Ahwatukee Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and policy review, the facility failed to ensure that one resident's medications were administered as ordered by the provider based on standards of practice for two resident's (#68, #35), medications are not left unattended at the bedside for one resident (#40), and medications are not left unattended on the floor. The deficient practice could result in residents not receiving prescribed does of medications, and residents taking medications that are not ordered. The facility census was 89, and the sample was 18 residents. -Regarding Fluticasone Nasal Spray A medication administration task observation was conducted on August 1, 2023 at 7:20 AM with a Licensed Practical Nurse (LPN/staff #29). At the medication cart the LPN prepared mediation for Resident #35, that included Fluticasone Propronate Nasal Spray. The LPN took the nasal spray and entered the resident's room. She administered 1 puff of the Fluticasone Propronate nasal spray in each nostril. Review of the physician's order…

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 clinical record review, staff interviews and policy and procedure, the facility failed to ensure consistent treatments were provided to one resident (#82) with pressure ulcers. The deficient practice could result in worsening of pressure ulcers. The facility census was 89, and the sample was 18 residents. Resident #82 was admitted on [DATE] with diagnoses that included atrial fibrillation, leukemia, type 2 diabetes mellitus, pressure ulcer of buttock, adult failure to thrive, depression, need of assistance with personal care. Review of the clinical record revealed the resident currently had six wounds: -#6 genital region new #6 pressure unstageable -#5 Right gluteus medial - Pressure - Unstageable - #4 Coccyx medial - pressure unstageable - present on admission -#3 Right Ischial Tuberosity lateral and middle - present on admission -#2 Right lateral Calf - pressure, unstageable -#1 right shin, medial - pressure, unstageable Review of a care plan revealed the following areas of focus: -Actual skin…

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 review of the clinical record, interviews and facility policy, the facility failed to ensure an as needed psychotropic medication was monitored appropriately. The deficient practice could cause prolonged usage of medications intended for an as needed basis without appropriate monitoring. Findings include: Resident #20 was re-admitted on [DATE] with diagnoses that included major depressive disorder, lung transplant, immunodeficiency, bipolar disorder, mild cognitive impairment, PTSD, and anxiety disorder. Review of the clinical records revealed that a PRN (as needed) Psychotropic had been administered to the resident since October 21, 2022. Review of a pharmacy consultation report dated October 26, 2021 revealed a recommendation to re-evaluate continued use of PRN Clonazepam. The report was signed by the provider but it contained no evidence of acceptance of the recommendations. A handwritten note revealed a lung transplant patient with rejection depression/anxiety to current treatment. Review of a…

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

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary kitchen; six ventilation exhausts above clean dishware and food prep areas were unclean, food storage for the kitchen area and three nourishment refrigerators were not monitored, maintained and documented for safe food handling. The census was 89. The deficient practice could result in residents becoming ill. Findings include: Regarding dusty ventilation exhausts: The facility's policy, Food and Nutrition Services Policies and Procedures, dated May 01, 2023 states Food and Nutrition Services staff monitors the cleanliness of the pantry/nourishment rooms including refrigerators/freezers, cabinets, equipment, and surfaces. The policy further states Food storage and service equipment and surfaces are routinely cleaned by designated staff. Review of the kitchen's maintenance work order revealed most recent vent cleaning was June 03, 2023 at 10:43 am. On July 31, 2023 at 8:40 a.m., a kitchen inspection was conducted with the Food Service Director (staff #205) and an observation of six…

