Inspire Rehabilitation And Health Center LLC

Based on observations and staff interviews, facility staff failed to employ staff with the appropriate competencies. The findings include:During the initial kitchen survey on 03/02/2026 approximately at 11:15 AM, it was observed that the kitchen food service manager has not obtained a valid certified food protection manager identification card issued by the DC Department of Health.During a face-to-face interview on 03/02/2026, approximately at 11:15 AM, the above observation was acknowledged by Employee #14, Food Service Manager and Employe #15, Nutritionist.

Based on observations and staff interviews, facility staff failed to prepare and distribute food under sanitary conditions, and store food at the appropriate temperatures as evidenced by the following observations. The findings include:During an initial kitchen survey in the kitchen on 03/02/2026 approximately at 11:15 AM, the following observations were made: Interior surfaces of the ice making machines were not cleaned.There was no hand-washing soap provided in the dispenser mounted on wall above hand washing sink at the food preparation area in the kitchen.Food service manager, Employee #13 and Employee #14, Nutritionist, were immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 03/02/2026, approximately at 11:45 AM, the above observations were acknowledged by Employee #13, Food Service Manager and Employee #14, Nutritionist.During follow-up kitchen survey on 03/11/2026 approximately at 12:50 PM, the following observations were made: Cooked chicken was not held at proper hot holding temperature on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that residents and or their representatives understood the binding arbitration agreements made between the residents and /or their representatives and the facility. Residents #125, ##27, #33, and #127.The findings included:A review of the facility's most recent admission packet included the following binding arbitration agreement for residents and the facility that documented: Resident-Facility Binding Arbitration Agreement[Name of Facility] and [Resident's Name](Resident, or :Resident Legally Authorized Representative (hereinafter, collectively, Resident) understand and agree that any dispute, disagreement, controversy, demand or claim, including but not limited to, legal claims, arising between them regarding any service or health care provided to the Resident by the Facility, even if such dispute arises after the Resident's stay at 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 Number of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that binding arbitration agreements made between the facility and the resident and or their representative provided for the selection of a neutral arbitrator agreed upon by both parties; and provided for the selection of a venue that is convenient to both parties. Residents # 125, #27, #33, and #127.The findings included:A review of the facility's most recent admission packet included the following binding arbitration agreement for residents and the facility that documented: Resident-Facility Binding Arbitration Agreement [Name of Facility] and [Resident's Name](Resident, or :Resident Legally Authorized Representative (hereinafter, collectively, Resident) understand and agree that any dispute, disagreement, controversy, demand or claim, including but not limited to, legal claims, arising between them regarding any service or health 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 observations, record review and staff interviews for eight (8) of 49 sampled residents, it was determined that the facility staff failed to: (a.) implement appropriate infection control measures to manage the transmission of a Norovirus outbreak when five (5) residents-four (4) residents on one floor and one (1) resident on another floor-became ill within a five-day period with nausea and vomiting. Subsequently, during this period, one (1) of the five (5) residents became ill after he was allowed to cohort in the same room with his roommate who had exhibited symptoms of the Norovirus (b.) perform hand hygiene when providing services to three (3) residents during meal time; and (c.) conduct an annual review of two (2) infection control policies. Residents' #144, #194, #162, #130, #99, #180, #33, #12. The findings included: A facility policy titled 'Infection Prevention and Control Policy' with a review date of 1/2026 [January 2026] documented, in part: Purpose: The facility will maintain an infection…

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 maintain equipment in safe operating condition.The findings included:During the initial kitchen survey on 03/02/ 2026 approximately at 11:15 AM, it was observed that:1. The automatic dish washer pressure gauge was not functional2. The back flow preventer valve next to the pressure gauge at the automatic dishwashing machine was leaking water.3. Water was spraying out of the dishwashing machine when the dish mashing machine was operating. Plastic bags were put atop the machine in an effort to stop the water from spraying out of it.4. The spray hose was placed on the garbage scrap board, below the floor rim level and there wasn't a hook or a hanger provided to store it above flood rim level when it is not in use. 5. Condensate water drainpipe originating from air conditioning unit installed above ceiling was extended through the ceiling tile and drained into the garbage disposer sink. Employee # 14, Food Service Manager, and Employee #17, Maintenance Director, were immediately made aware of these findings 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.

Based on observations, record reviews and staff interviews, facility staff failed to maintain an effective pest control program so that the facility is free of pests.The findings included:During the follow-up kitchen survey on 03/10/ 2026 approximately at 12:50 PM, it was observed a dead cockroach on floor in the dry storage room. Employee #14, Food service manager, and Employee #16, Maintenance Staff, were immediately made aware of these findings and proceeded to implement measures to address the issue.Record review of the pest control reports from Bay City pest management Co. Inc dated 2.28.2026 and 2.7.2026 documented in part that there was no cockroach activity noted in the kitchen.During a face-to-face interview on 03/10/2026, approximately at 12:50 PM, the above observations were acknowledged by Employee #14, Food Service Manager and Employee #16, Maintenance Staff.During a face-to-face interview on 03/10/2026 approximately at 1:10 PM, Employee #1, Administrator, stated the contracted professional pest exterminator services the facility biweekly and as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 12 sampled residents, facility staff failed to develop a comprehensive care plan with goals and interventions to address one resident's use of a Foley Catheter. Resident #9. The findings included: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Gastrostomy Status, and Aphasia. Review of the resident's medical record showed the following: 04/10/25 at 10:43 PM admission Note: - The resident arrived from [hospital name] around 9:00 PM on a stretcher accompanied by 2 paramedic staff. - Resident has Foley Catheter draining yellow urine. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded that the resident had an indwelling catheter. A Physician's orders dated 05/29/25 directed, Foley Catheter due to Obstructive Uropathy. During an observation on 06/23/25 at 10:33 AM, 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 interviews for one (1) of 12 sampled residents, facility staff failed to ensure that one resident was free of a significant medication error as evidenced by ordering. transcribing and dispensing a medication that included an incorrect route for the Resident's medication. Resident #4 The findings included: Resident # 4 was admitted to the facility on [DATE] with diagnoses that included: Seizure Disorder, Adrenal Insufficiency, resolved COVID-19, Bowel dysfunction, Diabetes Mellitus DM, Intellectual Delay, Ogilvie syndrome, Gastrostomy Status, Dependence on Supplemental Oxygen, Aspiration Pneumonia. A review of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is under the control of a healthcare professional, patient, or consumer.Medication errors occur at any stage of the medication management…

