Cobalt Lodge Health Care And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of facility policies/procedures and interviews for two sampled residents (Resident#1, and Resident #24) reviewed for food, the facility failed to post accurate menus and failed to post and or announce changes to the daily menu. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease, unspecified, age-related osteoporosis without current pathological fracture, and hyperlipidemia. The care plan dated 9/3/24 identified Resident #1 was at risk for weight loss related to esophageal stricture with interventions that included no added salt diet, regular texture. The annual MDS assessment dated [DATE] identified Resident #1 was cognitively intact, had no behaviors, was independent with bed mobility, transfers, and required supervision with dressings and set up clean up assist with personal hygiene. The assessment further identified that the resident ambulated and utilized a walker and a wheelchair. Resident #24'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 lack of facility documentation and interviews for the facility reviewed for quality and performance improvement, the facility failed to have written policies and procedures for feedback, data collections systems, and monitoring including adverse event monitoring. The findings included: Interview on 11/19/24 at 2:55 PM with one the [NAME] President and the DNS identified the facility had an anonymous suggestion box and a customer survey and identified the facility did not have written policies and procedures for feedback, data collections system and monitoring. He identified that the facility is a small facility, and residents and families address concerns in person. The VP identified that if a staff member identified a concern, or an error, the facility would address this in real time. There is not a system of tracking unless a pattern is noticed. The DNS identified that if a problem was identified, the facility would bring the problem to the QAA committee to address. The DNS identified the QAA committee met quarterly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation, facility policy, and interviews for two of five residents (Resident #33 and Resident #35) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was offered and/or assessed to resident. The findings include: 1. Resident #33's was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies. The admission MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment. The assessment further identified that Resident #33 pneumococcal vaccination was not up to date. Review of Resident #33's immunization consents and records, along with the new admission consent documentation with Infection Preventionist (RN #1) on 11/18/24 at 1:30PM failed to identify that the pneumococcal vaccine was offered to the resident. 2. Resident #35's was admitted to the facility on [DATE] with diagnosis that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #26) reviewed for advance directives, the facility failed to ensure the physician's order accurately reflected the resident's chosen code status. The findings include: Resident #26 was admitted to the facility in October of 2024 with diagnoses that included acute respiratory failure with hypoxia, dependence on supplemental oxygen, congestive heart failure and Alzheimer's disease. The physician's order dated [DATE] directed a code status of Do Not Resuscitate, A do-not-resuscitate order, or DNR order, is a medical order written by a health care provider. It instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating. Do Not Intubate, A do not intubate (DNI) order is a medical directive that instructs medical professionals not to insert a breathing tube into a patient's trachea. A DNI order is part of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #31) reviewed for weight loss, the facility failed to notify the dietician, and physician regarding a significant weight loss. The findings include: Resident #31's diagnoses included congestive heart failure, disorder of kidney and ureter, depression, anxiety, and atrial fibrillation. Physician's orders dated 5/15/24 directed to check weight three times per week and notify physician for weight gain or loss equal to 3 pounds (lbs.). Physician's orders dated 8/26/24 directed Resident #31 be provided a regular diet of regular texture, thin liquids and fluid restriction of 1500 milliliters(ml) per day. Review of the weight and vital summary record identified Resident #31 was weighed on 9/25/24 at 11:20 AM with a noted weight of 238.6 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition, and dependent for bed mobility, toileting, hygiene, transfers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #13) reviewed for abuse, the facility failed to ensure that an injury of unknow origin was reported to the state survey agency. The findings include: Resident #13's diagnoses included Parkinson's, dementia, and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #13 was severely cognitively impaired, had physical behavioral symptoms directed at others, and required total assistance for bed mobility, transfers, dressing and personal hygiene. The assessment further identified the resident was non-ambulatory and had no functional limitations in range of motion. A nurse's note dated 9/3/24 at 11:30 PM written by RN #2 identified Resident #13 was found with a bruise below the left eye that measured 4 cm by 1 cm and was dark purple in color. The resident was unable to communicate what occurred, neurological checks were initiated, and the on-call APRN,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #13), with an injury of unknown origin, the facility failed to ensure that an investigation was conducted