The Blossoms At Van Buren Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 4 (Residents #28, #69, #128, and #331) sampled residents who were dependent on staff for bathing/showers, and nail care was provided for 1 (Resident #20), and oral care was provided for 1 (Resident #28) to promote good personal hygiene and grooming. The findings are: 1. An Entry Minimum Data Set (MDS) noted Resident #128 was admitted on [DATE]. On 2/12/24 at 1:23 PM, Resident #128's fingernails were long and jagged. There was a black substance under the nails. The Surveyor asked when was the last time the staff had trimmed and cleaned the fingernails. Resident #128 stated, They haven't been cleaned since I've been here. I've been here almost a week. The Surveyor asked, When was the last time you had a shower? Resident #128 stated, I haven't had one since I've been here. On 2/12/24 at 2:55 PM, Resident #128's fingernails were long and jagged. There was a black…

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 complete the required quarterly assessments for 2 (Residents # 6, and #278) of 2 sampled residents. The findings are: 1. Resident #6 had diagnoses of Heart failure, Gout; unspecified, and Vascular dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/2024 documented a Brief Interview for Mental Status [BIMS] of 11 (8-12 indicates moderate cognitive impairment), weight 209, weight loss: No/Unknown. a. On 02/12/24 at 01:54 PM, Resident #6 reported not caring for the food, it was often cold when served and alternatives were not offered. Resident #6 confirmed that an alternate meal is never offered. b. A Physician's Order for Resident #6 documented .No Added Salt diet, Regular texture, Thin Liquids consistency . c. A care plan for Resident #6 documented .Has a diagnosis of gout and is medicated and is at risk for the problems relate to this .Avoid food high in purine, such as: red meats, gravy, broth, poultry,…

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 the water temperature was maintained at a safe level to prevent burns on the 200 Hall, and failed to ensure medications were not left at bedside for 1 (Resident #278) of 1 sampled resident. The findings are: 1. On 02/12/2024 at 01:13 PM, a resident reported that the water was scalding hot on the unit on which the resident resided, the 200 Hall. The Surveyor turned the hot water on in the resident's bathroom and was only able to tolerate touching the water momentarily. On 02/13/2024 at 01:16 PM, the Surveyor requested the Maintenance Supervisor test the water temperature on the 200 Hall using the facility's test equipment. The Maintenance Supervisor reported the water temperature was 125 degrees Fahrenheit. The Surveyor asked the Maintenance Supervisor which water heaters were supplying hot water to the 200 Hall and was shown a Maintenance Room at the end of the hallway containing two water heaters. The Surveyor asked if the restrooms that were open to the residents on the 200 Unit received water from…

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 the head of the bed was elevated appropriately to decrease the potential of aspiration for 1 (Resident #53) of 1 sampled resident who required a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube passed into the stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). The findings are: Resident #53 had diagnoses of Dysphagia following cerebral infarction, Gastrostomy malfunction, and Gastrostomy. The Order Summary with an order date of 11/09/2023, showed the resident's diet was nothing by mouth; Enteral Feeding Order (Nutritional Supplement) at 60 milliliter per hour with a 30 milliliter water flush every hour. No order was found for positioning the head of the bed. The Care Plan with an initiated date of 12/11/2023, showed the resident required tube feedings for nutrition and hydration. The resident needs the head of bed (HOB) elevated 45 degrees during tube feedings. On 02/12/24 at 11:18 AM, Resident #53 was lying in bed and the head 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 oxygen was administered as ordered by the physician for 1 (Resident #428) of 10 sampled residents who had a physician's orders for oxygen; the facility failed to ensure a (portable ventilator) filter and tubing was changed weekly and dated for 1 (Resident #23) of 1 sampled resident who required the use of a (portable ventilator); the facility failed to ensure a tracheostomy collar was changed for 1 (Resident #26) of 1 sampled resident who required the use of a ventilator. The findings are: Resident # 23 diagnoses included Muscular dystrophy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/23 showed a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). The MDS indicated the resident is dependent for all activities of daily living. The Physician's Order with an active date of 10/16/22, documented .change filter to the [portable ventilator] on day shift every Saturday; Clean the [portable ventilator], change the filter and tubing, date…

