Lord Chamberlain Manor Nursing & Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility policy for 1 of 1 sampled resident (Resident #374) reviewed for dialysis, the facility failed to implement a baseline care plan that met the immediate needs of a hemodynamically managed resident. The findings include: Resident #374's was admitted to the facility in October 2024 with diagnoses that included end stage renal disease with dependence on renal dialysis, type 2 diabetes with diabetic chronic kidney disease, and bipolar disorder. Physician orders dated 10/17/24 identified Resident #374 received dialysis at an outpatient dialysis facility every Monday, Wednesday, and Friday. The physician orders further identified Resident #374 received Lamotrigine 25 mg by mouth one time a day (a medication to stabilize mood in bipolar disorder). The Baseline Resident Care Plan (RCP) dated 10/18/24 identified Resident #374 had experienced a subdural hematoma and was to have his/her vital signs monitored for changes and had fall interventions due to multiple…

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 interviews, a review of the clinical record, and facility policy for 1 of 2 sampled residents (Resident #175) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure Resident #175 was assisted with bed mobility according to the physician's orders and the resident's needs. The findings include: Resident #175 was admitted to the facility in October 2024 with diagnoses that included congestive heart and respiratory failure, muscle weakness and obesity. A Nursing admission assessment dated [DATE] identified Resident #175 had a history of one to two falls within the past three months and was hospitalized between the dates of 10/4/24 through 10/16/24 for congestive heart failure and a right foot chronic ulcer that was debrided surgically with the placement of a wound vacuum. The Nursing admission Assessment further identified Resident #175 was non-ambulatory, was bed/chair-bound, and was incontinent. Although the admission Care Plan dated 10/16/24 did not identify that Resident #175 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 interviews, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #326) reviewed for tube feeding, the facility failed to ensure medication orders indicated an appropriate route of administration for a resident who was to have nothing by mouth (NPO). The findings include: Resident #326 was admitted to the facility in October 2024 with diagnoses that included dysphagia of oropharyngeal phase, gastrostomy (g-tube) status and gastro-esophageal reflux disease (GERD) with esophagitis. A physician's order dated 10/8/24 in the electronic health record (EHR) directed nothing by mouth (NPO) and to provide mouth care every shift and as needed. A physician's order dated 10/9/24 in the EHR directed NPO diet, NPO texture and NPO consistency. A physician's order dated 10/9/24 in the EHR directed Aspirin 81 mg oral tablet chewable give one tablet by mouth at bedtime (a discrepancy in the route of administration from the physician order NPO status on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to implement bumper guards and floor mats per the physician's order for a resident on seizure precautions and for 1 of 2 sampled residents (Resident #11) reviewed edema, facility failed to follow physicians order for the application of heel booties. The findings include: 1. Resident #1's diagnoses included seizures, encephalopathy, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the right dominant side. A physician's order dated 10/8/24 directed seizure precautions to be in place every shift. A physician's order dated 10/9/24 directed to apply bumper guards to bed rails when in bed and floor mats at bedside when in bed, every shift related to seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively 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, review of facility policy, and interviews for 2 of 3 sampled residents (Resident #374) reviewed for accidents, the facility failed to ensure that appropriate assistance was provided with transfer of a resident, and for the only sampled resident (Resident #624) reviewed for smoking, the facility failed to ensure a smoking assessment was conducted as part of the initial admission assessment. Additionally, the facility failed to ensure appropriate disposal of used cigarette materials. The findings include: 1. Resident #374's diagnoses included acquired absence of left leg below knee, generalized muscle weakness, end stage renal disease, and hypertension. The Nursing admission assessment dated [DATE] identified Resident #374 was alert, oriented but forgetful and required a wheel chair for mobility. An Occupational Therapy (OT) assessment dated [DATE] identified Resident #374 with impairments in balance, fine motor coordination, gross motor coordination, mobility, sensation, strength,…

