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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. These failures had the potential to impact the quality of care delivered to all residents. Findings: Resident 81 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's admission Record. On 8/10/21 at…

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

Based on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement action plans related to the following: 1. Baseline care plans were not consistently developed to address resident diagnoses, care, and treatments. (cross reference F-Tag 655) 2. Resident specific care plans were not consistently developed. (cross reference F-Tag 656) 3. There was not sufficient staffing to respond to resident requests in a timely manner. (cross reference F-Tag 725) These failures had the potential to affect the health and safety of the residents. Findings: On 6/21/21 at 3:34 P.M., an interview was conducted with the facility's administrator (ADM) and the director of nursing (DON) regarding the facility's QAA committee. The ADM stated the QAA committee met monthly and identified concern areas through multiple sources, which included resident council meetings, employee and resident family feedback, daily meetings, and use of the facility's hotline. The ADM stated the QAA committee was working on three areas 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 document review the facility failed to provide sufficient staff to meet the needs of seven residents (Residents 3, 12, 17, 25, 88, and Confidential Residents [CR] 1 and 2). As a result residents 3, 12, 17, 25, 88, CR 1 and CR 2 did not receive care in a timely manner, putting them at risk for skin break down and creating unnecessary fear. In addition, Resident 17 did not receive wound treatment consistently due to insufficient staffing. Findings: 1. Resident 88 was admitted to the facility on [DATE] with diagnoses that include surgical aftercare, difficulty walking and muscle weakness, per the facility's admission Record. On 06/15/21 at 2:50 P.M., an interview was conducted with Resident 88. Resident 88 stated almost every night no one answered his call light in a timely manner. Resident 88 stated many times he had to get himself out of bed, into his wheelchair and then push himself down to the nurse's station to get help with changing of his brief and getting cleaned up.…

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's medical director (MD) failed to ensure medical care was provided to residents according to acceptable standards of practice for the following: - Development and Implementation of Care Plans (See F-Tag 656) - Quality of Care/Treatment (See F-Tag 684) - Accidents and Hazards (See F-Tag 689) - Dialysis Assessments (See F-Tag 698) - Sufficient Nursing Staff (See F-Tag 725) - Pharmacy Services (See F-Tag 755) - Medication Errors Greater than Five Percent (See F-Tag 759) - Lab Reports (See F-Tag 775) - Medical Records (See F-Tag 842) - Infection Control (See F-Tag 880) As a result, resident care was not provided in accordance to the facility policies and procedures, which could potentially result in physical and psychosocial harm to the residents. Findings: On 9/8/21 at 9:10 A.M., a telephone interview with the MD was conducted. The MD stated he was aware of results of the facility's re-certification survey completed on 6/21/21. The MD stated he knew there would be a revisit wherein the facility would be expected to be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75), had their right to refuse care honored, when certified nursing assistant (CNA) 1 continued to provide care after Resident 75 had refused care. This failure had the potential for Resident 75 to feel disrespected. Findings: Resident 75 was readmitted to the facility on [DATE], per the facility's admission Record. On 6/18/21 at 9:06 A.M., an interview was conducted with Resident 75 inside the resident's room. Resident 75 stated she had an incident with her assigned CNA (CNA 1) the other night on 6/16/21. Resident 75 stated she had a specific way she preferred to be cleaned after an incontinence (inability to control urine and feces) episode and that her personal hygiene routine took time. Resident 75 stated she saw CNA 1 around 4 P.M. on 6/16/21, and they both agreed upon 9:30 P.M. as the time to change her incontinence brief. Resident 75 stated CNA 1 arrived to change her after 10 P.M. Resident 75 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 observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 247) was free from restraints when approximately seven to nine pillows were utilized in order to keep the resident from leaving the bed. This deficient practice had a potential negative psychosocial impact for Resident 247's wellbeing by being restrained. Findings: Resident 247 was admitted to the facility on [DATE], per the facility's admission record. A review of Resident 247's admission History and Physical dated 5/28/21, indicated the resident was diagnosed with dementia (a group of thinking and social symptoms characterized by memory loss that interferes with daily functioning). On 6/15/21 at 12:03 P.M., an observation of Resident 247 was conducted in the resident's room. Resident 247 was in bed laying on her back, partially covered with a sheet. Resident 247 was on a low air loss mattress (specialized mattress used to prevent pressure injuries) and had two full-sized pillows under each…