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 there was Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week. The findings are: 1. Review of staffing for 8 consecutive hour work shifts showed the following: a. On 01/14/24 and 01/20/24, there was no documentation that an RN was on duty. b. On 01/21/24, there was no documentation that an RN was on duty. c. On 02/16/24 at 11:16 am, the Director of Nursing (DON) was asked, have you had any RN shortages where there is not an RN here? The DON said, no, a weekend supervisor has been hired and I have been working weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure monthly medication regimen reviews (MRR) were performed for 2 (Residents #10 and #28) of 5 (Residents #10, #26, #28, #65, and #128) sampled residents who were selected for unnecessary medication review. The findings are: 1. Resident (R) #10 was admitted to the facility on [DATE]. The Surveyor was unable to locate MRRs for R #10 in the resident's electronic health record. On 02/14/2024 at 02:00 PM, Nurse Consultant #1 provided documentation related to MRR's for R #10. R #10 did not have an MRR performed for the months of October, November, and December. Nurse Consultant #1 reported that R #1 had been hospitalized on two occasions, preventing an MRR from being performed. On 02/15/2024 at 02:45 PM, the Assistant Director of Nursing (ADON) confirmed an MRR should be performed monthly for each resident to improve resident outcomes. On 02/15/2024 at 02:55 PM, the Administrator confirmed MRR's were to be performed on a monthly basis. 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 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 (561) Self Determination (677) failed to ensure bathing services, nail care and oral care were provided for residents dependent on staff, (684) Quality of Care (695) Physician Order (PO) was followed for Use of Oxygen (O2), (727) failed to ensure a Registered Nurse (RN), worked 8 consecutive hours a day seven days a week, (847) Arbitration Agreement was explained to resident/representative. These failed practices had the potential to affect 79 residents. The findings are: 1. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F561 was cited for failure to ensure a resident got to a scheduled appointment. A review of the facility' s Plan of Correction, with a correction date of 01/27/23 indicated: a. Based on interview and record review 1/23/2023 to 1/25/2023, the facility failed to ensure residents had the right to…

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 that staff washed their hands in between residents when administering medication for 1 (Resident #53) sampled resident, failed to ensure an uncapped feeding tip was not connected to the percutaneous enteral gastrostomy (PEG) for 1 (Resident #53) sampled resident, and failed to ensure that dirty linen did not touch employee clothing. The findings are: 1. On 2/14/24 at 08:02 AM, Licensed Practical Nurse (LPN #3), went into Resident (R) #22's room to obtain vitals then returned to the medication cart without sanitizing hands before preparing medications for R #53. 2. On 2/14/24 at 08:28 AM, LPN#3 administered medication to R #53 then removed the tube feeding line hanging from the pole which was uncapped and connected to the PEG. 3. On 2/14/24 at 08:45 AM, LPN#3 was asked, What should you do after coming out of one resident room before going into another resident room to give medications? LPN#3 stated, Wash my hands. LPN #3 was 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 observation and interview, the facility failed to ensure a safe environment on the 100 Hall. This potential failed practice had the potential to affect 7 (Residents # 6, #8, 17, #51, #55, 72, and #284) sampled residents who could independently locomote. The findings are: On 02/13/24 at 02:18 PM, the 100 Hall shower room door was left half-way open with a black mesh basket hanging on the inside of the door and keys left in the doorknob for 5 minutes with staff walking around the open door and not shutting it. On 02/13/24 at 02:23 PM, the black mesh bag contained the following items four 4-ounce bottles of aftershave with aloe vera, one 4-ounce bottle of baby oil, three 1.5-ounce bottles of anti-perspirant, two 4-ounce bottles of moisturizing lotion, and 3 disposable razors. All bottles showed caution external use only, avoid contact with eyes, keep out of reach of children. The anti-perspirant label documented instructions to contact poison control if accidentally swallowed. On 02/13/24 at 02:31 PM, Certified Nursing Assistant (CNA) #5 was asked, Should the shower door be…