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, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #11) reviewed for respiratory care, the facility failed to administer oxygen per physician orders. The findings include: Resident #11's diagnoses included acute respiratory failure with hypoxia, heart failure and muscle weakness. A physician's order dated 9/7/24 directed to apply oxygen as needed to maintain oxygen saturations over 92% for heart failure. A physician's order dated 9/7/24 directed to apply oxygen at 15L via nasal cannula or non-rebreather mask as needed if oxygen saturation (blood oxygen level) fall below 90%. A physician's order dated 9/11/24 directed to administer oxygen at 2 liters via nasal cannula at baseline every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired, was dependent on staff for personal hygiene, bed mobility and transfers and supervision assistance with eating. Observations on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, review of clinical records, and facility policy for the only sampled resident (Resident #374) reviewed for dialysis, the facility failed to identify and monitor Resident #374 Arteriovenous (AV) fistula (an artificial connection made between an artery and a vein for dialysis access). The findings include: Resident #374's diagnoses included end stage renal disease with dependence on renal dialysis, type 2 diabetes with diabetic chronic kidney disease, and bipolar disorder. Physician orders dated 10/17/24 identified Resident #374 received dialysis at an outpatient dialysis facility every Monday, Wednesday, and Friday. The Baseline Resident Care Plan (RCP) dated 10/18/24 identified Resident #374 had experienced a subdural hematoma and was to have his/her vital signs monitored for changes and had fall interventions due to multiple falls but failed to identify Resident #374 received dialysis and had a AV fistula in place. The admission Nursing assessment dated [DATE] 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 interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #674) reviewed for unnecessary medications, the facility failed to ensure that a resident receiving an antipsychotic medication had an appropriate diagnosis and monitoring. Resident #674 was admitted to the facility in October 2024 with diagnoses that included anxiety/depression disorder, chronic obstructive pulmonary disease, and breast cancer. The Nursing admission assessment dated [DATE] identified Resident #674 was alert and oriented to person, place and time, communicated verbally, speech was clear and was able to understand and be understood when speaking. The Nursing admission Assessment further identified Resident #674's mood was pleasant with no unwanted behaviors. A physician's order dated 10/14/24 directed to give Zyprexa (an antipsychotic medication) 2.5 milligrams(mg), give 1 tablet by mouth at bedtime related to anxiety disorder. a. A physician's order dated 10/14/24…

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 the clinical record and interviews, for 1 of 2 sampled residents (Resident #625) reviewed for food concerns, the facility failed to provide the requested alternative menu option. The findings include: Resident #625's diagnoses included dysphagia, depression, and gastro-esophageal reflux disease. The nurse's admission note dated 10/3/24 indicated that Resident #625 was taking nutrition orally and that his/her appetite had decreased since surgery. The Resident Care Plan dated 10/3/24 identified nutritional status and diet as a concern. Interventions included to provide diet and fluids as ordered. Interview with Resident #625 on 10/21/24 at 11:32 AM identified that he/she had not been receiving the menu substitutions that he/she had requested. Review of Resident #625's weight record identified that he/she had gained 3.8 pounds between 10/3/24 and 10/22/24. Observation on 10/25/24 at 9:00 AM, identified that Resident #625 had received pudding and not yogurt as indicated on their meal slip. Interview with Dietary Aide (DA) #1 on 10/25/24 at 9:14 AM indicated that 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 staff interviews, review of clinical records, and facility policy for 1 of 5 residents (Resident #624) reviewed for immunizations, the facility failed to offer a resident an influenza vaccine or document a refusal or proof of prior immunization of an influenza vaccine. The findings include: Resident #624 was admitted to the facility in October 2024 with diagnoses that included sepsis, chronic kidney disease, and type 2 diabetes. The Baseline Resident Care Plan (RCP) dated 10/16/24 identified Resident #624 was at risk for falls and interventions included use of a call bell when assistance was needed. The admission Nursing assessment dated [DATE] identified Resident #624 was alert and oriented to person, place, and time. The admission Nursing Assessment further identified that he/she had a right hip incision. Physician orders dated 10/16/24 identified that Resident #624 was weight bearing as tolerated with a rolling walker and directed to administer the Pneumovax 23 vaccine for pneumonia prophylaxis if…

