Lord Chamberlain Nursing & Rehabilitation Center

Based on observation, clinical record review and staff interviews for 1 of 4 residents (Resident #123) reviewed for physician's orders, the facility failed to ensure staff were trained in the procedure for using the electronic physician order system and their responsibility in ensuring physician orders were signed timely. The findings include: An observation and record review with RN #1 and Unit secretary #1 on 10/24/2024 at 10:45 AM identified s/he was not able to find Resident # 123's signed physician's orders (written or electronic signed by the physician for 30- or 60-day review and renew of orders). A review of Resident # 123's clinical record with Unit Secretary indicated s/he knows the physician reviewed the physician's orders because a progress note was written. RN #1 indicated the facility had only been utilizing the electronic system for a few months. Observation of the electronic record indicated in bold red lettering in the order section orders 55 days overdue. RN #1 and Unit secretary #1 could not recall any educational training for using the physicians order system 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 staff interviews, review of the clinical record, and facility policy for 1 of 5 residents (Resident #33) reviewed for unnecessary medications, the facility failed to prevent the administration of an unnecessary medication for constipation. The findings include: Resident #33's diagnoses included osteoarthritis, chronic pain, and polyneuropathy. The admission Minimum Data Set assessment dated [DATE] identified Resident #33 was cognitively intact and required supervision or touching assistance with eating, partial/moderate assistance for rolling left and right, and was dependent with moving from lying to sitting on the side of the bed. A physician's re-admission order dated 8/26/24 directed to administer naloxegol oxalate 25 milligrams (mg) by mouth daily for Gastrointestinal (GI) upset. A nursing note dated 8/26/24 at 2:20 PM identified that MD #3 had been called following Resident #33's re-admission and all Resident #33's medications were reviewed and approved by MD #3. An Advanced Practice Registered…

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 the clinical record, and facility policy for 1 of 5 residents (Resident #33) reviewed for unnecessary medications, the facility failed to implement a stop date for a psychotropic (drugs used to treat mental illness) medication. The findings include: Resident #33 's diagnoses included depression, anxiety disorder, and insomnia. The admission Minimum Data Set assessment dated [DATE] identified Resident #33 was cognitively intact and required supervision or touching assistance with eating, partial/moderate assistance with personal hygiene, and was dependent with moving from lying to sitting on the side of the bed. The physician's re-admission orders dated 8/26/24 directed to administer trazodone 50 milligrams (mg) by mouth at bedtime for sleep and administer trazodone 25 mg by mouth 3 times a day as needed. The order lacked a stop date. A nursing note dated 8/26/24 at 2:20 PM identified that MD #3 had been called following Resident #33's re-admission and all of Resident #33'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 observations, facility policy review and staff interviews, the facility failed to ensure medications were secured during medication administration, and failed to discard expired heparin flushes and the facility failed to store a narcotic liquid medication securely, ensure expired over the counter medications were not in the medication cart for use and failed to ensure an insulin bottle was labeled with the resident's name and the date the medication was opened. The findings included: 1. a. An observation on 10/22/24 at 8:35 AM during medication administration identified Licensed Practical Nurse, LPN #2 dispense (3) medications from their blister packs, pick up the medication cup with medications and a drink and began entering resident room [ROOM NUMBER] without first securing (3) medication blister packs left on top of the medication cart and locking the cart. Surveyor intervene before LPN #2 entered room [ROOM NUMBER]. An interview with LPN #2 on 10/22/24 at 8:35 AM identified medications should not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy and interview for 1 of 2 residents (Resident #10) reviewed for dinning, the facility failed to honor resident's food choices. The findings include: Resident #10's diagnoses included dysphagia, hypertension, and hyperlipidemia. A physician's order dated 4/19/24 directed to provide a no added salt, regular texture, thin diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 as cognitively intact and required set up assistance with eating and maximum assistance with bathing and dressing. The Resident Care Plan dated 10/15/24 identified resident had a potential nutritional risk. Interventions included to provide a no added salt diet and regular thin diet with food preferences as possible. In the initial screening with Resident #10 on 10/21/24 11:40 AM she/he identified s/he does not get the foods s/he chooses and gets food items that s/he does not like. For example, s/he does not like chicken on a bun and received the food for dinner. 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 observations of the breakfast, policy review and staff interviews for 2 of 6 residents reviewed for food (Residents #67 and # 146), the facility failed to follow the resident meal ticket which resulted in food items missing from the breakfast meal. The findings include: 1. Resident #67 was admitted with diagnoses that included diabetes mellitus and heart failure. The annual MDS assessment dated [DATE] identified Resident #67 was cognitively intact and independent with eating. A physician's order dated 9/30/2024 directed a heart-healthy regular-textured diet. A care plan dated 10/1/2024 indicated the resident had a potential nutrition risk related to diabetes mellitus and heart failure. Interventions included providing a cardiac regular texture diet with food preferences as possible. On 10/24/2024 at 9:10 AM during an observation with LPN #9 and RN #1 identified Resident #67 had received his/her breakfast tray that consisted only of two slices of toast on a white plate. Resident #67 questioned LPN #9 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 observations of the noon meal, review of facility policy and staff interviews for 1 of 6 residents reviewed for nutrition (Resident #82), the facility failed to provide appropriate food consistency for a resident on a pureed diet. The findings include: Resident #82 was admitted with diagnoses that included tongue cancer and a hip replacement. The quarterly MDS assessment dated [DATE] identified Resident #82 was cognitively intact and independent with eating. The MDS assessment also indicated the resident did not have a swallowing disorder but had been on a mechanically altered diet while a resident at the facility. A care plan dated 8/8/2024 identified that Resident #82 had a risk of swallowing difficulty, had a diagnosis of tongue cancer, and the resident requested pureed food. Interventions included monitoring the resident's response to the diet and serving requested foods if the diet allowed. An observation of Resident #82's lunch tray on 10/21/2024 at 1:03 PM identified the resident's meal ticket…