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 12 sampled residents, facility staff failed to follow infection control policies and procedures for residents on Enhanced Barrier Precautions (EBP). Residents' #9 and #12The findings included:A facility policy Infection Prevention and Control Policy dated January 2025 documented:- Standard and transmission-based precautions are to be followed to prevent the spread of infections.1. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Gastrostomy Status, and Aphasia. Review of the resident's medical record showed the following:A care plan focus area: [Resident #9] is on Enhance Barrier Precautions (EBP) last reviewed on 04/11/25 that had interventions that included, use Enhanced Barrier Precautions: use of gown and gloves only for high-contact resident care activities due to G (gastrostomy) tube, Foley [Catheter]…

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 five (5) sampled residents, the facility's staff failed to inform a resident's physician about a difficulty with getting a medication for resident. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Hepatic Encephalopathy, Carvernous Hemangioma Liver Status Post Resection, Chronic Hepatic Failure, Cirrhosis of Liver, and Ascites. A physician order dated 09/06/23 at 7:44 AM instructed, Xifaxan (Rifaximin) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day for Hepatic Encephalopathy. According to a review of progress notes from 09/06/23 to 11/30/23, there was no documented evidence that the facility's staff informed Resident #1's physician that her insurance would not cover the cost of Rifaximin. In addition, payment approval was required before delivery. A State Survey Agency's Complaint Intake Form DC~12435 dated 11/17/23 at 5:06 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, for one (1) of five (5) sampled residents, the facility failed to ensure a resident was free from Neglect. As evidenced by staff not administering Rifaximin and Lactulose as prescribed. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Hepatic Encephalopathy, Carvernous Hemangioma Liver Status Post Resection, Chronic Hepatic Failure, Cirrhosis of Liver, and Ascites. 1a.The facility's staff failed to administer Resident #1's Rifaximin as ordered. Record Review A physician order dated 09/06/23 at 7:44 AM instructed, Xifaxan (Rifaximin) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day for Hepatic Encephalopathy. A physician order dated 09/12/23 at 10:30 PM instructed, Rifaximin (Xifaxan) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day related to Hepatic Encephalopathy. A review of a pharmacy document titled; Delivery Manifest…

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 five (5) sampled residents, the facility's staff failed to ensure: Resident #1 was administered medications (Rifaximin and Lactulose) as prescribed; and Resident #2's care plan was followed to provide proper body alignment at all times.Consequently, on 11/30/23, the resident nearly fell off his wheelchair. (Residents #1 and #2) The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Hepatic Encephalopathy, Carvernous Hemangioma Liver Status Post Resection, Chronic Hepatic Failure, Cirrhosis of Liver, and Ascites. 1a.The facility's staff failed to administer Resident #1's Rifaximin as ordered. A physician order dated 09/06/23 at 7:44 AM instructed, Xifaxan (Rifaximin) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day for Hepatic Encephalopathy. A physician order dated 09/12/23 at 10:30 PM instructed, Rifaximin (Xifaxan) Oral Tablet 550 milligrams.…

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's staff failed to ensure a resident's Medication Administration Records contained accurate information for one (1) of five sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Hepatic Encephalopathy, Carvernous Hemangioma Liver Status Post Resection, Chronic Hepatic Failure, Cirrhosis of Liver, and Ascites. 1a.The facility's staff failed to ensure Resident #1's Medication Administration Records for September, October, and November of 2023 contained accurate information related to the administration of the medication Rifaximin. A physician order dated 09/06/23 at 7:44 AM instructed, Xifaxan (Rifaximin) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day for Hepatic Encephalopathy. A physician order dated 09/12/23 at 10:30 PM instructed, Rifaximin (Xifaxan) Oral Tablet 550 milligrams. Give 1 tablet by mouth two times a day related…

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, record review and staff interviews, for two (2) of 47 sampled residents, facility staff failed to provide a clean, homelike environment. Residents' #132 and #113. The findings included: 1. A Complaint, DC~12341, received by the State Agency on 10/04/23 from Resident #132's representative documented that: - Residents are in unsanitary living conditions - The facility failed to provide daily clean and safe living environment During an observation of Resident #1332's room, 515 bed A, on 10/30/23 at 10:50 AM, the air conditioning/heating unit was noted with thick layers of gray dust-like material. The resident's over-bed table was sticky to the touch, wet, and had with dark colored stains. During a face-to-face interview on 10/30/23 at 10:55 AM, Employee #6 (Director of Housekeeping and Laundry) acknowledged the findings, stated that cleaning the resident overhead tables and the grills of the air conditioning/heating unit is part of the housekeeping duties and would get someone from housekeeping to come to Resident #132's room. 2. A Complaint DC~12130 received by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility's staff failed to follow it's Abuse Policy by not thoroughly investigating: an allegation of staff-to-resident sexual abuse (inappropriate touch), an allegation of staff-to-resident verbal abuse,a fall incident, an allegation of a verbal altercation between residents and an unusual occurance for five (5) of 47 sampled residents. (Residents #228, #229, #230, #331, and #332). A review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation with a revision dated of 06/23 instructed, All allegations are thoroughly investigated. 1.The facility's staff failed to thoroughly investigate Resident #228 allegation of staff-to-resident sexual abuse (inappropriate touch). Resident #228 was admitted to the facility on [DATE] with multiple diagnoses including Hemiplegia, Morbid Obesity, and Muscle Weakness. The staff assignment for the night shift on 01/29/23 revealed five (5) employees worked that shift. According 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 interviews for two (2) of 47 sampled residents, the facility staff failed to report allegations of abuse and an unusual incident to the State Agency. Resident #331 and #332. The findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating with a revision date of 06/2023 instructs the facility staff to do the following: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, 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 . 1. If resident abuse, neglect, exploitation, misappropriation of resident property, unusual occurrences or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law.…

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 three (3) of of 47 sampled residents, facility staff failed to have documented evidence that they took corrective actions to protect and prevent further potential abuse of Resident #103 by Employee #13 (Smoke Aide), the alleged perpetrator, after an allegation of physical abuse; failed to show documented evidence that investigations were conducted into Resident #331's report to a social worker of a verbal altercation with another resident; and Resident #332's abuse allegation and unusual incident. Residents #103, #331 and #332. The findings included: Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy documented: - The Administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. - If the investigation reveals that the allegation(s) of abuse are unfounded, 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 two (2) of 47 sampled residents, facility staff failed to provide the residents or their representative with bed-hold notice upon transfer to the hospital. Residents' #87 and #278. The findings included: 1. Resident #87 was admitted to the facility on [DATE] with diagnoses that included: Benign Prostatic Hyperplasia, Cerebellar Ataxia and Degenerative Diseases of Basal Ganglia. Review of Resident #87's medical record revealed the following: A Modified Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating intact cognition. A physician's order on 08/30/23 directed, Transfer patient to nearest ER (emergency room) for evaluation and treatment for worsening sacral stage 4 wound and possible infection. An admission Note dated 09/13/23 at 11:45 PM documented that Resident #87 was re-admitted from [Hospital name] at 8:30 PM. Review of a Notice of Discharge, Transfer…