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 clinical record review, facility documentation, staff interviews, and review of policy, the facility failed to ensure that 1 out of 18 sampled residents' (#72) needs and preferences were addressed, regarding his wheelchair. The deficient practice could result in residents' needs and/or preferences not being addressed. Findings include: Resident #72 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, muscle weakness, and pain. Review of resident #72's inventory log dated June 13, 2023 revealed that he did not have a wheelchair when he arrived at the facility. However, the inventory log indicated that he had a battery charger for a power wheelchair. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS also indicated that the resident used a wheelchair as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, clinical record review, and policy, the facility failed to ensure that one resident (#40) received ADL (activity of daily living) care related to getting resident out of bed consistently. The sample size was 18. The deficient practice could result in residents not receiving care-planned ADLs and not maintaining mobility. Findings include: Resident #40 was admitted on [DATE] with diagnoses that include osteoarthritis, polyneuropathy, chronic kidney disease, venous insufficiency and lymphedema. Review of a care plan revealed the following areas of focus: -Resident states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences with interventions that included getting up in the morning between 7 AM - 9 AM, initiated December 20, 2021. -admitted for ongoing LTC( long term care) with a history of lymphedema, bilateral venous stasis ulcers, chronic kidney disease with interventions that included…

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, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#40). The facility census was 89, and the sample was 18 residents. The deficient practice could result in resident's not consistently being provided activities to meet their interest and to support their physical, mental and psychosocial well-being. Findings include: Resident #40 was admitted on [DATE] with diagnoses that include osteoarthritis, polyneuropathy, chronic kidney disease, VI, and lymphedema. An observation of resident #40's room revealed a type written note affixed to the resident's wall and door stating to come in and wake her up, she's sleeping because she is bored. An interview was conducted with resident #40 on August 1, 2023 at 8:37 AM. The resident stated that she used to go to bingo, but has not been to activities since January 2023. She also stated that she stopped asking because they do not have enough…

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, staff interviews, clinical record review, and policy and procedure, the facility failed to ensure hydration care and services were provided and documented for one resident (#62). The sample size was 18. The deficient practice places residents at risk for potential dehydration. Findings include: Resident #62 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysphagia following other cerebrovascular disease, paranoid schizophrenia and bipolar disorder. A nutritional risk care plan, initiated on December 14, 2020, related to significant weight loss, dysphagia, a mechanically altered diet and hospice status. Interventions included to offer/encourage fluids of choice. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Further review…

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, staff interviews, and review of policy, the facility failed to ensure their system of medication records enabled accurate reconciliation and accounting for all controlled substances. The deficient practice could result in misappropriation of residents' medications. The facility census was 89, and the sample was 18 residents. Findings include: An observation conducted on August 1, 2023 at 11:05 AM with a Licensed Practical Nurse (LPN/staff #21) of the Orthopedic, 200 Hallway. Review of the Shift Verification of Controlled Substances sheets dated July 20, 2023 through July 26,2023, revealed no evidence of a two-nurse reconciliation being conducted on July 22, 2023 and July 23, 2023. An interview was immediately conducted with staff #21 who stated that nurses reconcile all narcotic medications at the beginning and end of each shift. She also stated that the facility policy is that both nurses (on-coming and off-going shifts) sign the Shift Verification of Controlled Substances Sheet at each shift change. She reviewed the Shift Verification of Controlled…

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, staff interview, and policy review, the facility failed to ensure that medications were labeled according to professional standards, and that expired medications were not available for resident use. The census was 98, and the sample was 18 residents. The deficient practice could result in expired medications being administered to residents, or resident's receiving the wrong medication. Findings include: -Regarding multi-use insulin: During a medication storage observation conducted on August 1, 2023 at 12:22 PM with a Licensed practical nurse (LPN/staff #28) of medication cart #3 on the 100/200 hall. A multi-use vial of Novolin R 100 units/milliliters which had a date of June 3, 2023 written on the outside of the vial was observed in the medication cart drawer. An interview was conducted with the LPN (staff #28), who stated that the date written on the outside of the Novolin R vial was the date it was opened. She also stated that the facility policy was to discard medications that are in multi-use vials 28 to 31 days after it was opened. She further stated 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, staff interview, and policy review, the facility failed to ensure expired glucometer controls were not available for use. The census was 98, and the sample was 18 residents. The deficient practice could result in inaccurate blood glucose test results. Findings include: An observation of a medication cart was conducted on [DATE] at 11:05 AM with a Licensed Practical Nurse (LPN/staff #21) on the Orthopedic 200 Hallway. Three glucometer control boxes were observed in the medication cart drawer, none of the boxes or control solutions revealed evidence of the date the controls were opened. An interview was immediately conducted with the LPN (staff #21), who stated that the facility policy was to write the date the control solution was opened on the side of both control solutions (high and low). She stated that it looked like two of the boxes looked like they had been used previously, but that there was no evidence of the date they were opened on the boxes or on the control solutions. She also…