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, facility policy, and interviews for 1 of 2 residents (Resident #38) reviewed for limited range of motion, the facility staff failed to wear appropriate Personal Protective Equipment (PPE) when direct care for a feeding tube was provided to a resident who required Enhanced Barrier Precautions (EBP). The findings include: Resident #38's diagnoses included dysphagia, placement of a feeding tube, and aphasia following a stroke. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #38 was severely cognitively impaired and was dependent for eating, personal hygiene, and rolling left and right. The Resident Care Plan dated 8/23/24 identified Resident #38 was at risk of alteration in nutrition related to requirement of tube feeding due to dysphagia and history of a stroke. Interventions included to administer the tube feeding per physician's order, perform feeding tube site care per physician's order, and maintain EBP every shift 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for change in condition, the facility failed to ensure the physician was notified when a resident refused medications. The findings include: Resident #1 had diagnoses that included depression, spondylolysis lumbar region, hypertension, and anxiety. An admission MDS dated [DATE] identified Resident #1 had intact cognition, required moderate assistance with dressing upper body, maximal assistance personal hygiene, bed mobility, toileting, and was dependent with dressing lower body. A care plan dated 2/14/2024 identified Resident #1 had an ineffective airway clearance related to excessive tenacious secretions and exudate secondary to congestion. Interventions directed to auscultate for decreased breath sounds, wheezing, or any abnormality, assess respiratory rate, and administer bronchodilator per physician orders. A nurse's note dated 2/14/2024 at 6:31 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.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for change in condition, the facility failed to ensure vital signs were obtained and respiratory assessments was performed prior to and after administering respiratory treatments. The findings include: Resident #1 had diagnoses that included depression, spondylolysis lumbar region, hypertension, and anxiety. A care plan dated 2/14/2024 identified Resident #1 had an ineffective airway clearance related to excessive tenacious secretions and exudate secondary to congestion with interventions that directed to auscultate for decreased breath sounds, wheezing, or any abnormality, assess respiratory rate, and administer bronchodilators per physician orders. A nurse's note dated 2/14/2024 at 6:31 A.M. written by LPN #2 identified Resident #1 had increased phlegm and was expelling clear discharge. LPN #2 indicated she put a note in the APRN book to have Resident #1 assessed by the APRN. A APRN's note dated 2/14/2024 at 9:22 A.M. written by…