to ascertain the origin of the bruise. The findings include: Resident #13's diagnoses included Parkinson's, dementia, and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #13 was severely cognitively impaired, had physical behavioral symptoms directed at others, and required total assistance for bed mobility, transfers, dressing and personal hygiene. The assessment further identified the resident was non-ambulatory and had no functional limitations in range of motion. A nurse's note dated 9/3/24 at 11:30 PM written by RN #2 identified Resident #13 was found with a bruise below the left eye that measured 4 cm by 1 cm and was dark purple in color. The resident was unable to communicate what occurred, neurological checks were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of five sampled residents (Resident #5) reviewed for unnecessary medications, the facility failed develop a care plan for a resident on an anticoagulant. The findings include: Resident #5's diagnoses included long term use of anticoagulants, peripheral vascular disease, acute coronary thrombosis. The physician's order dated 8/19/24 directed to administer 5mg of Eliquis (anticoagulant) every 12 hours by mouth. The annual MDS assessment dated [DATE] identified Resident #5 was cognitively intact, had no behaviors, required maximal assistance with bed mobility, transfers, dressings and personal hygiene, was ambulatory for short distance with maximal assistance and utilized a wheelchair for mobility. The assessment further identified the resident was taking an anticoagulant. The care plan dated 9/30/24 identified Resident #6 was at risk for altered cardiovascular status related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #17) reviewed for controlled substance reconciliation, the facility failed to ensure medications were administered accurately according to physician's orders and for one sampled resident (Resident #26) reviewed for oxygen use, the facility failed to ensure the physician's order for oxygen use and documentation of resident status including lung sounds were followed. The findings include: 1. Resident #17's diagnoses included anxiety disorder, major depressive disorder and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #17 was cognitively intact, no behaviors, required supervision or touch assistance with personal hygiene and ambulated with minimal assistance using a walker. The assessment further identified Resident #17 was taking antianxiety medication. The care plan dated 6/20/24 identified Resident #17 uses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #20) reviewed for range of motion and splint usage, the facility failed to ensure the splint was applied according to physician's orders. The finding include: Resident #20's diagnoses included dementia, delusional disorders and dysthymic disorders. The quarterly MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition, was dependent for toileting hygiene, dressing, personal hygiene, transfers, was non-ambulatory and had functional limitations in range of motion to bilateral upper and lower extremities. The care plan dated 10/31/24 identified Resident #20 was at risk for contractures to the left upper extremity (LUE) with interventions that included monitor skin integrity of LUE with each splint application and removal for the presence of any redness, skin breakdown and resting hand splint on left arm to be on at all times…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #31) reviewed for nutrition, the facility failed to ensure that the dietician and/or physician assessed the resident for significant weight loss timely. The findings include: Resident #31 's diagnoses included congestive heart failure, disorder of kidney and ureter, depression, anxiety, atrial fibrillation. Physician's orders dated 5/15/24 directed to check weight three times per week and notify physician for weight gain or loss equal to 3 pounds(lbs.). Physician's orders dated 8/26/24 directed for Resident #31 to have regular diet of regular texture, thin liquid and fluid restriction of 1500 Milliliters(ml) per day. Review of the weight and vital summary identified Resident #31 was weighed on 9/25/24 at 11:20 AM with a weight of 238.6 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition and dependent assistance with bed mobility, toileting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #5) reviewed for unnecessary medications, the facility failed to ensure medication reviews were provided to the provider and action taken. The findings included: Resident #5's diagnoses included long term use of anticoagulants, bipolar II disorder, and anxiety disorder. The annual MDS assessment dated [DATE] identified Resident #6 was cognitively intact, had no behaviors, required maximal assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident could ambulate a short distance with maximal assistance and utilized a wheelchair for mobility. The care plan dated 9/30/24 identified Resident #6 was at risk for altered cardiovascular status related to elevated blood pressure and chest pain secondary to angina, hypertension with interventions that included assess for chest pain, enforce 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, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #6) reviewed for medication administration, the facility failed to ensure Metoprolol Succinate ER (extended release) was not crushed. The findings include: Resident #6's diagnoses included unspecified atrial fibrillation, dysphagia and long-term use of anticoagulants. The care plan dated 7/1/24 identified Resident #1 was at risk for hypertension and atrial fibrillation related to congestive heart failure with interventions that included give cardiac medication as