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 notify a resident's representative about change of services. This failed practice had the potential to affect 1 (Resident #53) of 1 sampled resident who are receiving therapy and have a power of attorney (POA). The findings are: Resident #53 had diagnoses of Muscle weakness and Lack of coordination. The Medicare 5-day Minimum Data Set with an Assessment Reference Date (ARD) of 2/2/24 documented a Brief Interview of Mental Status (BIMS) score of 00 (0 to 7 indicates severe cognitive impairment). The Physician order summary for Resident #53 documented an order for Occupational Therapy to treat five times a week for four weeks, active 2/1/24, Physical Therapy to treat five times a week for four weeks, active 1/31/24, Speech Therapy to treat three times a week for eight weeks, active 2/2/24. On 2/13/24 at 9:14 AM, the resident's POA voiced frustration about resident not being placed on therapy. On 2/14/23 at 2:20 PM, Licensed Practical Nurse (LPN) #3 was asked, Who notifies families of new orders and changes of condition? LPN…

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 provide a written discharge notice for 1 (resident #53) of 6 sampled residents who were sent to the hospital in the last month. The findings are: Resident #53 had diagnoses of Pneumonitis due to inhalation of food and vomit, Gastro-Intestinal bleed, and Gastrostomy malfunction. The Medicare 5-day Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 2/2/24 documented a Brief Interview of Mental Status (BIMS) score of 00 (0 to 7 points indicates severe cognitive impairment). On 2/13/24 at 3:00 PM, a written Bed Hold notice required to be sent to the family was not found in the resident's chart. On 2/13/24 at 4:00 PM, a written Bed Hold notice that was required to be sent to the family for the hospitalization dated 1/21/24 through 1/27/24 was requested. On 2/13/24 at 4:21PM, Nurse Consultant #1 confirmed the facility did not have the written Bed Hold notice for Resident #53.

Based on interview and record review, the facility failed to ensure accurate Minimum Data Sets were performed for 1 (Resident #55) of 25 sampled residents. The findings are: A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/11/2023 documented that Resident (R) #55 was taking an anticoagulant. The Surveyor was unable to locate a physician's order for R#55 that included an anticoagulant. On 02/14/2024 at 03:12 PM, the MDS Coordinator was asked if R#55 had been ordered an anticoagulant, and if the MDS for the resident had been coded to include an anticoagulant. The MDS Coordinator stated, Yeah, [R#55] is getting an antiplatelet. I believe the anticoagulant may have been selected by mistake. Both are selected. I'll fix that now. On 02/15/2024 at 02:45 PM, the Assistant Director of Nursing (ADON) confirmed the importance of accurate assessments to resident care. On 02/15/2024 at 02:55 PM, the Administrator acknowledged that the MDS assessment for R#55 was performed inaccurately. On 02/16/2024 at 08:58 AM, Nurse Consultant 2 reported the facility followed 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.

Based on interview and record review, the facility failed to form a baseline care plan within 48 hours of admission for 1 (Resident #67) of 25 sampled residents. The findings are: An admission Summary Progress Note for Resident (R) #67 dated 9/26/2023 at 09:46 PM documented, .Resident admitted 1450 [2:50 PM] 9/26/2023 . The Care Plan for R#67 was initiated 09/29/2023. No baseline care plan was found in the chart of R#67. On 02/14/2024 at 02:15 PM, the MDS Coordinator was asked if they were able to locate a baseline care plan for R#67. The MDS Coordinator stated, No, doesn't look like we have anything for them. They must have missed that one. On 02/15/2024 at 02:45 PM, the Assistant Director of Nursing (ADON) confirmed that no baseline care plan had been completed for R#67, and that it was required for a resident to have a care plan in place within 48 hours of admission. On 02/15/2024 at 02:55 PM, the Administrator confirmed that a baseline care plan should have been implemented for R#67 within 48 hours of admission. On 02/16/2024 at 08:54 AM, Nurse Consultant 2 reported 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.