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 complete baseline care plans for 3 of 21 sampled residents (Residents 71, 199 and 200). This failure had the potential for registered nurses (RN's) and licensed vocational nurses (LVN's) and certified nursing assistant (CNA's) with the inability to care for the sampled residents. Findings: Resident 71 was re-admitted to the facility on [DATE] with diagnoses to include generalized weakness and urinary tract infection (UTI - an infection in any part of the kidneys, bladder and or urethra). During initial tour of the facility on 06/15/21 at 3:13 PM the resident was observed on her back in bed with eyes closed. Call light was within reach, water pitcher on the bed side table, Foley catheter (a flexible tube inserted into the bladder) covered with a dignity bag and a nasal cannula (NC- device used to deliver supplemental oxygen to a person in need of respiratory help.) During a review of Resident 71's, care plans on 06/18/21, at 09:38 A.M.…

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 individualized and resident-specific written care plans were developed for three of 30 sampled residents (Residents 32, 50, and 75), reviewed for care planning, when: 1. Resident 75's personal preferences for incontinence (the inability to control urine or feces) care were not developed in a written care plan. 2. Resident 50's lack of teeth was not included in the development of a written care plan. 3. Resident 32's risk for choking was not developed in a written care plan. These failures had the potential to negatively effect the residents' health, safety, quality of life, and cause miscommunication among caregivers. Findings: 1. Resident 75 was readmitted to the facility on [DATE] with diagnoses to include urge incontinence, per the facility's admission Record. On 6/18/21 at 9:06 A.M., an interview was conducted with Resident 75. Resident 75 stated she liked to be cleaned in a specific way after an incontinence episode. 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 observation, interview, and record review, the facility failed to ensure wound treatment was provided in accordance with the physician's order for one of 30 sampled residents (Resident 17). This failure had a potential for Resident 17's wound to develop infection. Findings: Resident 17 was readmitted to the facility on [DATE], per the facility's admission Record. During an observation on 6/16/21 at 9:23 A.M., Resident 17 had a wound dressing on his right hand with a date of 6/8 written on the dressing. A record review was conducted. The physician's order dated 6/7/21, indicated, Right hand abrasion: cleanse with NS (Normal saline), pat dry, apply dry dressing, every day shift every 3 days. Resident 17's June 2021 eTAR (electronic Treatment Administration Record - a record where nurses mark treatment was done) was reviewed. The June 2021 eTAR indicated the resident's wound treatment for his right hand abrasion had been initialed as done on 6/8/21, not initialed on 6/11/21, and was initialed on 6/14/21 as…

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 pressure ulcer (skin injuries caused by prolonged pressure on the skin) preventative measure was implemented when a pressure relieving mattress was not programmed in accordance with the physician's order for one of 5 residents (Resident 32) reviewed for pressure ulcer/injury. This failure had the potential for Resident 32 to develop pressure ulcer. Findings: Resident 32 was readmitted to the facility on [DATE] with diagnoses that include of Traumatic brain injury (sudden injury that causes damage to the brain), functional quadriplegia (paralysis of all four limbs) per the admission Record. On 6/16/21 at 9 A.M., Resident 32 was observed sitting on a wheelchair. Resident 32 had a pressure relieving mattress on his bed. Resident 32's mattress control panel indicated a setting of 1 was to be use for residents weighing up to 120 lbs. (pounds). The control panel also indicated, settings of 2 -5 were to be use for residents weighing more…

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 range of motion (ROM) exercises for one of four residents (Resident 25) reviewed for position/mobility. This failure had a potential for Resident 25 to develop muscle weakness and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: Resident 25 was readmitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis of all four limbs) per the facility's admission Record. On 6/15/21 at 3:48 P.M., an observation and interview with Resident 25 was conducted. Resident 25's left hand and fingers was observed to be stiff. Resident 25 was able to slowly move the left hand and fingers on her own. Resident 25 stated, she was not receiving any exercises on her upper extremities. Resident 25 stated, restorative nursing assistant (RNA) 1 assisted her with sit to stand exercises. Resident 25 stated, she asked RNA 1 if she…

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 two of 30 sampled residents (Resident 37 and 32 ) reviewed for accidents, were free from the risk of accidents and hazards when: 1. Certified nursing assistant (CNA) 1 and CNA 7 unsafely transferred Resident 37 from the resident's bed to the wheelchair. 2. Resident 32 had a crumpled up surgical mask inside of his mouth. These failures had the potential for Resident 37 to sustain falls or other injuries, and for Resident 32 to choke. Findings: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms characterized by memory loss that interferes with daily functioning), difficulty in walking, muscle weakness, and a history of falling, per the facility's admission Record. A review of Resident 37's Annual History and Physical dated 8/26/20, indicated, .Orientation to time, place, and person: Patient appears somewhat disoriented . Recent memory appears to be mildly…

