Deanwood Rehabilitation And Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for one (1) of six (6) sampled residents, facility nursing staff failed to ensure that one resident received care and services according to accepted standards of clinical nursing practice as evidenced by no documented evidence that the physician was notified prior to a licensed registered nurse altering a resident's medication order label. Resident #1.The findings included:According to the National Institute of Health (NIH)- The standard of practice for registered nurses (RNs) is that they do not have the authority to prescribe medication independently.- Advanced Practice Registered Nurses (APRNs), specifically nurse practitioners (NPs), do, with their authority determined by state Nurse Practice Acts. https://www.ncbi.nlm.nih.gov/books/NBK574557/A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- If a dosage is believed to be inappropriate or excessive for 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 observation, record review and staff interview, for one (1) of six sampled residents, facility staff inaccurately documented that they administered Trazadone (antidepressant medication) 50 MG (milligrams), one tablet to Resident #1.The findings included: A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- The individual administering the medication checks the label to verify the right medication, right dose, right time and right method (route).Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy.Review of the resident's medical record showed the following: An admission Minimum Date Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 02 indicating severely impaired cognitive function; total 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff and resident interviews, the facility staff failed to provide respect to a resident when the resident spoke about a concern with her television for one (1) of 10 sampled residents (Resident # 2). The findings included: Resident #2 was admitted on [DATE] with multiple diagnoses including Hemiplegia, Cervical Disk Disorder and Morbid Obesity. A quarterly Minimum Date Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 10 indicating that the resident's cognitive status was moderately impaired. During an observation with Employee #2 (DON) and Employee #4 (Assigned RN) on 01/24/25 at approximately 10 AM, Resident #2 was noted in her room lying in bed, well groomed, alert, oriented to person, place, time, and situation. At the time of the observation, the resident stated that she prefers to stay in bed and watch tv, but her tv had not worked for approximately a week. As the resident was speaking, Employee #4 interrupted 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 observations, and resident and staff interview, the facility failed to maintain the required comfortable air temperature range of 71°F to 81°F for one for one (1) of 10 sampled residents. (Resident #2) The findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Hemiplegia, Cervical Disk Disorder and Morbid Obesity. A quarterly Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 10 indicating that the resident's cognitive status was moderately impaired. During an observation on 1/23/2025 at 10:45am, the resident was observed lying in bed alert, oriented to name, place and time. At the time of observation, the resident was lying in bed with a heavy blanket covering her, stating that her room has been cold for the past week. The resident further stated that her room gets colder at night. The resident added that she informed the nursing staff her room was cold, but she couldn't recall…

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 record review and interview, the facility failed to implement their Advanced Directive (5 Wishes) policy for one (1) of three (3) sample residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia and acute respiratory failure. A physician order dated [DATE] instructed, No, CPR (Cardiopulmonary Resuscitation) palliative and supportive care. A review a policy tilted, End of Life Planning Policy-Five Wishes dated 01/2023 documented in part, The policy applies to all residents upon admission and throughout their stay, with assessments and updates conducted by the social worker and the Interdisciplinary Team The social worker will complete the Advanced Life Care Planning Assessment with 48 to 72 hours of admission .The Interdisciplinary Care Planning Team will review M.O.S.T [and] Advanced Directives [5 wishes] with the resident during quarterly care planning session to determine if the resident wishes to make changes in such…

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 record review and interview, the facility failed to have documented evidence that the resident or the resident representative was provided with a written copy of the base line care plan. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia and acute respiratory failure. A review of the resident's Base Line Care Plan dated 10/14/23 documented in part, Initial Baseline Care Plan meeting held today for [Resident #1] 10/14/2023 in the resident's room with all the team members present. Resident responsible party] joined via telephone conference. The care plan lacked documented evidence, a written copy was provided to the resident or resident's party responsible. A review of the progress notes dated from 10/14/23 to 10/31/23 lacked documented evidence that a written copy of the Base Line Care Plan was provided to the resident or the resident's representative. An admission Minimum Date Set assessment dated [DATE] revealed resident had a brief…

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, residents and staff interviews, facility staff failed to make information on how to file grievances available to the residents. The census on the first day of the survey was 265. The findings included: Review of the facility's Resident Grievance/Concerns policies and procedures dated January 2024 documented: - The facility must make information on how to file a grievance or complaint available to the resident. During observations on 04/19/24, 04/22/24 and on 04/23/24 on the second, third, fourth and fifth floors, the following was noted: - Each floor had a black lock box, with a small opening labeled Grievance Box; there was a compartment behind the box that was noted to be empty. During a Resident Council Meeting on 04/24/24 at 2:00 PM, multiple residents stated that grievance forms were not readily available to them and were not sure of where to find them. During a face-to-face interview on 04/25/24 at 12:00 PM with the Social Services Department, the surveyor asked them where the grievance forms are kept/located. Employee #14 (Social Worker) stated 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 record reviews and staff interviews, for four (4) of 94 sampled residents, facility staff failed to maintain accurate medical records. (Residents' #365, #417, #464, and #467). The findings included: A review of the facility's Clinical Documentation/Record' policy dated [DATE], documented, Clinical documentation is required to record pertinent facts, findings, and observations about resident's health history including past and present illnesses, examinations, tests, treatments, and outcomes. 1. Resident #365 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2, End-Stage Renal Disease, and Hemodialysis. A review of Resident #365's medial record revealed the following: A Quarterly MDS (Minimum Data Set) assessment dated [DATE] that revealed that the resident had a Brief Interview for Mental Status (BIMS) summary score was 15, indicating that the resident had intact cognition. The resident was also coded for had taking insulin and being on dialysis. A physician'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, record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to treat Resident #68 with dignity and respect. The findings included: Review of the resident Admissions Packet provided to the survey team on 04/19/24 documented: - Your rights and protections as a nursing home resident: You have the right to be treated with respect and dignity. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses that included: Huntington's Disease, Multiple Sclerosis, Lack of Coordination and Fall. Review of the resident's medical record revealed the following: A physician's order dated 09/14/23 directed, Admit to skilled level of care. The resident requires SNF (skilled nursing facility) covered care on a daily basis. A physician's order dated 09/15/23 directed, Provide incontinent care every shift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech, usually understood others and usually makes self…

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 record review and staff interviews, for one (1) of 94 sampled residents, the physician failed to follow the resident's/resident representatives (RP) Advanced Directives wishes. Resident #109. The findings included: Resident #109 was admitted to the facility on [DATE] with multiple diagnoses that included Cerebral Infarct, Hemiplegia Affecting Right Dominant Side, and Aphasia. Review of the resident's medical record revealed the following: A face sheet that documented [Resident #109's daughter's name] as the representative (RP). An Advanced Life Care Planning Five Elements/Wishes Form signed on [DATE] by the resident's RP and facility staff that documented: - The person I want to make care decisions for me when I cannot, [Daughter's name]. - The kind of treatment I want, Full Code. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded the following: a Brief Interview for Mental Status (BIMS) summary score of 00, indicating severely impaired cognitive status. A physician'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 record review and staff interview, for one (1) of 94 sampled residents, facility staff failed to have documented evidence that they provided Resident #216 or their representative with Notice of Medicare Non-Coverage (NOMNC). The findings included: Resident #216 was re-admitted to the facility with Medicare Part A services on 01/10/24 with multiple diagnoses that included: Morbid Obesity, Type 2 Diabetes Mellitus, Heart Failure and Atrial Fibrillation. Review of the resident's medical record showed the following: A face sheet that showed the resident had a guardian that waws also her Resident Representative (RP), care conference person and emergency contact #1. A physician's order dated 01/10/24 directed, Admit to skilled level of care. The resident requires SNF (skilled nursing facility) covered care on a daily basis. A Quarterly/Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff documented: - Medicare Part A services started on 01/10/24 and had a Brief Interview…

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 and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, orderly environment as evidenced by two (2) of two (2) storage rooms that were filled with miscellaneous items that were scattered throughout. The findings include: During an environmental walkthrough of the facility on May 1, 2024, at approximately 2:00 pm, one (1) of one (1) storage room on unit 2 South, and one (1) of one (1) storage room on unit 4 South, were filled with clothing items that were stored on the floor, in multiple storage bins. These observations were acknowledged by Employee #11 during a face-to-face interview on May 2, 2024, at approximately 4:00 pm.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of 94 sampled residents, facility staff failed to report Resident #120's incident of elopement to the State Agency in a timely manner (within 2 hours); and failed to have documented evidence that they reported an unusual incident in which Resident #127 had a psychiatric emergency and broke her bedroom window to the State Agency. The findings included: 1. Facility staff failed to report Resident #120's incident of elopement to the State Agency in a timely manner (within 2 hours). Resident #120 was admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder, Type 2 Diabetes Mellitus, Hypertension, Atrial Fibrillation, Seizure Disorder, and Gait Abnormality. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognition; used a wheelchair…