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 (1) of three (3) residents, (Resident #2), reviewed for abuse, the facility failed to ensure a resident was free from physical abuse. The findings include: 1. Resident #2 had diagnoses that included encephalopathy, heart failure, and hypertension. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 had severely impaired cognition, was occasionally incontinent of bowel, frequently incontinent of bladder, and was dependent with Activities of Daily Living. The care plan dated 2/14/2024 identified Resident #2 has cognitive loss with interventions that directed to use simple, direct communication, verbal cues, task segmentation, encourage socialization and recreation activity. 2. Resident #3 had diagnoses that included bipolar disorder, neurocognitive disorder with Lewy bodies, and Parkinson's disease. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition, 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure a care plan was implemented to include interventions for a resident with impaired cognition and was at risk for falls who frequently got up unassisted resulting in falls. The findings include: Resident #1 had diagnoses that included dementia, anxiety, insomnia, history of falling, and muscle weakness. The fall risk evaluation dated 2/16/2024 identified Resident #1 at risk for falls. Review of a physical therapy evaluation dated 2/16/24 identified that the resident required assistance of one for transfers and ambulation. The care plan dated 2/17/2024 identified Resident #1 as a risk for falls with interventions that directed to keep the call bell within reach, encourage use of call bell, to educate based on current knowledge base and ability to learn. A nurse's note dated 2/17/2024 at 10:34 P.M. written by RN #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.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents, (Resident #1) who were reviewed for care and services, the facility failed to ensure a resident was treated in a dignified manner. The findings include: Resident #1's diagnoses included wedge compression fracture of thoracic 11-12 vertebra (mid spine). An inter-agency referral report dated 11/18/23 identified recommendations that included assist of one with a rolling walker to transfer from the bed to the commode. A nursing admission note dated 11/18/23 at 2:57 PM identified Resident #1 was alert and oriented to person, place, and time, communicated verbally with clear speech, was able to understand and be understood when speaking. A nurse's note dated 11/18/23 at 11:15 PM identified Resident #1 reported a complaint of being unhappy with care. Attempted to reassure h/her that the situation would be addressed. Resident #1 refused to accept the response. The RN supervisor was notified. A Grievance dated 11/18/23 identified Resident #1 was concerned that s/he 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 reviews, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents, (Resident #1), who were reviewed for care and services, the facility failed to ensure neurological assessments were initiated in accordance with facility policy. The findings include: Resident #1's diagnoses included wedge compression fracture of thoracic 11-12 vertebra (mid spine). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was without cognitive impairment and required supervised minimal touch assist with bed mobility, transfer, and toileting. The Resident Care Plan (RCP) dated 11/30/23 identified Resident #1 Resident #1 exhibited a decline in the ability to ambulate, transfer, toilet, and positioning self in the bed with interventions that directed to provide assist of one with bed mobility, transfers, and toileting. Physician orders dated 12/22/23 directed modified independence with toileting using the wheelchair and grab bar. A facility…

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, facility documentation, facility policy, and interviews for 3 residents (Resident # 40, 51 and 161) reviewed for respiratory care, the facility failed to ensure oxygen tubing was changed and dated on a weekly basis. Further, for Resident #40 the facility failed to obtain Covid testing following the development of respiratory symptoms in a timely manner, and for Resident #51, the facility failed to ensure respiratory equipment was stored according to policy and infection control standards and failed to respond to a specialty service recommendation to determine the ongoing need for oxygen therapy following the initiation of oxygen therapy. The findings include: 1. Resident #40 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD), polyneuropathy and Type II diabetes. The annual MDS dated [DATE] identified Resident #40 had intact cognition and required assist with personal care. The care plan dated 5/12/22 identified Resident #40…

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 and interviews, the facility failed to ensure staff followed infection control practices regarding glove removal and hand hygiene. The findings include: 1. Observation on 7/17/22 at 10:05 AM identified NA #2 exited room [ROOM NUMBER] with gloves on both hands and touched a doorknob to close room door. NA #2 walked down the hallway with gloves on carrying soiled and dirty linen in hands. NA #2 indicated she should not have walked out of the room with gloves on both hands. NA #2 indicated she has been employed with the facility for 9 years. Interview on 7/17/22 at 10:10 AM with RN #5 identified she has been employed with the facility for 14 years. RN #5 indicated NA #2 did not follow the infection control practices. RN #5 indicated NA #2 should have removed one glove before exiting the room. RN #5 indicated NA #2 should not have touched the doorknob with gloved hand. 2. Observation on 7/17/22 at 10:27 AM identified LPN #5 at the medication cart in the hallway with gloved hands changing 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 review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #115) reviewed for care planning, the facility failed to ensure the resident had the right to participate in the development and implementation of his or her person-centered plan of care. The findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, and atrial fibrillation. The care plan dated 1/4/22 identified a discharge plan with interventions to provide ongoing communication to the interdisciplinary team members, physician, and resident about the discharge process. The admission MDS dated [DATE] identified Resident #115 had intact cognition and required limited assistance for transfers, dressing, toileting, and personal hygiene. Additionally, the MDS identified it was very important for the resident to choose own clothing, take care of personal belongings, and his/her bedtime. The social services quarterly progress notes…

