveyor down the 300 Hall, to check the temperatures on the last tray to be delivered to the 300 Hall. The temperatures were as follows: Pureed…

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 review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for Residents in Room #'s 311-B, 405-A & B, and 414-A. This failed practice had the potential to affect all 47 residents. The findings are: 2. On 11/20/23 at 11:09 AM, the Surveyor observed room [ROOM NUMBER] bathroom. There was a Blue Geri chair stored in the bathroom. The toilet had large amounts of toilet paper floating in the water, and there were brown streaks, and specks of debris visible on the sides of toilet bowl. 2a. On 11/21/23 at 8:36 AM, the Surveyor observed room [ROOM NUMBER]-B bathroom The bathroom smelled of old urine, and the toilet bowl had brown specks, and streaks of brown debris visible on the surface of the bowl. The water in the toilet bowl was cloudy and there was a liquid substance on the floor in front of the toilet, on the toilet seat, and 2 drops of liquid were on the surface of the blue Geri chair seat that was in the bathroom. 2b. On 11/21/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care to maintain oxygen equipment to ensure cleanliness and minimize risk of cross contamination or infection for 2 sampled residents (R #6 and R #29) on hall 300. The findings are: 1. Resident #6 had diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A Quarterly Minimum Data Set (QMDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 (8-12 moderately impaired cognition) requiring extensive assistance with 2-person support for bed mobility, transfers and toileting. a. A physicians order dated 9/22/23 documented, 02 [oxygen] 2LPM [liters per minute] /NC [nasal cannula] for shortness of breath hypoxia 02 2LPM/NC for c/ [complaints of] shortness of breath or 02 Sat below 90%. b. A Care Plan initiated 9/22/22 documented, .The resident has prn [when needed] oxygen therapy r/t [related to] ineffective gas exchange, shortness of breath . and .oxygen settings, O2 via nasal cannula at 2L when needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure licensed nurses demonstrated competency with necessary care, treatment, safety, and services required by each resident, as evidenced by: 1. On 11/21/23 at 8:21 AM, the Surveyor observed LPN #1 administer morning medications on hall 400. LPN #1 donned gloves, opened the medication cart drawers, and pulled out medications to give to resident in room [ROOM NUMBER]-B. LPN #1 popped the tablets from the blister pack into a medication cup sitting on top of the cart for resident in room [ROOM NUMBER]-B and dropped a pill onto the surface of the cart, picked it up, and placed it in the medication cup. The Surveyor asked LPN #1 if she had sanitized the cart prior to administering the medications. LPN #1 stated answered, No, I was feeling nauseous this morning and sick to my stomach. The Surveyor asked LPN #1 if she always wore gloves when administering medications as she wasn't wearing them yesterday. LPN #1 stated I have gout and arthritis…

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 refrigerated narcotic medications were stored in a permanently affixed container to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect all 47 residents. The facility also failed to ensure insulin bottles were dated after opening, and that insulin vials past expiration date of opening were discarded and removed from medication cart. This failed practice had the potential to affect 8 residents. The findings are: 1. On 11/21/23 at 9:39 AM, the Surveyor accompanied the Director of Nursing (DON) to the medication storage room and observed an unsecured narcotics box inside the locked refrigerator. The box contained: 2-30 milliliter [mL] bottles of Lorazepam; 1-2 mL vial of Lorazepam; 3 Single-dose 2 mL syringes of Lorazepam. 1A. On 11/21/23 at 01:40 PM, the Surveyor asked the DON, was the narcotic box attached to the refrigerator? The DON stated, No. The Surveyor asked, how should the narcotic box be stored in the refrigerator? The DON stated, I guess it…

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 that food was used prior to the use by date and that food was stored properly including the date of arrival into the facility to minimize potential for food borne illness. The failed practice had the ability to affect 65 residents who receive their meals from one of one kitchen. The findings are: On 11/20/23 at 10:20 AM, a clear plastic, 1 quart container of chocolate pudding which was observed on the top shelf of the walk-in refrigerator had a use by date of 11/09/23. A 5-pound container of sour cream which was observed on one of the middle shelves had a use by date of 9/19/23. A second container of sour cream located on the same shelf had a use by date of 10/28/23. Dietary Manager stated, I'm not sure how this happened, it seems like we just got this stuff. On 11/20/23 at 10:26 AM, a box was observed on the middle shelf of the dry storage area. The box contained approximately 85 individuals 1-ounce containers of dry cereal. The box contained no date of entry or use by date. The bottom shelf contained a 1-gallon…