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 label the peripherally inserted venous catheter (PIV/IV - needle inserted into a blood vessel used for hydration and/or medication) site with date, time, and initials of the licensed nurse (LN) for one of 30 sampled residents (Resident 199). This failure had the potential to increase Resident 199's risk of infection. Findings: Resident 199 was admitted to the facility on [DATE], with diagnoses that included cellulitis (bacterial skin infection), per the facility's admission Record. During the initial tour of the facility on 6/15/21 at 3:30 P.M., Resident 199, was observed in bed, with a PIV in her right hand. At the bedside, was an IV antibiotic hanging on the IV pole. The PIV site on Resident 199's right hand did not indicate the date, time, initials, and size of the needle used. During a subsequent interview with LN 32 on 6/15/21 at 3:46 P.M., LN 32 stated there was no time or date it was inserted, initials, or size of the needle used.…

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 consistent completion of hemodialysis (dialysis- a life support treatment that replaces many of the kidney's functions) assessments for 2 of 2 sampled dialysis residents (Resident 21 and 36). This failure had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care for Resident 21 and Resident 36. Findings: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses, which included end stage renal disease (kidney failure), per the facility's admission Record. During an interview with Resident 21 on 6/16/21 at 9:15 A.M., the resident stated he went out for dialysis three times a week every Tuesday, Thursday, and Saturday. During an interview with the assistant director of nursing (ADON) on 6/18/21 at 9:59 A.M., the ADON stated each dialysis resident had a binder that went with them to each treatment at the dialysis center. The ADON stated the Pre/Post…

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 the target behaviors were appropriate and side effects were monitored for the use of psychotropic (affecting mental activity) medications for two of 5 residents (Residents 36 and 3) reviewed for unnecessary medications. Failure to monitor appropriate target behaviors for Resident 36 had the potential to affect the ordering physician's ability to determine the effectiveness of the medication. In addition, Resident 3 experienced drowsiness that was not identified and reported to the resident's physician. Findings: 1. Resident 36 was admitted to the facility with diagnoses, which included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with everyday activities), per the facility's admission Record. During a phone interview with Resident 36's responsible party (RP) on 6/17/21 at 9:04 A.M., the RP stated Resident 36, Can get agitated and combative at times. According to Resident 36's…

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 faility failed to ensure that IV tubing was labeled apropriatly for two of 30 sampled residents [199 and 200]. Findings: During the initial tour of the facility 06/15/21 at 3:30 P.M., Resident 199, was observed in bed, with a peripheral inserted catheter (PIV.) in her right hand. There was no date, time, RN initials when inserted, or the size of the needle inserted into Resident 199. At the bedside was an IV pole with IV antibiotics hanging on the IV pole, there was no label on the tubing to indicate when the tubing was hung. During a subsequent interview on 6/15/2021 at 3:46 P.M., with RN 32. RN 32 acknowledged that, there is no date or RN signature of who started the PIV or the size of the needle. RN 33 further stated there was no label on the tubing letting other RN's know when the IV tubing was hung or when to replace the tubing. During an interview and record review with RN 33, on 06/17/21, at 3:54 P.M., RN 33, stated we change peripheral IV sites every…

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 have laboratory reports filed in the resident's clinical record for one of three residents (Resident #31). As a result, the nursing staff was unable to properly assess if Resident 31 had abnormal laboratory results that had the potential for Resident 31 not to receive competent medical interventions if needed. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses that include ileus (intestine that gets twisted inside the body causing severe pain and potential blockage), gastrointestinal hemorrhage (bleeding inside the intestine or stomach), muscle weakness and heart disease, per the facility's admission Record. On 06/18/21 at 10:35 A.M., a record review was conducted. The record indicated that Resident 31 had blood laboratory (lab) orders from the physician on 6/3/21 that included a complete blood count (CBC), basic metabolic panel (BMP) and thyroid stimulating hormone (TSH) with reflex. There was no documented evidence of any lab…