Based on observation and interview the facility failed to ensure 1 (Resident #128) of 17 sampled residents who depended on staff for bed mobility was repositioned in bed. The findings are: Resident #128 had diagnoses of Spondylosis without myelopathy or radiculopathy, lumbar region, Need for assistance with personal care, Unspecified lack of coordination, Unspecified abnormalities of gait and mobility, Muscle weakness (generalized), and Unspecified spinal stenosis, cervical region. A care plan initiated 2/12/24 documented, .I require extensive assist x2 staff with bed mobility .Please turn and reposition me [every] 2 hours and [as needed] . On 2/13/24 at 1:37 PM, Resident #128 was in bed leaning to the left side while eating lunch. The Resident had a bowl in the bed and was having trouble eating. On 2/13/24 at 1:38 PM, Resident #128 was asked if they were comfortable. The Resident He stated, No, I can't get to my food. On 2/13/24 at 2:10 PM, Certified Nurse Aide (CNA) #1 was asked, Did you give Resident #128 a meal tray for lunch? CNA #1 stated, No I didn't. CNA #1 was asked, Can…

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 staff assisted 1 (Resident #128) of 5 sampled residents that depended on staff for assistance with meals. The findings are: Resident #128 had diagnoses of Spondylosis without myelopathy or radiculopathy, lumbar region, Need for assistance with personal care, Unspecified lack of coordination, Unspecified abnormalities of gait and mobility, Muscle weakness (generalized), and Unspecified spinal stenosis, cervical region. A care plan initiated 2/12/24 documented, .I require extensive assist X 1 staff with eating . On 2/13/24 at 1:37 PM, Resident #128 was in bed having trouble eating lunch from a bowl of food. On 2/13/24 at 1:38 PM, Resident #128 was asked if they were comfortable. The Resident stated, No, I can't get to my food. On 2/13/24 at 2:07 PM, Certified Nurse Aide (CNA) #1 was asked, How much assistance does [Resident #128] require with meals? CNA #1 stated, Starting today, he is one hundred percent. He was feeding himself, but today he was leaning. CNA #1 was asked, Did the care plan indicate that he could feed…

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 medications were administered as ordered for 1 (Resident #69) of 25 sampled residents who received medications from staff in the facility. The findings are: Resident (R) #69 was admitted to the facility on [DATE]. On 10/12/2024 at 03:54 PM, the ordered medications were approved by R#69's physician. On 02/15/2024 at 09:58 AM, the Assistant Director of Nursing (ADON) provided a document titled, Packing Slip Proof of Delivery. It documented that R#69's prescribed medications were delivered to the facility on [DATE] at 06:33 PM. A Physician's Order documented, Fluticasone Propionate Suspension 50 MCG/ACT [micrograms per actuation] 2 spray in each nostril in the afternoon related to Allergic rhinitis, unspecified . with a start date of 01/12/2024. R#69 did not receive the medication on 01/12/2024, 01/13/2024, 01/14/2024, 01/16/2024. The Medication Administration Record (MAR) for R#69 documented 9=Other / See Nurse Notes Effective for these days. 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.