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 two (2) of 47 sampled residents facility staff failed to accurately code Resident #379's Quarterly Minimum Data Set (MDS) assessments to accurately reflect the resident's history of falls and failed to accurately code Resident #174's admission MDS to reflect the resident's surgical wound. The findings included: 1.Resident #379 was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit, Muscle Weakness, Unspecified, Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, History of Falls, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. A review of Resident #379's medical record revealed the following: A physician's order dated 12/01/2 at 11:0 PM documented: Precautions: Fall every shift. A care plan initiated on 12/02/22 documented: Focus: [Resident #379] has Fall Prevention in place . Goal: [Resident Name] will have reduced incidents of falls through the next review period x 90 . An admission Minimum…

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 47 sampled residents facility staff failed to implement a Resident's care plan for the use of carrot palm guards to bilateral hands to prevent skin integrity impairment and further immobility/contractures. Resident #25 The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Convulsions, Muscle Wasting and Atrophy, Schizophrenia, Muscle Weakness, Contracture Left Knee, and Dementia. A review of Resident #25's medical record revealed the following: A Quarterly MDS dated [DATE] showed that facility staff coded the Resident as having a Brief Interview for Mental Status (BIMS) Summary Score of 06, indicating the Resident had severely impaired cognition, had functional limited range of motion to both upper and lower extremities, and was dependent on facility staff for all ADL (assisted daily living, such as grooming, bathing, transfers) care. A physician's order dated 12/04/19 read:…

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 47 sampled residents facility staff failed to ensure that a resident with a limited range of motion received the appropriate treatment and services to increase the resident's range of motion or prevent further decrease in range of motion. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Convulsions, Muscle Wasting and Atrophy, Schizophrenia, Muscle Weakness, Contracture Left Knee, and Dementia. A review of Resident #25's medical record revealed the following: A Quarterly MDS dated [DATE] showed that facility staff coded the Resident as having a Brief Interview for Mental Status (BIMS) Summary Score of 06, indicating the Resident had severely impaired cognition, had functional limited range of motion to both upper and lower extremities, and was dependent on facility staff for all ADL (assisted daily living, such as grooming, bathing, transfers) care. A physician's order…

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 47 sampled residents, the facility staff failed to adequately supervise Resident #331, while toileting as required by the residents Minimum Data Set (MDS) assessment which staff coded as requiring supervision and a one person staff assist with toileting. (Resident #331.) The Findings Included: A review of the facility's policy titled Fall and Fall Management documents .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .Staff will monitor if interventions have been successful in preventing falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Resident #331 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Cirrhosis of the Liver, Muscle Weakness and Cognitive Communication Deficit. A review of 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.

Based on observation, record review and staff interview, facility staff failed to ensure that the established procedures for the accurate reconciliation of narcotics were followed. The findings included: During an observation on 11/01/23 at 8:13 AM of the 3rd Floor narcotic book, it was noted that there was no signature in the section Balance verified by nurse coming on duty for the 7:00 AM - 3:00 PM shift on 11/01/23. The evidence showed that facility staff failed to ensure that the established procedures for the accurate reconciliation of narcotics were followed as evidenced by failing to sign off that the narcotic count was correct with the off-going nurse. During a face-to-face interview done at the time of the observation, Employee #19 (Licensed Practical Nurse/LPN) stated that her shift started 7:00 AM. The employee further stated, I had to run to the bathroom during the [narcotic] count and forgot to sign off. Cross Reference 22B DCMR Sec. 3224.3

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews for one (1) of 47 sampled residents, the facility staff failed to show documented evidence in the medical record that the physician reviewed the pharmacy regimen review for Resident #137. The Findings included: A review of the facility's policy tilted Medication Regimen Review with a revision date of 06/2023 documents .The Consultant Pharmacist shall review the medication regimen of each resident at least monthly .Routine reviews will be done monthly .Copies of drug/medication regimen review reports including physician responses will be maintained as part of the permanent medical record . Resident #137 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Dementia, Paranoid Schizophrenia, and Gastrostomy Status. Review of Resident #137's medical record revealed the following: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], shows that the facility staff coded the resident as having a Brief Interview for…

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 two (2) of ten (10) observations and facility interviews, facility staff failed to store and label biologicals in accordance with currently accepted professional practices. The findings included: According to the Institute for Safe Medication Practices (ISMP) - Vials of insulin dispensed from the pharmacy should be labeled appropriately and include the patient's name. https://www.ismp.org/resources/clinical-reminder-about-safe-use-insulin-vials According to Healthline: - Insulin is effective for 28 days after opening - Users are supposed to mark the date they open a vial or began using a pen, and then keep track and discard it after 28 days https://www.healthline.com/diabetesmine/what-to-do-with-expired-insulin 1. During an observation of the 4th floor medication storage room on [DATE] at 2:10 PM, one opened Lantus (type of Insulin) vial stored for use that was not labeled with an open or expire date During a face-to-face interview at the time of the observation, Employee #21 (Licensed Practical…

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 two (2) observations of the dishwashing cycle and staff interview, facility staff failed to ensure that the dishwasher reached the required temperature (150 degrees to 165 degrees Fahrenheit) to clean dishes and utensils under sanitary conditions. The findings included: During an observation in the facility kitchen on 10/31/23 at 10:55 AM, it was noted that the high temperature dishwasher, during the wash cycle, reached a high of 130 degrees Fahrenheit. In a second observation on 10/31/23 at 11:00 AM, the wash cycle temperature reached a high of 132 degrees Fahrenheit. During a face-to-face interview at the time of the both observations, Employee #25 (Food Service Director) acknowledged the findings and stated that the Maintenance Director would be notified to address the issue. Cross Reference 22B DCMR Sec. 3219.1