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, record reviews and staff interviews, for three (3) of 94 sampled residents, facility staff failed to: follow their corrective actions of ensuring a resident's safety after Resident #313's allegation of abuse by a male caregiver; follow their corrective actions of ensuring Resident #43's safety from further potential abuse and retaliation by staff after an allegation of abuse; and have documented evidence that Resident #466's injury of unknown origin was thoroughly investigated. Residents' #313, #43 and #466. The findings included: Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy with a review date of 01/2024 documented: - All reports of resident abuse, including injuries of unknown origin, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - Cause identification: Appropriate steps…

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 record reviews and staff interviews, for four (4) of 94 sampled residents, facility staff failed to provide documented evidence that the resident or resident's representative was provided with written notification that specified the duration of the state bed hold policy to include notification of when the resident is permitted to return to the facility and resume residence in the nursing home. Resident's #3, #79, #414, and #419. The findings included: Review of the facility policy entitled, Transfer or Discharge, Emergency Care dated 03/2022 documented: - The Social Worker/Designee during hospital transfer will ensure that the resident and responsible party is notified verbally or by telephone or in writing of how many bed hold days the resident has. 1. Resident #3 was admitted to the facility on [DATE] with diagnoses including: Urinary Tract Infection, Severe Sepsis without Septic Shock, and Chronic Diastolic Congestive Heart Failure. Review of Resident #3's medical record revealed the following: 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 record review and staff interview, for one (1) of 94 sampled residents, facility staff failed to accurately code Resident #79's falls history on the Quarterly Minimum Data Set (MDS) assessment. The findings included: Resident #79 was admitted to the facility on [DATE] with multiple diagnoses that included: History of Falling, Personal History of Transient Ischemic Attack, and Dementia. Review of Resident #79's medical record revealed the following: A Nursing Progress Note dated 03/31/24 at 10:05 AM, documented: - At 8:45 AM, resident was observed by staff sitting on the floor at bedside with laceration on left side of head measured 5.0 cm (centimeters)x (times) 0.5cm(centimeters) x (times) 0.1cm (centimeters) slight bleeding, no hematoma. A Facility Reported Incident (FRI), DC~12611, was submitted to the State Agency on 03/31/24 documented, [Resident #79] was observed by staff sitting on the floor at bedside with laceration on left side of head, slight bleeding, no hematoma. RP (resident representative)…

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, record reviews, resident, and staff interviews, for two (2) of 94 sampled residents, facility staff failed to implement care plan interventions as indicated in the resident's comprehensive care plan. Residents' #79 and #189. The findings included: Review of the facility's Care Plan Meeting policy, dated January 2024, documented: - The care plan must be customized to each individual patient's preferences and needs. - Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 1. Resident #79 was admitted to the facility on [DATE] with multiple diagnoses that included: History of Falling, Personal History of Transient Ischemic Attack and Cerebral Infarction Without Residual Deficits, and Dementia. Review of Resident #79's medical record revealed the following: A Nursing Progress Note dated 03/31/24 at 10:05 AM, documented: - At 8:45 AM, the resident was observed by staff sitting on the floor at bedside with laceration on left…

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 record review, resident, and staff interviews, for one (1) of 94 sampled residents, facility staff failed to provide Resident #189 with the necessary restorative nursing treatment, care, and services to maintain or improve ability to carry out the activities of daily living (mobility and ambulation) based on the comprehensive assessment of the resident and consistent with the resident's care plan. The findings included: Review of the facility's Restorative Nursing Care policy, dated January 2024, documented: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence. - Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. Resident #189 was admitted to the facility on [DATE] with diagnoses that included: Muscle Weakness, End Stage Renal Disease, Type 2 Diabetes Mellitus, Fluid Overload, and Hyperlipidemia. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that 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, record review and staff interviews, for two (2) of 94 sampled residents, facility staff failed to ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Residents' #68 and #107. The findings included: 1. Facility staff failed to ensure Resident #68 received personal hygiene care in a timely manner. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses that included: Huntington's Disease, Multiple Sclerosis, Lack of Coordination and Fall. Review of the resident's medical record revealed the following: A physician's order dated 09/14/23 directed, Admit to skilled level of care. The resident requires SNF (skilled nursing facility) covered care on a daily basis. A physician's order dated 09/15/23 directed, Provide incontinent care every shift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech, usually understood…

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 record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to have documented evidence of any skin changes on Resident #466's sacrum prior a deep tissue injury being found that measured 5 centimeters (cm) by 5 cm. The findings included: Review of the facility's Wounds and Skin Assessments policy dated January 2024, documented: - Upon readmission, the resident's skin will be evaluated head-to-toe by a licensed nurse and documentation will be maintained in the resident's Electronic Medical Record (EMR). - Daily, during routine care and showers, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse and the licensed nurse will proceed to complete an assessment and appropriate documentation. - The wound team, wound physician/NP (Nurse Practitioner) or wound nurse, captures the measurements and evaluation of existing wounds for the resident. - Residents that are admitted or…

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, record reviews and staff interviews, for two (2) of 94 sampled residents, the facility staff failed to provide pain management services that were consistent with professional standards and in accordance with the resident's care plan. Residents' #463 and #68. The findings included: Review of the facility's Pain Assessment and Management policy revised in January 2024 documented: - Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. - Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain. - Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated. - Implement the medication regimen as ordered, carefully documenting the results of the interventions. - Document the resident's reported level of pain with adequate detail (i.e.,…

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 record reviews and staff interviews, for one (1) of 94 sampled residents, the nurse practitioner failed to timely address a resident's known subtherapeutic Valporic Acid (anitconvulsant medication) level. Resident #120. The findings included: According to the National Institute of Health (NIH), Valproic Acid (VPA) is a medication used to treat neurological and psychiatric disorders. The therapeutic uses of VPA include epilepsy treatment across different seizure types, bipolar disorder management, and migraine. The therapeutic range for total valproate in epilepsy is 50 to 100 mcg (micrograms)/ml (milliliters), and in mania, it is 50 to 125 mcg/ml . https://www.ncbi.nlm.nih.gov/books/NBK559112/#:~:text=Valproic%20acid%20(VPA)%20ia%20as,disorder%20management%2C%20and%20migraine%20prophylaxis. Resident #120 was admitted to the facility on [DATE] with multiple diagnoses including Seizure Disorder. A physician's order dated 09/12/23 directed, Diazepam Rectal Gel 10 MG (Diazepam Anticonvulsant), insert 1…

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 record review and staff Interview of one (1) of 94 sampled resident, the physician staff failed to review Resident #177's total program of care to include documented reports of critical lab values. The findings included: According to the American Diabetes Association (ADA), the following is ranges a guide for normal blood glucose levels: - Fasting: 80 -180 mg (milligrams)/dL (deciliters). - Pre-prandial (before meals): 100 -180 mg/dL. - Postprandial (one to two hours after eating): Less than 180 mg/dL. - Bedtime: 110-200 mg/dL. - If you experience high blood sugar levels or low blood glucose levels compared to this range you should speak to your doctor. https://diabeticme.org/learning-center/health-guides/what-are-normal-blood-sugar-levels/ Resident #177 was admitted to facility on 05/14/22 with diagnoses of Pituitary Gland Disorder, Anemia, Hypertension, Cerebral Infarction, and Viral Hepatitis. Review of the resident's medical record revealed the following: An Annual Minimum Data Set (MDS) assessment…

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 record reviews and staff interviews for, two (2) of 94 sampled residents, the facility staff failed to have nursing staff with the appropriate skill sets to care for residents needs as identified in the residents plan of care as evidenced by a Licensed Practical Nurse documenting Resident #417's blood glucose reading as 1 in the medical record on multiple dates, and a Licensed Practical Nurse who was observed administering pain medication for Resident #68 without doing a pain assessment and after Resident #68 complained of pain and for also failing to reposition Resident #68 who asked repeatedly to be repositioned for comfort. Residents' #417 and #68. The findings included: 1. The facility staff failed to ensure that nursing staff with the appropriate skill sets to care for residents needs as identified in the resident's plan of care as evidenced by a Licensed Practical Nurse documenting a residents Blood glucose reading as 1 in the medical record on multiple dates for Resident #417.…