Based on interview and record review, the facility failed to ensure the binding arbitration agreement was explained in a manner that the residents or resident's representatives fully understood for 2 (Residents #42, and #278) of 3 sampled residents who signed a binding arbitration agreement upon admission. This failed practice had the potential to affect 191 residents who signed binding arbitration agreements since September 16, 2019. The findings are: 1. On 02/13/24 at 09:00 AM, the Administrator provided the facility's arbitration agreement and a list of residents that signed an arbitration agreement since September 16, 2019. 2. On 2/14/24 at 2:18 PM, Resident (R) #278 was asked, Were you aware that you signed an arbitration agreement when you admitted ? R#278 stated, No, what is an arbitration agreement? R#278 stated, I was told just to sign the admission paperwork I didn't have anything explained to me. I would have never signed something like that. R#278 and the family member voiced intent to have Admissions revoke it this day. 3. On 2/14/24 at 2:33 PM, R#42 was asked, Were you…

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 policy review, the facility failed to ensure that the proper smoking equipment was available in the designated smoking area. This had the ability to affect 8 (Residents #21, #27, #32, #36, #37, #43, #50, #52) sampled residents who use the smoking area. The findings are: 1. On 2/13/24 at 3:54 PM, there was no smoking blanket or smoke apron available in the designated smoking area. 2. On 2/14/24 at 2:53 PM, the Administrator was asked, What equipment should be in the designated smoking area? The Administrator stated, A smoke apron and fire extinguisher. The Administrator was asked, What negative outcome could happen if a resident cigarette fell in their lap? The Administrator confirmed they could burn themselves, catch on fire. What equipment should be available to use to assist with putting out a fire. Administrator confirmed, smoke blanket. 3. On 2/14/24 at 2:57pm the administrator provided a policy titled, Resident Smoking, documented, .Policy Interpretation and Implementation .2) a. The smoking area will be equipped with a fire extinguisher,…

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, facility failed to ensure Home Health was provided at the time 1 (Resident #283) resident was discharged back to the community from the facility. The findings are: Resident (R) #283 had diagnoses of Chronic obstructive pulmonary disease, Dysphagia and hemiparesis following hypertension, Hemiplegia following other cerebrovascular disease, Muscle wasting atrophy, Other cervical disc degeneration, Atherosclerotic heart disease, Cerebral infarction, and Cognitive communication deficit. On 11/01/23 R #283 was admitted to nursing facility. On 12/02/23 R #283 was discharged back to the community. On 2/14/24 at 11:36 AM, the Social Worker (SW) was asked, Who is responsible for making sure a resident that discharges back to the community has the services needed in their home? The SW stated, I do all the discharges and referrals. The SW was asked, Do you remember R #283 discharging? The SW stated, Yes I do. The SW was asked, Do you remember setting up home health for R #283? The SW stated, Yes, I made a referral to [a home health agency], however they…

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 resident and staff interviews, the facility failed to treat a resident with dignity and respect for 1 (R4) of 5 (R1, R2, R3, R4 and R5) Case mix residents reviewed. The Finding include: 1. Resident 4 was admitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. 2. Care Plan Focus: Resident has potential for UTI due to indwelling catheter related to Neuromuscular dysfunction of the bladder Date Initiated: 04/29/2023.Intervention: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Ensure privacy bag in place. 3. On 10/30/23 at 9:45 AM during observation rounds the resident catheter bag was not in a privacy bag and the resident tube feeding pump had dried formula on it and on the stand and pedestal legs. 4. On 10/30/23 at 11:26 AM the administrator gave the facility policies and procedures for Dignity. Policy statement: Each resident shall be care for in a manner that promotes and enhances…

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 resident with a feeding tube (g-tube) received care and services for the feeding tube to meet the resident's needs for 1 (R4) of 5 (R1, R2, R3, R4 and R5) Case mix residents. The facility also failed to ensure liquid feeding formula was not expired and safe to administer. This had the potential to affect 1 resident in the facility with a feeding tube. The Finding include: 1. Resident 4 was admitted to the facility on [DATE] with a diagnosis of Gastrostomy. 2. The care plan documented: Focus: The resident requires tube feeding related to Swallowing deficits which was Date Initiated: [DATE] Section: Intervention: The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. Date Initiated: [DATE]. 3. Physician ordered dated [DATE] Enteral Feeding every shift (Nutritional Supplement)1.5 Calorie Continuous 75ml/hr. with 30 ml water flush. 4. On [DATE] at 9:45 AM during observation rounds 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.