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, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during wound treatment for one resident (#82). The census was 89 residents, and the sample was 18. The deficient practice could result in transmission of infection, or exposing the wound to other organisms. Findings include: Resident #82 was admitted on [DATE] with diagnoses that included atrial fibrillation, leukemia, type 2 diabetes mellitus, pressure ulcer of buttock, adult failure to thrive, depression, need of assistance with personal care. Review of the clinical record revealed the resident currently had six wounds: -#6 genital region new #6 pressure unstageable -#5 Right gluteus medial - Pressure - Unstageable - #4 Coccyx medial - pressure unstageable - present on admission -#3 Right Ischial Tuberosity lateral and middle - present on admission -#2 Right lateral Calf - pressure, unstageable -#1 right shin, medial - pressure, unstageable Review of a care…

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 staff interview, facility policy, and review of the Center for Disease Control (CDC) recommendations, the facility failed to ensure that their Infection Preventionist have completed the specialized training in Infection Prevention and Control. The deficient practice could result in improper infection prevention practices within the facility. Findings include: A review of the Infection Preventionist's (IP/staff #35) personnel/training record conducted on August 2, 2023 at 9:04 a.m. revealed that staff #35 had not completed all the Center for Medicare and Medicaid (CMS) recommended specialized training topic. She had not been awarded a certificate for the CMS and CDC developed training titled The Nursing Home Infection Preventionist Training Course. During an interview with the IP (staff #35) conducted on August 2, 2023 at 2:05 p.m., staff #35 stated that she has been the IP since November 2022. When asked if she had completed the Nursing Home Infection Preventionist Training Course, she presented a certificate with a completion date of August 2, 2023. Staff #35 stated 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 -Resident #44 was admitted to the facility on [DATE] with diagnoses that included Methicillin Resistant Staphylococcus Aureus infection, intraspinal abscess and granuloma, and diabetes. Review of the clinical record revealed a Smoking Evaluation dated April 12, 2022 that the resident required supervised smoking. A Resident Smoking Responsibility Agreement and a Resident Smoking policy dated April 14, 2022, signed by the resident, included documentation of the resident's understanding and agreeing to comply with the facility smoking policy. However, review of the admission MDS assessment dated [DATE] revealed the section J1300 (Current Tobacco Use) was coded no for current tobacco use. An interview was conducted on June 6, 2022 at 12:06 PM with resident #54, who stated he is a smoker and that he is allowed to smoke outside in the smoking area. The resident stated he does not have to have a staff member present when he smokes and there is no smoking log. The resident stated that he is required to give the staff…

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, clinical record reviews, interviews, and facility documentation and policy, the facility failed to ensure that 3 residents (#238, #2 and #7) received adequate assistance with Activities of Daily Living (ADL). The sample size was 8. The deficient practice could result in resident needs being unmet. Findings include: -Resident #238 was readmitted to the facility on [DATE] with diagnoses that included pneumonia, urinary tract infection, and mental disorder due to a known physiological condition. Review of facility documentation revealed that the facility provided residents with two showers or bed baths per week. An ADL care plan, revised on 10/13/20, had a goal for ADL care needs to be anticipated and met. Interventions included to provide the resident with extensive assistance of 2 for transfers using a mechanical device. Review of the facility's bathing documentation for December 2021 revealed the resident received showers or bed baths on 12/04, 12/07, 12/09, 12/16, 12/18, 12/29. There was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure thorough skin assessments were conducted for one resident (#44) and that two residents (#238 and #397) were consistently provided adequate wound care. The sample size was 2. The deficient practice could result in delayed treatment and healing of skin wounds. Findings include: -Resident #44 was admitted on [DATE] with diagnoses of methicillin resistant staphylococcus aureus, intraspinal abscess, gangrene, diabetes, moderate protein-calorie malnutrition, and right lower limb cellulitis. During the initial part of the survey, an interview was conducted on June 6, 2022 at 1:49 PM with resident #44. The resident was observed lying in bed watching television. Resident #44 was wearing shorts and visible scabbing to the left knee was observed. The resident stated that he had some falls recently. The resident stated he skinned his knee when he fell out of his wheelchair. The resident stated that he was…