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, facility documentation, facility policy, and interviews for 1 resident (Resident #15) reviewed for dialysis, the facility failed to ensure an emergency pressure dressing kit was at bedside per facility policy and for 1 of 3 residents (Resident #136) reviewed for pressure ulcers, the facility failed to obtain a physician order for a specialized pressure relieving mattress,. The findings include: 1. Resident #15 was admitted to the facility in August 2020 with diagnoses that included chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes with diabetic peripheral angiopathy. The care plan dated 4/7/22 identified in the event of emergency: AV shunt begins to leak, or bleeding, maintain standard precautions, apply pressure to upper arm with tourniquet or pressure dressing to site of bleeding, vital signs every 15 minutes and immediately call attending physician and 911 per physician. The quarterly MDS dated [DATE] identified Resident #15…

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, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #69) reviewed for pressure ulcers, the facility failed to ensure weekly assessments of the pressure ulcer. The findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included stroke dysphasia, and dementia. The quarterly MDS dated [DATE] identified Resident #69 had severely impaired cognition, had a feeding tube that provided over 51% of the calories per day and was at risk for a pressure ulcer or skin injury. A physician's order dated 3/21/22 directed to cleanse the skin under the flange of the feeding tube with normal saline, apply Aquacel AG and a dry dressing daily on the evening shift. The care plan dated 6/2/22 identified the resident had a skin integrity irritation around the feeding tube with interventions that included to complete treatments as ordered by the physician, keep wound dry and clean, and complete wound measurements 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #78) reviewed for accidents, the facility failed to ensure the residents bed was locked to prevent a fall. The findings include: Resident #78 was admitted to the facility with diagnoses that included dementia, pneumonia, and respiratory failure with a tracheostomy. A physician's order dated 6/1/22 directed to provide assistance of one staff with rolling walker for transfers. The significant change of condition MDS dated [DATE] identified Resident #78 had intact cognition and required extensive assistance for bed mobility and transfers. A reportable event form dated 6/15/22 a 12:30 PM identified LPN #9 witnessed Resident #78 attempt to sit on the bed, which was not locked, and the resident slid to the floor. Resident #78 indicated as he/she went to sit on the bed it moved and was unlocked, and he/she slid to the floor. The care plan dated 6/15/22 identified an actual fall (sat on bed…