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 47 sampled residents, facility staff failed to ensure resident's records contained accurate information. Residents' #229, #132 and #128. The findings included: 1A.The facility's staff failed to ensure Resident #229's Post Fall Huddle dated [DATE] contained accurate information as evidence by documenting the resident's fall as witnessed. Resident #229 was admitted to the facility on [DATE] with multiple diagnoses including Stage 4 Malignant Neoplasm of Lower Lobe, A nursing note dated [DATE] at 11:30 PM documented the following but not limited to: Resident was observed by medication nurse at 11:00 pm and she was sleeping. Around 11:15 pm resident was observed on floor, unresponsive resident was transferred back to bed. CPR was initiated. 911 was called. A review of a Post Fall Huddle dated [DATE] at 11:40 PM documented the following but not limited to: Was fall witnessed? Yes. 1B. The facility's staff failed to ensure accurate information was included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility staff failed to ensure that one (1) of 47 sampled residents had a current written hospice care plan that included both the most recent hospice plan of care and a description of the care and services furnished by the long term care facility. Resident #15 The findings included: A review of the facility's Hospice agreement documented, .Hospice Plan of Care means a written plan which is established, maintained, reviewed and modified if necessary by an Interdisciplinary Hospice Team . Nursing Home Plan of Care means a written care plan which is established, maintained, reviewed and modified if necessary by a Nursing Home Interdisciplinary Team . Design and Maintenance of Hospice Plan of Care .Hospice shall furnish the Nursing Home with a copy of the following items: .2) the most current Hospice Plan of Care . The Hospice Plan of Care will identify the care and services that are needed and specifically identify which provider is responsible for performing 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, staff interview, and family interview, the facility staff failed to offer or provide a resident's family with a copy of the base-line care plan for one (1) of six (6) sampled residents. (Resident #6) The findings included: Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Esophagus, Gastrostomy, and Dysphagia. A review of a Baseline Care Plan with a signature date of 01/30/23 documented, Initial IDT (Interdisciplinary Team) meeting held for [Resident #6] . the R/P [name] participates over the phone . A review of progress notes dated 01/30/23 to 02/07/23 lacked documented evidence Resident #6's responsible party was offered or provide a copy of the Base Line Care plan dated 01/30/23. During a face-to-face interview on 08/05/23 at 10:40 AM, Employee #16 (registered nurse (RN)/Unit Manager) stated that she conducted the Base Line Care Plan meeting on 01/30/23 and the responsible party participated over the phone. The employee said 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 record reviews and staff interviews, the facility's staff failed to develop a care plan that outlined goals and interventions to address a resident's need for the physical assistance of one staff member for locomotion while off the unit for one (1) of six (6) sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Muscle Weakness and Dementia with Agitation. A review of an admission Minimum Data Set, dated [DATE] documented Resident #1 had a Brief Interview for Mental Status summary score of 4, which suggested the resident had a severely impaired cognitive status. Resident #1 was coded for wandering that occurred 1 to 3 days during the assessment period, requiring the supervision and supported by the physical assistance of one staff person when off the unit. In addition, the resident was not coded for using restraints or alarms. A review of Resident #1's care plan revealed it did not outline how staff would supervise…

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's staff failed to ensure a non-prescribed hypertensive medication (Hydralazine HCL - 25 milligrams) was secure and inaccessible for one (1) of six (6) sampled residents. (Resident #4) The findings included: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including Amnestic Disorder due to known Physiological Condition, Wernick's Encephalopathy, Alcohol Abuse with Withdrawal with Perceptual Disturbances, and Hypertension. A review of Resident #1's physician orders to include active, complete, discontinued and struck out orders dated from 06/06/23 to 08/03/23 lacked documented evidence Resident #4 was ordered Hydralazine 25 milligrams. A review of a Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 08, indicating the resident had moderate cognitive impairment. A review of Resident #4's Medication Administration Record (MAR) 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 record review and staff interview, for one (1) of six (6) sampled residents, the facility's staff failed to ensure Resident #1's medical record included a Medication Administration Record and an accurate and complete Elopement Assessment. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Dementia with Agitation, Cognitive Communication Deficit, and Muscle Weakness. A review of a document entitled, Elopement Risk Evaluation dated 07/05/23 revealed that section D - mobility and section E - diagnoses were not complete A review of physician order dated 07/06/23 instructed, Xarelto 20 mg (milligrams) one tablet by mouth one time a day for unspecified atrial flutter take with dinner. A review of a physician order dated 07/07/23 instructed, Depakene (Valproic Acid) 250 mg one capsule by mouth two-times-a-day for mood disorder. A review of the MAR for July 2023 revealed that on July 27, 2023, Employee #5 (registered nurse (RN)/Nursing Supervisor) signed…

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, facility staff failed to have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control. The findings included: During a face-to-face interview conducted on 08/04/22 at 12:47 PM, Employee #3 (Assistant Director of Nursing/ADON), the facility's designated Infection Preventionist (IP), revealed that she had not completed the specialized training in infection prevention and control. Employee #3 stated, I am working on completing the infection prevention and control course.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide the resident or their representative(s) with information regarding formulating an advanced directive. Resident #97. The findings included: Review of the policy Advance Directive revised in February 2022 documented, .Upon admission, Social Services staff will meet with the resident to inquire if there is an existing Advance Directive (AD) . and the right to formulate and to issue Advance Directives . provide written information to the resident . if the Resident does not have an Advance Directive and chooses not to complete one: Obtain signature on the Advance Directive status form . Resident #97 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Muscle Weakness, Hemiplegia, and Hemiparesis. Review of Resident #97's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] where facility staff coded Resident #97 as 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 observations, record reviews, and staff interviews for seven (7) of 50 sampled residents, facility staff failed to implement policies for investigating allegations of abuse and injuries of unknown origin, as evidenced by the failure to: obtain interviews or written statements from potential witnesses; and to adhere to the reporting time to the State Agency. Residents #87, #212, #313, #314, #133, #363, and #51. The findings included: Review of the facility's policy entitled Investigating Incidents Processrevised in March 2022, stated: .Interview and/or obtain a statement from the person reporting allegation or suspicion .Interview and/or obtain statements from potential witnesses as determined by the scope of the investigation . Review materials and complete investigation . Review of the facility's policy entitled Injury of Unknown Origin revised March 2022 documented, . Immediately a resident is identified with an injury of unknown origin, the facility will . interview and/or obtain statements from all…

