Apple Rehab Watertown

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, review of job descriptions, and interviews for 4 of 4 units, the facility failed to ensure the environment was clean, sanitary, maintained in good repair and homelike. The findings included: Review of the infection control surveillance & safety rounds form dated 4/24/24 identified rounds were completed by RN #1 and the Maintenance Supervisor. The infection control surveillance & safety rounds form failed to reflect documentation regarding resident room conditions. Observations on 6/16/24 at 2:08 PM through 2:35 PM, on 6/17/24 at 9:22 AM through 9:50 AM, and on 6/18/24 at 8:46 AM with the Maintenance Supervisor, Housekeeping/Laundry Supervisor, Administrator, and RN #1 identified the following: a. Damaged, missing and/or broken floor tiles in the bedroom on [NAME] unit in room [ROOM NUMBER], and on Cortland unit in room [ROOM NUMBER], and 213. b. Damaged, missing and/or broken floor tiles in the bathroom on [NAME] unit in rooms [ROOM NUMBER], c. Damaged,…

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, facility policy, and interviews, the facility failed to place resident council funds in an interest-bearing account and hold, safeguard, manage, and account for the funds. The findings include: The Resident Council Funds bank account statements dated 4/1/21 to 4/30/24 identified that the account was closed on 4/14/21 and there was $1808.64 withdrawn at that time. Review of the resident council meeting minutes from 1/1/23 to 3/24/24 failed to reflect any discussion of resident council funds. Interview with Residents #13, 17, 23, 33, 35, and 61 on 6/16/24 at 2:00 PM indicated that there was a council president and secretary but not a treasurer. Resident Council residents were in agreement they were not aware of any money or any account that had money for them to use as part of the resident council. Interview with the Director of Recreation on 6/16/24 at 2:45 PM indicated that there was not a treasurer for the resident council. The Director of Recreation indicated that were no monthly or quarterly bank statements for the residents since April…

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, review of facility documentation, facility policy, and interviews, the facility failed to ensure the refrigerator and freezers temperatures were recorded, prepared food items were labeled, dated and discarded timely, the kitchen fan was dust free, dietary staff wore a beard guard while preparing food, employee personal items were not stored in kitchen area, the nourishment refrigerator food items were labeled, dated, and discarded when expired, food temperatures were recorded prior to serving. The findings include: Tour of the kitchen with the Director of Dietary (DOD) #1 on 6/16/24 at 7:00 AM identified: 1a. Observation on 6/16/24 at 7:03 AM identified that the temperature log for the walk-in refrigerator and the walk-in freezer were not completed. The log indicated that the temperatures were not recorded between 6/12/24 - 6/16/24 in the mornings. Interview with the DOD #1 on 6/16/24 at 7:05 AM indicated that the cook was responsible for checking and recording the temperatures of the walk-in refrigerator and walk in freezer every morning. DOD #1 indicated that…

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, facility policy, and interviews the facility failed to ensure the nurse completed hand hygiene during the medication administration according to facility policy. The findings include: Inservice Education dated 1/12/24 identified LPN #7 was educated on hand washing. Licensed Nurse Competency for LPN #7 dated 3/26/24 identified infection control demonstrated hand washing and LPN #7 met the competency. Observation of medication administration on 6/17/24 at 8:10 AM identified LPN #7 moved the medication cart to the room of Resident #23, opened the medication cart and prepared Resident #23's 9:00 AM medications and administered Resident #23's medications without the benefit of hand hygiene prior. Further, while Resident #23 was taking the medications, LPN #7 went over to the resident's roommate and touched him/her on the hair and shoulder, exited the room and did not hand sanitize or wash her hands. LPN #7 moved the medication cart to Resident #37's room and prepared the residents medications and proceeded into Resident #37's room and gave…

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 facility documentation, facility policies, and interviews for 5 of 16 residents reviewed for elopement (Resident #24, 40, 41, 43 and 79) the facility failed to effectively manage roam alert bracelets resulting in residents wearing expired roam alert bracelets, bracelet serial numbers improperly documented in the physician order and a resident wearing an elopement bracelet without a physician's order, and for 2 of 5 residents (Resident #41 and 51) reviewed for falls, the facility failed to ensure that neurological assessments and post fall assessments were completed following falls, and for 2 of 4 residents (Resident #46 and 53) reviewed for nutrition, the facility failed to ensure that the physician's orders were followed related to weight monitoring. The findings include: 1. Resident #24 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included Alzheimer's disease, dementia, and a history of falling. The quarterly MDS 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 review of facility documentation, facility policy and interview for 1 resident (Resident #91) who had orders to monitor oxygen saturation, the facility failed to monitor oxygenation saturation as ordered by the physician. The findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, malignant neoplasm of breast, and supraventricular tachycardia. The care plan dated 2/20/24 identified a focus on cardiovascular disease with interventions that included oxygen therapy, oxygen saturations as ordered, and vital signs as ordered per policy. The quarterly MDS dated [DATE] identified Resident #91 had moderately impaired cognition, required moderate assistance with toileting, showering, upper and lower body dressing, and personal hygiene. Resident #91 was dependent with putting on and taking off footwear and was on oxygen therapy. A physician's order dated 6/1/24 directed to monitor oxygen saturation with pulse oximeter every 8…