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 the facility failed to ensure that the facilities binding arbitration agreement was written in a language/manner that could be understood by the resident/representative, that signatures were provided attesting to the fact that the resident/representative understood the agreement, that the resident had 30 days to resend the agreement. The failed practice had the ability to affect all 47 residents who currently reside in the facility. The findings are: On 11/21/23 at 3:04 PM, Admissions Director (AD) reports that in October 2023 the facility added two lines at the bottom of the admission agreement that allows the resident or their representative to agree to sign or decline the Arbitration. In October, 2023 the corporate office emailed the AD a two page document entitled, Purpose of Arbitration Agreements. The surveyor asked the AD, prior to October, 2023 the residents who were admitted signed the admission agreement which included a section, Arbitration, which stated, by signing this admission agreement, the Facility, Resident, Responsible party, and Guarantor agree…

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 arbitration documentation includes the selection of a neutral arbitrator and a location that is convenient for all. The failed practice had the ability to affect all 47 residents who currently reside in the facility. The findings are: On 11/21/23 at 2:00 PM, a review of the facility arbitration agreement revealed that the facility admission agreement, section f. pertains to Arbitration. On 11/21/23 at 3:04 PM, the admission Director (AD) was asked to identify the language in section f. of the admission agreement that describes the process for selecting an arbitrator and the location where the arbitration will take place. After examination the AD stated, I don't see that in there. On 11/22/23 at 7:55 AM, the Surveyor asked the Administrator to locate in section f. of the admission agreement where it describes how an arbitrator, and a location is chosen. The Administrator stated, It ' s in the new part .I didn't see it in the admission agreement. On 11/22/23 at 9:20 AM the Administrator reported that 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 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 for (F584) providing a homelike environment, (F677) providing nail care for resident dependent on staff, (F812) Sanitation and (F880) Infection Control. These failed practices had the potential to affect 47 residents. The findings are: 1. A Recertification survey was conducted on 11/22/23. During this survey, F584 was cited for facility failure to provide a safe, clean, comfortable, and homelike environment for Residents in room [ROOM NUMBER]B, #414A, #405A and #405B. A review of the facility's Plan of Correction [POC], for the recertification survey completed on 12/1/22 with a correction date of 12/31/22 indicated: Step #1: Corrective Action: the Maintenance Director observed/checked the following as identified by survey to ensure a safe, clean, and comfortable environment that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure standard infection control precautions were demonstrated during medication administration to prevent the possible transmission of communicable diseases and infections. This failed practice had the potential to affect 16 residents receiving medications on hall 400. Findings included: a. On 11/21/23 at 8:21 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 administer morning medications on hall 400. The LPN #1 donned gloves, opened the medication cart drawers, and removed medications for the resident in room [ROOM NUMBER]-B. As LPN #1 was removing the tablets from the medication blister pack into a medication cup sitting on top of cart, the LPN #1 dropped a medication tablet onto the surface of the cart, picked it up, and placed it in the medication cup. The Surveyor asked the LPN #1 if the cart had been sanitized prior to administering medications. The LPN #1 answered, no. The Surveyor asked LPN #1 what the issue was with placing the pill…

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 call lights were placed within resident's reach to allow resident to request assistance to accommodate their individual care needs for 1 (Residents #32) of 4 sampled residents (Resident #6, #27, #29, #32) who were dependent on staff for assistance. This failed practice had the potential to affect 10 residents on 300 hall who were cognitive enough to use a call light. The findings are: 1. Resident #32 had diagnoses of hemiplegia, affecting the left nondominant side and need for assistance with personal care. A Quarterly Minimum Data Set [QMDS] with an Assessment Reference Date [ARD] of 09/13/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status [BIMS]. a. On 11/20/23 at 9:50 am, the surveyor asked Resident #32 if the call light was within reach. The Resident stated, I don't even know where it is. The surveyor asked how do you get help when you need it? Resident #32 stated, I just holler at someone, I holler until somebody comes in here.…