Based on interview, and record review, the facility failed to ensure there was Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week. The findings are: 1. On 01/25/23 at 2:30 PM, the Surveyor asked the Human Resource (HR) Coordinator to provide the license for the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The HR Coordinator stated, We do not currently have a DON or ADON. The Surveyor requested the Minimum Data Set (MDS) Coordinator's license and the other RN's license who were at the facility when the MDS Coordinator was not. The HR Coordinator went into the Administrator's Office to ask the Administrator who the RN was when the MDS Coordinator was not at the facility. The HR Coordinator returned and provided the license for the weekend supervisor RN. The Surveyor requested documentation for RN coverage and weekend staffing for October, November, and December 2022 from the HR Coordinator. 2. On 01/26/23 at 11:30 AM, the HR Coordinator provided the October, November, and December 2022 staffing documentation which showed…

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 staffing schedules for Nursing staff and Certified Nursing Assistants (CNAs) were posted in a prominent area that was readily accessible to residents and visitors in 1 of 1 facility. The findings are: 1. On 01/23/23 at 7:50 PM, a sign in a case on the wall on the 200 Hall documented, Schedule is now posted in the Battery Room!!! 2. On 01/25/23 at 3:20 PM, the Social Service Director informed the Surveyor where the Battery Room was located. The signage on the door stated, Therapy Tub, and the door was locked. Upon entry, the staff schedule for the Nurses and CNAs was on the wall inside. 3. On 01/25/23 at 3:30 PM, the Surveyor asked the Administrator who was responsible for posting the required staff information. The Administrator stated, My staffing coordinator is, but she quit and is just PRN [as needed] now. My Activities Director is now responsible. The Surveyor asked what was required to be posted on the staff schedule. The Administrator stated, It just has to have who works what shift and what hall for the CNAs…

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 foods stored in the kitchen area and in the freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 1 ice machine was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages and failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 55 residents who received meals from the kitchen (total census: 57), as documented on a list provided by the Dietary Supervisor on 01/25/23 at 8:22 AM. The findings are: 1. On 1/23/23 at 6:11 PM, the following observations were made in the kitchen area: a. An opened box of tea was stored below the counter. The box was not covered or sealed. b. 25 loose tea bags with stains on them. c. 30 loose tea filters in a box below the counter. The box was not…

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 Certified Nursing Assistants (CNAs) were provided with the required in-service training to ensure they were prepared and competent with the skills required to meet the needs of the residents of 1 of 1 facility. The findings are:. 1. On 01/25/23 at 2:30 PM, the Human Resource (HR) Coordinator informed the Surveyor that the CNAs were provided a minimum of 12 units of in-service training annually by the facility. 2. On 01/25/23 at 4:00 PM, the Surveyor requested the in-service training for Abuse/Neglect/Exploitation, Resident Rights, Dementia Care, Infection Control, Communication, Behavioral Health, and Special Resident Needs such as Pain, Trach Care, Medication Side Effects, Hospice, and Changes in Condition. The Administrator provided a binder to the Surveyor and stated, I have had to redo all of the in-services because the staff that was no longer there, had taken the training documentation when she left. 3. On 01/26/23 at 8:38 AM, the Surveyor reviewed the In-Service binder documentation and none of 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 interview, and record review, the facility failed to ensure residents had the right to receive visitors of their choice in their home for 1 (Resident #36) of 1 sampled resident who desired to have their visitors come indoors for visits. The findings are: 1. Resident #36 had diagnoses of End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, and Acquired Absence of Left and Right Leg Above the Knees. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required one person physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing and personal hygiene. a. The Care Plan with a revision date of [DATE] documented, .Little involvement in formal activities related to personal choice - does self initiated activities in room at this time. Reads, watches TV and does puzzles, etc. [etcetera]. Receives one on one…