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, record reviews, and staff interviews for three (3) of 94 sampled residents, the facility staff failed to ensure that the residents' medications were labeled and stored in accordance with currently accepted professional principles. As evidenced by multiple loose and unwrapped pills noted in two (2) residents' sections in the medication cart. Also, noted was a resident's expired Acetaminophen-Codeine 300-30 mg tablets in a locked narcotic box which contained other residents' current medications. The findings included: A review of the facility's policy titled Medication Storage revised on 01/2024 documented the following: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas…

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 record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to provide services in compliance with all applicable Federal and State regulations in the facility as evidenced by failing to conduct quarterly care plan meetings for Resident #107. The findings included: Review of the facility's Care Plan Meeting policy, dated January 2024 documented, It is the policy of the facility to arrange for an interdisciplinary team care plan meeting on a quarterly basis/on a significant change and as needed. Documentation for the care plan meeting is maintained in the Electronic Medical Record. Resident #107 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebrovascular Disease, Type 2 Diabetes Mellitus and Dysphagia. A face sheet that listed the resident's sister as emergency contact number #1. An IDT Care Plan Meeting summary dated 09/28/23 documented, Quarterly IDT meeting was held today. The Responsible Party was notified by mail and by phone to no…

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 staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 255. The findings include: Facility staff failed to develop and implement appropriate plans of action to correct identified quality deficiencies as follows: Under §483.12, F600 Freedom from Abuse, Neglect, and Exploitation Under §483.25(d)(2), F689 adequate supervision and assistance devices to prevent accidents Under § 483.25(i), F695 Respiratory care Under §483.25(k) F697 Pain Management During a face-to-face interview was conducted with Employee #2 and Employee #5 on 04/20/22 at approximately 12:00 PM, at the time of the Quality Assessment and Assurance (QAA) interview. They were asked if the facility identified resident-to-resident abuse and altercations, resident behaviors, residents wandering, activities of daily living (ADL) care,…

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 staff interview, facility staff failed to: (1) ensure Resident #132's urine collection bag was not resting on the floor and (2) maintain infection control and prevention practices to help prevent the development and transmission of communicable diseases and infections. The census on the first day of survey was 255. The findings include: 1. Facility staff failed to provide ensure Resident #132's urine collection bag was not resting on the floor. According to the Center for Disease Control (CDC) guidelines for prevention of catheter associated urinary tract infections (CAUTI) includes: . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (https://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf) On 04/07/22 at approximately 3: 45 PM, Resident #132 was observed resident lying in bed with his urine collection bag resting lying on the floor. Resident #132 was readmitted to the facility on [DATE] with diagnoses that included: Urinary…

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 and staff interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by damaged privacy curtains in six (6) of 76 resident's rooms, soiled bathroom vents in five (5) of 76 resident's rooms, a foul, offensive odor in (5) of 76 resident's rooms and malfunctioning packaged terminal air conditioner (PTAC) units in three (3) of 76 resident rooms. The findings include: During an environmental walkthrough of the facility on 03/30/22, at approximately 4:00 PM, and on 04/04/22, between 10:00 AM and 3:45 PM, the following was observed: 1. Privacy curtains were torn and separated from the rails in six (6) of 76 resident's rooms including rooms #211, #308, #309, #310, #311, and #329. 2. Bathroom vents were soiled with dust in five (5) of 76 resident's rooms specifically rooms #401, #405, #428, #420, and #529. 3. A strong urine odor was evident in resident room [ROOM NUMBER], #428, #502, #516, and #524, five (5) of 76…

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 record review and staff interview, for eight (8) of 105 sampled residents, facility staff failed to implement its policies and procedures for investigating allegations of abuse, neglect and injuries of unknown source. Residents' #11, #50, #67, #71, #151, #221, #408 and #409. The findings include: Review of the facility policy entitled, Prohibition of Abuse (not dated), documented, . Reports on abuse are reviewed and investigation conducted by the director of nursing . within 24 hours following the incident .If suspected abuse/inappropriate behavior are between two residents, residents will be immediately separated from each other and monitored until appropriate interventions are implemented .All employees will sign a memo attesting, their understanding and compliance to abuse standards . Review of the facility's policy also showed that neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical…

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 record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) conduct investigations for unusual occurrences for Residents' #3 and #409; (2) conduct investigations of resident-to-resident altercations with Residents' #67, #71 and #151; and (3) conduct a thorough investigation of Resident #221's threat of violence against his roommate. The findings include: Review of the facility's policy titled, Prohibition of Abuse with a revision date of 02/2022, showed neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy revealed that staff are to complete an incident/accident form for any unusual occurrences and submit it to the Director of Nursing or designee .A final report of the investigation will be reported and signed by the Administrator .If suspected abuse/inappropriate behavior are between two…

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 record review and staff interview, for six (6) of 105 sampled residents, the facility staff failed to: (1) notify Resident #3's, #132's and #406's representative(s) in writing the reason for the resident's transfer to a hospital and (2) provide written notification to Resident #82's, #233's and #404's representatives of room relocation. The findings include: 1.Facility staff failed to: (1) notify Resident #3's, #132's and #406's representative(s) in writing the reason for the resident's transfer to a hospital. 1A. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Larynx, Carcinoma of Larynx, Acquired Absence of Larynx, and Tracheostomy Status. Review of the Resident #3's medical record showed a physician's order dated 12/03/21 that instructed, Transfer resident to the nearest ER (emergency room) for further evaluation related to stuck humified moisture exchange (HME) in stoma. 12/03/21 at 2:42 PM [Nursing Progress Note] The respiratory therapist…

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 record review and staff interview, for five (5) of 105 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS). Residents' #50, #155, #160, #183 and #502. The findings include: 1. Facility staff failed to code Resident #50's MDS to reflect the need of 2 person's physical assist. Resident #50 was admitted to the facility on [DATE] with multiple diagnoses that included: Morbid Obesity, Anxiety Disorder, Mood Affective Disorder and Major Depressive Disorder. Review of Resident #50's medical record revealed the following: 01/30/20 (Revision date) [Care Plan] [Resident #50] has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited ROM (range of motion), limited mobility, morbid obesity . the resident requires 2 staff participation to reposition and turn in bed, the resident requires total assistance with personal hygiene care . 11/16/20 (Creation Date) [Care Plan] Alleged abuse . 2 CNAs (Certified Nurse Aides) to provide ADL care all shift .…

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 record review and staff interview, for eight (8) of 105 sampled residents, facility staff failed to develop and/or comprehensive care plans with measurable goals, timeframes and approaches to address resident care concerns (Stoma Site Care, 2 CNAs for ADL care, assistance with dentures, indwelling urinary catheter, speech deficit, new diagnosis of chest pain, behavior of urinating on the bathroom floor, refusal of care and complaints of chest pain. Residents' #3, #50, #204, #126, #132, #155, #180 and #403. The findings include: Review the facility's policy entitled, Interdisciplinary Team Meeting (Care Plan Meeting) revised 03/2022 documented, . It is the policy of [Facility Name] to develop and implement person-centered care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care . 1. Facility staff failed to include interventions to care of Resident #3's stoma site. Resident #3 was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for 11 of 105 sampled residents, the facility staff failed to update the comprehensive care plan with goals and approaches that address one (1) resident's visit to the dentist for actual tooth extractions, one (1) resident with a right upper arm fistula access site post-dialysis care, three (3) residents with a PermaCath; and three (3) resident exhibiting behaviors and failed to update one (1) residents care plan to address their need to have two (2) person physical assist. Residents' #27, #61, #82, #95, #126, #151,#71, #67, #182, #404 and #502. The findings included: Review the facility policy entitled, Interdisciplinary Team Meeting (Care Plan Meeting) revised 03/2022 documented, . A comprehensive, individualized care plan will . be reviewed and revised by the interdisciplinary team . Review the facility policy entitled, Resident-To-Resident Altercation/Incidents revised 01/2022 documented, . When a resident is observed or identified as being aggressive to having…

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 record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) have a discharge plan for one resident; (2) record/document information related to the resident's discharge plan to the community in the clinical record;(3) ensure the residents discharge needs were adequately identified and the results developed into a discharge plan. Residents' #155, #170, #227, #237, #406 and #412. The findings include: 1. Facility staff failed to update Resident #155's discharge plan and avoid unnecessary delays in the discharge process. Resident #155 was admitted to the facility on [DATE], with multiple diagnoses including, Dysphagia, Oropharyngeal Phase, Unspecified Lack of Coordination, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Dominant Side. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that facility staff coded the following: In section C (Cognitive Patterns) BIMS (Brief Interview for Mental Status) Summary…