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 fingernails were clean and trimmed to promote good grooming and hygiene for 1 (Resident #26) of 6 (Resident #6, #26, #27, #29, #32, and #47) sampled residents who were dependent on staff for nail care. This failed practice had the potential to affect 16 residents who were dependent on staff for nail care residing on 300 Hall. The findings are: 1. Resident #26 had the diagnosis of chronic kidney disease, Stage 3 and dementia, with mood disturbance and major depressive disorder. A Quarterly Minimum Data Set [MDS] with Assessment Reference Date [ARD] 11/12/23 documented . Self-Care .E. Shower/bathe self: 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently . a. On 11/20/23 at 10:55 am, Resident #26's fingernails were approximately 1/4 longer than the fingertips on all fingers, both hands. There was brown substance under the right…

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 resident required to wear a compression sleeve and glove received care and treatment in accordance with the physician's plan of care, for (Resident #6) of 1 case mix resident who had Lymphedema. The findings are: Resident #6 had diagnoses of: Personal history of malignant neoplasm of breast, Lymphedema, not elsewhere classified, and Chronic Obstructive Pulmonary Disease (COPD) A Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11 (8-12 moderately impaired cognition) requiring extensive assistance with 2 persons assist with bed mobility, transfers, and toileting. a. A physician's order dated 8/16/23 documented, Right Arm/Fingers - Check fingers for discoloration, capillary refill, cool/cold to touch, check for tightness of wrap and placement, if wrap has fallen down, pullback up. If any of the above present, contact the TX (treatment) nurse or Lymphedema clinic. b. A physician's order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility menu and policy review, the facility failed to ensure the planned, written menu was followed for residents who received meals from 1 of 1 kitchen. Specifically, the facility failed to provide milk with breakfast and/or dinner as per the menu for five days. This affected all 47 residents who resided in the facility and had a physician's order for a regular diet. Findings included: Review of a facility policy titled, Menu Substitution, dated 2019, revealed, Kitchen staff will consult with the director of food and nutrition services or designee on any needed menu substitutions. Review of a Diet Type Report, dated 12/01/2022, revealed all 47 residents were to be served a regular diet. Review of the facility's menu for a regular diet from 11/24/2022 through 11/28/2022 revealed milk was to be served to residents for breakfast and dinner each day. During an interview on 11/28/2022 at 9:05 AM, [NAME] #4 stated the facility had not had any milk since 11/24/2022. She stated…

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 observations, interviews, and facility policy review, the facility failed to food was stored properly and dishes were maintained in clean condition and in good repair in 1 of 1 facility kitchen. Specifically, the facility: - failed to ensure food stored in the walk-in refrigerator was labeled, dated, and stored off of the floor. - failed to ensure dishes and pans were allowed to air dry before stacking/storing. - failed to ensure plates used to serve resident meals were free of chips/cracks. The failed practices had the potential to affect all 47 residents who resided in the facility and received meals from the kitchen. Findings included: 1. Observations in the walk-in refrigerator on 11/28/2022 from 8:51 AM to 9:01 AM revealed the following: - A plate of salad was not dated. - Four trays of covered Styrofoam bowls were not labeled or dated as to their contents. - A cardboard box of chilled salad was stored on the floor. - Four bowls of lemon meringue pie were not dated. - A plastic container of peas and potatoes was not dated. - A plastic container of an undetermined type…

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 and document review, it was determined the facility's administration failed to ensure the staff member acting as the administrator was knowledgeable regarding abuse reporting requirements, which resulted in failure to immediately report an allegation of abuse to the state survey agency (SSA) for 1 (Resident #23) of 1 resident reviewed for abuse. Additionally, the facility's administration failed to ensure a reliable system of addressing maintenance concerns was in place during a period when no maintenance staff were employed. The failed practices had the potential to affect all 47 residents who resided in the facility. Findings included: Review of the facility's Job Description for the administrator position revealed, The primary purpose of your job position is to direct the day to day functions of the facility in accordance with current Federal, State and local standards, guidelines, and regulations that govern the Long Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all…