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 4. Facility staff failed to conduct a thorough investigation of Resident #313's injury of unknown source/origin that occured on 04/06/22. Resident #313 was admitted to the facility on [DATE] with multiple diagnoses that included: Lack of Coordination, Unspecified Abnormalities of Gait and Balance and Altered Mental Status. Review of a Complaint, DC00010664, received by the State Agency on 04/07/22 documented, .Tonight was the absolute final straw for our family, as we learned that my mother has a fractured leg that seemingly occurred without anyone's knowledge or a report by employees . Review of a Facility Reported Incident (FRI), DC00010667, received by the State Agency on 04/08/22 documented, .Upon assessment, no bruises, no swelling nor any sign of trauma noted. Resident medicated as per PRN (as needed) order. Resident re-assessed later and no complains nor signs of pain noted. Resident was visited by son 04/06/22 who made staff aware that resident is in pain, area assessed, no bruises, no swelling and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for five (5) of 50 sampled residents, facility staff failed to provide written information related to the facility's bed hold policy for the resident and/or resident's representative. Residents' #71 #47, #415, #313, and #314. The findings included: Review of the facility policy, 18-Day Bed Hold for Medicaid Residents with Long Term Care Medicaid, revised on 09/27/19, revealed, We are required to provide you with our facility policy for requesting a bed to be held due to hospital transfer . 1. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Heart Failure, and Unspecified Dementia Without Behavioral Disturbance. Review of Resident #71's medical record revealed the following: A copy of Resident # 71's face sheet documented that the resident had a guardian. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the facility staff coded a Brief Interview for Mental Status (BIMS) summary score 08,…

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 50 sampled residents, the facility's staff failed to: implement Resident #71's fall care plan; develop a care plan to address Resident #19's hypoglycemia; develop a care plan to address Resident #15's diagnosis of cataracts and refusal to wear glasses; develop a care plan to address Resident #87's dental care; implement Resident #90's elopement care plan; implement Resident #414's wound care plan; implement Resident #84's use of a bed alarm, and develop a care plan to address Resident #314's use of an arm sling. Residents' #71, #19, #15, #87, #90, #414, #84, and #314. The findings included: Review of the policy, Interdisciplinary Team Meeting (Care Plan Meeting), revised on March 2022, showed, It is the policy of [Facility Name] to develop and implement a person-centered care plan for each resident . 1. Facility staff failed to implement Resident #71's fall care plan, as evidenced by having the entrance to the room filled with clutter and the entrance…

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 50 sampled residents, the facility staff failed to follow standards of transmission-based precautions to prevent the spread of infection as evidenced by: failure to perform hand hygiene prior to providing direct care for one resident; not following infection control practice after providing wound/dressing care for one resident; not wearing appropriate personal protective equipment (PPE); not reviewing and updating its COVID-19 Testing for residents' staff, visitors and volunteers policy at least annually. Residents' #71 and #110. The findings included: 1. The facility staff failed to perform hand hygiene prior to engaging in direct resident care of Resident #71. Resident #71 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Muscle Weakness, Cognitive communication Deficit, Heart Failure, and Unspecified Dementia Without Behavioral Disturbance. During a dining observation conducted in Resident #71'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 interviews, the facility staff failed to ensure that alleged violations involving abuse and neglect or mistreatment were reported immediately for one (1) of 50 sampled residents. Resident #51. The findings included: Review of the facility's policy titled Prohibition of Abuse section F Reporting with a revised date of 05/01/18 documented, All alleged violations, the Administrator, Director of Nursing, or designee shall notify the Department of Health, via the event reporting electronically, or by phone in the event of the electronic system being unavailable within twenty-four (24) hrs of knowledge of the alleged incident and within two (2) hours if serious bodily injury has occurred or there is an allegation of abuse . Resident #51 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Diabetes Mellitus, Unspecified Psychosis, and Cognitive communication Deficit. Facility Reported Incident (FRI), DC00010669, to the State Agency dated 04/11/2022…

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 50 sampled residents, the facility's staff failed to convey all of the required documents to the receiving health care provider when the resident transferred from the facility. Resident #110. The findings included: Resident #110 was admitted to the facility on [DATE] with multiple diagnoses that included: Diabetes Mellitus, Hypertension, Hyperlipidemia, Osteoporosis, Dementia, and Alzheimer's. Review of the medical record revealed: The physician's telephone order dated 07/16/22 at 9:15 AM, directed, Transfer Resident to the hospital to [Hospital's name] via 911. 07/29/22 at 10:05 AM [Facility transfer/discharge packet] showed: a physician's order documenting the reason for transfer/discharge, diagnoses, allergies, recent vital signs, Face sheet, advance directives, comprehensive care plan goals, copy of bed hold notice, copy 6-108 C (transfer or discharge notice sent to ombudsman), recent labs, diagnostic test and immunization, precautions isolation 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 record reviews, and interviews, for two (2) of 50 sampled residents, facility staff failed to notify the resident or their representative(s) of the resident's transfer to the hospital in writing, and failed to send a copy of the notice of transfer to the Office of the State Long-Term Care Ombudsman. Residents #47 and #415. The findings included: 1. Resident #47 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebrovascular Accident (CVA), Hemiplegia or Hemiparesis, Muscle Weakness, and Chronic Kidney Disease (Stage 3). Review of the medical record revealed: A copy of Resident # 47's face sheet documented that the resident had a legal guardian/conservator. A Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff coded the following: a Brief Interview for Mental Status summary score of 99, indicating the resident was unable to complete the interview. 04/28/22 at 2:17 PM [Change in Resident Condition]: .[Resident #47] returned from [a] friend's visit…

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 50 sampled residents, facility staff failed to ensure that Resident #147 had a physician's order to receive continuous supplemental oxygen. The findings included: Resident #147 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis, Chronic Respiratory Failure, and Moderate Persistent Asthma. During a tour on 07/26/22 at approximately 11:00 AM, the surveyor observed Resident #147 lying on her back while in bed. The resident was receiving supplemental, humidified oxygen via nasal cannula at 2 liters per minute. Review of Resident #147's medical record revealed: 06/29/22 at 10:48 AM [Hospital Discharge Summary] read: .Assessment/Plan .COPD: On 2 L (liters) at baseline, Continue home inhalers, Albuterol (asthma medication) .Attending Attestation: .COPD exacerbation will monitor WOB (work of breathing) carefully. Rest of the plan as above. 07 /01/22 at 12:06 AM [admission…

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 50 sampled residents, facility staff failed to develop a baseline care plan (within 48 hours of admission) to address resident #146's sacral wounds. Resident #146. The findings included: Review of the policy, Interdisciplinary Team Meeting (care Plan Meeting) revised in March 2022 showed, . A baseline care plan must be developed within 48 hours and include the minimum information necessary to properly care for a patient . Resident #146 was admitted to the facility on [DATE] with multiple diagnoses that included: Fluid Overload, Chronic Kidney Disease and Dysphagia. Review of Resident #146's medical record revealed the following: 05/26/22 [Quarterly Minimum Data Set (MDS)]: facility staff coded: moderate impaired cognition; one (1) unstageable pressure ulcer and two (2) venous and arterial ulcers. 06/13/22 at 8:33 PM [admission Note] .admitted from [Hospital Name] . Resident has the following skin issue: Mid Sacral wound: 7 X 5 X < 0.2, Left Sacral Area:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team. Resident #312. The findings included: Review of the policy Mobility and Falls/Fall with Injury Prevention, revised in May 2022, documented, .Update care plan to reflect new interventions . Resident #312 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia without Behavioral Disturbances and Hypertension. Review of the Facility Reported Incident (FRI), DC00010421, received by the State Agency on 12/02/21, documented, . Residents has H/O (history of) attempts to leave the floor. She missed her step and fell forward as she tried to rush into an opened elevator before it closes . Upon assessment mild bleeding noted from mouth .Resident to be transferred to the hospital for evaluation . Review of Resident #312's medical record revealed the following: 07/23/21 [Physician's Order]…

