Knollwood Hsc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, for one (1) of 22 sampled residents, facility staff failed to ensure that Resident #21 was treated with respect and dignity as evidenced by failure to provide a privacy cover for the resident's urine collection bag, which was visible from a commonly accessed hallway in the facility. The findings included: Resident #21 was admitted to the facility on [DATE] with multiple diagnoses' which included: Urinary Tract Infection, Chronic Kidney Disease Stage 3 Moderate and Unspecified Dementia. Review of the resident's physician orders revealed the following: -01/13/20 Catheter Care: routine catheter care every shift . -01/13/20 Flush Foley catheter with 30 ml (milliliters) of normal saline solution every shift . -07/01/21 Catheter Foley keep free of kinks and below bladder . -02/13/23 Catheter Foley 18 FR (French) 5 CC (cubic centimeters) balloon, change as needed . A review of Resident #21's medical record revealed an Annual Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 22 sampled residents, facility staff failed to implement its policies and procedures for conducting investigations. (Residents' #17 and #196.) The findings included: Review of the policy Abuse Neglect and Exploitation with a revision date of 09/20/22, documented, It is [Facility Name]'s policy that reports of abuse ( .including injuries of unknown origin) are promptly and thoroughly investigated .The investigation will include .involved staff and witness statements of events . Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 22 sampled residents, facility staff failed to conduct a thorough investigation of a resident's allegation of abuse by staff and report the findings to the administrator, and to the State Survey Agency within 2 hours of the allegation. Resident #17. The findings included: Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be submitted within five working days of the initial report .The Administrator or Designee will be notified immediately. The Department of Health shall be notified as soon as possible but not to exceed 2 hours after…

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 22 sampled residents, facility staff failed to conduct a thorough investigations for one resident's allegation of abuse and one resident's unwitnessed fall. Residents' #17 and #196. The findings included: Review of the facility's policy titled Abuse Prohibition with a review date of 01/06/23, instructs staff to do the following: .Investigation of abuse when an incident or suspected incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include Who was involved, resident's statements .Involved staff and witness statements of events .The follow-up investigative notes will be submitted within five working days of the initial report .The Administrator or Designee will be notified immediately. The Department of Health shall be notified as soon as possible but not to exceed 2 hours after forming a suspicion of abuse. 1. Facility staff failed to show…

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 22 sampled residents, facility staff failed to accurately code the resident's Minimum Data Set (MDS) assessment. Resident #17. The findings included: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side and Acquired Absence of Left Leg Above Knee. Review of the medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded that the resident required supervision with one-person physical assistance to walk in the room. During an observation on 04/19/23 at approximately 12:30 PM in the dining area, Resident #17 was seen sitting in a wheelchair and had a left above-the-knee amputation. During a face-to-face interview conducted on 04/24/23 at 3:17 PM, Employee #9 (Registered Nurse/Charge Nurse) stated that the resident has an above-the-knee amputation of 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 one (1) of 22 sampled residents, facility staff failed to implement Resident #196's fall care plan approaches/interventions and subsequently the resident had a fall with injury on 11/18/21. The findings included: Resident #196 was admitted to the facility on [DATE] with multiple diagnoses that included: Parkinson's Disease, Other Abnormalities of Gait and Mobility, Dizziness and Giddiness, Pneumonia, Disorientation and Dementia. Review of Resident #196's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded: severely impaired cognition; required extensive assistance for bed mobility transfers, eating, toilet use, and personal hygiene. [Physician's Order] 11/09/21: Falls precautions every shift. Call lights and personal needs within reach, frequent rounds, bed in low position while in bed, every shift . [Physician's Order] 11/09/21: Floor mats to both sides of bed while in bed. Dx…

