Vienna Nursing And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to assess pain and provide timely pain relief for one of 35 sampled residents (Resident 2) when Resident 2 reported moderate (medium level) pain, waited for 10 minutes for non-pharmacological interventions (comfort measures that do not involve medication), and was not reassessed for pain.This failure resulted in Resident 2 experiencing ongoing, uncontrolled pain, which affected Resident 2's comfort and emotional well-being (the ability to feel calm, comfortable, and free from distress). Findings:Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses including unspecified B-Cell lymphoma (type of blood cancer with swollen glands), depression, age-related osteoporosis (weak or brittle bones), and pain.Review of Resident 2's Pain Assessment - V1 dated 12/5/25 indicated Resident 2 had chronic (long lasting) pain relieved by repositioning and pain pills.Review of Resident 2's Care Plan, initiated on 12/8/25, in the section titled Focus, indicated .I [Resident 2] have…

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 assess the safe use of bed rails (side rails) for one of 35 sampled residents (Resident 80) when Resident 80 did not have a completed bed rail assessment to determine whether bed rails were needed and safe to use.This failure placed Resident 1 at risk of entrapment and serious injury.Findings:Review of Resident 80's admission RECORD, indicated Resident 80 was admitted to the facility in 10/2025 with diagnoses including Alzheimer's disease (a condition that causes memory loss and confusion), hyperosmolality and hypernatremia (high levels of salt or concentration in the blood that can cause dehydration and confusion), anxiety disorder, depression, metabolic encephalopathy (confusion caused by a medical condition), and anemia.Review of Resident 80's Minimum Data Set Assessment (MDS: an assessment tool) dated 2/5/26, in the section titled Section C-Cognitive Patterns, indicated Resident 80 had short-term and long-term memory problems, impaired recall ability and severely impaired cognitive skills for daily…

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 medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of three errors out of 28 opportunities which resulted in a facility wide medication error rate of 10.71%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The three medication errors were identified in two residents (Resident 93 and Resident 83) out of eight residents observed for medication administration observation as follows:1. Resident 93 was given medication without a doctor's order.2. Resident 93's ordered medication was not given.3. Resident 83's medication that was ordered to be given with food was not given as ordered.These failures could contribute to unsafe medications use, medication error, and not following the doctor's orders.Findings:1. During a medication observation with Licensed Nurse (LN) 7, at station 2 hallway, on 2/18/26, at 8:44 AM, LN 7 prepared and poured…

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 safe medication storage and labeling practices in one out of two medication rooms and two out of three medication carts when:1. An expired bottle of ocular vitamins (specialized supplements containing high concentrations of nutrients designed to support vision and reduce the risk of age-related eye disease) was found in the Station 2 Medication Storage Room and an expired bottle of ocular vitamins was found in the Station 1 Medication Cart 3; and2. Two pill cutters (a device used to safely and accurately divide medication tablets, vitamins, and supplements) were found with white and grayish residue in two different medication carts (Medication Cart 5 and Medication Cart 3).These failed practices could contribute to unsafe medication use, medication error, and risk of contaminated products or supplies.Findings:1. During a concurrent interview and inspection of the facility's medication storage room at Station 2, on 2/17/26 at 8:41 AM, accompanied by Licensed Nurse (LN) 2, a bottle of ocular vitamins had…

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's Resident Care/Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members, when the Infection Preventionist (IP) did not attend the quarter 2 meeting on 4/24/25.This failure had the potential of leading to staff lacking knowledge and coordination of care for a census of 136, thereby resulting in risk for safety, spread of infection, and hospitalization.Findings: During a concurrent interview and record review on 2/20/26, at 11:50 AM, with the Director of Nursing (DON), the Quality Assurance and Performance Improvement (QAPI- a data-driven, proactive approach mandated by the Centers for Medicare & Medicaid Services [CMS] for healthcare facilities to continuously monitor, analyze, and improve the quality of care and services) 2025 binder was reviewed. The DON…