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 coordinate dental services as ordered for one resident (Resident 50). As a result, Resident 50 did not get her ordered dentures and was at risk for choking, poor nutrition, and potential loss of dignity. Findings: Resident 50 was readmitted to the facility on [DATE] with diagnoses that include deficiency (lack of) of B group vitamins, aphasia (loss of ability to express speech caused by brain damage), and cerebral infarction (lack of blood supply to the brain causing brain damage) affecting the left dominant side (left side of body), per the facility's admission Record. On 06/15/21 at 11:01 A.M., an observation and interview were conducted with Resident 50. Resident 50 appeared to have no top teeth when observed during interview. Resident 50 stated she had no dentures but would like some very much. Resident 50 stated she had no top teeth and only a few bottom teeth. Resident 50 smiled and said, that would be great if I could get dentures.…

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 unsampled resident (Resident 23) had his food allergies, dislikes, and preferences clearly identified. In addition, some nursing staff could not identify a dislike from a food allergy. This failure had the potential to cause harm if a food allergy was served to a resident by mistake. Findings: Resident 23 was admitted to the facility on [DATE], per the facility's admission Record. On 6/15/21 at 11:59 A.M., an observation of resident dining was conducted in the second floor dining room. Resident 23 was observed eating cottage cheese. Resident 23's meal ticket dated 6/15/21, indicated, .Allergies/dislikes .cheese cottage . Preferences . Cottage cheese Resident 23 stated he liked cottage cheese. On 6/15/21 at 12:05 P.M., a joint interview and record review was conducted with licensed nurse (LN) 5. LN 5 reviewed Resident 23's meal ticket dated 6/15/21 and stated cottage cheese was listed as both an allergy/dislike and a preference…

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

Based on observation, interview, and record review, the facility failed to ensure the residents' refrigerator on Station 2 was maintained in a clean and sanitary condition. This failure had the potential to expose the residents' food to unclean conditions. Findings: On 6/17/21 at 10:37 A.M., a joint observation of the residents' refrigerator on Station 2 was conducted with certified nursing assistant (CNA) 9. The residents' refrigerator had food stored inside that visitors and family brought in for the residents as well as snacks that were provided by the facility. The surface of the refrigerator's bottom shelves were heavily stained with dried-on brownish liquid, small pieces resembling food debris, and a loose piece of crumpled plastic wrap. The inside of the bottom drawers had dried golden stains, and small particles resembling food debris. CNA 9 stated the residents' refrigerator was dirty and the stains looked old. CNA 9 stated she did not know who was responsible for maintaining the cleanliness of the inside of the residents' refrigerator. CNA 9 stated this was the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents' (Resident 17) medical record was accurate, when a licensed nurse (LN) documented a wound treatment as done, when the treatment to the resident's wound was not performed. This failure had the potential to cause miscommunication of Resident 17's wound treatment to the other health care providers. Findings: Resident 17 was readmitted to the facility on [DATE] per the facility's admission Record. During an observation on 6/16/21 at 9:23 A.M., Resident 17 had a wound dressing on his right hand with a date of 6/8 written on the dressing. A record review was conducted. The physician's order dated 6/7/21, indicated, Right hand abrasion: cleanse with NS (Normal saline), pat dry, apply dry dressing, every day shift every 3 days. Resident 17's June 2021 eTAR (electronic Treatment Administration Record - a record where nurses mark treatment was done) was reviewed. The June 2021 eTAR indicated the resident's wound…

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 fully implement infection control standards of practice when hand hygiene was not performed between glove changes during a wound treatment observation on 1 of 30 sampled residents (Resident 398). This failure had the potential for an increase in facility-acquired infection and medical complications for Resident 398. Findings: Resident 398 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the digestive system per the facility's admission Record. According to a physician order dated 6/8/21, Resident 398 was to have her abdominal wound cleansed three times a week; with white sponge applied to wound undermining (pockets at the wound edge) and black sponge to fill wound and wound VAC (vacuum-assisted closure: a method of decreasing air pressure around a wound to assist the healing). According to Resident 398's Wound Observation Tool, dated 6/14/21, the resident's abdominal wound was 6…

