Concord Post Acute

Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 2 (Resident #142 and Resident #113) of 7 sampled residents reviewed for resident assessments. Findings included: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14. The document indicated, The ARD must be set no later than day 14, counting the date of admission as day 1. The document revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis unless an SCSA [significant change in status assessment] or an SCPA [significant correction to prior comprehensive assessment] has been completed since the most recent comprehensive assessment was completed. A review of Resident #142's admission Record…

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 reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #98, #85, and #110) of 7 sampled residents reviewed for resident assessments. Findings included: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type. It is used to track a resident's status between comprehensive assessment to ensure critical indicators of gradual change in a resident's status are monitored. The document indicated, The MDS completion date must be no later than 14 days after the ARD. A review of Resident #98's admission Record revealed the facility admitted the resident on 10/15/2020. A review of Resident #98's quarterly MDS, with an Assessment Reference Date (ARD) of 07/07/2023,…

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 interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was accurate for 1 (Resident #176) of 3 sampled residents reviewed for closed record review. Findings included: A review of Resident #176's admission Record revealed the facility admitted Resident #176 on 07/04/2023. Per the admission Record, the resident discharged home on [DATE]. A review of Resident #176's discharge MDS, with an Assessment Reference Date (ARD) of 08/31/2023, revealed the resident discharged to an acute hospital on [DATE]. A review of Resident #176's discharge summary Progress Notes, dated 08/31/2023, revealed the resident discharged home on [DATE] at 11:20 AM. During an interview on 11/16/2023 at 11:28 AM, the MDS Registered Nurse (RN) stated he was responsible for ensuring the accuracy and completeness of the MDS assessments. The MDS RN stated that according to the Progress Notes, Resident #176 discharged home, and he verified the MDS assessment was coded incorrectly 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 record reviews, interviews, and policy review, the facility failed to refer a resident with a newly evident serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 2 (Resident #48 and Resident #130) of 5 sampled residents reviewed for PASARR requirements. Findings included: A review of the facility policy titled, admission Criteria, revised in March 2023, revealed b. If the level I screen indicates that the individual may meet the criteria for a MD [mental disorder], ID [intellectual disorder], or RD [related disorder], he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. Review of Resident #48's admission Record revealed the facility admitted the resident on 01/25/2022 with diagnoses that included bipolar disorder and unspecified psychosis. A review of Resident #48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2023, revealed the resident had active…

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

Based on observation, record review, interviews, and policy review, the facility failed to ensure staff followed professional standards of practice by not leaving medications at the bedside of 1 (Resident #128) of 8 residents observed for medication administration. Findings included: A review of Resident #128's admission Record revealed the facility admitted the resident on 08/26/2021, with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus, fibromyalgia (nerve pain), hypertension (high blood pressure), malignant neoplasm (cancer) of the right breast, and chronic kidney disease. A review of Resident #128's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #128's care plan initiated on 10/11/2021, revealed the resident had an alteration in neurological mental status related to disease process. Interventions directed staff to give medications as ordered.…

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, record review, and policy review, the facility failed to ensure respiratory equipment was sanitized and properly stored for 1 (Resident #134) of 4 sampled residents reviewed for respiratory care. Findings included: Review of a facility policy titled, CPAP [continuous positive airway pressure]/BiPAP [Bi-level positive airway pressure] Support, revised in March 2015, revealed 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. A review of Resident #134's admission Record revealed the facility admitted the resident on 09/30/2023 with diagnoses that included asthma and encephalopathy. A review of Resident #134's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/2023, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used a non-invasive mechanical ventilator. A review of Resident #134's care plan, initiated on 10/01/2023, revealed the resident was at risk for…

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

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure bed rails were used properly per assessment for 1 (Resident #152) of 5 sampled residents reviewed for accidents. Findings included: A review of the facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. A review of Resident #152's admission Record revealed the facility admitted the resident on 07/08/2023 with diagnoses that included traumatic subdural hemorrhage (brain bleed) with loss of consciousness, encephalopathy (brain disorder), and cerebral edema (swelling of the brain). Review of Resident #152's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed Resident #152 had a Brief Interview for Mental Status…