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 three residents (Resident #1) reviewed for pressure wounds, the facility failed to ensure the responsible party was notified timely when a pressure wound worsened and the treatment plan changed. The findings include: Resident #1 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and status post recent COVID- 19 infection. Clinical record review identified Resident #1's spouse was the responsible party. An APRN progress note dated 12/20/2023 identified Resident #1 was seen to evaluate a redness on the coccyx cleft. The note identified the area was determined to be a decubitus ulcer of the coccygeal region, stage 1, described as a non-blanchable area with the plan to apply house barrier cream to coccyx every shift and as needed. An admission MDS dated [DATE] identified Resident #1 was severely cognitively impaired, dependent for personal hygiene and bed mobility,…

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 three resident (Resident #1) reviewed for pressure wounds, the facility failed to ensure a urine sample and weekly weights were obtained timely, in accordance with physician orders. The findings include: Resident #1 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and status post recent COVID- 19 infection. Clinical record review identified Resident #1's spouse was the responsible party. An admission MDS dated [DATE] identified Resident #1 was severely cognitively impaired, dependent for personal hygiene and bed mobility, frequently incontinent, was at risk for development of pressure ulcers and had a deep tissue injury (DTI). A Resident Care Plan (RCP) dated 12/25/2023 identified Resident #1 had DTI on the coccyx and was at nutritional risk. Interventions directed to reposition, pressure redistribution mattress, record and report any new changes, to follow 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 review, facility documentation review, facility policy review, and interviews for two of three sampled residents (Resident #1 and #2) reviewed for pressure wounds, the facility failed to ensure the record was complete and accurate to include weekly skin assessment results and weights. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and status post recent COVID- 19 infection. An admission MDS dated [DATE] identified Resident #1 was severely cognitively impaired, dependent for personal hygiene and bed mobility, frequently incontinent, was at risk for development of pressure ulcers and had a deep tissue injury (DTI). A Resident Care Plan (RCP) dated 12/25/2023 identified Resident #1 had DTI on the coccyx. Interventions directed to record and report any new changes, to follow the facility skin care protocol and to monitor weight. A physician's order dated 12/29/2023 directed skin protocol Braden scale upon…

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 staff records, facility documentation, facility policy, and interviews for 4 of 6 sampled staff for NA # 2, NA # 3, LPN #1 and RN # 11) reviewed for staff competencies, the facility failed to provide annual staff competencies and evaluations per the facility assessment. The findings included: 1. Review of Nurse Aide (NA) #2 s personnel files identified that her last performance evaluation was complete 11/5/19 and although requested the facility was unable to provide an annual revalidation or competency validations except for COVID -19, Personal Protective Equipment (PPE) and handwashing dated 5/5/22. The facility failed to provide an annual competency validation for NA #2 after 11/5/19. 2. Review of NA #3's personnel files identified NA #3 was hired 7/28/2020 and noted NA # 3 completed her annual competencies on 7/28/20 upon hire. However, the facility was unable to provide NA # 3's annual revalidation or competency validations except for COVID -19, Personal Protective Equipment (PPE) 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 observation, review of facility policy and interviews, the facility failed to ensure that proper beard restraint during food handling and preparation and failed to ensure that bottle juice store in the emergency food supply was not expired and that refrigerator/freezer temperature were monitored and maintained. The findings included: 1 Observation in Kitchen on 7/6/22 at 11:00 AM identified Maintenance Worker #1 entered the kitchen during meal preparations. 3 stations in the kitchen were prepping various meal components that included meat into steam table trays and side dish preparation. [NAME] #1 was at the meat tray table and there were 5 trays on the counter that were being prepared and open to air. Maintenance Worker #1 entered the kitchen from the back of the kitchen, walking through the 2 prep areas without the benefit of beard restraint or hair net and began to ask [NAME] #1 questions. Maintenance Worker #1 had facial hair that appeared to be longer than 1 inch in length. Subsequent to the…