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 there was adequate staff to provide the necessary care for six confidential residents (CR 1, CR 2, CR 3, CR 4, CR 5, and CR 6), and 8 of 28 residents reviewed for sufficient staffing (90, 105, 318, 321, 44, 103, 316, and 319). This failure had the potential for residents to experience physical and emotional harm. Findings: A. Resident 90 was admitted to the facility on [DATE], with diagnoses which included legal blindness, per the facility's admission Record. A review of Resident 90's medical record was conducted on 9/11/19. According to Resident 90's MDS (health status screening and assessment tool), dated 8/5/19, Resident 90 had a BIMS (an assessment tool for cognitive status) score of 15. A BIMS score of 15 indicated a person was considered cognitively intact. On 9/9/19 at 10:21 A.M., an interview with Resident 90 was conducted. Resident 90 stated staff took a long time to answer her call light. Resident 90 stated she walked to the bathroom…

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 follow the lunch menu for one of six residents reviewed for food (318). This failure had the potential for Resident 318's nutritional status to go unmet. Findings: Resident 318 was admitted to the facility on [DATE], per the facility's admission Record. On 9/12/19, a review of Resident 318's MDS assessment, dated 9/11/19, indicated Resident 318 had a BIMS score of 15. A BIMS score of 15 indicated cognition was intact. On 9/9/19 at 11 A.M., an interview with Resident 318 was conducted. Resident 318 stated she was on a special heart diet while she was at the facility, and received the same meal everyday pretty much. Resident 318 stated she received chicken and rice frequently, and it was depressing eating the same meal every day. On 9/10/19, a review of Resident 318's physician orders were conducted. An order dated 9/4/19 indicated Resident 318 was on a low sodium diet. On 9/9/19 at 12 P.M., an observation and interview with Resident 318…

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 respectful care for one of three residents (317) reviewed for dignity. This failure had the potential to negatively impact Resident 317's psychosocial well-being. Findings: Resident 317 was admitted to the facility on [DATE], per the facility's admission Record. On 9/12/19, a review of Resident 317's MDS (health status screening and assessment tool), Section C, dated 9/11/19, indicated Resident 317's BIMS Score (test for cognitive function) was 15. A score of 13-15 indicated cognition was intact. On 9/9/19 at 10:15 A.M., an interview with Resident 317 was conducted. Resident 317 stated some nurses ignore me; I think they don't like me. On 9/11/19 at 8:50 A.M., an observation was conducted in Resident 317's room. Resident 317 was lying in bed, and asked CNA 11 to help him sit up straight in bed. CNA 11 stated she would ask for assistance from another CNA to help, and left Resident 317's room. After a few minutes, CNA 11 and CNA 12…

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 an appropriate call light device was provided to one of 26 residents (9) reviewed for accommodation of needs. This failure resulted in Resident 9 being unable to call for assistance when Resident 9 required help. Findings: Resident 9 was re-admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, difficulty walking, and fracture of the right index finger. On 9/9/19 at 10:01 A.M., Resident 9 was observed asleep. A soft push call-button was placed on Resident 9's lap. On 9/9/19 at 11:39 A.M., an observation and interview with CNA 21 was conducted. CNA 21 stated, Resident 9 made needs known to him by yelling out. Resident 9 attempted to press down on the push call-button with the heel of her left hand, but was weak and unable to activate the push call-button. Resident 9 was not able to bend and use her fingers to activate the push call-button. On 9/11/19 at 2:57 P.M., an interview with CNA 21 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 record review, the facility failed to ensure privacy during the delivery of care, for one (29) of 26 residents reviewed for privacy. This failure resulted in a lack of privacy when care was provided to Resident 29. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses which included, impaired mobility and a right below the knee amputation, per the resident's History and Physical. On 9/9/19 at 3:24 P.M., an observation of Resident 29 was conducted in her room. Resident 29 was lying in the second bed, farthest from the door. A review of Resident 29's medical record was conducted. Resident 29's MDS (an assessment tool), dated 6/10/19, indicated the resident required a one-person, extended assistance with bed mobility and personal hygiene. Resident 29 had a BIMS Score of 12. A BIMS Score of 8-12 indicated moderate cognitive impairment. On 9/10/19 at 4:50 P.M., an observation of Resident 29 and CNA 22 was conducted. The door to Resident 29's room was wide…

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 accurately document a discharge status in the MDS (health status screening and assessment tool) for one of three residents (116) reviewed for MDS coding. This failure had the potential to result in miscommunication of the resident's discharge status. Findings: Resident 116 was admitted to the facility on [DATE] per the facility's admission Record. On 9/11/19, a review of Resident 116's Progress Notes, dated 8/13/19, indicated Resident 116 was discharged home on 8/13/19. On 9/11/19, a review of Resident 116's MDS, Section A, dated 8/13/19, indicated Resident 116's discharge status was to an acute hospital. On 9/11/19 at 3 P.M., an interview with the MDSC was conducted. The MDSC stated Resident 116's MDS was miscoded as discharge to hospital. The MDSC stated Resident 116's MDS should have been coded as discharge to home. On 9/12/19 at 12:08 P.M., an interview with the DON was conducted. The DON stated residents' information should be accurately…