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, record review, family interview and staff interview, for four (4) of 105 sampled residents, the facility's staff failed to ensure that residents received treatment and care in accordance to the physicians' order and the comprehensive person-centered care plan as evidenced by: failed to provide stoma site for one (1) resident; failed to schedule one (1) resident for an audiology consult appointment; failed to implement the care plan intervention of having two (2) certified nurse aides (CNAs) for activities of daily living (ADLs) for one (1) resident; and failed to administer nebulizer inhaler as ordered the physician's order for one (1) resident. (Residents' #3, #50, #82 and #181). The findings include: 1. The facility's staff failed to follow standards of practice by not providing stoma care for Resident #3 from 12/01/21 to 02/06/22. Review of an intake form for a complaint received by the DC Department of Health, Health Care Regulation and Licensing Administration on 01/26/22 showed 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, record review and staff interview for five (5) of 105 sampled residents, facility staff failed to: (1) ensure the dialysis communication form (used to reflect ongoing collaboration between the facility and dialysis staff contained pertinent information that reflected the resident care) was completed and included in the medical record as part of the record and (2) have an emergency kit (pressure bandage) at bedside of a resident who had an arteriovenous graft dialysis access site. Residents' #61, #95, #181, #182 and #502. The findings include: 1. Facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility staff and dialysis staff was included as part of Resident #61's medical record. Resident #61 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Viral Hepatitis C, Anemia, Hypertension, Peripheral Vascular Disease, Acute Kidney failure,…

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 record review and staff interviews, facility staff failed to ensure that the system used for the reconciliation of controlled medications was followed; and failed to accurately reconcile controlled medications for three (3) of 16 records reviewed. The findings include: The facility's policy and procedures for the storage of controlled substances revised on 08/2020 stated: Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations .Procedures: .Unless otherwise indicated .the following will be performed . At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented . Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a Control Count Sheet (or similar form) or in accordance 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 record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) show documented evidence that the attending physician or designee reviewed the monthly medication regimen review and that they acted upon the pharmacists' recommendations. Residents' #16, #22, #61, #167, #190, #238 The findings include: Review of the facility policy entitled, Medication Regimen Review, dated 08/2020 documented, . Recommendations are acted upon and documented by the facility staff and/or prescriber. The prescriber accepts and acts upon recommendation or rejects provides an explanation for disagreeing . The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure . 1. Facility staff failed to act upon the pharmacist recommendation to Please eval Risperdal for a GDR (gradual dose reduction) . for Resident #16. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses…

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 staff interview, facility staff failed to serve and distribute foods in accordance with professional standards of practice for food services safety as evidenced by hot food temperatures that tested at less than 135° Fahrenheit (F) during a food tray assessment on April 12, 2022. The findings include: Hot foods temperatures were inconsistent during a test tray assessment on April 12, 2022. Hot foods from the regular diet, such as fried fish ([NAME]), green beans, and rice, tested under 135° Fahrenheit (F), while mechanical and pureed foods were above required temperature. Fried Fish (regular diet) = 132° F White [NAME] (regular diet) = 132° F Green Beans (regular diet)) = 129° F Mixed Vegetables (mechanical) = 138° F Fried Fish (mechanical) = 147° F White rice (mechanical) = 142° F Fried Fish (puree) = 150° F Mixed Vegetables (puree) = 148° F Mashed Potatoes = 150° F These findings were acknowledged by Employee #15, during a face-to-face interview on April 12, 2022, at 3:45 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by failure to ensure that: staff implemented measures to prevent resident-to-resident abuse and altercations for six (6) residents; adequate supervision was provided to one (1) resident who sustain a dislocated hip of unknown origin; to adequately supervise one (1) resident who sustained a fall with injury; ensure the appropriate respiratory medical supplies were on hand for care and treatment, and to ensure staff were trained on how to care for two (2) residents with a laryngectomies. The census on the first day of survey was 255. The findings include: 1. In the area of 42 CFR§ 483.12, Freedom from Abuse, Neglect, and Exploitation, Administration failed to ensure residents were free from abuse (willful infliction of injury) and neglect as evidenced by: failure 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 observation, record review and staff interview, Governing body failed to ensure that established and implemented policies regarding the management and operation of the facility were followed and action plans were developed and implemented to: prevent resident-to-resident abuse and altercations for six (6) residents; ensure adequate supervision was provided to one (1) resident who sustain a dislocated hip of unknown origin; adequately supervise one (1) resident who sustained a fall with injury; ensure the appropriate respiratory medical supplies were on hand for care and treatment; ensure staff were trained on how to care for two (2) residents with a laryngectomies; and to ensure the administrative staff maintained the integrity of an Incident/Accident Report (investigative report) for one (1) resident. The census on the first day of survey was 255. The findings include: 1. In the area of 42 CFR§ 483.12, Freedom from Abuse, Neglect, and Exploitation, Administration failed to ensure residents were free…

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 record review and staff interview, for five (5) of 105 sampled residents, the facility's staff failed to ensure a resident's record contained accurate information as evidenced by failure to: accurately record information on a Treatment administration record for one (1) resident; maintain the integrity of an Incident/Accident Report related to a resident-to-resident altercation resulting in serious injury to the resident; and ensure resident's medical record were accurately documented for three (3) residents. Residents' #3, #126, #164, #404, and #408. The findings include: Review of the facility policy entitled, Clinical Documentation/Record dated 03/2022 revealed, It is the policy of [Facility Name] to ensure accurate documentation of important elements contributing tote high quality care of our residents . Clinical documentation is required to record pertinent facts, findings and observations about resident's health . 1. The facility staff failed to ensure Resident #3's Treatment Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to ensure that there was documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization, the administration or the refusal of or medical contraindications to the vaccine(s). Residents' #182 and #603. The findings include: Review of the policy entitled, Pneumococcal Policy and Procedure (not dated) documented, It is the policy of [facility Name] to offer to all residents pneumococcal upon admission and administer in accordance with the recommendations of the Centers of Disease Control (CDC) and the facility Medical Director . 1. Resident #182 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Heart Failure, Type 1 Diabetes Mellitus and Anemia in Chronic Kidney Disease. According the Quarterly Minimum Data Set (MDS) dated [DATE], facility staff coded Resident #182 with a Brief Interview for Mental Status (BIMS)…

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 record reviews and staff interviews, for one (1) of 105 sampled residents, facility staff failed to ensure that Resident #64 was treated with respect and dignity evidenced by failure to provide an environment that enhances the resident's quality of life, was based on his individuality and medical condition. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included: Acquired Absence of Unspecified Leg below Knee, Pathological Fracture, Unspecified Femur, Initial Encounter for Fracture, Muscle Weakness (Generalized), Spinal Stenosis, Site Unspecified. According to the quarterly Minimum Data Set, dated [DATE], the resident was coded as 15 under Section C0500 BIMS Score indicating that he is cognitively intact. Under Section G0110 Functional Status, the resident was coded as 3, indicating he required extensive assistance for toilet use, with one-person physical assist. Under Section G0110 Functional Status, the resident was coded as 3, indicating he required…

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 resident and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to provide Resident #113 access to the bathroom and an elevated toilet seat causing the resident to be dependent on staff to use the bathroom. The findings include: During an observation on 03/29/22 at approximately 11:30AM, Resident #113's bathroom was locked, and the surveyor had to access the bathroom from the neighbor's side. It was also observed that the bathroom did not have an elevated toilet seat. Resident #113 was admitted to the facility on [DATE]. The resident has a history of General Muscle Weakness, Generalized Arthritis, Difficulty Walking, and Osteoporosis. Review of a Quarterly Minimum Date Set dated 02/09/22 showed Resident #113 had a BIMs summary score of 15, indicating the resident had intact cognition. Further review of the MDS revealed Resident #113 was coded for needing supervision and requiring the physical assistance of one person for toilet use, not moving on and off…