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 report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of three sampled residents (Resident 1) when Resident 1 had a bruise on the right side of her neck and left clavicle (a bone that connects the breastbone to the shoulder blade) identified on 11/14/24 and 11/15/24 respectively, and the facility did not report this to the Department until 11/21/24. This failure resulted in a delay in the Department investigation into Resident 1' s bruises and had the potential for an occurrence of abuse to go undetected. Findings: A review of Resident 1' s admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person ' s ability to perform everyday activities). During a review of Resident 1' s Minimum Data Set (MDS-an assessment and care planning tool), dated 10/17/24, the 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 food storage and service was in accordance with professional standards for food service safety, for the 139 residents who ate facility prepared meals when: 1. The cook's refrigerator was found with the temperature varying anywhere from 42-50 degrees Fahrenheit; 2. The three-door freezer (used for meats) had ice buildup behind the second and third doors, around the top of the door frame; 3. The three-door freezer had an open box of vegetarian meatballs that was exposed to the air; 4. Three fans were found with discolored blades; 5. Two metal shelves in cook's preparation area found with rusted areas; and 6. Four cutting boards found with black staining and deep grooves on cutting surfaces. These failures had the potential of leading to food borne illness for the 139 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 10/15/2024 at 8:15 a.m., the temperature for the cook's refrigerator was found varying between 42 degrees Fahrenheit (F, a unit of measurement) for 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 provide consistent guidance to staff regarding food brought to residents from outside sources. This failure had the potential of unsafe food items being distributed to the 139 residents leading to choking risk, allergic reactions, and food borne illness. Findings: During a review of facility policy and procedure (P&P) on 10/15/2024 at 1:18 p.m., from the survey binder titled Food Brought To Resident By Family/Friends/Activity Department revised 11/28/16 indicated that 6. Cooked left-over food be discarded after two (2) hours bedside. The policy did not include procedures for storing food for residents. During an interview with the Quality Assurance (QA) nurse on 10/15/24 at 3:20 p.m. in unit 2, the QA nurse stated that family can bring food into facility for resident. Food brought for the resident would be stored in the resident refrigerator. The QA nurse showed where the resident refrigerator was located in the hospitality suite. An observation of signage on the resident refrigerator indicated All staff must…

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 professional standards of practice were followed for two of 34 sampled residents (Resident 114 and 70) when: 1. Licensed Nurse 3 (LN 3) did not wear gloves during the administration of Resident 114's Paroxetine (medication used to treat depression) per physician's order; and 2. The dose for Resident 70's Zolpidem (medication used to treat insomnia [trouble falling asleep]) was not given but was signed as administered. These failures had the potential to result in contamination of the medication and exposure of Resident 114 and the LN to side effects, and confusion and inaccuracies in Resident 70's medication administration. Findings: 1. During a review of Resident 114's admission records, the records indicated Resident 114 was admitted in June 2024 with diagnoses which included depression. Resident 114's Minimum Data Set (MDS, an assessment tool) indicated Resident 114 had intact cognition. During a review of Resident 114's physician order dated 6/24/24, the order indicated, Paroxetine .40 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 interview and record review, the facility failed to ensure the physician was notified in a timely manner of a medication refusal for one of 34 sampled residents (Resident 12). This failure had the potential to cause negative outcomes to Resident 12's physical and mental well being. Findings: A review of the admission Record indicated Resident 12 was admitted with diagnoses including pulmonary embolism (a blood clot gets stuck in a blood vessel in the lung blocking blood flow) and atrial fibrillation (irregular heart rhythm that may lead to blood clots if left untreated). A review of Resident 12's Order Summary Report indicated a physician order dated 9/26/24, Xarelto (blood thinner, treats or prevents blood clots) Oral Tablet 20 MG (milligram, unit of measurement) .Give 1 tablet by mouth one time a day for A. Fibrillation. Hold for heavy vaginal bleeding. On hold from 10/02/2024 .to 10/09/2024 . A review of Resident 12's care plan initiated 2/10/24 indicated, I am at risk for bleeding r/t: [related to] Xarelto use A review of Resident 12's Medication Administration Note…

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 services to prevent pressure injuries (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for 2 of 34 sampled residents (Resident 3 and Resident 37) when: 1. Resident 3 did not have a foot cradle (device used to relieve pressure from the lower extremities by preventing blankets and linens from laying directly on the lower extremities) and sheepskin padding in place as ordered by physician; and, 2. Resident 37's foot cradle was used incorrectly when linens and towels were placed on top of the frame allowing bed linens and blankets to lay directly on lower extremities. These failures had the potential to result in Resident 3 and Resident 37 developing pressure injuries. Findings: 1. A review of the admission Record indicated Resident 3 was admitted with diagnoses including unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 3's physician order's indicated orders for Foot cradle in bed dated 10/11/14,…

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 34 sampled residents (Resident 45) received care and services to address her right hand contracture (a tightening of the muscles, tendons, and skin, causing resident's fingers to bend and curl towards the palm), when the facility did not implement preventative measures to maintain the resident's hand mobility and prevent worsening of Resident 45's contracture. This failure resulted in Resident 45 experiencing a severe right hand contracture leading to further decline in use of her hand and had the potential to result in pain and skin problems. Findings: A review of Resident 45's admission Record indicated the facility admitted the resident in 2016 with multiple diagnoses including hemiplegia (paralysis of one side of body) and hemiparesis (weakness of half of the body) following a stroke affecting the right dominant side). A review of the physician progress note dated 9/29/23 indicated Resident 45 was alert and oriented,…