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 one (1) of 22 sampled residents, facility staff failed to ensure that respiratory treatment was provided to Resident #4 in accordance with the physician's order. The findings included: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Congestive Heart Failure, and Morbid Obesity. Care plan dated 09/05/22 documented: Respiratory . requires use of oxygen therapy continuously due to chronic respiratory failure. Approach . staff will check vital signs, administer oxygen and breathing treatment as ordered and report to physician. [Physician's Order] 12/01/22: Oxygen at 5 L (liters)/min (minutes) via nasal cannula continuously every shift. Diagnosis: SOB (shortness of breath) every shift . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having intact cognition 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 reviews and staff interviews, for one (1) of 22 sampled residents, facility staff failed to ensure that Resident #16 received pain management that was consistent with the standards practice. The findings included: Resident #16 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction, Hemiplegia, affecting Left Dominant Side, Dysphagia, Dementia with Behavioral Disturbances, Anxiety, and Depression. Review of Resident #16's medical record revealed the following: an Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded: severely impaired cognition; visual and hearing impairment; on a scheduled pain medication regimen; and having a life expectancy of less than six months. A Care plan initiated 06/17/22 documented, [Resident #16] is risk for pain related to generalized arthritis, new stroke with left side hemiplegia, decreased functional mobility, and peripheral neuropathy. Goal: [Resident #16] c/o (complaint of) pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, for two (2) of 22 sampled residents, facility staff failed to maintain Standards of Infection Control Practices when assisting the residents with their meals in the common dining area. Residents' #17 and #21. The findings included: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side and Acquired Absence of Left Leg Above Knee. A review of Resident #17's Significant Change Minimum Data Set (MDS) dated [DATE], showed that the resident required supervision and set up help when eating. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Heart Failure and Dysphagia. A review of Resident #21's Quarterly Minimum Data Set (MDS) dated [DATE], showed that the resident required extensive assistance with a one person physical assist for eating. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 18 sampled residents, facility's staff failed to accurately code a resident's Quarterly Minimum Data Set (MDS) to include a Stage 3 pressure ulcer. Resident #5. The findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, Parkinson's Disease, Coronary Artery Disease, Atrial Fibrillation, Legal Blindness, and Spinal Stenosis. Review of a Quarterly MDS (Assessment Reference Date of 05/24/2021), documented the following: In Section M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at each Stage), the resident was coded for having one (1) Stage 4 pressure ulcer. Review of the Wound/Skin Record documented the following: 05/13/21 site - A (coccyx), stage - Stage III, size - 5 X 5 cm (centimeters), depth - 0, exudate - 0, odor - 0, wound bed - redness with scattered pinpoint areas within, surrounding skin color - WNL (within normal limits), surrounding tissue/wound edges - this area was left blank.…

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, facility staff failed to implement supervision as outlined in the Fall's Care Plan for one (1) of 18 sampled residents. Resident #5. The finding include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including, Parkinson's Disease, Coronary Artery Disease, Atrial Fibrillation, Legal Blindness and Spinal Stenosis. Review of a Quarterly Minimum Data Set (Assessment Reference Date of 06/05/2020), documented the following: In Section C0500 (Brief Interview for Mental Status), the resident had a summary score of 12, indicating the resident was cognitively intact. In Section E (Behavior), resident was not coded for psychosis, rejection of care or wandering. In Section G (Functional Status), the resident was coded for needing extensive assistance with the assistance of one person for ambulation in room and toileting use. In Section H (Bladder and Bowel) - the resident was coded for frequent incontinence of both bladder and bowel. In Section I…

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, for one (1) of 18 sampled residents, facility staff failed to ensure a resident receiving enteral feedings received appropriate care to prevent complications. Resident #10. The findings include: Resident #10 was admitted to the facility 03/11/2020, with diagnoses that included: Anemia, Hypertension, Dysphagia (Oropharyngeal Phase), and Gastrostomy Status. A physician's order dated 03/11/2020, revealed, Enteral Feeding: Change G [gastrostomy] Tube irrigation set QD [every day] Once a Day 09:00 AM. Review of Resident #10's care plan for the focus area, Feeding Tube created on 11/04/2020, revealed the approach, change feeding syringe label with date and time daily. During an observation inside of Resident #10's room on 05/25/2021, at approximately 11:15 AM, it was noted that there was an unlabeled syringe irrigation set at the resident's bedside. During a face-to-face interview conducted on 05/25/2021, at approximately 11:15 AM with Employee #4 (Licensed Practical Nurse), when asked if she used the irrigation set observed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to provide the specialized care needs for a resident receiving nebulizer treatments in accordance with the professional standards of practice. Resident #19. The findings include: Resident #19 was admitted to the facility on [DATE], with diagnoses that included: Asthma, Hyperlipidemia, Muscle Weakness, and Hypertension. A physician's order dated 03/09/2021, revealed, Start Date Change neb [nebulizer] mask every week on Wednesdays (3-11 PM shift) . Review of the Treatment Administration Record for May 2021 revealed that facility staff signed off in the area that documented, Change neb [nebulizer] mask every week on Wednesdays (3-11 PM shift) indicating that it was done on the date 05/26/2021. During an observation of Resident #19's room on 06/02/2021, at approximately 10:30 AM, revealed a nebulizer treatment set at the resident's bedside with a pink label that was dated, 5/19/21. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 18 sampled residents, the facility staff failed to ensure that the pharmacist progress notes mentioned whether there were irregularities and recommendations for the Monthly Medication Regimen Review (MRR). Resident's #28 and #31. The findings include: 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including Dementia, Depression, Anemia, Hyperlipidemia, Hypertension, Diabetes Mellitus, Gastro Esophageal Reflux Disease, and Osteoporosis. A review of the Medication Regimen Review progress notes dated 02/08/2021, to 05/10/2021, noted by the Pharmacist stated Medication Regimen Review completed however, there was no mention on whether there were any irregularities found and recommendation given. During a face-to-face interview on 05/12/21, at approximately 10:30 AM, Employee #12 reviewed the previously mentioned documents and acknowledged the finding. 2. Resident #31 was admitted to the facility on [DATE] with multiple…