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, record review, and interviews for one (1) out of 105 sampled residents, facility staff failed to offer a resident who had been moved due to a COVID-19 outbreak, the opportunity to move back to her previous room or previous unit once COVID-19 precautions were lifted. Resident #233. The findings include: Resident #233 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, Stage 4, and Cerebral Infarction Due to Unspecified Occlusion or a Stenosis of Unspecified Cerebellar Artery. Quarterly Minimum Data Set, dated [DATE] facility staff coded Resident #233 in the following manner: Section C (Cognitive Patterns) Brief Interview for Mental Status Summary Score was 15, indicating that the resident was cognitively intact. A review of Resident #233's medical record revealed: 01/01/22 at 9:53 AM [Activities Note -In-house Transfer]: [Resident #233's Name] was relocated from room [ROOM NUMBER]B to room [ROOM NUMBER]A as 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 record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to ensure that two (2) residents or their representative was provided the NOMNC form no later than noon of the day before the effective date indicated/date listed as discontinuance of skilled services. Residents' #209 and #553. The findings include: The Notice of Medicare Non-Coverage form stipulates that every Medicare resident in a facility has the right to appeal the decision of non-coverage to the Quality Improvement Organization .The Quality Improvement Organization will notify you of its decision as soon as possible, generally no later than two days after the effective date of the notice if you are in Original Medicare . 1. Resident #209 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, Anemia, Hypertension, and Vertebral Sacral Fracture. According to the NOMNC form, Resident #209's last day of coverage for Skilled Nursing Services was March 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 on record review and staff interview, for three (3) of 105 sampled residents, facility staff failed to: (1) report the unusual occurrences for Resident #3 and Resident #409 and (2) report the results of the investigation for Resident #408's injury of unknown origin. The findings include: Review of the facility's policy titled, Prohibition of Abuse with a revision date of 02/22, showed neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy revealed that staff are to, complete an incident/accident form for any unusual occurrences and submit it to the Director of Nursing or designee .A final report of the investigation will be reported and signed by the Administrator. 1. Facility staff failed to report Resident #3's heat and moisture exchanger (HME) being stuck in his stoma (unusual occurrence) and Resident #409's dislocated hip (unusual…

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 record review and staff interview for three (3) of 105 sampled residents, the facility's staff failed to ensure: (1) Resident #3's discharge, transfer, or relocation form dated 12/03/21 included accurate information and (2) Resident #126's and #155's care plan goals were sent to the receiving hospital. The findings include: 1. The facility's staff failed to ensure Resident #3's discharge, transfer, or relocation form dated 12/03/21 included the accurate information. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Larynx, Carcinoma of Larynx, Acquired Absence of Larynx, and Tracheostomy Status. Review of the Resident #3's medical record showed a physician's order dated 12/03/21 that instructed, transfer resident to the nearest ER (emergency room) for further evaluation related to stuck HME in stoma. 12/03/21 at 2:42 PM [Nursing Progress Note] The respiratory therapist notified writer that resident has an HME stuck in the stoma (airway). 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 record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to provide Resident #132 and Resident #151 or their representative(s) with written information that specified the bed-hold policy. The findings include: Review of the facility policy entitled, Transfer or Discharge, Emergency Care dated 03/2022 documented, .The Social Worker/Designee during hospital transfer .will ensure that the resident and responsible party is notified verbally or by telephone or in writing of how many bed hold days the resident has . 1. Resident #132 was readmitted on [DATE] from a [Local hospital] with diagnoses that included: Urinary Tract Infection (UTI), Alzheimer's, Dementia, Epilepsy and Muscle Weakness (Generalized). A review of the Quarterly Minimum Data Set (MDS) for Resident #132 dated 02/17/22 revealed that facility staff coded the resident with a Brief Interview for Mental Status (BIMS) Summary Score was 99, indicating that the resident had severely impaired cognition. A review…

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 record review and staff interview, for 2 (two) of 105 sampled residents, the facility's staff failed to ensure that Resident #181's Quarterly Minimum Data Set (MDS) dated [DATE] and Resident #188's Quarterly Minimum Data Set (MDS) dated [DATE] were completed 14 days after the assessment reference date. The findings include: 1. Resident #181 was admitted to the facility on [DATE] with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Asthma, Heart Failure, and End Stage Renal Disease. Review of the resident's Quarterly MDS dated [DATE] showed Resident #181 had an assessment reference date of 03/01/22, which made the MDS required completion date 03/15/22. Sections G (Functional Status), GG (Functional Abilities and Goals) and Z (Assessment Administration) showed that Employee #19 (Regional MDS Coordinator) completed these sections on 03/22/22. Additionally, Section Z0500, RN Assessment Coordinator's Signature and Date to verify completion was left blank. 2. Resident #188 was admitted 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 record review, family interview, and staff interview, for one (1) of 105 sampled residents, facility staff failed to provide Resident #3's representative with a summary of the baseline care plan. The findings include: Facility staff failed to provide Resident #3's representative with a summary of the baseline care plan. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Larynx, Carcinoma of Larynx, Acquired Absence of Larynx, and Tracheostomy Status. Review of the Resident #3's medical record lacked documented evidence that the summary of the base-line care plan was provided to Resident #3's representative(s). During a telephone interview on 04/12/22 starting at 11:35 AM, the resident's granddaughter stated that neither she nor her mother (responsible party) ever received a copy of the baseline a care plan or attended a care plan meeting for Resident #3. During a face-to-face interview on 04/13/22 at 11:47 AM, Employee #11 (4th Floor Social Worker)…

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, record review, resident and staff interview, for two (2) of 105 sampled residents, facility staff failed to: 1) assist a resident with applying her dentures before meals; and 2) failed to ensure one (1) resident was seen by audiology to address his ability to hear when communicating with others. Residents' #204 and #82. The findings include: 1. Facility staff failed to assist Resident #204 with applying her dentures before meals. During an observation on 03/30/22 at approximately 1:30 PM, Resident #204 the resident was observed with her lunch tray. When asked if she liked the food at the facility, the resident reported that the food in the facility was okay, but she wanted to wear her dentures when she eats. The writer asked if her dentures were with her in the facility and she stated, Yes. Resident #204 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Human Immuno-Deficiency Virus (HIV), Diabetes Mellitus, and Cognitive Communication…

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 record review, resident interview, and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to provide Resident #113 showers. The findings include: During an observation on 03/29/22 at approximately 11:30 AM, Resident #113 was in bed and a certified nurse aide (CNA) had just finished providing am care. The resident was asked, how often does she receive showers, Resident #113 said, I don't get showers. I just wash myself up in my bed. Resident #113 was admitted to the facility on [DATE]. The resident has a history of General Muscle Weakness, Generalized Arthritis, Difficulty Walking, and Osteoporosis. Review of a Quarterly Minimum Date Set dated 02/09/22 showed the following: In section C (Cognitive Pattern) - the resident had a Brief Interview for Mental Status Summary Score of 15, indicating the resident had intact cognition. In section G (Functional Status) - Resident #113 was coded as needing supervision and set-up assistance with bathing, not steady and only able 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 observation, record review, resident and staff interviews, for one (1) of 105 sampled residents, facility staff failed to ensure that Resident #82 received assistive devices to maintain hearing ability. The findings include: During a face-to-face interview conducted on 03/29/22 at approximately 10:00 AM, Resident #82 stated, I can't hear. You have to come closer. No hearing assistive devices were observed in the resident ' s ear or in his room. Resident #82 was admitted to the facility on [DATE]with multiple diagnoses that included: Sensorineural Hearing Loss and Schizophrenia. Review of Resident #82's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] that showed facility staff coded a Brief Minimum Interview for Mental Status (BIMS) summary score, 14, indicating intact cognitive response. 09/21/21 [Physician's Orders] Referral for Audiology consult 2/2 (secondary to) to pt (patient) reports of bilateral hearing loss impacting communication and quality of life 30 days 09/21/21…

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 on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to administer pain medication to Resident #118 in accordance with the physician's order; and failed to assess Resident #236's pain before administering Tylenol (pain reliever). The findings include: Review of the facilities policy titled Pain Management revised March 2022, showed: .The relief of pain in resident becomes a priority. It is also our duty to monitor and assess for signs and symptoms of pain, advocate for pain management and meet our goal of keeping resident as comfortable as possible.Meeting resident need for pain management; nursing staff will proceed as follows: -Assess for signs and symptoms of pain which include verbal and nonverbal gestures. - Vital signs if appropriate -note the type of pain -Location of pain -Characteristics of the pain (sharp, stabbing and throbbing etc.) -Rating of Pin numerically on a scale od 0-10 or use of facial expression chart to determine pain severity. -Provide…

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, record reviews and staff interviews, the facility staff failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety as evidence by failure to: (1) follow facility policy to make changes in Resident #56's active clinical record; (2) ensure the facility's nurse was competent on how to administer Tiotropium Bromide Aerosol Inhaler for Resident #181; and (3) address Resident #404's intrusive behavior which led to a resident-to resident altercation resulting in serious injury to Resident #404. The resident census on the first day of survey was 255. The findings include: Policy Title: Correction in Resident Medical Records revised 03/2022 documented, .Procedure and Implementation- Whenever there is an error or multiple errors observed in resident(s) medical records or clinical chart. The facility will proceed as follows: The medical staff or clinical staff that made error in the resident electronic…