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 the interviews, record review, document reviews, and policy review, the facility failed to act on a pharmacy recommendation to lower the dosage of medication for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review. Findings included: Review of the facility's policy titled, Medication Monitoring Medication Regimen Review and Reporting, dated January 2023, revealed, 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale or why the recommendation is rejected in the resident's medical record. Review of Resident #42's admission Record revealed the facility admitted the resident on 08/14/2019 with diagnoses that included atrial fibrillation, Alzheimer's disease, and…

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

Based on observations, record reviews, interviews, document review, and policy review, the facility failed to have a medication error rate less than 5%. Specifically, there were two medication errors out of 25 opportunities, which yielded a medication error rate of 8% for 2 (Resident #89 and Resident #380) of 8 residents observed for medication administration. Findings included: A review of the facility policy titled, Administering Medications, revised in April 2019, revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. During medication administration observation on 11/15/2023 at 8:41AM, Licensed Vocational Nurse (LVN) #13 prepared and administered medications for Resident #89 that included one senna (a laxative) 8.6 milligrams (mg) tablet. A review of Resident #89's Order Summary Report with active orders as of 08/01/2023, revealed an order dated 10/29/2022, for senna-docusate sodium 8.6-50 mg,…

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, record review, and policy review, the facility failed to ensure a resident's urinary catheter drainage bag was not on the floor for 1 (Resident #7) of 3 sampled residents reviewed for urinary catheters. Finding included: A review of a facility policy tilted, Catheter Care, Urinary, revised in August 2022, revealed, Infection Control 1. Use aseptic technique when handling or manipulating the drainage system. 2. Be sure the catheter tubing and drainage bag are kept off the floor. A review of Resident #7's admission Record revealed the facility admitted the resident on 10/24/2017 with diagnoses that included dementia and retention of urine. A review of Resident #7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for toilet use and had an indwelling catheter. Review of Resident #7 s care plan initiated 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, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received a written notification prior to being moved to another room within the facility. This failure placed Resident 1 at risk to experience increased anxiety and confusion related to spontaneous/unplanned change of environment. Findings: During a review of Resident 1's admission Record dated 7/25/23, the record showed Resident 1 was admitted to the facility on [DATE] with diagnosis of Anxiety (worry that interferes with daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Psychosis (loss of contact with reality), Mood disorder (inconsistent emotions leading to inability to function). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/23/23, the MDS assessment showed Resident 1's Brief Interview for Mental Status (BIMS- a mental status exam) was 12 of 15, indicating…

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 an interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment of necessity for special services relating to psychiatric and/or intellectual disability) assessment for one of three sampled residents (Resident 1) was completed accurately. Resident 1's PASARR assessment did not reflect current diagnoses of Anxiety (a feeling of fear, dread, and uneasiness). This failure placed Resident 1 at risk to not receive care and services appropriate to her needs. Findings: During a review of Resident 1's admission record titled admission Record dated 7/25/23, the record showed Resident 1 was admitted to the facility on [DATE]. The record showed Resident 1 had diagnoses of Depression (loss of pleasure or interest in daily activities), Adult Failure to Thrive (physical decline, inactivity and depression), Mood Disorder (inconsistent emotions leading to inability to function), Anxiety Disorder, Psychosis (loss of contact with reality) and Cognitive…

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 one of three sampled residents (Resident 1) received incontinent care in a timely manner, when Resident 1 was left unchanged in a soiled incontinent disposable brief. This failure resulted in Resident 1 wearing a soiled/wet incontinent brief for an extended period of time and made him feel highly annoyed . Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted in April 2023 with a diagnosis of muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 4/30/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS-a mental status exam) was 14 out of 15, indicating cognitively intact mental status. The MDS assessment also indicated, Resident 1 required one staff's extensive assist with toilet use and he was incontinent of both bowel and bladder. During a review of Resident 1's Activities of daily living (ADL) care plan, dated 4/23/23, the care plan indicated…

