Victorian Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required period of within 14 days of admission for two of 19 sampled residents (Resident 21 and Resident 90). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 90. Findings: a. During review of Resident 21's clinical record, indicated Resident 21 was admitted on [DATE]. Review of Resident 21's admission MDS assessment indicated, the assessment was completed on 1/11/23, 20 days after admission. b. During review of Resident 90's clinical record, indicated Resident 90 was admitted on [DATE]. Review of Resident 90's admission MDS assessment indicated, the assessment was completed on 4/6/23, 15 days after admission. During an interview on 4/19/23, at 9:48 AM, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete significant change in status assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 14) when Resident 14 was discharged from hospice services. This failure could potentially delay the provision of appropriate treatment and services for Resident 14. Findings: Review of Resident 14's profile in the electronic health record (EHR) indicated, was admitted on [DATE] with diagnoses included atrial fibrillation (irregular, rapid heart rate that causes poor blood flow), heart failure, kidney failure, and hypertension (high blood pressure). Review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 2/15/23, indicated, Resident 14 was on hospice care. During an interview on 4/19/23, at 1:39 PM, Licensed Vocational Nurse (LVN) 2 stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for six of 19 sampled residents (Resident 6, 21, 62, 14, 80, and 50). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents. Findings: Review of the MDS Summary in the electronic health record (EHR), indicated the following: a. Resident 6 was admitted on [DATE]. Review of Resident 6's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 3/23/23, 16 days after the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). Further review revealed, quarterly MDS assessment dated [DATE] indicated, 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 complete and accurate assessment for one of 19 sampled residents (Resident 36) when coding in Section M of the Minimum Data Set (MDS, a resident assessment tool) did not reflect Resident 36's actual skin condition as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). The deficient practice resulted in an inaccurate assessment and interventions provided for Resident 36. Additionally, the deficient practice lead to delayed healing and development of a new pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) for Resident 36. Findings: Review of Resident 36's clinical record, indicated Resident 36 was admitted on [DATE] with diagnoses included rhabdomyolysis (a breakdown 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 to provide care and services for one of 19 sampled residents (Resident 21) when physician's treatment orders for Resident 21's healing burn area on right forearm were not implemented. Failure to implement physician's treatment orders could result to delayed wound healing and the potential for infection. Findings: Review of Resident 21's clinical record indicated, Resident 21 was admitted on [DATE] with diagnoses included but not limited to burn of third degree (full-thickness burn) of right forearm and other site of trunk, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (memory loss), and Parkinson's disease (refers to brain conditions that cause slowed movements, stiffness, and tremors). Review Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/23, indicated, Resident 21 had severe cognitive impairment. The MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide preventive care and treatment to avoid worsening and development of additional pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) on left medial toe (big toe); and promote healing of existing pressure injuries for one of 4 sampled residents (Resident 36) when: 1. The facility did not ensure complete and accurate wound assessment on admission that includes identification, measurement, and description of wound. Additionally, there was no consistency in wound identification, measurement, and description of wound among nursing and physician/practitioner. 2. There was no ongoing wound assessment to monitor the status and progress of Resident 36's multiple pressure injuries. 3. The care plan addressing Resident 36's pressure injuries did…

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 trauma informed care for one of three residents (Resident 12) when facility did not identify and address symptoms of PTSD (Post -Traumatic Stress Disorder). This failure to identify symptoms had the potential to result in inaccurate and inappropriate provision of care. Findings: Review of Resident 12's clinical record on 4/19/23 at 1:00 PM, Resident 12 was admitted to facility on 11/16/2016 with diagnoses included bipolar disorder (mood swings disorder) and PTSD. During observation on 4/18/23 at 11:00 AM, Resident 12 was awake and lying in bed. Resident 12 did not respond when greeted. During interview on 4/18/23 at 12:00 pm with CNA 2, CNA 2 stated, 'I have worked with resident since he was admitted , I have worked here over 20 years. He eats by himself, he gets violent if you remove something from his table, he does not talk to strangers, he starts screaming and yelling, and he tends to be forgetful. He refused to go out of bed, even for showers. CNA 2 cleans him up in bed. Resident 12 speaks Spanish…