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 2 of 4 medication carts, the facility failed to ensure Insulin was dated when opened and discarded when expired. The findings include: Review of the medication cart on the upper level on [DATE] at 9:00 AM with LPN #3 identified a Humalog Insulin vial dated as opened on [DATE] and expired on [DATE]. A Lispro Insulin pen was opened but was not dated. Review of the medication cart on the lower level on [DATE] at 9:15 AM with LPN #7 identified a Lispro Insulin pen not dated when opened. A sticker on the Lispro Insulin pen indicated to discard after 28 days once opened. A Levemir Insulin pen was opened and not dated, and a sticker indicated to discard after 42 days once opened. Interview with the DNS on [DATE] at 9:20 AM indicated that all Insulin vials and pens were to be dated when first opened. The DNS indicated that all the Insulin pens and vials have a different number of days that they were good for once opened.…

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 clinical records, facility documentation, facility policy and interviews for 1 of 5 residents reviewed for accidents (Resident #8) the facility failed to reheat soup to a safe temperature. The findings include: Resident #8 was admitted to the facility on 5/2023 with diagnoses that included multiple sclerosis (MS), spasmodic torticollis, and dementia. The care plan dated 4/8/24 identified Resident #8 required assistance with ADLs due to history of MS. Interventions included providing total assistance with ADLs. The annual MDS dated [DATE] identified Resident #8 had severely impaired cognition, had a functional limitation in range of motion on one side of the upper extremity and required set up only with meals. Review of a reportable event form dated 5/6/24 identified Resident #8 called for staff assistance between 5:30 PM - 6:00 PM and reported he/she had spilled soup and had a 3 cm x 2 cm reddened area with small, scattered blisters at the left upper quadrant of his/her abdomen/chest area.…

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, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for accidents, the facility failed to ensure that the clinical record reflected clear, complete and accurate documentation related to a burn obtained during mealtime, for 1 of 4 residents (Resident #61) reviewed for pressure ulcers, the facility failed to ensure that the clinical record accurately reflected documentation related to a newly found pressure ulcer, and for 1 of 5 residents (Resident #51) reviewed for falls, the facility failed to ensure that the resident's clinical record reflected accurate documentation following an unwitnessed fall. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), spasmodic torticollis, and dementia. The care plan dated 4/8/24 identified Resident #8 required assistance with ADLs due to history of MS. Interventions included to provide total assistance with…

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 (2) of three (3) residents reviewed for abuse and neglect, the facility failed to ensure that the resident received incontinent care, resulting in a finding of neglect, (Resident #1), and the facility failed to ensure that a resident was free from mistreatment and was treated in a dignified manner (Resident #2). The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and chronic kidney disease. The admission MDS dated [DATE] identified Resident #2 had severely impaired cognition and inattention behavior present, required extensive assistance of one staff for bed mobility, transfers, toilet use, personal hygiene and walking and was frequently incontinent of bladder. A care plan dated 7/25/23 identified a Resident #2 could be physically and/or verbally aggressive toward staff members or other residents and on 7/27/23 was aggressive 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 Residents (Resident #1), reviewed for incontinence care, the facility failed to complete a thorough and accurate investigation for an allegation of neglect. The findings include: Resident #1 was admitted to the facility with diagnoses that included diverticulitis of the intestine, Alzheimer's disease, and down syndrome. Nursing admission assessment dated [DATE] identified Resident #1 was not able to follow commands, was not able to understand, was not oriented to place or time. It further identified Resident #1 was incontinent with bowel and bladder. The care plan dated 9/7/23 identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included incontinent care per policy and transfers/ambulation per physician orders. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was frequently incontinent of bowel and bladder 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 review, interviews, and facility policy review for one resident (Resident #1) reviewed for Cardiopulmonary Resuscitation (CPR), the facility failed to ensure that an Automatic External Defibrillator (AED) was accessible when a resident required CPR. The finding included: Resident #1's diagnoses included kidney failure, heart failure Schizophrenia and history of TIA. Review of a quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and was dependent for ADLs and personal hygiene. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 requested to be a full code with interventions that directed to follow resident's wishes for CPR. Review of physician's orders dated [DATE] identified a medical directive for the resident full code status. Review of RN #1's nurses note dated [DATE] at 7:30 AM identified that RN #1 was called by Charge Nurse at 4: 30 AM that the [resident ] was on the floor and appeared to be unresponsive. On arrival…