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 50 sampled residents, facility staff failed to ensure that Resident #86, who is unable to carry out activities of daily living, received the necessary care and services to maintain good personal hygiene. The findings included: Review of the policy, Activity of Daily Living (ADL) revised in May 2022 documented, .It is the policy of [Facility Name] to ensure that we provide best care possible .activities of daily are provided by our CNAs (Certified Nurse Aides), LPNs (Licensed Practical Nurses), RNs (Registered Nurses) . activities of daily living includes: bathing, showers .grooming . Resident #86 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Hypertension and Hyperlipidemia. On 07/26/22 (Tuesday) at 11:01 AM and 07/28/22 (Thursday) at 3:07 PM, Resident #86's fingernails were observed to be long and soiled. Review of Resident #86's medical record showed the following: 02/01/22 [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 observation, record review, and resident and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide Resident #84 with individual activities designed to meet the interests of and support the resident's choice. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included: History of Falling, Epilepsy, and Hypertension. During an observation and interview on 08/01/22 at approximately 10:00 AM, Resident #84 was observed with a newspaper dated July 01, 2022. At the time of the observation, Resident #84 stated, I would like to have a fresh newspaper to read. That's all I want. Review of Resident #84's medical record revealed the following: 06/10/22 at 8:40 AM [Activities Note] .[Resident #84] enjoys being in the comforts of his own room watching TV (television). He is receiving 1:1 such as reality orientation, conversing with staff, and activity calendar orientation. Activities staff will invite, remind [resident] of activity…

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 50 sampled residents, facility staff failed to adequately assess and monitor one resident who eloped from the facility; and failed to ensure one resident's room was free from clutter and hazards. Residents' #90 and #71. The findings included: 1. Facility staff failed to provide adequate monitoring and supervision to Resident #90 who had a history of elopement behaviors before his admission to the facility. Subsequently, the resident eloped from the facility on 07/09/22. Resident #90 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Unspecified, Dysphagia, Generalized Muscle Weakness, Schizoaffective Disorder, Cognitive Communication Deficit, and Unspecified Lack of Coordination. A Facility Reported Incident (FRI), DC00010849, received by the State Agency on 07/09/22, documented, .At around 12.45, assigned CNA (Certified Nurse Aide) went to serve resident his lunch, but he was nowhere to be found. Room 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, for one (1) of 26 sampled residents, facility staff failed to ensure Resident #1's flow rate of oxygen was set as directed by the physician. The findings included: During an observation made on 11/09/2022 at 10:03 AM, Resident #1 was observed receiving oxygen via nasal cannula, at a flow rate of 3 Liters. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Hypoxemia and Chronic Systolic Heart (Congestive) Failure. Review of the physician's order dated 06/24/22 directed, Oxygen continuous 2L/min (2 liters per minute) for SOB (short of breath) via nasal cannula every shift. During a face-to-face interview conducted at the time of the observation, Employee #9 (Registered Nurse) observed the oxygen flowmeter and stated that it should be at three (3 liters of oxygen).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 50 sampled residents, facility staff failed to ensure that one (1) resident received pain medication treatment and care related to pain management in accordance with professional standards of practice. Resident #98. The findings included: Resident #98 was admitted to the facility on [DATE] with the following diagnoses that included: Anemia, Gastroesophageal Reflux Disease, Pressure Ulcer at Right Buttocks Stage 3, and Pressure Ulcer of Sacral Region, and Multiple Sclerosis. A review of medical record showed the following physician's orders: 06/02/21 Evaluate and Document the presence of pain each shift every shift. 06/02/21 Acetaminophen (pain reliever) tablet 500MG (milligram) Give 2 tablets by mouth every 4 hours as needed for pain. 06/02/21 Tylenol Extra Strength (pain reliever) Tablet 500MG Give 2 tablets by mouth every day shift for pain Give 30 minutes prior to wound dressing change daily. 06/17/21 Oxycodone (opioid pain reliever) HCL…

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 50 sampled residents, facility staff failed to ensure that a resident who required dialysis, received appropriate care consistent with professional standards of practice for removing the dialysis access site dressing after hemodialysis. Resident #75. The findings included: According to Kidney Health Care, Fistula Care . Check patency of fistula daily by feeling the thrill over the anastomosis and along the fistula and by listening for bruit with a stethoscope. Notify a hemodialysis nurse or nephrologist if fistula is not functioning. Remove fistula dressing 4 - 6 hours post dialysis. If the patient 's hemodialysis puncture sites bleed, apply pressure for 10 minutes and reapply gauze dressing when bleeding stops. No constrictive clothing, armbands, or watches should be worn on the fistula arm. www.kidneyhealth.ca/wp/wp-content/uploads/80.20.05.pdf Resident #75 was admitted to the facility on [DATE] with the following diagnoses that included: Chronic…

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 50 sampled residents, the facility's nursing staff failed to provide nursing and related services to meet the residents' needs and promote the resident's well-being. Subsequently, a resident eloped from the facility. Resident #90. The findings included: Resident #90 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Generalized Muscle Weakness, Schizoaffective Disorder, Cognitive Communication Deficit, and Unspecified Lack of Coordination. A Facility Reported Incident (FRI), DC00010849, received by the State Agency on 07/09/22, documented: .At around 12.45 [12:45 PM], assigned CNA (Certified Nurse Aide) went to serve resident his lunch, but he was nowhere to be found. Room to room and all ares (areas) of the unit were searched, .code pink called and ares (areas) of the facility and outside were searched resident could not be found, . A review of Resident #90's medical record revealed: An admission Minimum Data Set (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to develop and implement an individualized person centered care plan for Resident #84 who has a diagnoses of Non-Alzheimer's Dementia. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included: History of Falling, Epilepsy and Hypertension. Review of Resident #84's medical record revealed a Quarterly Minimum Data Set (MDS) dated [DATE] that showed facility staff coded the following: intact cognitive response and an active diagnosis of Non-Alzheimer's Dementia. Further review of the medical record showed no documented evidence that facility staff developed and implemented a person-centered care plan to support the Dementia care needs of Resident #84. During a face-to-face interview conducted on 08/01/22 at 10:08 AM, Employee #9 (4th Floor Unit Manager) stated, I will look into it.