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

Based on resident, family, and staff interviews, facility documentation, facility assessment, and policy review, the facility failed to ensure that there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents' needs not being met. Findings include: During the initial part of the survey, interviews were conducted with residents and family regarding staffing. They stated staff takes 2-3 hours to answer their call light for assistance, that they have had to hold bowel/urine for 2 hours, waited an hour for requested medications, waited 2 hours for assistance from the wheelchair to the bed, requested a medication and the staff never came back, and that skin breakdown is the result of not getting the resident out of bed. Review of the facility assessment updated August 31, 2021 revealed the facility is licensed to provide care to 192 residents, and the average daily census is eighty. To ensure they have sufficient staff to meet the needs of the residents at any given time based upon the facility resident population and their needs…

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 clinical record reviews, staff interviews, and facility policy, the facility failed to ensure two residents (#78 and #54) and/or their representatives were informed of the risks and benefits of psychotropic medications prior to receiving the medications. The sample size was 6 residents. The deficient practice could result in residents and/or their representatives not being fully informed of the risks and benefits of psychoactive medications. Findings include: -Resident #78 was admitted to the facility on [DATE] with diagnoses that included streptococcal sepsis, local infection of the skin and subcutaneous tissue, and bipolar disorder. Review of the physician's orders revealed several orders dated 02/7/22 for antidepressant medications. These included the following: -Citalopram 20 milligrams (mg) per day for depression. -Mirtazapine 15 mg per day for depression. -Trazodone 100 mg per day for depression. Review of the February 2022 Medication Administration Record (MAR) revealed the resident received 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, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that housekeeping services necessary to maintain a safe and clean environment were provided for two residents (#69 and #77). The deficient practice could result in residents not having a safe and clean environment. Findings include: -Resident #69 was admitted on [DATE], with diagnoses of pneumonia, pleural effusion, chronic kidney disease, chronic heart failure, and alcoholic cirrhosis of liver without ascites. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed no evidence the Brief Interview for Mental Status (BIMS) was conducted. An observation of the resident's room conducted on June 6, 2020 at 11:19 a.m., revealed the floor had spill stains on the side of the bed closest to the window. The biggest stain was approximately the length of a legal-size printer paper, while the rest formed a few splatter patterns around it. The floor also had spot stains…

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 clinical record reviews, interviews, the State Agency (SA) database, and facility documentation and policy, the facility failed to ensure an allegation of abuse was reported timely to the SA for one resident (#439) and failed to report the results of an investigation to the SA within the required timeframe for one resident (#238). The sample size was two residents. The deficient practice could result in further allegations and investigations of abuse and neglect not being reported. Findings include: -Resident #439 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb, type 2 diabetes mellitus, neuropathy, and peripheral vascular disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The resident's behavior care plan dated June 5, 2022, revealed the resident exhibits or has the potential to demonstrate…