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 1 of 3 residents (Resident #158) reviewed for nutrition, the facility failed to ensure follow the policy and reweigh the resident when a significant weight loss was identified. The findings included: Resident #158's diagnoses included stroke, epilepsy, diabetes, septicemia, sacral pressure ulcer, Alzheimer's disease, dementia and psychotic disorder. The care plan dated 6/20/22 identified Resident #158 had a potential nutrition risk related to dementia and need for tube feeding. Interventions included to monitor weight and nothing by mouth (NPO). The significant change in condition MDS dated [DATE] identified Resident #158 had severely impaired cognition, required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene, the resident weighed 160 lbs., had a feeding tube, had a stage IV pressure ulcer and was receiving nutrition and hydration intervention to manage skin problems. 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, facility documentation, facility policy, and interviews for 2 residents (Resident #126 and 147) reviewed for Medication Storage, the facility failed to ensure insulin pens/vials where dated when opened per facility policy. The findings include: 1. Resident #126 was admitted to the facility with diagnoses that included uncontrolled diabetes and cerebral infarction. The significant change of condition MDS dated [DATE] identified Resident #126 had intact cognition and required limited assistance for dressing and personal hygiene. Additionally, receives insulin injections 7 days a week. The care plan dated 3/3/22 identified a type 2 diabetes with interventions that included to monitor blood sugars and medications as ordered. A physician's order dated 6/29/22 directed to administer Levemir (Insulin) 62 units in the morning, Levemir (Insulin) 70 units at bedtime, Humalog (Insulin) 24 units before meals and a Lispro (Insulin) sliding scale starting at 150 to 399 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 the clinical record, facility documentation, facility policy, and interviews for 3 of 4 sampled residents reviewed for pressure ulcers (Resident #19, Resident #30 and Resident #159), the facility failed to ensure the appropriate pressure relieving device was utilized and failed to complete weekly Braden Scale assessment per physician orders (Resident #159). The findings include: 1. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 sampled residents reviewed for pressure ulcers (Resident #19, Resident #30 and Resident #159), the facility failed to ensure the appropriate pressure relieving device was utilized and failed to complete weekly Braden Scale assessment per physician orders (Resident #159). The findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, Rheumatic aortic (valve) stenosis and vascular dementia with behavioral disturbance. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, a review of the clinical record, staff interviews, a review of the facility documentation, and the facility policy, for one of four residents reviewed for the use of an antipsychotic medication (Resident #131), the facility failed to consistently monitor behaviors for a resident that was administered antipsychotic medication. The findings include: Resident #131 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbances, diabetes, hypertension, and chronic kidney disease. The Resident Care Plan (RCP) dated 10/20/19 identified Resident #131 received psychotropic medications for the treatment of Alzheimer's disease with behavioral disturbances. Interventions directed to monitor behaviors on a behavior tracking sheet and to monitor for a decline in mood. The quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, required extensive assistance with activities of daily living, 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.

Based on observation, staff interview, and review of the facility policy, the facility failed to maintain food holding temperatures according to facility policy. The findings include: Observation and interview with Dietary Aide (DA) #1 in the second floor dining room on 11/25/19 at 12:38PM identified the following holding temperatures after the last meal was served: meatballs 123.4 degrees Fahrenheit and ground meatballs 115 degrees Fahrenheit. DA #1 identified the holding temperature should be 163, 175 or 190 degrees Fahrenheit and then identified he/she was not sure of the holding temperature. Further, the food pans were stored on the steam table with hot water under the pan. Interview with the Dietary Manager on 11/25/19 at approximately 12:40 PM identified the holding temperature should be 135 degrees or above and did not know the reason temperatures were low. Additionally, the Dietary Manager identified the food temperatures should be so far above the holding temp when they come from the kitchen and should not drop that low. Further, the Dietary Manager identified the heating…

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 and interview for one of one resident in survey sample reviewed for fluid restriction (Resident #235), the facility failed to ensure Resident #235 did not exceed a physician directed fluid restriction. The findings included: Resident #235 was admitted to facility on 11/21/18 with diagnoses that included Congestive Heart Failure (CHF), atrial fibrillation (A-Fib), Chronic Obstructive Pulmonary Disease (COPD) and endocarditis. A Resident Care Plan (RCP) dated 11/21/18 identified a problem with alteration in cardiac /circulatory status related to A-Fib. Interventions included to monitor intake and output as indicated. A RCP dated 11/21/18 identified a problem with CHF. Interventions included to monitor resident for signs and symptoms of CHF and to notify the medical doctor regarding any abnormal findings. Physician's orders dated 11/26/18 directed to obtain brain natriuretic peptide (BNP) to morning labs (an indicator for presence of CHF), obtain chest x-ray this morning and to give…

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, facility documentation, facility policy, and interviews for 2 of 3 residents reviewed for accidents (Resident #89 and Resident #117), the facility failed to provide adequate supervision to a resident during the administration of a nebulizer treatment to prevent a burn injury (Resident #89) and failed to report a potential injury so an assessment could be completed by the Registered Nurse (Resident #117). The findings include: 1. Resident #89 was admitted to the facility on [DATE] and diagnosis that included Chronic Obstructive Pulmonary Disease, acute and chronic respiratory failure, anxiety, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 was cognitively intact, required extensive assistance of one person for bed mobility, transfers, dressing, and personal hygiene. The Resident Care Plan dated 5/15/19 identified a problem with breathing with interventions that included to administer medication, inhalers…

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.