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, record review and staff interview, for one (1) of 105 sampled residents, facility staff failed to: monitor and provide ongoing assessment of the effectiveness of interventions for a resident with a mental or psychosocial disorder; and demonstrate reasonable attempts were made to implement approaches to help meet the behavioral health needs to assure resident safety. Resident #404. The findings include: Review of a Facility Reported Incident (FRI) dated [DATE], documented, .The charge nurse observed [Resident 404] sitting on the floor besides his roommate's . bed #420A; the charge nurse noticed blood on [Resident #404's] left ear and mouth. The nurse assessed [Resident #404's] left ear and mouth and there was no skin tear or abrasion including his face . [Resident #82] was interviewed he said, that man keeps coming over to my bed side and when I asked him to go back to his side of the bed, he punched me on my stomach and chest and I punched him on the chin and he fell . Review of a Complaint…

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 and staff interviews, facility staff failed to ensure that medications and biologicals were properly labeled and stored for three (3) of 16 medication carts. The findings include: The facility's policy and procedures for storage of medications revised on 08/2020 stated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . Procedures: III. Expiration Dating (Beyond-Use Dating) . When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated . The nurse shall place a date opened sticker on the medication and record the date opened, and the new date of expiration. The expiration date of the vial or container will be 30 days from opening unless the manufacturer recommends another date . If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed, and the expiration date will be calculated accordingly .All expired medications will be removed from the active…

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 and staff interview, facility staff failed to prepare foods under sanitary conditions as evidenced by missing ceiling tiles in the main kitchen, a dusty electric fan in use in the food preparation area, two (2) of four (4) dietary staff members who failed to wear gloves while clearing off breakfast food trays, and erroneous documentation of dishwashing machine final rinse temperatures. Findings included . During a walk through of dietary services on July 20, 2020, at approximately 9:15 AM, and on July 21, 2020, at approximately 9:30 AM, the following were observed: 1. Ceiling tiles were missing from an area located by the dishwashing machine. 2. A fan, soiled with dust, was observed in use, in the food preparation and service area. 3. Two (2) of four (4) staff members failed to wear gloves while clearing off food trays. 4. During a review of the Dish Machine Temp Log from January 2020, to present, it was noted that the dish machine final rinse temperatures were recorded at less than the minimum, required temperature of 180 degrees Fahrenheit on several…

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 and staff interview, facility staff failed to have adequate trash receptacles to dispose of used personal protective equipment (PPE) on the Person Under Investigation (PUI) and COVID-19 Unit; follow acceptable infection control standards to prevent the spread of infection in one (1) of two (2) dressing change observations; and follow acceptable standards to prevent the spread of infection between residents while using a glucose meter. Findings include . 1. The facility failed to have adequate trash receptacles to dispose of used personal protective equipment on the Person Under Investigation (PUI) and COVID-19 Unit. On 7/21/20 at approximately 2:00 PM, observation of rooms [ROOM NUMBER] revealed each room contained a white laundry basket with multiple holes. Three (3) of three (3) of the previously mentioned laundry baskets were lined with red plastic bags and contained used PPEs. The facility staff failed to ensure that used PPE were being properly discarded in the rooms of PUI and COVID…

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 and staff interview, the facility failed to protect the resident's dignity during one (1) of two (2) dressing change observations. Findings include . Resident #135 was admitted to the facility on [DATE] with medical diagnoses of Cerebrovascular Disease, Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Retention of urine, Pressure Induced Deep Tissue Damage of Sacral Region, Pressure Induced Deep Tissue Damage of Left Heel, Pressure Induced Deep Tissue Damage of Right Heel, Pressure ulcer of Left Elbow, Bacteremia, and Sepsis. During a tour of Unit 5 south on 7/28/2020 at 10:30 AM, the surveyor observed the following: Employee #14 was in the process of changing the dressing to Resident #135's sacral wound. During this time Employee #14 removed the resident's adult brief and sacral wound dressing with gloved hands. Employee #14 then removed the gloves and proceeded to wash his hands. After washing his hands, Employee #14 stated, There are no paper…

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 record review and staff interview for one (1) of 66 sampled residents, the facility staff failed to ensure the physician's order for the resident's code status was reflective of Resident #196 wishes to be a DNR (do not resuscitate). Findings included . Policy: Advance Directives will be respected in accordance with state law and facility policy. Updated 7/1/2020. Procedure #4 The Unit Manager or designee will notify Physician or Nurse Practitioner of advance directives so that appropriate orders can be documented/updated in the resident's medical record. Resident #196 was admitted to the facility on [DATE] with diagnoses, which included Hypertension, Hyperlipidemia, Degenerative Joint Disease, Closed left Humeral Fracture, Alzheimer's, and Dementia. A review of the Social Worker's progress note dated 6/23/2020 at 17:33 showed, This worker assisted (resident's name) to call her son .Contacted the son back and discussed resident's status and progress. Confirmed that son is the POA/responsible party. He…

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 record review and interview, facility staff failed to code accurately the Minimum Data Set (MDS) for one (1) of 66 sampled residents (Resident #231). Findings included . Resident #231 admitted to the nursing home on [DATE] with diagnoses to include Cerebral Vascular Accident (CVA), Debility due to Acute CVA, hypertension, urinary tract infection (UTI), muscle weakness, major depression, cognitive deficit UTI and thromboembolic stroke. On 08/03/20 at 12:00 PM, review of the Physician's Discharge Summary note dated 5/8/20 at 17:54:05, showed that Resident #231 was admitted on [DATE] and discharged on 5/11/20; Disposition: discharged home; and Rehabilitation Potential: Good. Nursing Note (5/11/20 at 22:21:44) Resident was discharged home today in stable condition at 1:15 pm. He was escorted by staff to the gate to meet with family. Medications were reviewed with family and were encouraged to assess residents [blood pressure] prior administering meds. They had no questions regarding the medications…

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 record review and staff interview for one (1) of 66 sampled residents the facility staff failed to develop a care plan to address Resident #196's code status. Findings include . Resident #196 was admitted to the facility on [DATE] with diagnoses, which included Hypertension, Hyperlipidemia, Degenerative Joint Disease, Closed left Humeral Fracture, Alzheimer's, and Dementia. A review of the Social Worker's progress note dated 6/23/2020 at 17:33 showed, This worker assisted (resident's name) to call her son .Contacted the son back and discussed resident's status and progress. Confirmed that son is the POA/responsible party. He informed this worker that (Resident's name) will be a long-term care resident. She no longer has the apartment that she had before. We reviewed the assessment and made updates. Son reported that his mother is DNR and that she was always clear about that. He doesn't have email so requested this worker mail the documents that need signing to him in NC [North Carolina]. This worker…

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 record review and staff interview the facility failed to update two residents care plans to include the actions and interventions related to preparing one (1) resident for discharge and the code status for one (1) resident in two of 66 sampled residents. Residents' #43 and #159. Findings include . 1.The facility's staff failed to update Resident #43's Care Plan with person centered discharge planning approaches/interventions. Resident #43 was admitted to the facility on [DATE] with diagnoses of anemia, heart failure, hypertension, diabetes mellitus, hyperlipidemia, asthma, chronic obstructive pulmonary disease. Review of the progress note dated 3/25/2020 at 17:07 - Social Work Progress: Resident #43 asked the [social worker] to assist him with locating appropriate housing. The [social worker] stated that she would assist him in exploring that option if it is feasible. The initial step is getting assistance in the community . He will need a new [level of care] for the community and a referral 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.