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 facility document review, the facility's governing body failed to employ a licensed facility administrator to be responsible for managing the facility for the period of September 2022 through 12/01/2022. This deficient practice had the potential to affect all 47 residents residing in the facility. Findings included: Review of the facility's Job Description for the administrator position revealed, The primary purpose of your job position is to direct the day to day functions of the facility in accordance with current Federal, State and local standards, guidelines, and regulations that govern the Long Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all times. During an interview on 11/28/2022 at 8:35 AM, when the survey team entered the facility, the Social Services Director/Manager with Administrative Duties (SSD/MAD) stated she was the Acting Administrator, and the facility was operating on Consultant (CST) #16's administrator…

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, interviews, and facility policy review, the facility failed to ensure 3 (Residents #4, #21, and #40) of 3 sampled residents reviewed for care plan participation were invited to attend care plan conferences to afford the residents the opportunity to participate in planning their care. Findings included: Review of an undated facility policy titled, Woodland Hills Policy and Procedure for Care Plans, revealed, Residents and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Care Plan. Further review of the policy revealed 4. The Interdisciplinary Team will review the plan of care at CCP [comprehensive care plan] meeting with the resident and his/her representative. 5. The resident and/or representative will be offered a Care Plan Summary during the Admission, Annual, and/or Significant Change Care Plan review meetings and upon request. 1. A review of an admission Record revealed Resident #4 had diagnoses including…

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 facility policy review, the facility failed to ensure walls in residents' rooms were maintained in good repair in order to provide a clean and homelike environment for residents who resided on 2 (100 Hall and 400 Hall) of 3 halls observed. Findings included: Review of an undated facility policy titled, Resident Rights, revealed, The facility must provide a safe, clean, comfortable, home-life environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services. 1. Review of an admission Record revealed the facility admitted Resident #44 on 01/15/2021. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident was severely cognitively impaired. During a concurrent observation and interview on 11/28/2022 at 10:31 AM, Resident #44, who resided on the 100 Hall,…

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, interviews, and facility policy review, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the potential spread of influenza. Specifically, the facility failed to ensure proper signage was posted on residents' doors to indicate which personal protective equipment (PPE) should be in utilized in the rooms of 7 (Residents #8, #26, #203, #42, #5, #32, and #6) of 2 residents reviewed for isolation precautions. Findings included: Review of a facility policy titled, Chapter 21 Managing Infections, dated 01/2014, revealed, Droplet Precautions In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets larger than 5 microns in size that can be generated by the individual coughing, sneezing, talking, or by the performance of such procedures as suctioning). The policy included a list of infections that required droplet precautions, and influenza was on 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, interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state survey agency (SSA) within the required timeframe for 1 (Resident #23) of 1 sampled resident reviewed for abuse. Specifically, the facility received a report of alleged abuse involving Resident #23 on 11/27/2022 but failed to report the allegation to the SSA until 11/29/2022. Additionally, the facility failed to ensure its abuse reporting policy and procedure addressed the federally required timeframes for reporting allegations of abuse. Findings included: A review of an admission Record revealed Resident #23 had diagnoses including generalized anxiety disorder, need for assistance with personal care, muscle wasting and atrophy, cognitive communication deficit, Parkinson's disease, and pain. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #23 scored 7 on a Brief Interview for Mental Status (BIMS), which indicated severe…

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 facility policy review, the facility failed to ensure a resident who required extensive assistance with personal hygiene was regularly offered trimming or shaving of facial hair and trimming of nails to maintain good grooming and hygiene for 1 (Resident #44) of 2 sampled residents reviewed for activities of daily living (ADLs). Findings included: Review of a facility policy titled, Chapter 9 Personal Care, dated January 2014, revealed the purpose of Care of Fingernails/Toenails was, to clean the nail bed, keep nails trimmed, and to prevent infections. According to the policy, Nail care includes daily cleaning, filing and/or regular trimming. Proper nail care can aid in skin problem around the nail bed. Additionally, the policy indicated the purpose of Shaving the Resident was to promote cleanliness and to provide skin care. Review of an admission Record revealed Resident #44 had diagnoses that included unspecified dementia, major depressive disorder, lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure a monitoring for side effects of psychoactive medications was consistently provided and documented for 1 (Resident #4) of 4 sampled residents reviewed for psychoactive medications. Findings included: Review of a facility policy titled, Depression, dated 01/2014, revealed, The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. Review of an admission Record revealed Resident #4 had diagnoses including other recurrent depressive disorders and insomnia (trouble falling or staying asleep). A review of an annual Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident received an antidepressant medication on seven days during the seven-day…

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.