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 fingernail trimming in a timely manner for two of two residents (6 and 20) reviewed for ADLs. This failure had the potential to cause skin tears and infection. Findings: 1) Resident 6 was admitted to the facility on [DATE] with diagnoses that included functional (limited movement) quadriplegia (paralysis of all four limbs), per the facility's admission Record. A review of Resident 6's MDS, dated [DATE], indicated, Resident 6 required extensive assistance with ADLs. On 9/10/19 at 7:55 A.M., an observation and interview was conducted with Resident 6. Resident 6 had approximately half inch long fingernails on all four fingers and the thumb of his left hand. Resident 6 stated he would have liked to have had his finger nails trimmed. On 9/11/19 at 10:26 A.M., an observation and interview was conducted with CNA 31. CNA 31 stated Resident 6's fingernails were too long. CNA 31 stated Resident 6's long fingernails could have scratched his…

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 monitor and record the urinary output for one of four residents (70) reviewed for catheter care. This failure had the potential to cause Resident 70 to have a urinary output deficit. Findings: Resident 70 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease Stage 3 (a moderate decline in kidney function), and urinary retention (an inability to empty the bladder completely), per the facility's admission Record. Resident 70's Care Plan, revised 8/27/19, indicated, The resident has Indwelling Catheter. at risk for UTI (urinary tract infection) . Catheter care every shift and as needed . On 9/11/19 at 10:15 A.M., a joint interview and record review was conducted with CNA 31. CNA 31 stated all the residents who have a catheter should have a urinary output chart. CNA 31 stated there was no urinary output chart for Resident 70. CNA 31 stated Resident 70 should have had a urinary output chart to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess the lunchtime meal intake for two of six residents (3 and 5) reviewed for nutrition. This failure had the potential to cause the residents to become malnourished. Findings: 1) Resident 3 was admitted to the facility on [DATE] with diagnoses that included palliative care (a shortened life expectancy of six months or less), per the facility's admission Record. On 9/9/19 at 12:42 P.M., a dining observation was conducted in a facility dining room. Resident 3 was seated at a dining table with three other female residents. Resident 3 fed herself lunch from a dinner plate. Resident 3's lunch consisted of cooked ham cut into bite sized pieces, mashed potatoes and steamed green beans. The serving sizes were equal sized portions each covering approximately a third of the plate. A slice of cornbread in the shape of a biscuit was served on the side in a small bowl. A small glass of orange liquid was observed to the right of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the administration of a pain medication was documented in the eMAR for one of four residents (79) reviewed for medication reconciliation. This failure had the potential for Resident 79 to receive too much or too little pain medication. Findings: Resident 79 was admitted to the facility on [DATE], with diagnoses to include an open wound, per the facility's admission Record. A review of Resident 79's medical record was conducted. There was a physician order, dated 9/3/19, for oxycodone 5 mg every four hours as needed for pain. On 9/12/19 at 10:59 A.M., a joint record review and interview was conducted with LN 23. Resident 79 had a medication card containing 5 mg tablets of oxycodone (a controlled medication to treat pain). According to Resident 79's CS (a log to track the number of tablets taken from the medication card), ten doses of oxycodone were signed out as taken from the medication card, from 9/4/19 to 9/11/19. Resident 79's…

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 a dietary staff member was unable to competently test the chemical concentration of the sanitizing solution. As a result, there was the potential for placing the residents at risk for food borne illnesses. Findings: On 9/9/19 at 8:18 A.M., a concurrent observation of the kitchen and an interview with the FSD was conducted. A red bucket with sanitizing solution was underneath the sink area. The FSD removed a test strip from a container and put it into the solution to test for the chemical concentration of the sanitizing solution. When compared to the test strip chart, the concentration was 10 parts per million (ppm). The FSD stated there was no numerical value needed for the concentration of the solution, as long as the color of the test strip after contact time was purple. In addition, the FSD added liquid bleach to the solution without measuring it, in an attempt to increase the concentration of the sanitizing solution. On 9/9/19 at 4:10 P.M., an interview with RD 1 was conducted. RD 1 stated the FSD…

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.