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 medically related social services to attain or maintain highest practicable physical, mental, psychosocial well-being for one (Resident 12) of three residents reviewed when social worker (SW) did not address care plan and progress note on diagnoses of PTSD and history of trauma. This failure can result in staff not recognizing the trauma symptoms can trigger re- traumatization. Findings: Review of Resident 12's clinical record, Long Term Care Psychiatry dated 4/18/23, Nurse Practitioner (NP) indicated, PTSD symptoms after being tortured in Nicaraguan civil war. He is alert, calm pleasant and cooperative, grateful to God. Says he has a lot of memories of his participation in war, dreams about weapons or about killing people from a helicopter, makes him feel like a murderer. Does not like seeing news on tv about war, is concerned about Russia/Ukraine war, he was trained by Russians in Nicaragua. He hopes for International peace. Impression: still has some PTSD symptoms, hard to tell how often or…

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 document review the facility failed to meet the needs of the residents when unauthorized personnel that had access to the station one medication room. Findings: During an observation on 4/18/23 at 7:00 AM the station one medication room was left unlocked and opened. The deadlock was holding the door open. The deadlock was preventing the door from closing. There were multiple staff and residents that walked by the opened medication room. During an observation and interview on 4/18/23 at 7:00 AM CNA 1 walked past the open medication room. CNA stated that she was not supposed to have access to the medication room. During an observation and interview on 4/18/23 at 7:05 AM Staff 1 walked past the open medication room. Staff 1 stated that she primary does housekeeping and was not supposed to have access to the medication room. During an observation on 4/18/23 at 7:05 AM inside the medication room was multiple prescription medications on the shelves and the medication refrigerator. During an observation on 4/18/23 at 2:00 PM the station two medication…

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 document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for twenty-six observed opportunities which would equal a medication error rate of eleven percent. Findings: 1. During an observation on 4/18/23 at 8:25 AM LVN 1 prepared 30 mg of Furosemide (diuretic medication used for edema) for Resident 90. LVN 1 had prepared the 30 mg of Furosemide for administration. A review of the physician orders indicated that Resident 90 was to receive 60 mg daily of Furosemide. When asked why LVN 1 was about to administer the 30 mg instead of the 60 mg she stated that the pharmacy label indicated to administer 30 mg. During an interview on 4/18/23 at 8:45 AM Pharmacist 1 stated that Resident 90's pharmacy label was mislabeled. Pharmacist 1 also stated the instruction on the label indicated that the 30 mg daily would be administered instead of the 60 mg daily as ordered by the physician. 2. A review of the Enoxaparin manufacture's' insert indicated Subcutaneous Injection Technique…

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 appropriately label and store medications as evidence by: 1. The facility pharmacy dispensed medications that was mislabeled. The labeling indicated incorrect administration instructions that did not correspond to the physician's orders. 2. The facility station two medication refrigerator was too cold for the medications that were stored inside the refrigerator. Findings: 1. During an observation on 4/18/23 at 8:25 AM LVN 1 prepared 30 mg of Furosemide (diuretic medication used for edema) for Resident 90. LVN 1 had prepared the 30 mg of Furosemide for administration. A review of the physician orders indicated that Resident 90 was to receive 60 mg daily of Furosemide. When asked why LVN 1 was about to administer the 30 mg instead of the 60 mg she stated that the pharmacy label indicated to administer 30 mg. During an interview on 4/18/23 at 8:45 AM Pharmacist 1 stated that Resident 90's pharmacy label was mislabeled. Pharmacist 1 also stated the instruction on the label indicated that the 30 mg daily would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. For Resident 62, the undated urinary drainage bag (collection bag) was stored together with the undated urinal (a bottle for urination) in a black bag touching the floor. 2. Resident 25 and Resident 18's oxygen tubing in use were undated. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents. Findings: 1. Review of Resident 62's undated Facesheet indicated, was admitted on [DATE] with diagnoses included spinal stenosis (narrowing of the spinal canal), quadriplegia (paralysis that affects all a person's limbs and body from the neck down), and neuromuscular dysfunction of bladder (a condition where a person lacks bladder control due to brain, spinal cord or nerve problems). During an observation on 4/17/23, at 9:47 AM, in resident's room, Resident 62 was lying in bed watching…

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 required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care and may impact their quality of life. Findings: The room measurement indicated multiple resident rooms were less than 80 square feet per resident. Room # # of occupants Space per Resident 1 2 74.27 2 3 74.27 3 2 75.25 4 3 74.27 5 2 76.58 6 3 72.26 8 3 77.19 9 3 74.80 11 3 74.53 12 3 76.13 14 2 76.22 15 2 77.59 16 2 73.61 17 2 76.13 18 3 76.13 19 2 76.13 20 2 77.90 21 3 76.13 22 3 76.13 23 3 76.13 24 3 79.32 25 3 73.66 26 2 76.39 27 3 73.12 28 3 78.36 29 3 73.12 30 2 73.12 31 3 74.00 32 2 75.37 33 2 75.93 34 2 75.93 35 2 75.93 None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and Geri chairs (medical recliners) were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern.…