Based on observations and staff interview, facility staff failed to store, prepare, distribute and serve foods under sanitary conditions as evidenced by fifteen of nineteen nine-inch sheet pans that were stored wet and ready for use, one (1) of one (1) case of evaporated milk with a Best By date of February 2017, stored for use as emergency food, and three (3) of four (4) puree food dishes that tested at less than 135 degrees Fahrenheit (F) from the test tray. Findings included . 1. Fifteen of nineteen nine-inch sheet pans were stored wet, on a ready-for-use shelf. 2. One (1) of one (1) case of evaporated milk with a Best By date of February 28, 2017, was stored for use as an emergency food item. 3. Puree food dishes such as beef (129 degrees F), vegetables (119 degrees F), and bread (117 degrees F) were below 135 degrees F during a test tray assessment on March 19, 2019, at approximately 2:00 PM. During a face-to-face interview on March 18, 2019, at approximately 11:00 AM, Employee #13 acknowledged these findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview for one (1) of 68 sampled residents facility staff failed to maintain infection control standard of practicice by failing to use approriate personnel protective equipment (PPE) when providing Foley catheter care for Resident # 591 with Vancomycin-Resistant Enterococcus (VRE) in the urine and to ensure that laundry items are handled, stored, and processed in a sanitary manner as evidenced by two (2) of two (2) soiled electrical fans, in use in the clean laundry area, four (4) of four (4) soiled exhaust vents, and fifteen of nineteen nine-inch sheet pans that were stored wet and ready for use. Findings included . According to the Center for Disease Control [CDC] Guidelines for preventing spread of VRE Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning gown and gloves upon room entry and discarding before exiting the patient…

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 and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by torn and worn door gaskets from two (2) of two (2) steamers in Dietary Services. Findings included . During a walkthrough of the kitchen on March 20, 2019, at approximately 9:00 AM, door gaskets to two (2) of two (2) steamers were worn, torn, and damaged. During a face-to-face interview on March 20, 2019, at approximately 11:30 AM, Employee #13 and/or Employee #14 acknowledged these findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, record review, resident and staff interview for one (1) of 68 sampled residents, facility staff failed to ensure that one resident who was observed with medications at her bedside was cleared by the Interdisciplinary Team (IDT) to self-administer her medications. Resident #248 Findings included. Resident #248 was admitted to the facility on [DATE] with diagnoses which include Generalized Muscle Weakness, Type 2 Diabetes without complications, Essential (Primary) Hypertension, Cerebral Infarction Unspecified, Alcohol Abuse Uncomplicated, Drug Abuse Counseling and Surveillance of Drug Abuser and Acquired Absence of Right leg below knee. Review of Section C (Cognitive Patterns) of the admission Minimum Data Set (MDS) dated [DATE] and the last quarterly MDS dated [DATE] both show the resident with a BIMS (Brief Interview for Mental Status) score of 15; which indicates that the resident's cognitive ability is intact and she is able to make her own decisions. The resident is coded as a one (1)…

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 resident and staff interviews and facility document review for one (1) of 68 sampled residents, the facility staff failed to provide Resident #7 with quarterly statements within 30 days after the end of the quarter and/or upon request. Findings included . Resident #7 was admitted to the facility on [DATE] with diagnoses which include: Hypertension, Diabetes Mellitus, Hyperlipidemia and Chronic Obstructive Pulmonary Disease. Review of the Quarterly Minimum Data Set 12/4/18 showed Section C-Cognitive Patterns: Brief Interview for Mental Status scored as 15 which indicates cognitively intact. During an interview with Resident #7 on 3/18/19 at approximately 11:30 AM, he was asked, do you get a quarterly statements from the facility? Resident #7 responded, I don't get my monthly statements. During an interview on 3/18/19 at 2:00 PM with Employee #3, he stated, yes, the residents are supposed to get their statements but some residents throw them away. I don't have anything to show you that I have given 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 an observation, record review and staff and resident interview for one (1) of 68 sampled resident's, the facility staff failed to respect Resident #96's privacy by failing to knock on the resident's door and entering the resident's room without receiving permission to enter. Findings included . Resident #96 was admitted to the facility on [DATE], with diagnoses which included Arthritis, Depression, Hypertension, Atrial Fibrillation, Heart Failure and Renal Insufficiency as recorded in Section I of the annual Minimum Data Set, dated [DATE]. Review of Section G (Functional Status) shows that the resident requires extensive assistance and support from one person for all activities of daily living except transfer and eating. The resident requires assistance from two persons for transfer and only requires cueing and/or oversight for eating. Review of the Brief Interview for Mental Status BIMS in Section C (Cognitive Patterns) showed a score of 15 which indicated that the resident was cognitively intact 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, medical record review and staff interview for one (1) of 68 sampled resident facility staff failed to ensure Resident #186 was free from neglect by failing to assess the resident's care needs after the resident repeatedly called a Certified Nursing Assistants (CNA) for assistance. Resident #186. Findings included . Record review of the facility's policy titled Prohibition of Abuse Administration with a revision date of 1/19, showed Neglect- is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #186 was admitted to the facility on [DATE] with diagnoses which include; Anemia, Heart Failure, Hypertension, Alzheimer Disease, Cerebrovascular Accident and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set [MDS] dated 2/8/19 showed Section C-Cognitive Patterns. Brief Interview for Mental Status [BIMS] is scored as 12 which…

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, investigative documents, medical record review and staff interview of one (1) of 68 sampled residents facility staff failed to conduct a thorough investigation involving an incident of neglect. Resident# 186. Findings included Record review of the facility's policy titled Prohibition of Abuse Administration with a revision date of 1/19, showed Neglect- is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident# 186 was admitted to the facility on [DATE] with diagnoses which include; Anemia, Heart Failure, Hypertension, Alzheimer Disease, Cerebrovascular Accident and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set [MDS] dated 2/8/19 showed Section C-Cognitive Patterns. Brief Interview for Mental Status [BIMS] is scored as 12 which indicates cognition is moderately impaired. Section G-Functional Status [Activities of Daily…

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 record review and staff interview for three (3) of 68 sampled residents, the facility staff failed to document the information communicated to the receiving health care institution for Residents' #126, # 215 and #247. Findings included . 1. The facility staff failed to document the information communicated to the receiving health care institution for Resident #126. Resident #126 was admitted to the facility on [DATE], with diagnoses to include Anemia, Hypertension, Hyperlipidemia, Osteoporosis, End Stage Renal Disease, Alzheimer's and Major Depressive Disorder. A review of the Significant Change in Status Minimum Data Set [MDS] dated January 21, 2018. Section C [Cognition Patterns] C1000 Cognitive Skills for Daily Decision Making coded 3 Severely impaired which indicates, Resident never/rarely made decisions. A review of the physicians' order dated December 28, 2018, showed, Transfer to the hospital for poor PO intake (unable to swallow) GI consult for G-Tube placement (family agreed to G-tube…

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 record review and staff interview, the facility failed to notify one (1) of 68 residents of the reason for transfer from the facility to the hospital. Resident #215. Findings included . Resident #215 was admitted to the facility on [DATE], with diagnoses which include Anemia, End Stage Renal Disease, Hypertension, Pneumonia, Diabetes Mellitus, Depression and Muscle Weakness. A review of the resident's record on March 19, 2018 at 11:00 AM showed he was transferred to hospital from the facility on January 3, 2019. Review of Resident #215's nurse's notes and social work progress note on March 24, 2019 at 9:00 AM showed there was no documentation indicating that the resident and the resident's representative were notified in writing or verbally of the transfer and the reasons for the move in writing. The medical record lacked documentation to support the facility communicated the name of the practitioner who is responsible for the care of the resident, resident's representative contact information, advance…

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 record review and staff interviews of three (3) of 68 sampled residents, the facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) Resident's Discharge to home, for one (1) Resident's use of psychotropic medications and for one (1) resident with a behavioral indicator for psychosis. Residents' #70, #198 and #258. Findings included . 1. Resident #70 admitted to the facility on [DATE], with diagnoses which include: Opioid Use unspecified, Encephalopathy, unspecified, Pressure Ulcer of Sacral Region (Unstageable), Right Heel (Unstageable) and Left Heel (Unstageable). Review of the Physician Order dated 1/29/19 showed discharge patient to home on 1/31/19 scripts done. Review of the physicians Discharge summary dated [DATE] discharge date : [DATE], disposition: home. Review on the Nursing Home Discharge Minimum Data Set [MDS] dated 2/1/19 showed Cognitive Patterns: Brief Interview for Mental Status scored as 13 which indicate cognitively intact. Review of Identification Information…