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 reassess the effectiveness of interventions, and review and revise the Care Plan for 3 (Residents #18, #43 and #55) of 15 (#3, #9, #10, #13, #16, #18, #19, #31, #34, #36, #43, #45, #55, #67 and #219) residents whose Care Plans were reviewed. This failed practice had the potential to affect all 57 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 01/23/23 at 8:39 AM. The findings are: 1. Resident #18 had diagnoses of Type 2 Diabetes Mellitus and Cerebrovascular Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required Supervision with setup help only with eating and had no weight loss or weight gain in the last 6 months. a. The Medical Record documented Resident #18 weighed 145.2 pounds on 06/20/2022 and 126.4 pounds on 12/30/22 for a weight…

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 cleaned and trimmed for 1 (Resident #219) of 1 (Resident #219) sampled resident who was dependent or required assistance with nail care. The findings are: 1. Resident #219 had a diagnosis of Unspecified Intercranial Injury with Loss of Consciousness. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 10/31/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance from one person for personal hygiene. a. The Care Plan with an initiated date of 10/11/21 documented, .Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, feeding, locomotion, etc. [etcetera] . BATHING/GROOMING/PERSONAL HYGIENE/ORAL CARE: requires Extensive assist *1 staff for personal hygiene and oral care. Ensure is neatly cleaned and groomed with acceptable appearance daily and PRN [as needed]: hair, clothing, shave (if needed), oral…

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 residents received all of their physician ordered medications in a timely manner after admission for 1 (Resident #67) of 1 sampled resident. The findings are: 1. Resident #67 was admitted on [DATE] and had diagnoses of Non-ST Elevation (NSTEMI) Myocardial Infarction, Vitamin Deficiency, Hypomagnesemia, and Rosacea. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). 2. The Progress Notes in the electronic records documented Resident #67 left AMA (Against Medical Advice) 0n 10/29/22. The following six medications were either, awaiting arrival from supplier or supplement not available, in a 5-day period in Resident #67's progress notes. During a telephone interview with Resident #67's family member, the Surveyor asked about the resident's discharge. The Family Member stated Resident #67 was not…

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 provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice by administering oxygen at the prescribed rate for 3 (Residents #16, #45 and #219) and failed to date the oxygen tubing and humidifier bottle for 1 (Resident #55) of 14 (Residents #3, #9, #12, #16, #22, #31, #34, #36, #39, #45, #53, #55, #58, and #219) sampled residents who had a Physician's Order for oxygen as documented on a list provided by the MDS (Minimum Data Set) Coordinator on 01/25/23 at 10:00 a.m. The findings are: 1. Resident #16 had a diagnosis of Metabolic Encephalopathy. The admission MDS with an Assessment Reference Date (ARD) of 12/12/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy while a resident. a. The Physician's Orders dated 05/29/20 documented, .O2 [oxygen] at 2 L/M [liters per minute] via NC [nasal cannula] at HS [hour of sleep] at bedtime related to SOB…

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 pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 2 residents who received pureed diets, as documented on a list provided by the Dietary Supervisor on 01/25/23 at 8:22 AM. The findings are: 1. On 01/24/23 at 7:22 AM, the following were on the steam table: a. A pan of pureed blueberry muffins, the consistency of the pureed blueberry muffins was not smooth, the consistency was lumpy. b. A pan of pureed sausage, the consistency of the puree sausage was not smooth, the consistency was lumpy. c. On 01/24/23 at 11:19 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed foods served to the residents at breakfast. She stated, The pureed muffins were gritty. It had lumps of blueberries in it and was sticky. The pureed sausage was gritty. 2. On 01/24/23 at 11:01 AM, the Dietary Supervisor used a 4 ounce spoon…