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

Based on observation and interview, the facility failed to maintain a safe and pest free environment for residents and an effective pest control program, when a rodent was sighted on 4/18/23 in the basement. This failure can result to infection control problem. Findings: During observation on 4/18/23 at 8:15 AM, a running mouse was sighted in the basement near the kitchen. Housekeeping supervisor (HKS) stated, It's a mice [sic]. During interview with kitchen supervisor (KS) on 4/18/23 at 10:00 AM, KS stated, did not see mice in the kitchen today. During interview with Maintenance Supervisor (MS), MS stated, there has been no reports of sighting or droppings this month, but has been in the past month. No logged in report this month. Terminix is the commercial General Pest Control we use, comes in 2 times a month. We had a problem with mice in the building in December 2022, we did what Terminix recommended for us to do, patching the holes, replaced the ceiling with hole in the kitchen, patched the holes with Foam patch to areas with holes as identified by Terminix. To prevent 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 display the total and actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) each shift, and the actual hours worked by the Certified Nursing Assistants (CNAs) each shift. This deficient practice had the potential to misinform residents and visitors on the facility's staffing levels, and the deficient practice had the potential to lead to inadequate RN, LVN, and CNA staffing levels. Findings: During an initial tour observation, on 8/19/19, at 8:36 AM, a double-sided sheet of paper titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 8/19/19, was displayed in the bulletin board and at the reception desk. The DHPPD, and other posted information, did not contain the total and actual hours worked by RNs and LVNs each shift, or the actual hours worked by the CNAs each shift. During an observation, record review, and interview with the Admissions Coordinator (AC), on 8/20/19, at 9:06 AM, AC found staffing information in the bulletin board, and on the front lobby…

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 store foods in accordance with accepted professional standards of practice when: 1. Five cartons of Glucerna Therapeutic Nutrition (medical nutritional beverages meant for people with diabetes) were stored beyond expiration date; and 2. One opened container of Parsley Flakes was undated. This deficient practice may put the residents at risk for food borne illnesses, and may affect the appetite of the residents due to loss of potency and flavor of expired seasonings. Findings: 1. During an observation of the kitchen and concurrent interview with the Dietary Supervisor (DS) on 8/19/19 at 9:30 AM, there were five cartons of Glucerna Therapeutic Nutrition with expiration date of 7/1/19 stored in the kitchen cabinet. The DS stated, . They (referring to kitchen staff) have to throw it away . if given to patients, they're gonna affect the resident . 2. During an observation of the kitchen and concurrent interview with the DS on 8/19/19 at 9:12 AM, there was one unlabeled opened container of parsley flakes stored in…

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 required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care, and may impact their quality of life. Findings: During the entrance conference interview and record review with the Administrator (Admin), on 8/19/19, at 8:40 AM, Admin stated and presented the written room waiver request for resident rooms one through six, eight through 12, and rooms 14 - 35. During the initial tour observation, on 8/19/19, at 9:03 AM, there were more than one resident in all of the resident rooms noted on the room waiver request. Residents in the aforementioned rooms were observed and interviewed by members of the survey team and the residents had no concerns about the quality of life, quality of care, and safety related to the room size. During a concurrent interview and record review with Admin, on 8/23/19, at 11:56 AM, Admin presented and submitted the Client Accommodation Analysis, dated 8/23/19, indicating more than one resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a complete and accurate notice before discharge in writing to the resident and the Office of the State Long-Term Care Ombudsman (Office of the State LTC Ombudsman) for two of two sampled residents (Resident 61 and Resident 81). In addition, the facility did not store the written notice in the medical record of Resident 61 and Resident 81. This deficient practice had the potential to result in an unsafe discharge for Resident 61 and Resident 81. Findings: 1. A review of Resident 61's admission Records indicated Resident 61 was admitted to the facility, on 7/30/2019, with diagnoses that included cutaneous abscess of abdominal wall (a collection of pus that has built up on, or within, the exterior skin of the abdomen), chronic (long term) pain syndrome, and chronic kidney disease. Resident 61 was responsible for himself. During an interview with Resident 61, on 8/20/19, at 2:52 PM, he stated he was going to be discharged this week. Resident 61…