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 medications were stored in a secure location for one (1) of three (3) sampled residents (Resident 1), when Resident 1's medication was located unattended at the counter next to the sink near the door of Resident 1's room. This deficient practice had the potential for other residents, unauthorized staff, and visitors to have access to medications and the potential for misuse and ineffective treatment. Findings: During a review of Resident 1's, admission Record , printed on 8/24/23, the admission record indicated Resident 1 was originally admitted to the facility in 2017 and readmitted in 2022 with a medical diagnosis of acute and chronic respiratory failure ( a serious condition that makes it difficult to breathe on your own) and Chronic obstructive pulmonary disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow from the lungs and causes breathlessness). During an observation on 8/24/23 at 11:25 a.m., at Resident 1's room , a vial of medication labeled Acetylcysteine ( 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 2. During a review of Resident 31's Minimal Data Set (MDS- An assessment used to plan care) assessment dated [DATE] indicated Resident 31 required extensive assistance with mobility. During an observation, on 5/5/21, at 9:10 a.m., in Resident 31's room, Resident 31's call light was clipped to the bed sheet at the head of the bed while Resident 31 was sitting in a wheelchair beyond the foot of the bed. During an interview, on 5/5/21, at 9:14 a.m., with Certified Nursing Assistant (CNA 11), CNA 11 stated the call light should be within Resident 31's reach. CNA 11 also stated since Resident 31's room was kept closed for COVID-19 (a mild to severe respiratory illness that is airborne and is spread person to person or by contact with infectious materials such as respiratory droplets in the air and to lesser degree on high touch surfaces in the environment) she should have her call light within reach. During a record review of facility's Policy and Procedure (P&P) titled, Answering the Call Light dated 10/2010, 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 observation, interview, and record review, the facility failed to ensure two (Resident 599 and 140) of 21 sampled residents were provided a clean, safe and homelike environment when: 1. Resident 599 was missing a light fixture at the head of bed. This failure to provide a light fixture placed Resident 599 at risk for injury and the inability to perform his usual activities. 2. The bathroom in Resident 140's room had brown, dried fecal matter sticking on the toilet bowl and the floor. This failure provided an unclean and unsanitary environment. Findings: 1. During an observation on 5/3/21, at 11:21 a.m., Resident 599 was lying in bed, with his privacy curtains closed. Resident 599's room was dark and the light fixture at the head of the bed was missing. During an interview on 5/3/21, at 11:21 a.m., with Resident 599, Resident 599 stated he had stayed in the room for the last couple of days. Resident 599 stated, it gets really dark, and he could not color his paper without the light. During an interview on 5/3/21, at 11:40 a.m., with Certified Nursing Assistant (CNA3), CNA3…

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 38 residents (Resident 20, 26, 2, 30, 25, 6, 7, 69, 38, 1, 19, 5, 90, 23, 39, 85, 8, 11, 18, 16, 13, 12, 89, 57, 125, 21, 92, 141, 60, 83, 43, 28, 97, 52, 14, 129, 53, and 98) of 45 sampled residents were assessed comprehensively, when the facility did not complete their Quarterly Minimal Data Set (MDS- An assessment used to plan care for residents) assessments for a period of seven months. This failure had the potential for residents to not receive individualized care based on their physical, mental and emotional needs. Findings: During a concurrent interview and record review, with the MDS Coordinator (MDSC), on 5/5/21, at 12:22 p.m., the MDSC stated the facility was required to complete MDS assessments every quarter (every three months) for the residents staying at the facility. The MDSC reviewed the most recently completed Omni Budget Reconciliation Act (OBRA) required MDS assessments and stated following residents were still staying at the facility but the facility did not complete the following MDS…

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

Based on observation, interview, and record review, the facility failed to provide grooming assistance for four (Residents 106, 549, 140 and 497) of 32 sampled residents when: 1. Resident 106 was unshaved. 2 Resident 497 had long, fingernails with black dried substance underneath them. 3. Residents 549 had long fingernails with dark brown substance underneath them. 4. Resident 140 had long finger and toe nails with black substance underneath them. These failures to provide personal hygiene care to Residents 106, 549, 140, and 497 resulted in potential of low self esteem and self worth. Findings: 1. Review of the clinical record indicated Resident 106 was admitted to the facility with diagnoses that included dementia with behavioral disturbance, (a progressive disease that destroys memory) and age related macular degeneration, left eye (an eye disease that causes vision loss). A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 3/17/2021 indicated Resident 106 required encouragement or cueing for all personal hygiene activities including shaving.…