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

Based on review of the facility Infection Control program, observations, review of facility policy and interviews, the facility failed to ensure that an accurate surveillance data tool was in place to track infections and the facility failed to ensure that freshly laundered resident clothing was kept in a clean and sanitary manner. The findings included: A review of the facility antibiotic stewardship program on 7/7/22 identified the facility was able to provided a line list for infections requiring antibiotic use with McGeers criteria for June 2022. The facility also provided line lists for 12 months (January 2021 through December 2021. However, the facility was unable to provide any line lists or documentation regarding infection tracking or infection surveillance from January 2022 through May 2022. Interview with RN #7 (Infection Control IC Nurse) and RN #8 on 7/7/22 at 10:36 AM identified they were unable to locate infection tracking logs for January 2022 through May 2022. RN #8 reported the facility had been unable to locate any logs for 2022. RN #7 reported the facility had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, observation, facility policy and interviews for 3 of 16 sampled residents (Residents #15, #31, #242) reviewed for advanced directives, the facility failed to ensure that the clinical record correctly reflected the advanced directive choice selected by the resident. The findings included: 1. Resident # 15 was admitted to the facility with diagnoses included Malignant Neoplasm of the brain, pancreatic and renal masses, and acute Cholecystitis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15's cognition and memory were intact. A signed Advanced Directive Form dated [DATE] identified that Resident #15's wishes included no Cardiopulmonary Resuscitation (CPR), no intubation, and no enteral feedings. A physician's order dated [DATE] failed to identify a code status for Resident #15 reflected in the physician's orders. The Resident Care Plan (RCP) dated [DATE] identified a care plan for the resident's code…

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, observation, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #32) reviewed for skin condition, the facility failed to report an injury of unknown origin to the state agency. The findings include: Resident #32's diagnoses included pleural effusion, chronic kidney disease, acute respiratory failure with hypoxia, sepsis, atrial fibrillation, depression, anxiety, cognitive communication deficit and benign prostatic hyperplasia. An admission nursing assessment dated [DATE] at 7:08 PM which included a skin integrity assessment section that failed to identify that the resident had an open purpura to the left upper arm. The Resident Care Plan (RCP) dated 6/17/22 identified Resident #32 at risk for complication from anti-coagulant. Intervention included to administered medication as ordered, laboratory as ordered and directed staff to report any signs and symptoms of bleeding. The admission MDS assessment dated [DATE] identified 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 clinical record review, observation, facility documentation review and interviews for 1 of 4 residents (Resident #32) reviewed for skin condition, thoroughly investigate the origin of the resident's open purpura to the left upper arm. The findings include: Resident #32's diagnoses included pleural effusion, chronic kidney disease, acute respiratory failure with hypoxia, sepsis, atrial fibrillation, depression, anxiety, cognitive communication deficit and benign prostatic hyperplasia. An admission nursing assessment dated [DATE] at 7:08 PM which included a skin integrity assessment section that failed to identify that the resident had an open purpura to the left upper arm. The Resident Care Plan (RCP) dated 6/17/22 identified Resident #32 at risk for complication from anti-coagulant. Intervention included to administered medication as ordered, laboratory as ordered and directed staff to report any signs and symptoms of bleeding. The admission MDS assessment dated [DATE] identified Resident #32 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 clinical record review , observations facility policy and interviews for one resident ( Resident #744) reviewed for Leave Of Absence (LOA), the facility failed to document and communicate the resident's departure from the facility and one five residents (Resident #35) reviewed for safe medication administration, the facility failed to ensure safe administration of an extended release medication to meet professional standards . The findings indicated: 1.Resident #744's diagnoses included bipolar disorder and cervical disc disorder with radiculopathy high cervical region. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 744 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment and required extensive assistance with transfers, extensive assistance with walking in the corridor, and extensive assistance with toilet use. Resident #744 required the use of mobility devices, both a walker and a wheelchair. 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 review, observation, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #286) reviewed for skin condition, the facility failed to provide appropriate treatment for skin condition timely and the written physician order failed to specify the specific affected site. The findings include: Resident #286 had diagnoses included gout, right knee osteoarthritis, chronic diastolic congestive heart failure, ischemic cardiomyopathy, hypertension, Chronic Obstructive Pulmonary Disease (COPD). An admission nursing assessment on 6/21/22 at 4:24 PM - in part noted a skin integrity assessment which identified multiple open and close blisters to Resident # 286's bilateral lower extremity, open areas to right shin and left calf, redness to both heels, blisters to the right digits and redness to right knuckles. A review of clinical record of the Advance Practitioner Registered Nurse (APRN) note dated 6/23/22 at 1:45 PM - in part for skin identified 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.