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 clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that one resident (#39) with a diagnosis of a serious mental illness was referred to the appropriate State-designated mental health or intellectual disability authority for review once the resident's stay exceeded 30 days. The sample size was 3, residents. The deficient practice could result in necessary specialized services not being provided for residents that need it. Findings include: Resident #39 was admitted to the facility on [DATE], with diagnosis of vascular dementia with behavioral disturbance. Review of the PASRR (preadmission screening and resident review) Level 1 screening dated July 8, 2014 revealed the resident met the criteria for convalescent care indicating the physician had certified that the resident required 30 days or less of nursing facility services. The Level 1 screening also revealed the resident did not have a primary diagnosis of a serious mental illness and that a referral 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 clinical record review, staff interviews and review of facility documentation, the facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were completed accurately and timely for two residents (#2 and #78). The sample size was 3 residents. The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Metabolic Encephalopathy; Anxiety Disorder, unspecified: Major Depressive Disorder, Recurrent, Unspecified and Unspecified Psychosis not due to a Substance or Known Physiological Condition. Review of the PASRR Level I screening from the hospital dated January 27, 2022 revealed the resident met the criteria for a 30-day convalescent care. The screening also revealed the nursing facility must update the Level I at such time that it appears the individual's stay will exceed 30 days. Continued review of the clinical…

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 clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#397) received adequate pressure ulcer care. The sample size was two residents. The deficient practice could result in residents developing pressure ulcers or worsening of pressure ulcers. Findings include: Resident #397 was admitted to the facility on [DATE], with diagnoses that included Cutaneous Abscess of the Umbilicus and Acquired Absence of the Left Leg Above the Knee. Review of the Skin Integrity Report dated May 17, 2022 revealed the resident had a pressure ulcer to the coccyx that was present on admission. The report included the appearance of the wound was epithelial and that the wound measured 0.1 centimeter (cm) x 1 cm. A physician order dated May 17, 2022 stated to apply moisture barrier every shift and as needed to the peri-area and the buttocks every night shift. Review of the care plan initiated on May 17, 2022 revealed the resident has actual skin breakdown to the coccyx. Interventions…

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 -Resident #19 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, age-related osteoporosis without current pathological fracture, and osteoarthritis. An activities of daily living (ADL) care plan revised on June 26, 2021, revealed an intervention to implement and deliver a restorative program as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 4, indicating the resident had severe cognitive impairment. The assessment also revealed the resident had no functional limitation in range of motion or impairment of the upper extremities (shoulder, elbow, wrist, and hand). Review of the physician order summary revealed an order late entry for March 26, 2022 for occupation therapy to evaluate and treat, and for skilled occupational therapy 3 times a week for 4 weeks for therapy exercise and orthotic fitting. Review of the occupational therapy initial evaluation revealed one of the goals was that the resident will increase range of motion in both…

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 clinical record review, observation, resident and staff interviews, and policy review, the facility failed to follow a physician order for bladder training for one resident (#47) who had an indwelling catheter. The deficient practice could result in residents having indwelling catheters unnecessarily. Findings include: Resident #47 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection, acute kidney failure unspecified, and congestive heart failure. Review of the clinical record revealed a physician order dated March 10, 2022 to change the 16 French with 30 cubic centimeter balloon Foley catheter for BPH (benign prostatic hyperplasia) every month starting on the 17th. A Nursing Documentation Note dated March 11, 2022 revealed the Foley catheter was patent and draining clear yellow urine. Review of a physician progress note dated April 7, 2022 revealed the resident was still wondering if the Foley catheter could be removed. The note stated will try bladder training…

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 clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident's (#7) medical record was accurate regarding advance directives. The sample size was 20. The deficient practice could result in residents' medical records not being accurate. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes, and memory deficit following unspecified cerebrovascular disease. Review of the Advance Directives/Medical Treatment Decision form obtained and signed November 25, 2020 revealed the resident chose Do Not Resuscitate (DNR). The box for Do Not Hospitalize was not checked. Review of the orange Prehospital Medical Care Directive (DNR) obtained and signed November 25, 2020 revealed that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures. Review of the physician's orders dated November 25, 2020 stated Do Not Resuscitate (DNR) Do 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.