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 medical record review, the facility failed to ensure Resident 249 was supervised by staff and the environment free from hazards. For Resident 249, this failure resulted in Resident 249 wandering, unnoticed by staff, in and out of residents' rooms, touching items that placed her at risk for injury and spread infection. Findings: During review of Resident 249's medical record, it indicated a history of impairment in cognitive skills for making daily life decisions and repeated falls. The Care Plan dated 7/20/20 indicated the resident was a wanderer with impaired safety awareness that included interventions to redirect or offer activity to divert the attention of the resident. According to the Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 10/24/20, it indicated Resident 249 required supervision when moving through hallway and limited assistance with staff to provide guided maneuvering. During an observation and interview on 5/3/21 at 1:17 p.m., Resident 249 entered Room H. The resident in Bed-A stated Resident 249…

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 that food was prepared, stored, and served under sanitary condition when multiple plastic containers of salad dressing beyond the consumption date was found in the walk-in refrigerator This failure had the potential of putting residents at risk for food contamination and food-borne illness. Findings: During the initial kitchen tour observation on 5/3/2021, at 10:15 a.m., with the Kitchen Supervisor (KS) the following were observed in the walk-in refrigerator: In a medium size pan, there were four small plastic containers of Italian dressing dated 4/19/2021, four small plastic containers of Italian dressing dated 4/28/2021, and ten small plastic containers of Ranch dressing dated 4/27/2021 with no used by date. In another medium size pan, there were six small plastic containers of Tartar sauce dated 4/21/2021 with no used by date. During an interview with Dietary Aide 1(DA 1) on 5/4/2021, at 10:05 a.m., DA 1 stated they should label the food with a date when prepared. Food should be labeled and was good…

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 5. During an observation on, 5/5/21, at 9:19 a.m., in Resident 31's room, an incentive spirometer (a device with a mouthpiece and it helps the lungs to breathe deeply) was on Resident 31's bedside table. The incentive spirometer was left uncovered and its mouthpiece was touching the bedside table. During a concurrent observation and interview on, 5/5/21, at 9:25 a.m.,with Licensed Vocational Nurse (LVN 7), LVN 7 stated that the incentive spirometer should be kept in a plastic bag for infection control. LVN 7 further stated that if the spirometer was not covered, it could have bacteria grow and Resident 31 could breathe it in because that goes in her mouth. During a review of Resident 31's Physician Order Summary Report dated 5/6/21, the report showed an order for Incentive Spirometer for at least 15 minutes every shift for (Pneumonia- A lung disease) PNA prevention for Resident 31. During a record review of facility's Policy and Procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed toensure pateint care equipments were in safe operating conditions for two residents ( Resident 463 and 464) 0 f 32 sampled residents when:. 1. Resident 463's head of the bed cannot be elevated. 2. Resident 464 did not receive bedside rails to assist her with bed mobility and positioning. These failures resulted in the residents inabilities to achieve their highest practicable physical, mental and psycho-social well-being. Findings: 1. During an observation and concurrent interview with Resident 463 on 5/3/2021, at 2:00 p.m., Resident 463 stated she does not sleep well at all. Resident 463 stated she feels tired most of the time. She also stated her doctor wants the head of her bed to be elevated 30 to 40 degrees to help her breath better when she is in bed. Resident 463 demonstrated how she was not able to raise the head of her bed. Resident 463 stated she reported the problem with her bed on 4/1/21 on the day she was admitted and found out…

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 one (Residents 60) of 32 sampled residents were treated with respect and dignity when the staff failed to close the privacy curtain during Resident 60's treatment procedure. This failure had the potential for unnecessary body exposure and embarrassment. Findings: A review of Resident 60's physician's order dated 4/28/2021, indicated left hip, cleanse area with normal saline, apply hydrocoloid dressing every 3 days change PRN for soiling or dislodgement for 14 days then reassess. During a treatment observation on 5/5/2021, at 1:32 p.m., Licensed Vocational Nurse (LVN) 5 assisted by CNA 8 approach Resident 60 (who was in bed A) and explained the treatment procedure to Resident 60. The privacy curtain surrounding Resident 60's bed on his right side all the way to the foot part was left open. LVN 5 pulled Resident 60's gown up above his left waist exposing Resident 60's left hip and leg. LVN 5 proceeded to provide treatment to Resident 60's left hip. During an interview with LVN 5 on 5/5/2021, at 1: 45…