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 proper storage, usage, handling, and labeling of respiratory care equipment were consistent with the facility's policy and procedures (P&P) for one of 34 sampled residents (Resident 13) when a nebulizer (a machine that turns medicine into a mist) mask and tubing were not properly stored and replaced as ordered, and nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was used and connected to a nebulizer machine. These failures had the potential to result in unsafe and unsanitary delivery of respiratory treatments to Resident 13. Findings: 1a. During a review of Resident 13's admission records, the records indicated Resident 13 was admitted in April 2023 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, diseases that block airflow and make it difficult to breath), shortness of breath, and dependence on supplemental oxygen. Resident 13's Minimum Data Set (MDS, an assessment tool) indicated Resident 13 had intact cognition.…

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 pain management was provided consistent with professional standards of practice for one of 34 residents (Resident 34) when doses of Resident 34's PRN (as needed) pain medication were given without adequate indication. This failure had the potential to increase Resident 34's risk of exposure to side effects and dependence on pain medication. Findings: During a review of Resident 34's admission record, the record indicated Resident 34 was admitted in September 2024 with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of half of the body), and disorders of bone density (amount of minerals in the bone) and structure. Resident 34's Minimum Data Set (MDS, an assessment tool) indicated Resident 34 had moderate cognitive impairment. During a review of Resident 34's Pain Assessment, dated 9/5/24, the assessment indicated Resident 34 was able to self-report pain and could comprehend use of numerical pain scale. The assessment further indicated Resident 34's goal for pain…

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 adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he was verbally threatened and then hit and kicked by Resident 2. This failure resulted in Resident 1 sustaining skin tears to the bridge of his nose and right arm, large abrasion to his left shoulder, experienced pain, and had the potential to negatively affect his long term emotional well-being. Findings: A review of the facility's policy titled, Resident to Resident Abuse, dated 3/2017 indicated, Our facility will not condone resident abuse by anyone .Facility will monitor residents for aggressive/inappropriate behavior towards other residents .or the staff. A review of the admission Record indicated the facility admitted Resident 1 in the summer of last year with multiple diagnoses, including tremors (excessive shaking or trembling). Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) dated 1/2/24, which indicated he was cognitively intact. According 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.

Based on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from verbal abuse by a staff member, by failing to ensure the facility's staff (FS 1), was not raising his voice, arguing with Resident 1, and calling the resident inappropriate names. This failure had the potential for Resident 1 to be fearful and to negatively affect her psychosocial well-being. Findings: A review of the admission record indicated the facility admitted Resident 1 with multiple diagnoses, including herpes viral encephalitis (a neurological disorder characterized by inflammation of the brain, which can lead to mental confusion) and depression. A review of Resident 1's ' Incident Note,' dated 10/19/23, at 11:06 a.m., indicated, Nursing staff reported to Administrator, witnessed incident between resident [Resident 1] and another staff member .Resident [1] saw staff member's lunch bag .opened lunch bag and took a bag of chips .and started to eat them .At 11:06 [a.m.] Staff member [FS 1] saw that his lunch bag had been…

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 follow their medication and pain management policy and procedure to ensure standards of professional practice were maintained during Medication Administration for a census of 115 when: 1. Pain was not assessed properly for Resident 66; 2. Glycolax powder (a medication used for constipation) was not administered as ordered for Resident 26; 3. Blood pressure (BP) was not checked as ordered prior to giving medication for Resident 85; 4. Medications administered or held were on not documented in a timely manner for Resident 16; and 5. Resident 16's electronic medical record was not protected during medication administration. These failures had the potential to negatively impact the resident's health outcomes. Additionally, failure to protect health records denied residents their rights to privacy of their information. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included fracture of the left ulna (a forearm bone) and unspecified…

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 three residents (Resident 47, Resident 81, and Resident 113) were assisted with Activities of Daily Living (ADL) when fingernails were long and had blackish substance underneath the nails, for a census of 115. These failures increased the potential to result in skin problems or injuries. Findings: A review of Resident 47's clinical record indicated a diagnoses including dementia (memory loss that interferes with daily functions) and macular degeneration (a condition that causes vision loss). A Minimum Data Set (MDS, an assessment tool) dated 8/9/22, indicated Resident 47 had severe cognitive impairment and required assistance with personal hygiene. A concurrent observation and interview was conducted on 10/11/22 at 12:34 p.m. with Certified Nursing Assistant 1 (CNA 1). Resident 47 had long fingernails and had blackish substance underneath her nails. The CNA 1 confirmed the finding and stated Resident 47's fingernails were long and…