Based on record review and staff interviews for two (2) of five (5) nursing units, the facility staff failed to ensure that the system used for an acceptable standards of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed. The findings included: Review of the facility policy entitled, Shift Verification of Accuracy of Controlled Drug Record . documented, .Shift count sheet for Narcotics balance must be verified by the nurse coming on duty and nurse going off duty at each change of shift. 1. During a review of the Shift Count Narcotic record of the 4th floor completed on 07/28/22, at approximately 9:00 AM, the following was observed: 07/1/22 to 07/04/22- 3:00 PM -11: 00 PM shift, same nurse signed coming on and going off 07/05/22, 07/07/22, 07/8/2022, 07/11/22, 07/12/22- 3:00 PM -11: 00 PM shift, nurse signed coming on/sign off was blank 07/13/22 7:00 AM - 3:00 PM shift, coming on was blank and 3:00 PM -11: 00 PM shift going off was blank 07/14/22 - 07/18/22: 3:00 PM -11: 00 PM shift, same nurse signed coming on 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 record review and staff interview, for one (1) of 50 sampled residents, pharmacist failed to write a report of the recommendations for Resident #100's monthly drug regimen review. The findings included: Resident #100 was admitted to the facility on [DATE] with multiple diagnoses that included: Psychotic Disorder, Dementia with Behavioral Disturbances, Major Depressive Disorder and Type 2 Diabetes Mellitus. Review of Resident #100's medical record revealed an Annual Minimum Data Set (MDS) dated [DATE] that showed facility staff coded the following: intact cognition, presence of verbal behaviors directed towards others that occurred 3-4 days; active diagnoses of Non-Alzheimer's Dementia; received antipsychotic medications and GDR (gradual dose reduction) clinically contraindicated on 06/09/22. Review of the monthly Pharmacy Drug Regimen Review from July 2021 to July 2022 revealed that on 12/18/21 and 04/07/22, the consultant pharmacist documented, . Recommendations given to the IDT (interdisciplinary…

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

Based on observation and staff interview for one (1) of 50 sampled residents, facility staff failed to properly store expired medications for one resident that was discharged from the facility. Resident #146 The findings included: During an observation on 07/28/22 at 12:50 PM of the second-floor nursing station, a large grey plastic bin was observed on the floor, under a desk surrounded by debris. The grey bin contained multiple blister packets of the following medications for Resident #146: Vitamin b-12 (Vitamin Supplement)1000mg/tab Gabapentin (Anticonvulsant) 100 mg capsule Vit C (Vitamin Supplement)500mg Tab Acetaminophen (Analgesics and Antipyretic) 500mg tab Albuterol (Bronchodilator) Lidocaine (Local Anesthetics) 5% patch Aspirin (Nonsteroidal anti-inflammatory Drugs) 81 mg Tab Review of the facility's administrative records showed that Resident #146 expired on 07/22/22 at 8:30 PM. The evidence showed that facility staff failed to ensure that the resident's medications were stored properly. An interview was conducted at the time of observation with Employee #11 (Second floor…

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 50 sampled residents, facility staff failed to assist a resident in obtaining routine dental care. The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side, Type 2 Diabetes Mellitus Without Complications, and Unspecified Lack of Coordination. During an initial tour observation and resident interview on 07/27/22 at 9:53 AM, Resident #87 reported that she wanted to see a dentist. When asked if she let the staff know that she needed a dental appointment, she stated that the facility staff was aware. The resident explained that she was supposed to receive a new set of dentures and that facility staff had provided the container for dentures about a year ago, but no dentures. The resident stated she was still waiting for some kind of follow-up appointment. During the interview, the surveyor observed a container…

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

Based on observation and resident and staff interviews, facility staff failed to ensure a resident's food was palatable. Resident #67. The findings included: During a face-to-face meeting with Resident Council members on 07/28/22 at 2:30 PM, the residents stated, The meals are cold, the food does not represent community preferences, we get cereal with no milk, pancakes without syrup, and tea bags with no hot water. During an observation on 08/05/22 at 10:00 AM, Resident #87 was observed sitting in front of her breakfast tray. The breakfast plate had pancakes that were untouched. Resident #87 stated, Who eats pancakes without the syrup. During a face-to-face interview on 08/05/22, at the time of the observation, Employee #22 (Certified Nurse Aide) stated that the facility did not have any syrup to provide to the residents.

Based on observations and staff interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on one (1) of six (6) observations. The findings include: 1. During a food test tray assessment on July 26, 2022, at approximately 1:30 PM, hot foods such as ham (125 degrees Fahrenheit), tested below the minimum required temperature of 135 degrees Fahrenheit (F). 2. Food preparation equipment such as one (1) of one (1) flat top grill, two (2) of two (2) convection ovens, two (2) of two (2) grease fryers, and one (1) of one (1) gas stove, were soiled with burnt food residue. Employee #12 and/or Employee #13 confirmed the findings at the time of observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 50 sampled residents facility staff failed to maintain medical records in accordance with accepted professional standards as evidenced by not accurately documenting the date of birth . Resident #71. The findings included: Resident #71 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Muscle Weakness, Cognitive communication Deficit, Heart Failure, and Unspecified Dementia Without Behavioral Disturbance. Review of the electronic health record revealed that Resident #71's date of birth was documented as 06/01/1902 and age 120. This was noted to be documented on the face sheet and on every section of the resident's record where there is a section to record date of birth . Review of a letter from Resident #71's legal guardian dated 07/23/20 stated the following .I am the Court appointed guardian for . [Resident #71] and am writing regarding a discrepancy pertaining to her date of birth . Upon information and belief…

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 two (2) of four (4) gas burners that failed to light up when tested, one (1) of two (2) broken grease fryer, one (1) of two (2) ford warmers with a missing temperature indicator, and damaged strip curtains at the loading dock entrance/exit door. The findings include: During a walkthrough of the facility's kitchen on July 26, 2022, at approximately 9:30 AM: 1. Two (2) of four (4) burners from the gas stove did not illuminate when tested. 2. One (1) of two (2) grease fryers was inoperative. 3. One (1) of two (2) food warmers (top one) was missing a temperature set knob. 4. Strip curtains mounted to the back door (loading dock) to limit the movement of pests and contaminants were torn throughout. Employee #12 and/or Employee #13 confirmed the findings at the time of observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide a safe and functional environment for Resident #71, as evidenced by there being no doorknob on the interior side of resident's room door. The findings included: Resident #71 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Muscle Weakness, Cognitive Communication Deficit, Heart Failure, and Unspecified Dementia Without Behavioral Disturbance. During an observation of Resident #71's room (206 A) on 07/26/22 at approximately 2:20 PM, the surveyor noted that there was no doorknob present on the interior of the door, that is the entrance and exit to the resident's room. Employee #11 (Second Floor Unit Manager) was present during the observation. Review of the resident's medical record: Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the facility staff coded the following: a Brief Interview for Mental Status (BIMS) 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.