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 inform the physician of one of 32 sampled residents (Resident 31) worsening condition when Resident 31's physician was not informed of This failure had the potential to delay interventions and could lead to development of a wound infection. Findings: During an observation on, 5/5/21, at 9:15 a.m., Resident 31 was sitting in the wheelchair in her room. Resident 31 had a quarter sized, open wound on the left knee. The wound had a small amount of yellow and red colored drainage. During a concurrent observation and interview on, 5/5/21, at 9:17 a.m., with Certified Nursing Assistant (CNA 11) and Licensed Vocational Nurse (LVN 7), CNA 11 stated Resident 31 had that wound on her left knee when she came back from the hospital. CNA 11 stated, they bleed a lot pointing at Resident 31's bed sheets with dried brown stains on it. During a concurrent interview and record review, on 5/6/21 at 10:30 a.m., with Licensed Vocational Nurse (LVN 8), Resident 31's Care plans were reviewed. LVN 8 stated there was no plan of care 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.

Based on observation, interview and record review the facility failed to provide daily wound care treatment to Resident 499 per physician orders. This failure had the potential to result in worsening wounds, increasing the risk for localized and/or systemic infection for Resident 499. Findings: During an interview on 05/03/21, at 1:05 p.m., Resident 499 stated the wound nurse was suppose to change my dressings every day, Resident 499 stated they never change my dressing every day. Resident 499 stated the last time the dressing to his feet was changed was Saturday, on 05/01/21. During a concurrent interview and record review on 05/03/21, at 2:20 p.m., with Licensed Vocational Nurse (LVN 1), Resident 499's treatment administration records (TARs) were reviewed. LVN 1 confirmed that dressings to the right lateral malleolus (knobby bone felt on outside of right ankle), right heel and left heel were to be changed daily. LVN 1 stated If the wound nurse is not there that day, then the dressing change is done by the medication nurse. During a concurrent interview and record review on 5/6/21,…

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 its medication error rate did not exceed five percent. There were two medication errors out of 29 opportunities, resulting in a 6.9 percent (%) medication error rate, when: 1. Licensed Vocational Nurse 1 (LVN 1) dispensed medication to Resident 45 from a medication container intended for Resident 498 ; and 2. LVN 1 dispensed high blood pressure medication to Resident 45 that should have been held per the physician's instructions on the prescription label. These deficient practices did not comply with safe medication administration practices and had the potential to cause harm and jeopardize Resident 45's physical health. Findings: During a review of Resident 45's admission Record, the review indicated the Resident 498 was admitted with multiple diagnoses, including a hip fracture, hypertension (high blood pressure), a pleural effusion (excess fluid between the two layers of tissue enveloping the lungs), iron-deficient anemia (lacking enough healthy red blood cells to carry sufficient oxygen to 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 observation, interview and record review, the facility failed to ensure one of 32 sampled residents (resident 140) was free from significant medication error when Furosemide (commonly known as Lasix and water pill) was not administered as ordered by the physician. This failure resulted in Resident 140's edematous (swollen) lower leg to worsen. Findings: During an observation on 5/3/21, at 1:30 p.m., with the Director of Nursing (DON), in Resident 140's room, Resident 140 was sitting in wheelchair and it was observed that both lower legs were edematous. During observation and interview, on 5/6/21, at 9:20 a.m., with LVN 8, Resident 140's both lower legs were observed. LVN 8 stated I see a lot of edema on both legs, maybe +2 or +3. LVN 8 stated Resident 140 had the edema on both legs since she was admitted to the facility. During a review of Resident 140's nursing admission assessment dated [DATE], the assessment indicated Resident 140 had edema on right lower leg and left lower leg upon admission. During…

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.