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 record review and staff interview for one (1) of 68 sampled residents, it was determined that facility staff failed to ensure that the Level II Pre-admission Screen/Resident Review for Mental Illness and or Mental Retardation screening was completed for Resident #262. Findings included . A review of the Pre-admission Screening/Resident Review for Mental Illness and or Mental Retardation Level I [PASRR] screen, signed as completed by the facility staff on January 9, 2019, revealed that Resident #262 was identified as positive for major mental disorder Schizophrenia, and a Level II screen is required. There is no evidence that the facility staff completed the Level II Pre-admission Screening/Resident Review as indicated from the level I screening. Facility staff failed to ensure that the Level 2 Pre-admission Screen/Resident Review for Mental Illness and or Mental Retardation was completed for Resident #262 who had a diagnosis of Schizophrenia. A face-to-face interview was conducted with Employee #22 on 3/25/2019 at 9:00 AM after a review of the findings she acknowledged 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview for one (1) of 68 sampled residents, the facility staff failed to provide the resident and or the resident's representative with a written summary of the baseline care plan within 48 hours after the resident's admission to the facility. Resident #591. Findings included Review of the medical record on 3/21/19 at 12:00 PM showed Resident # 591 admitted to the facility on [DATE] with diagnoses to include: Diabetes Mellitus, End Stage Renal Disease, Urinary Tract Infection, and Malignant Neoplasm of Prostate. Review of Resident #591 Face Sheet showed two Primary Contacts listed. A further review of the medical record showed an unsigned baseline care plan dated 3/18/19 the signature line for the resident, the resident's representative, and the facility's designee was blank (the signature indicates that the resident and/or the resident's representative was made aware of the initial goals and approaches to address the resident's care needs and services.) During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 68 sampled residents facility staff failed to revise/update the care plan after Resident #215's hospitalization. Findings included . Resident #215 was admitted to the facility on [DATE], with diagnoses which include Anemia, End Stage Renal Disease, Hypertension, Pneumonia, Diabetes Mellitus, Depression, and Muscle Weakness. On 3 /25/19, at 10:00 AM a review of Resident #215's quarterly Minimum Data Set [MDS] dated 2/24/19, showed Section C [Cognitive Patterns] a Brief Interview for Mental Status [BIMS] with a score of 15 which indicated the resident was cognitively intact. Section G [Functional Status] resident is coded as 1 supervision (oversight, encouragement or cueing) for locomotion on and off the unit. A further review of Resident #215's medical record on 3/25/2019 at 2:00 PM showed the Care Plan was not updated when the resident was hospitalized on 1/3/ 2019. There was no evidence facility staff revised/updated the care plan with goals 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, record review, resident and staff interviews for one (1) of 68 sampled residents, facility staff failed to provide necessary services to maintain good grooming (Removal of facial hair from chin) and Activities of Daily Living for Resident #223. Findings included . Resident #223 was admitted to the facility on [DATE]. Review of Section I (Active Diagnoses) of the annual assessment dated [DATE] shows diagnoses which include Anemia, Heart Failure, Hypertension, Gastroesophageal Reflux Disease (GERD), Renal Insufficiency, Viral Hepatitis and Diabetes Mellitus. Review of Section C (Cognitive Patterns) of the quarterly Minimum Data Set (MDS) dated [DATE], show the resident with a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact and able to make her own decisions. And, under Section G (Functional Status) - Activities of Daily Living (ADL) the resident was coded as a three (3), which indicated the resident required extensive assistance from…

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, medical record review, family and staff interviews for one (1) of 68 sampled residents facility staff failed to honor the resident's preferences and choice of activities to support her psychosocial well-being. Resident # 201. Findings included . Resident #201was admitted to the facility on [DATE] with diagnoses which included: Acute Pancreatitis, Contracture of Muscle, Unspecified Atrial Fibrillation, Chronic Kidney Disease, and Dependent on Renal Disease. Review of the admission Record showed the husband listed as the Resident Representative and Emergency Contact # 1 and the resident's daughter is listed as the Emergency Contact #2. Review of the Comprehensive Minimum Data Set [MDS] dated 2/6/19, showed Section A1100 [Language] preferred language Spanish, which indicates Spanish is resident's preferred language. A1200. Marital Status in the allocated space the code entered is 2 which indicates the resident is married. Section C [Cognitive Patterns]; Brief Interview for Mental Status…

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, record review and interview, the facility staff failed to administer oxygen in accordance with the physician's order for one (1) of 68 sampled residents. Resident #53. Findings included . Resident #53 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, Heart Failure, Hypertension, and Atrial Fibrillation. During an observation on 03/20/19 at approximately 10:40 AM, the dial on Resident # 53's oxygen concentrator was observed to be set at 3 liters. Review of the March 2019 physician's order on 03/20/19 at 10:45 AM showed Resident #53 was to receive Oxygen at 2 liters via nasal cannula. During a face-to-face interview on 03/20/19 at 10:50 AM, Employee #23 acknowledged the finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, facility staff failed to provide an environment free from accident hazards as evidenced by privacy curtains that were attached to an electrical power cord in one (1) of 56 resident's rooms. Findings included . During an environmental tour of the facility on March 19, 2019, between 9:07 AM and 2:30 PM, Privacy curtains to Bed (A) and Bed (B) in resident room [ROOM NUMBER] were tied to the power cord to Bed (B) with strands of cloth, one (1) of 56 resident's rooms surveyed. This practice presented an electrical safety hazard to residents, staff and visitors. During a face-to-face interview on March 20, 2019, at approximately 11:30 AM, Employee #14 and Employee #15 acknowledged these findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview,the facility staff failed to ensure the filter of an oxygen concentrator was free of dust for one (1) of 68 sampled residents. Resident #53. Findings included . Resident #53 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, Heart Failure, Hypertension and Atrial Fibrillation. On 03/20/19 at 10:40 AM, during an observation of Resident #53, it was noted that the resident's oxygen concentrator filter was covered with dust. A review of the physician's order on 03/20/19 at 10:45 AM showed Resident #53 was to receive oxygen at 2 liters per minute via nasal cannula continuously for short[sic] of breath .rinse O2 (oxygen) filter with H20 (water), pat dry and replace. During a face-to-face interview on 03/20/19 at 10:50 AM, Employee #23 acknowledged the finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview for one (1) of 68 sampled residents, facility staff failed to monitor and consistently document Resident# 258's aggressive/delusional behavior and to obtain necessary services to address the resident's behavioral health care needs. Findings included . Resident# 258 was admitted to the facility on [DATE], a review of the admission record showed the following diagnoses Anemia Unspecified, Dementia in Other Diseases Classified without Behavioral Disturbance, Delusional Disorders, Unspecified Psychosis and, Heart Failure. Review of the Comprehensive Nursing Home Minimum Data Set [MDS] dated 2/18/19, showed Section C-Cognitive Patterns: Brief Interview for Mental Status [BIMS] resident was scored as 99 which indicate the resident was not able to complete the interview. Section D [0100]- Mood was coded a 0 to indicate resident's mood interview was not conducted (resident is rarely/never understood). Section E [0100] Potential indicators of psychosis allocated box is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and resident interview for one (1) of 68 sampled residents, facility staff failed to have Resident #166's routine medication available for her use when she requested it. Findings included . Resident #166 was admitted to the facility on [DATE], with diagnoses which include Coronary Artery Disease (CAD), Deep Vein Thrombosis (DVT), Hypertension, Schizophrenia, Post Traumatic Stress Disorder (PTSD) and Asthma. Review of the annual Minimum Data Set (MDS) dated [DATE] shows the resident with a score of 15/15 on the Brief Interview for Mental Status in Section C (Cognitive Pattern). According to the MDS 3.0 User's Manual, page C-14, a score of '13-15 suggests that the resident is cognitively intact. According to Section G of the MDS (Functional Status) Activities of Daily Living, the resident is assessed as requiring supervision for bed mobility, transfers, ambulation, eating, toilet use and personal hygiene and totally independent for bathing. On March 25, 2019 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 record review and staff interview for two (2) of 68 sampled residents, facility staff failed to respond to a request from the pharmacist to evaluate one (1) resident's Trazadone and Seroquel and one (1) resident's Zoloft medication for a gradual dose reduction (GDR). Residents' #105 and #173. Findings included . 1. Facility staff failed to respond to a request from the pharmacist to evaluate Resident #105's Trazadone (used to treat bedtime insomnia) and Seroquel medication for a gradual dose reduction (GDR). Resident #105 was admitted to the facility on [DATE], with diagnoses, which included Chronic Pancreatitis, Diabetes Mellitus, Hypertension, Hyperlipidemia, and Depression Disorder. A review of the Quarterly Minimum Data Set [MDS] dated 1/4/19 showed Section C: Cognition; Brief Interview for Mental Status [BIMS] scored as 15 which indicates the resident is cognitively intact . A review of the physician's orders and the Medication Administration Records from January 2019 to present showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview the facility's staff failed to ensure metered dose inhalers Pulmicort (treatment of lung disease) and Spiriva Respimat (treatment of lung disease) were safely stored for one (1) of 68 sampled residents Resident #53. Findings included . Resident #53 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Heart Failure, Hypertension and Atrial Fibrillation. On 03/20/19 at 10:45AM, Employee # 23 was observed administering the medication to Resident #53. During the observation, it was noted that Pulmicort 180 mcg inhaler was stored in a manufacturers box labeled as Spiriva Respimat 2.5 mcg inhaler and Spiriva Respimat 2.5 mcg inhaler was stored in the manufacturers box labeled as Pulmicort 180 mcg inhaler. The facility's staff failed to ensure Resident #53's metered dose inhalers were safely stored in their appropriate manufacturers boxes. During a face-to-face interview on 03/20/19 at 11:30 AM, Employee # 23 acknowledged 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.