Based on observations, facility policy review and interviews for 3 medication storage rooms reviewed for temperature log maintenance, the facility failed to consistently maintain consistent temperature logs for 3 refrigerators reviewed and the facility failed to ensure that medication carts and medications were secured. The findings included: 1. Observations on 7/8/2022 at 11:15AM identified multiple omissions of temperature logs for the current month of July 2022,, June 2022 and May 2022 three medication storage rooms. Two medication storage rooms were missing log for July 2022 with multiple entries missing for June 2022 and May 2022 as well. An interview with the DNS on 7/8/2022 at 11:37AM identified that the logs should have temperature entries twice daily and indicated she could not explain why the temperature logs were missing for May, June and July 2022. Review of facility Medication Storage Policy directed in part, that medications requiring refrigeration are kept in a refrigerator at temperatures between 36°F and 46°F with a thermometer to allow for temperature monitoring.…

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 reviews, facility policy review and interviews for 3 of 5 sampled residents (Resident # 193, #196, and #197) reviewed for immunizations, the facility failed to ensure that education regarding the Covid 19 vaccine was provided to the resident, and that documentation regarding refusal of the Covid 19 vaccine was documented in the resident's medical record. The findings included: A review of Residents # 193, #196, and #197 clinical records on 7/7/22 failed to provide evidence that education regarding the Covid 19 vaccine was provided to the residents and any documentation regarding the resident's refusal of the Covid 19 vaccine documented in the medical record Interview with RN # 7 (Infection Control RN) on 7/7/22 at 10:36 AM identified the facility does not have any signed declinations or education provided to the residents regarding the Covid 19 vaccinations. RN #7 identified that the residents were transferred to the facility from outside acute care hospitals having declined Covid vaccinations. RN #7 indicated the facility does follow up with the resident on…

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

Based on observation, staff interviews and a review of the facility policy, the facility failed to store food in accordance with professional standards for food service safety. The findings include: Observation with the Food Service Director on 11/21/19 at 9:48 AM identified one refrigerator had five 2 to 3 inch blocks of 3.5 inch x 3.5 inch cheese slices wrapped in saran wrap and two (2) opened 1/3 filled 5 pound bags of shredded cheese without the benefit of an opened date on the containers. In a second refrigerator there were twelve opened containers of milk, and one 3/4 filled 46 fluid ounce container of tomato juice without the benefit of an opened date on the containers. The Food Service Director was unable to identify any dates on the items listed. Interview with the Food Service Director at the time of the observation identified all perishable food items should be dated when opened. He further indicated the milk cartons are picked up daily from the various areas and brought to the kitchen. He identified that the food service worker who opened or stored the item 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 a clinical record review, staff interviews, and a review of facility documentation for one of two residents reviewed for discharge (Resident # 182), the facility failed to ensure equipment needed to return to the community was obtained on the planned discharge date that resulted in a delayed discharge. The findings include: Resident # 182 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, abnormalities in gait and mobility, and hearing loss. An admission resident care plan dated 4/30/19 identified a problem related to activities of daily living (ADL) with self-care performance deficits related to dementia. Interventions included physical and occupational therapy. Resident # 182 was hospitalized from [DATE] through 5/14/19 and was readmitted with diagnosis that included acute renal failure. A 14-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 182 had short and long-term memory problems, required extensive assistance with bed mobility, 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 a review of the clinical record, staff interviews and a review of the facility policy for one of five Residents reviewed for psychotropic medications (Resident #10), the facility failed to properly monitor targeted behaviors. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included, insomnia, major depressive disorder, and anxiety. Physician's order dated 10/14/19 directed to administer Seroquel 50 milligrams (mg) by mouth at bedtime for depressive disorder, and Venlafaxine HCL ER (extended release) 187.5 mg by mouth one time a day related to depressive disorder. Additionally, the physician's order directed to perform behavior monitoring for psychoactive medication (Seroquel and Venlafaxine) every shift, and to monitor and document the number of behavior episodes during the shift. The order failed to identify what specific behavior to monitor for. An advance practice registered nurse (APRN) note dated 10/15/19 identified to monitor for change in mood,…

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.