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 the Binding Arbitration Agreement stated the resident and/or the resident's representative were not required to sign the agreement, allowed the resident and/or the representative to communicate with the Office Long Term Care (OLTC) Ombudsman, and was not required as part of the admission process for 3 (Residents #8, #23 and #45) of 3 sampled residents who were contacted regarding their Binding Arbitration Agreement signed upon admission since September 16, 2019. This failed practice had the potential to affect 39 residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. The findings are: 1. On 01/23/23 at 7:20 PM, the Administrator provided the Arbitration Agreement in the admission packet. 2. On 01/24/23 at 9:29 AM, the Administrator provided a list of residents that signed an arbitration agreement. a. On 01/26/23 at 10:09 AM, the Administrator provided a corrected list of residents that signed an arbitration…

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 Binding Arbitration Agreement provided for the selection of a neutral arbitrator and a venue convenient to both parties for 3 (Residents #8, #23, and #45) of 3 sampled residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. This failed practice had the potential to affect 39 residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. The findings are: 1. On 01/23/23 at 7:20 PM, the Administrator provided the Arbitration Agreement in the admission packet. 2. On 01/24/23 at 9:29 AM, the Administrator provided a list of residents that signed an Arbitration Agreement. a. On 01/26/23 at 10:09 AM, the Administrator provided a corrected list of residents that signed an Arbitration Agreement after September 16, 2019. 3. On 01/24/23 at 8:20 PM, the Surveyor reviewed the facility's Arbitration Agreement and was unable to find a statement which allowed for a neutral arbitrator agreed upon by both parties and/or a venue convenient to both parties. 4. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the care plan addressed the use of oxygen therapy to assure necessary information was available to provide care for 1 (Resident #55) of 14 (Resident #3, #9, #12, #16, #22, #31, #34, #36, #39, #45, #53, #55, #58 and #219) sampled residents who had Physician Orders for oxygen therapy as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 01/25/23 at 10:00 a.m. The findings are: 1. Resident #55 had a diagnosis of Heart Failure. The admission MDS with an Assessment Reference Date (ARD) of 01/09/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. The Physician's Order dated 02/07/22 documented, .O2 [oxygen] @ [at] 2-4 L/M [liters per minute] VIA NC [nasal cannula] every shift . b. The Care Plan with a revision date of 01/16/2023 did not address the use of oxygen therapy. c. On 01/23/23 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.

Based on observation, record review, and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more activities of daily living (ADL) for 1 (Resident #16) of 15 (Resident #3, #9, #10, #13, #16, #18, #19, #31, #34, #36, #43, #45, #55, #67 and #219) residents whose MDS was reviewed. This failed practice had the potential to affect all 57 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set Coordinator (MDSC) on 01/23/23 at 8:39 PM. The findings are: 1. Resident #16 had diagnoses of Spastic Hemiplegia affecting Left Dominant Side and Muscle Weakness. The admission MDS with an Assessment Reference Date (ARD) of 12/12/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive two plus person physical assistance with bed mobility and toilet use, was totally dependent on two plus persons for transfers and was totally dependent on one person's physical assistance…

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 Options Counseling referrals were submitted and the Notice of admission process was completed for residents and resident representatives who wished to receive information about returning to the community for 1 (Resident #67) of 1 sampled resident closed record review. This failed practice had the potential to affect 13 residents who were discharged home from the facility since 06/30/22 as documented on the Beneficiary Notice - Residents discharged Within the Last Six Months worksheets provided by the Administrator on 01/24/23 at 7:47 AM. The findings are: 1. Resident #67 had a diagnosis of Non-ST Elevation (NSTEMI) Myocardial Infarction. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). 2. On 01/25/23 at 11:00 AM, the Notice of admission form DHS (Department of Human Services)-9571 documented Options Counseling for community resources was not declined by…

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.