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

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two residents, (Resident 269) who received renal hemodialysis (HD, a treatment necessary for kidney failure to remove unwanted toxins, waste products, and excess fluids by filtering the blood), when the facility failed to communicate and collaborate with the transport agency. This failure resulted in fatigue and frustration when transportation was delayed for an hour or more on multiple occasions. Findings: A review of the admission Record indicated Resident 269 was admitted to the facility earlier this year with multiple diagnoses which included the after care after right hip surgery, end stage kidney failure resulting in the need for dialysis. A review of the Minimum Data Set, (MDS, resident assessment and care screening tool), dated 9/25/22 indicated Resident 269's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated intact cognition). Resident 269 was totally…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen in sanitary condition by failing to ensure the Quaternary Ammonium sanitizing solution (a chemical agent used to destroy germs) used for sanitizing kitchen surfaces and equipment had the required concentration to be effective and Dietary Aide 2 failed to follow proper hand hygiene between tasks. These failures had the potential to result in foodborne illness to 114 vulnerable residents receiving food from the facility kitchen. Findings: On 10/11/22 at 8:25 a.m., during an initial kitchen tour accompanied by the Dietary Supervisor and [NAME] 1 a red bucket containing clear solution inside was observed on the shelf. [NAME] 1 explained the solution in the red bucket was filled with Quaternary Ammonium solution to sanitize the clean surfaces after they were cleaned with soap and water. On 10/11/22, at 8:55 a.m., the Dietary Aide 1 stated the concentration of the chemical should be 200 ppm (parts per million, the concentration of the solution). After DA 1 dipped an orange test strip into 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 proper infection control practices were followed for a census of 115 when: 1. Reusable equipment was not sanitized after use and between residents for (Resident 16, Resident 26, and Resident 85) and, proper hand hygiene was not followed during medication administration for Resident 85; 2. Resident 268, who had an infectious condition, shared a room with a vulnerable resident, and 3. There was no Contact Isolation Precautions signage posted informing visitors that the resident was on isolation precautions (measures taken to prevent the spread of germs/infection from one person to another). These failures had the potential to spread infection between and among the residents. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included hypertension and unspecified pain. According to Resident 26's 'admission Record' she was admitted to the facility last year with multiple diagnoses that included dementia and hypertension. According…

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 Range of Motion (ROM, the degree of movement that occurs at a given joint during an exercise program) exercises were provided as ordered for one resident (Resident 81), for a census of 115. This failure increased the potential for Resident 81 to experience further reduction in ROM. Findings: A review of Resident 81's clinical record indicated a diagnoses including dislocation of right hip and presence of right artificial hip joint. A Minimum Data Set (MDS, an assessment tool) dated 8/25/22, indicated Resident 81 had moderate cognitive impairment and functional limitation in ROM on both lower extremity. Review of Resident 81's physician's order dated 8/26/22 indicated, RNA [Restorative Nursing Assistant] for ROM 3x/week .every day shift . A concurrent interview and record review with the Licensed Nurse 3 (LN 3) was conducted on 10/14/22 at 12:51 p.m. LN 3 confirmed Resident 1 had no documented RNA for ROM from 10/1/22 to 10/12/22. There was no documented evidence in Resident 81's clinical records as to why ROM 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 observation, interview, and facility document review, the facility failed to provide 80 square feet of living space per resident in rooms 24, 33, 43, and 68. This failure had the potential to compromise the residents' care and privacy. Findings: Review of a facility request for the square footage room waiver dated 9/17/2019, indicated the following multiple resident bedrooms measured less than 80 square feet (sq. ft.) per resident: room [ROOM NUMBER] measured 74 sq. ft. per resident, Rooms 33 measured 71.5 sq. ft. per resident, Rooms 43 measured 77.5 sq. ft. per resident; and, Rooms 68 measured 73.5 sq. ft. per resident. During an interview on 10/11/22, at 12:47 p.m., with the Certified Nursing Assistant (CNA)1, CNA 1 stated residents in room [ROOM NUMBER] needed assistance with transfer. One resident requires Hoyer lift for transfers and CNA 1 stated they have enough space to maneuver the Hoyer lift and provide care for residents in this room. room [ROOM NUMBER], 43 and 68 did not have four residents…

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.