Based on observations and staff interview, it was determined that facility staff failed to maintain resident areas in good condition as evidenced by one (1) of two (2) leaky shower valves, one (1) of two (2) shower valves with a broken shower head holder, two (2) of five (5) harpers that failed to flush when tested, and marred walls in five (5) of five (5) social rooms. Findings included . An environmental tour of the facility was conducted on December 3, and December 4, 2019. The following observations were made: 1. One (1) of two (2) shower valves located in the shower room on the fifth floor was leaking. 2. One (1) of two (2) shower valves located in the shower room on the fifth floor had a broken shower head holder. 3. Two (2) of five (5) harpers, one (1) located in soiled utility room on the fifth floor and another located in the soiled utility room on the second floor did not flush when tested. 4. Walls in five (5) of five (5) social rooms used for resident activities and dining were marred throughout. During a face-to-face interview on December 4, 2019, at approximately 12:00…

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 50 sampled residents facility staff failed to code Minimum Data Set (MDS) in accordance with the specified time frame as evidence by MDS record shown as over 120 days old. Resident #1. Findings included . Resident #1 was admitted to the facility on [DATE] with diagnoses which include: Anemia, Hypertension, Hyperthyroidism, Constipation, and Vitamin D Deficiency. Review of the Resident Assessment Report showed an MDS record over 120 days old for Resident #1. Employee #7 was asked what is the last MDS that was completed for the resident? Employee #7 replied, Here it is, the date is 7/5/19 [a quarterly MDS]. Review of the nurses' note dated 8/25/19 showed, the resident was transferred to the hospital and was admitted to the [Hospital Name] ICU (Intermediate Care Unit). The resident did not return to the facility. There was no evidence that facility staff completed a MDS tracking record within the specified coding time frame for Resident #1 who did not return…

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 interview for two (2) of 50 sampled residents facility staff failed to update/revise care plan with resident-centered goals for one (1) resident with hearing loss; and for one (1) resident with Cholecystitis. Findings included . 1.Resident #106 was admitted to the facility on [DATE], with diagnoses which include: Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease, Cognitive Communication Deficit and Major Depressive Disorder. During a face-to-face interview with Resident #106 on 12/3/19 at 2:00 PM, the resident stated, Can you come closer I can't hear you, I can't hear that well. Review of the admission Minimum Data Set [MDS] dated 10/29/19 showed resident with a Brief Interview for Mental Status (BIMS) summary score of 5 to indicate resident is severely cognitively impaired. Further review of the MDS showed Section B (Hearing, Speech, and Vision) B0200 Hearing showed item 2 is selected which indicates resident has moderate difficulty with hearing-speaker…

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 interview, the facility failed to provide an environment that is free from accident hazards as evidenced by surge protectors that were not mounted in two (2) of 43 resident's rooms. Findings included . During an environmental tour of the facility's fifth, fourth and third floor on December 3, 2019, at approximately 3:00 PM, a surge protector in resident room [ROOM NUMBER] was hanging loosely off a wall and a surge protector in resident room [ROOM NUMBER] was positioned on top of a resident's dresser. There was no evidence that surge protectors used in resident rooms were mounted securely to the wall. During a face-to-face interview on December 4, 2019, at approximately 12:00 PM, Employee #8 and/or Employee #9 acknowledged the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview for one (1) of 50 sampled residents, facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility and dialysis staff was included in the medical record for Resident #91. Findings included . Facility staff failed to ensure the Dialysis Communication form used to reflect ongoing collaboration between the facility staff and dialysis staff was included in Resident #91's medical record. Resident #91 was admitted to the facility on [DATE], with diagnoses, which included Anemia, Cardiomyopathy, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, Hypertension, End-Stage Renal Disease, and Diabetes Mellitus. Physician orders dated 7/14/19 directed, Dialysis 3x[times]/Week Tuesday, Thursday, and Saturday Review of Resident #91's medical records from October 31, 2019, to December 12, 2019, showed that the resident's dialysis record for communication between the dialysis center and the facility was not…

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 50 sampled residents facility staff failed to maintain a complete and accurate medical record for Resident #88. Findings included . Resident #88 was admitted to the facility on [DATE] with diagnoses which include: Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease, Neoplasm of Bladder and Essential Hypertension. Review of the Level I Pre admission Screen/Resident Review (PASARR) for Serious Mental Illness (SMI), Intellectual Disabilities (ID) or Related Conditions Form dated 9/15/16 showed the following: Section A: Exempting Criteria was signed by a medical doctor (with a date of 9/5/16); Section B: Evaluation Criteria for Serious Mental Illness (SMI) 1 was checked as No to indicate resident does not have a known diagnosis of a major mental disorder; Section C: Symptoms was left blank; Section D: Intellectual Disability (ID) Related Conditions (RC) 1 was checked as No to indicate the resident does not have a diagnosis of Intellectual…

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, the facility failed to maintain the call bell system in good working condition as evidenced by call bells in three (3) of 43 resident's rooms that failed to alarm when tested. Findings included . During an environmental tour of the facility's fifth, fourth and third floor on December 3, 2019, at approximately 3:00 PM, call bells in three (3) of 43 resident's rooms (#315B, #403A, #415C) did not alarm (audible as intended) when activated. These breakdowns could prevent or delay the resident, staff or the public from alerting staff in an emergency. During a face-to-face interview on December 4, 2019, at approximately 12:00 PM, Employee #8 and/or Employee #9 acknowledged the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to maintain handrails in good condition as evidenced by several hand rails and rails with no end caps in resident occupied areas and in common areas. Findings included . 1. End caps (2) to hand rails located next to resident room [ROOM NUMBER] were missing. 2. End caps (11) to rails located in common areas in the lobby were missing. During a face-to-face interview on December 4, 2019, at approximately 12:00 PM, Employee #8 and/or Employee #9 acknowledged the findings.