ordered. The quarterly MDS assessment dated [DATE] identified Resident #6 was cognitively intact, required extensive assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident required supervision for eating and had a mechanically altered therapeutic diet. The physician's order dated 11/12/24 directed to administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation, facility policy, and interviews for one of five residents (Resident #33) reviewed for immunizations, the facility failed to ensure that the COVID-19 vaccination was offered and/or assessed to resident. The finding include: Resident #33's was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies. The admission MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment. Review of Resident #33's immunization consents and records, along with the new admission consent documentation with Infection Preventionist (RN #1) on 11/18/24 at 1:30PM failed to identify that the COVID-19 booster vaccine was offered to the resident. Interview with the Infection Preventionist (RN#1) on 11/18/24 at 11:30 AM identified that she just started her position as Infection Preventionist at the facility and she was not sure who 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 clinical record reviews, reviews of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) who had a behavior of wandering and was at risk for elopement, the facility failed to ensure the courtyard gate was secured to prevent the resident from exiting the courtyard and wandering to the front of the facility. The findings include: Resident #1's diagnoses included dementia with behavioral disturbance, cognitive communication deficit, and anxiety disorder. The readmission Wandering Risk Scale assessment dated [DATE] identified Resident #1 scored a 12 and was considered to be a high risk of wandering. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, independent with transferring and ambulating, and a wander/elopement alarm was utilized daily. The Resident Care Plan dated 4/22/24 identified Resident #1 was at risk for wandering and elopement due to impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for two of three residents (Resident #1 and #2) reviewed for accidents, the facility failed to ensure orders for side rails and a comprehensive care plan were developed timely to include use of bed rails. The findings include: a. Resident #1 was admitted with diagnoses that included dementia, peripheral vascular disease (PVD) and depression. Physician order dated active 11/1/2023, directed assist of two for bed mobility and ADLs. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognitive status, was dependent for personal hygiene, moderate assist for rolling left to right and was not ambulatory. The Resident Care Plan (RCP) dated 11/30/2023 identified Resident #1 was at risk for falls. Interventions directed to anticipate needs and be sure the call light was in reach. A facility incident report dated 11/5/2023 identified Resident #1 was observed leaning to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for three of three residents (Resident #1, #2, and #3) reviewed for side rail use, the facility failed to ensure an assessment was completed timely to assess the risk for entrapment, resident risk/benefits of use, and to obtain informed consent for the use of a bed rail, and failed to maintain a maintenance log of routine maintenance. The findings include: a. Resident #1 was admitted with diagnoses that included dementia, peripheral vascular disease (PVD) and depression. Physician order dated active 11/1/2023, directed assist of two for bed mobility and ADLs. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognitive status, was dependent for personal hygiene, moderate assist for rolling left to right and was not ambulatory. The Resident Care Plan (RCP) dated 11/30/2023 identified Resident #1 was at risk for falls. Interventions directed to turn 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, facility policy review, and interviews for one sampled resident (Resident #1), the facility failed to accurately transcribe a medication order into the electronic Medication Administration Record which resulted in a change in the resident's condition. The findings include: Resident #1's diagnoses included chronic kidney disease, paroxysmal atrial fibrillation, major depressive disorder, and bipolar II disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life and required limited to extensive assistance of one person with ADL's. The Resident Care Plan (RCP) dated 06/26/2023 identified Resident #1 potential for alteration in mood secondary to depressive disorder and bipolar disorder. Interventions include administering medications as ordered, and to observe for potential side effects or adverse effects of medications, and consult Psych 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 clinical record review, review of facility documentation, facility policy review, and interviews for one sampled resident (Resident #1), the facility failed to accurately document a resident's medication administration in the clinical records. The findings include: Resident #1's diagnoses included chronic kidney disease, paroxysmal atrial fibrillation, major depressive disorder, and bipolar II disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life and required limited to extensive assistance of one person with ADL's. The Resident Care Plan (RCP) dated 06/26/2023 identified Resident #1 potential for alteration in mood secondary to depressive disorder and bipolar disorder. Interventions include administering medications as ordered. Observe for potential side effects or adverse effects of medications. Consult Psych as needed. A pharmacy medication review dated 06/11/23 identified Resident #1 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy review and interviews for one of one resident (Resident #4) reviewed for communication, the facility failed to ensure that Audiology recommendations were addressed timely. The findings include: Resident # 4's diagnosis included dementia with behavioral disturbance, unspecified hearing loss, macular degeneration, pseudobulbar infarct, and mood disorders. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a short and long term memory problem, required total assistance of 1 for bed mobility, dressing, toilet use and personal hygiene. The MDS further identified Resident #4 required extensive assistance of 1 for transfers and his/her ability to hear was moderately difficult, speaker had to increase volume an speak distinctly. Additionally, the MDS identified Resident #4 utilized a hearing aide. The Resident Care Plan (RCP) dated October 2021 identified Resident #4 had a communication problem…

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 clinical record review, facility documentation review, facility policy review during review of the Infection control program, the facility failed to ensure that the licensed staff providing IV therapy had completed annual competencies annual education The findings include: In an interview and review of facility documentation on 8/23/22 at 11:00 AM with the DNS and LPN#2, they were unable to provide any yearly IV education or competencies for licensed staff.Aditionally, the facility was not able to provide any IV education for licensed staff prior to the start of the new pharmacy in October 2021. The DNS could not explain why the competecies and/or education was not completed. The facility IV policy dated April 2010 indicated that it is the policy of the facility to educate staff on IV therapy on an annual basis. The IV infusion therapy policy and procedure manual dated 2011, section 2.3 scope of practice 4 and competency assessment indicated in part that initial competency is assessed and documented before the skill is performed without supervision and documentation 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.

Based on observations, facility documentation and interviews during the medication storage and labeling review for one of one medication storage rooms, the facility failed to ensure medications were stored safely in the medication refrigerator. The findings include: Observation of the facility medication storage area on 8/19/22 at 6:00 AM with RN #1 identified the refrigerator temperature log lacked documentation as of twice daily checks for August 2022 on 10 occasions. There were 22 unopened Insulin vials and 2 unopened vials of Influenza vaccine stored in the refrigerator. Interview with RN #1 on 8/19/ 22 at 6:20 AM identified that although she knew it should be checked she twice daily, stated that it is completed on the other shifts. She identified that the current temperature in the medication refrigerator was 40 degrees Fahrenheit. A review of the August 2022 refrigerator log with the DNS on 8/19/22 at 9:00 AM identified that there were 5 dates that were missing initials to identify that the refrigerator temperature monitoring had been completed for both the AM and the PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 2 of 8 residents (Resident # 10 and Resident #27) reviewed for vaccination compliance, the facility failed to ensure that residents were offered disease preventing vaccinations. The findings include: 1. Resident # 10 was admitted on [DATE] with diagnoses which included unspecified dementia anemia, chronic kidney disease, Hypertension, and hypercholesterolemia. Review of clinical record with LPN# 2 and the DNS on 8/23/2022 at 1:30 PM failed to provide evidence that the pneumovax vaccine had been offered, was historic or had been refused. LPN# 2 further indicated that she had only been employed at the facility for a few months and had not had a chance yet to review the vaccination status of the residents to see who needed consent and physician orders. 2. Resident # 27 was admitted [DATE] with diagnosis which included dementia with behavioral disturbance, chronic obstructive pyelonephritis, chronic kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #22) reviewed for abuse, the facility failed to report an allegation of rough care to the State Agency. The findings include: Resident #22's diagnoses included delirium due to known physiological condition, and major depressive disorder. The Resident Care Plan (RCP) dated 5/27/22 identified Resident #22 was at risk for psychosocial well being secondary to history of mental illness. Interventions included to monitor/record occurrence of target behavior symptoms, inappropriate responses to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #22 was moderately cognitively impaired and required extensive assistance for bed mobility, total dependence for transferring and total dependence for toileting. APRN #1's progress note dated 7/13/22 at 6:00 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #22) reviewed for abuse, the facility failed to thoroughly investigate an allegation of rough care. The findings include: Resident #22's diagnoses included delirium due to a known physiological condition and major depressive disorder. A Resident Care Plan (RCP) dated 5/27/22 identified Resident #22 was at risk for psychosocial well being secondary to a history of mental illness. Interventions included to monitor/record occurrence of target behavior symptoms, inappropriate responses to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired and required extensive assistance for bed mobility, total dependence for transferring and total dependence for toileting. APRN #1's progress notes dated 7/13/22 at 6:00 PM identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #21) reviewed for assessments, the facility failed to ensure an RN assessment was completed in a timely manner. The findings include: Resident #21's diagnoses included paranoid schizophrenia, type 2 diabetes, other personality and behavioral disorders due to known physiological condition, autistic disorder, and mild intellectual disabilities. The Resident Care Plan (RCP) dated 3/15/22 identified a potential for alteration in skin integrity and a history of chronic callous right left plantar. Interventions included nursing would assess right and left plantar daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was cognitively intact and required supervision with activities of daily living (ADLs). Nurse's notes from LPN #3 and dated 7/14/22 identified Resident #21 complained of foot pain and LPN #3 indicated assessing the foot and identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of one resident (Resident #12) reviewed for Dental services, the facility failed to ensure that dental services were offered. The findings include: Resident # 12 was admitted on [DATE] with diagnosis which included chronic ulcer (non-pressure) of right foot. Diabetes with foot ulcer, coronary artery disease, vascular dementia with behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact and required supervision for bed mobility transfer, eating, and toileting and physical assistance of one person for bathing. A physician's order dated 6/1/2021 directed to obtain a dental consult as indicated The resident care plan (RCP) dated 8/11/2022 identified that Resident #12 has a dental health problem related to lack of lower denture. The intervention in part included to coordinate arrangements for dental care and transportation as needed…

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 review of facility documentation, interviews, and review of facility policies and procedures, the facility failed to ensure the residents, the resident's legal representative and the public were notified of the facility's use of a twenty-four (24) hour video surveillance of the common areas. The findings include: Observations on 10/29/19 at 2:45 PM identified although there were cameras for video surveillance located in the dining room, recreation room, and hallway, the facility failed to post a notice related to the surveillance cameras at the front door entrance, the nurse's stations and/or the hallways. An interview with the Administrator on 6/27/18 at 2:25 PM identified that the twenty-four (24) hour surveillance cameras have been in use in the facility for a while and that the admission packet did not include any information regarding the cameras. The Administrator indicated the facility did not have a posting related to the surveillance cameras at the front door entrance and/or throughout the facility. The Administrator stated the video cameras were located in 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 clinical record reviews, review of facility documentation and interviews for 1 of 2 sampled residents (Resident #1) who was reviewed for allegation of mistreatment, the facility failed to complete a thorough investigation of the alleged violation. The findings include: Resident #1's diagnoses included adjustment disorder with depressed mood. The 30-day Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was able to make decisions regarding tasks of daily life, and was independent with locomotion on unit. The Reportable Event Form dated 7/14/19 identified that Resident #1 reported being scratched on the arm by another resident. The report identified Resident #1 sustained two (2) scratches to the right upper extremity measuring 8 centimeters (cm) by 0.5 cm and 9.5 cm by 0.5 cm. The nurse's note dated 7/15/19 at 11:13 AM identified that Resident #1 reported that another resident had scratched his/her right upper extremity. The note indicated Resident #1 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of mistreatment, the facility failed to document in the clinical record the psychosocial support that was provided to the resident by social services after the incident and for one of three sampled residents (Resident #288) who were reviewed for the provision of personal hygiene, the facility failed to document on the nurse aide documentation form that daily personal hygiene was provided or refused by the resident. The findings include: 1. Resident #1's diagnoses included adjustment disorder with depressed mood. The 30-day Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was able to make decisions regarding tasks of daily life, and was independent with locomotion on unit. The Reportable Event Form dated 7/14/19 identified that Resident #1 reported being scratched on the arm by another resident. 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, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for one Resident (Resident #7) reviewed for infection control, the facility failed to properly implement personal protective equipment use per standards of practice. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, type 2 diabetes mellitus, and urinary tract infection (UTI). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was always incontinent of bladder and frequently incontinent of bowel, required extensive assistance of one for toileting, and required supervision and setup help for eating. The care plan dated 10/23/19 identified alteration in urinary elimination related to UTI. Interventions directed to encourage fluid intake, labs as ordered, and medicate as ordered and monitor effectiveness. A physician's order dated…

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.