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, review of the facility infection control program, review of facility policy and staff interview, the facility failed to ensure proper storage of extended wear Personal Protective Equipment (PPE), failed to ensure proper cleaning of protective eye protection, and failed to ensure the antibiotic log was completed and failed to identify if infections met standardized criteria. The findings included: 1. Observation on Tour of the Laundry Room on 01/25/22 at 11:31 AM identified an open N 95 mask and face shield was laying on a towel on the clean linen table beside clean sheets, however not touching. Laundry Aide (LA) #1, identified she had been out on the units earlier and the mask and shield were used, and she was not instructed on where she should store her PPE. Additionally, she would reuse her mask and shield and change it every other day and at the end of the day she would put the mask in a plastic bag and store it in a grey bin near the clean linen storage area. LA #1 also indicated she cleaned her face shield with the facility hand sanitizer before resting…

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, review policy and staff interviews, the facility failed to ensure the infection control nurse had specialized training in infection prevention and control. The findings included: Review of an in-service education sheet provided by corporate staff identified RN #1 attended an education session on 11/7/2021 which included the program mission, infection control responsibilities, antibiotic stewardship and infection criteria, surveillance monitoring and statistics, MDRO, reportable disease and outbreak precautions. Review of the Certificate of Training for the Infection Control Nurse (RN #1) identified she completed Module 1 of the CDC infection Control Training Program. Interview with RN #1 on 1/24/22 1:55PM identified she assumed the role as Infection Control Nurse in September 2021 (4 months ago) and although she completed one module of the CDC infection control training, she did not have time to complete the training because she had to administer covid vaccinations and boosters and worked on the unit at least one day every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and staff interviews for one of two residents (Resident #237) reviewed for advanced directives, the facility failed to ensure the resident's advanced directive was addressed timely. The findings include: Resident #237's diagnoses that included heart failure, essential hypertension, COPD, chronic kidney disease. The admission physician's progress notes dated 1/19/2021 failed to address the resident's code status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition. The clinical record identified the resident was re-admitted to the facility on [DATE]. The January physician's orders 2022 failed to direct the resident's code status. The Medical Interventions Consent Form dated 1/25/2022 and signed by Resident #237's family member identified Resident#237 's choices regarding the administration for life support systems included Do Not Resuscitate (DNR) and Do Not Intubate and No Artificial Means of Nutrition…

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 one of three residents (Resident #52) reviewed for pressure wounds, the facility failed to notify the family of the resident's change in condition. The findings include: Resident #52 was admitted to the facility with diagnoses that included unspecified dementia with behavioral disturbance, anxiety, depression, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #52 had severely impaired cognition, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene, and had an unstageable pressure ulcer that was not present on admission. The care plan dated12/12/21 identified Resident #52 had a potential for alteration in skin related to incontinence as well as an unstageable pressure ulcer to coccyx. Interventions included: to encourage good nutrition and fluid intake, provide incontinent care as needed with use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one sampled resident (Resident #47) reviewed for skin condition, the facility failed to implement their abuse policy to investigate an injury of unknown origin. The findings include: Resident # 47 was admitted with diagnoses that include Alzheimer's disease, Dementia with behavioral disturbance, Diabetes Mellitus, and morbid obesity. A care plan initiated on 6/15/21 identified that Resident #47 is at risk for bruising due to anticoagulant therapy. Interventions include: to watch for signs of active bleeding and report to MD/APRN any hematuria, petechiae, bruising, bloody stools, or blood-tinged sputum. A quarterly MDS assessment dated [DATE] identified that Resident #47 was severely cognitively impaired requiring extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 for personal hygiene. A nursing weekly body audit dated 11/12/21 at 9:27 PM did not identify any new areas or area…

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 sampled resident (Resident #47) reviewed for skin condition, the facility report an unknown injury of origin timely. The findings include: Resident # 47 was admitted with diagnoses that include Alzheimer's disease, Dementia with behavioral disturbance, Diabetes Mellitus, and morbid obesity. A care plan initiated on 6/15/21 identified that Resident #47 is at risk for bruising due to anticoagulant therapy. Interventions include: to watch for signs of active bleeding and report to MD/APRN any hematuria, petechiae, bruising, bloody stools, or blood-tinged sputum. A quarterly MDS assessment dated [DATE] identified that Resident #47 was severely cognitively impaired requiring extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 for personal hygiene. A nursing weekly body audit dated 11/12/21 at 9:27 PM did not identify any new areas or area of altered skin integrity. A nursing…