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 meal plating observation, interview, and record review, the facility failed to accommodate the food preferences of six of 81 residents (Residents 28, 55, 78, 69, 74, and 36) during meal distribution. This failure had the potential for loss of appetite which may lead to decreased food intake and could potentially cause unintentional weight loss to the residents who receive food from the facility kitchen. Findings: During tray line (a cafeteria-style of food distribution) observation and concurrent interview on 8/21/19 beginning at 12 PM, Kitchen Staff (KS) 1 began plating meals for multiple residents. The plated meals were placed on the trays inside the food delivery cart by KS 2. KS 3 stated the meals were ready for distribution to the residents. During observation with the Dietary Supervisor (DS), on 8/21/19 at 12:14 PM, of the contents of the trays in the food delivery carts ready for distribution to the residents, showed each tray inside the food delivery carts included the plated meal and an undated diet card (a printed copy of the resident's physician prescribed diet…

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 distribute meals in accordance with the physician ordered therapeutic diet for one of 67 residents (Residents 78) when Resident 78 was plated with a whole cheeseburger sandwich during lunch meal distribution. Failure to follow physician ordered diets may further compromise the medical status of residents which may lead to unnecessary hospitalizations, and in severe instances may result in death. Findings: During a review of the clinical record for Resident 78, the admission Record indicated Resident 78 was admitted on [DATE]. The Order Summary Report dated 8/1/19, indicated, . Dietary -Diet . Mechanical Soft (a diet that is easy to chew and easy to swallow, and includes foods that readily break apart without a knife) with chopped meat texture . Start date 07/12/2019 . The . Speech Therapy . Evaluation and Plan of Treatment . Start of Care: 7/11/19 . Precautions: Diet: . m/s (mechanical soft) chopped . Patient Goals: . slow rate 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 did not ensure an allegation involving abuse was reported to appropriate authorities immediately but not later than 2 hours for 1 of 21 sampled residents (Resident 36). This failure had the potential to compromise protection of residents from abuse. Findings: Resident 36 was admitted on [DATE] with diagnoses that included intracerebral hemorrhage (bleeding inside the brain caused by a ruptured blood vessel), hemiplegia (paralysis on one side of the body) affecting left non-dominant side, contracture (tightening or shortening of a muscle or joint) on left hand, hypertension (high blood pressure), diabetes mellitus Type II (abnormal blood sugar levels), and depression. Review of Resident 36's Minimum Data Set (MDS, an assessment tool) dated 7/10/19, indicated a Brief Interview for Mental Status (BIMS, a brief scanner to detect cognitive impairment) score of 14, which indicated Resident 36 was cognitively intact. Under section G of the MDS, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan that reflect the current needs, treatment, and services for one of 21 sampled residents (Resident 130) when the care plan for at risk for fall was not revised to address an actual fall incident. This failure had the potential to result in provision of inaccurate and inadequate care and services that may prevent Resident 130 from achieving and maintaining her highest practicable quality of life/level of functioning. Findings: During a review of the clinical record for Resident 130, the admission Record dated 8/23/19 indicated Resident 130 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, sprain of left ankle, and history of falling. During an observation and concurrent interview on 8/19/19 at 10:19 AM, Resident 130 was in bed, alert, and watching TV. Resident 130 stated, . I fell yesterday. It happened around 4:30 PM . I needed to use the bathroom . I used a walker . the nurse walked…

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 meet the proper transfer and discharge requirements for one of two sampled resident (Resident 61) when Resident 61 did not receive comprehensive care plan goals, the reason for the discharge written by the physician, all special instructions for ongoing care, and a discharge summary containing the required information, such as the resident's post-discharge plan of care and the reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). This deficient practice had the potential to result in a discontinuation of necessary care and services for Resident 61. Findings: A review of Resident 61's admission Records indicated Resident 61 was admitted to the facility, on 7/30/2019, with diagnoses that included cutaneous abscess of abdominal wall (a collection of pus that has built up on, or within, the exterior skin of the abdomen), chronic (long term) kidney disease, diabetes mellitus (a metabolic disorder characterized by high blood sugar levels over 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 observation, interview and record review, the facility failed to ensure specialized rehabilitative service was provided for 1 of 21 sampled residents (Resident 67), when Resident 67 did not receive physical therapy (PT) on 8/13/19. This failure had the potential for residents to not attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being. Findings: Resident 67 was admitted on [DATE] with diagnoses that included cellulitis (bacterial skin infection) of right lower limb, muscle weakness, hypertension (high blood pressure), and obstructive sleep apnea (a condition in which the throat muscles relax causing airflow blockage during sleep). During an observation on 8/19/19 at 9:55 AM and concurrent interview, Resident 67 was lying in bed, awake, and wearing a mask attached to a CPAP (continuous positive airway pressure) machine (device used for treatment of obstructive sleep apnea). Resident 67 stated he had been at the facility for a couple 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.