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 sampled resident (Resident #47) reviewed for skin condition, the facility failed to implement their abuse policy to investigate an injury of unknown origin to prevent further abuse by protecting the resident . The findings include: Resident # 47 was admitted with diagnoses that include Alzheimer's disease, Dementia with behavioral disturbance, Diabetes Mellitus, and morbid obesity. A care plan initiated on 6/15/21 identified that Resident #47 is at risk for bruising due to anticoagulant therapy. Interventions include: to watch for signs of active bleeding and report to MD/APRN any hematuria, petechiae, bruising, bloody stools, or blood-tinged sputum. A quarterly MDS assessment dated [DATE] identified that Resident #47 was severely cognitively impaired requiring extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 for personal hygiene. A nursing weekly body audit 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record reviews, facility policy, and interviews for one of three residents (Resident # 40) reviewed hospitalization and for one of two resident's (Resident # 486) reviewed for pain management, the facility failed to establish a comprehensive care plan to address Resident #40's anticoagulant and Resident #486's pain. The findings included: 1. Resident #40 was admitted with diagnoses that included Gastrointestinal Hemorrhage, atrial fibrillation, and dementia without behavioral disturbance. A care plan review dated 3/26/21, 7/2/21, 8/1/21 and 11/12/21 identified that Resident #40 had orders for Pradaxa (anticoagulant). A discharge MDS assessment dated [DATE] identified that Resident #40 was severely cognitively impaired requiring extensive assistance with 2 staff for bed mobility, transfer and did not walk in room. Additionally, the MDS assessment identified that Resident #40 was on an anticoagulant. A physician's order revised on 11/29/21 (initiated on 7/21/21)…

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 review of the clinical record, facility policy and interviews for one of two residents (Resident #45) reviewed for nutrition, the facility failed to implement the dietician's recommendations when a significant weight loss was identified. The findings include: Resident #45 was admitted with diagnoses that included Diabetes Mellitus, heart failure, dementia without behavioral disturbance and hyperlipidemia. An active physician's order initiated on 8/3/21 directed a no salt added diet, regular texture, thin liquid consistency, low fat, and low cholesterol diet. A physician's order dated 11/19/21 directed to give ensure clear once daily, one time for daily supplement. Resident #45's weight on 11/20/21 was recorded as 151.5 lbs. A quarterly MDS assessment dated [DATE] identified that Resident #45 was severely cognitively impaired requiring extensive assistance of 1 staff member for bed mobility, dressing and personal hygiene. Resident #45 was independent with set up help only for eating. The Resident Care Plan…

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 review of the clinical record, review of facility policy and interviews for one of two residents (Resident #45) reviewed for nutrition, the facility failed to notify the APRN when a significant weight loss was identified. The findings include: Resident #45 was admitted with diagnoses that included Diabetes Mellitus, heart failure, dementia without behavioral disturbance and hyperlipidemia. An active physician's order initiated on 8/3/21 directed a no salt added diet, regular texture, thin liquid consistency, low fat, and low cholesterol diet. A physician's order dated 11/19/21 directed to give ensure clear once daily, one time for daily supplement. Resident #45's weight on 11/20/21 was recorded as 151.5 lbs. A quarterly MDS assessment dated [DATE] identified that Resident #45 was severely cognitively impaired requiring extensive assistance of 1 staff member for bed mobility, dressing and personal hygiene. Resident #45 was independent with set up help only for eating. The Resident Care Plan dated 12/4/21…

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, review of the facility COVID-19 outbreak testing line, the facility failed to ensure staff was tested within accordance to facility policy and infection control standards in response to an outbreak of COVID-19. The findings include: Review of the facility outbreak line list identified the COVID 19 outbreak started on 12/14/2021. Review of the new hire tracking identified that NA #1 was hired on 12/16/2021 and review of the vaccination card identified NA #1 was fully vaccinated. Review of the outbreak testing logs 12/16/2021 through 1/26/2022 failed to identify NA # 1 was tested. Interview with the Infection Control Nurse (RN#1) on 1-25-22 at 2:30 PM identified NA #1 was required to test two times per week, and she had no documentation to show that NA #1 had been tested. Additionally, the 11-7 AM nursing supervisor was responsible for ensuring that staff are tested. She would then leave sticky notes, or the test cards so RN #1 could document the results in the testing log. Review of the in-service sheet dated 1-26-22 identified NA #1 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.