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

Based on record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to ensure that a resident's monthly Medication Regimen Review (MRR) was conducted on a monthly basis. Resident #31. The findings include: Resident #31 was admitted to the facility on 10/15/ 2019, with multiple diagnoses that included: Dementia, Depression, Parkinson, Disease, Hypertension, Diabetes Mellitus, Gastro Esophageal Reflux Disease, Heart Failure, Acute Bronchitis, Ulcerative Blepharitis right eyes and History of Repeated falls. A review of Resident #31's medical record lacked documented evidence the pharmacist conducted a MRR for July 2020. During a face-to-face interview conducted on 06/02/2021, at approximately 11:00 AM, Employee #12 (Registered Nurse) acknowledged the finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, in one (1) of one (1) observation, facility staff failed to maintain infection control prevention practices in accordance with standards of practice to minimize the potential spread of infections. The findings include: Review of the facility's document entitled, Respiratory protection program dated 03/30/2021, revealed, .HCP [health care professional] will have an N95 and a face shield when in resident's area or within 6 feet of a resident . During an observation on 05/25/2021, at approximately 2:00 PM, Employee #6 (Private Duty Aide) was observed in resident room [ROOM NUMBER] A, sitting in a chair beside the resident (less than six feet away), wearing a N95 face mask but not wearing a face shield. It should be noted that the resident was not wearing a face mask or a face shield. During a face-to-face interview conducted on 05/25/2021, at approximately 2:00 PM, Employee #6 stated, I put it [face shield] back on when I am doing care. During a face-to-face…

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

Based on observations and interview, the facility failed to store, serve and distribute foods under sanitary conditions as evidenced by staff who were observed serving breakfast foods to residents before food temperatures were completed, soiled equipment such as four (4) of four (4) convection ovens, one (1) of one (1) deep fryer, one (1) of one (1) grill and the interior of one (1) of one (1) oven, 20 of 20 six-inch, one-third steam pans that were stored wet, four (4) of 20 six-inch one-third pans that were dented throughout. Findings included . The following observations were made during a walkthrough of the kitchen on the Special Care Center (SCC) on June 23, 2019, at approximately 8:15 AM. 1. Breakfast food temperatures from the Special Care Center (SCC) kitchen were not completed before foods were served to residents on June 23, 2019, at approximately 8:10 AM. Employee #4 was asked why food temperatures were not taken before residents were served and she explained that someone had removed the thermometer from the kitchen and she did not have one. Employee #4 was asked if she…

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 four (4) of 32 sampled residents, facility staff failed to develop baseline care plans with goals and approaches to properly care for four (4) newly admitted residents. Residents' # 38,53, 62 and 160. Findings included . 1. Facility staff failed to ensure that Resident # 38 had a baseline care plan completed within 48 hours of admission. Resident #38 was admitted to the facility on [DATE], with diagnoses, which included Chronic Pain, Gastro-Esophageal Reflux Disease, Vascular Dementia with Behavioral Disturbance, Hypertension, and Spinal Stenosis. Review of the facility's 48-hour baseline care plan showed the care plan was signed by the resident and the facility on May 14, 2019 (seven days after admission). There was no evidence that facility staff ensured that Resident # 38 had a Baseline Care Plan completed within 48 hours of admission. The findings were acknowledged during a face-to-face interview with Employee #2 on June 27, 2019 at approximately 2:45 PM. 2.…

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

Based on observations and interview, the facility failed to provide an environment free from accident hazards as evidenced by frayed remote bed controller cords in 12 of 20 resident's rooms. Findings included . During an environmental tour of the facility on June 25, 2019, at approximately 11:00 AM, remote bed controllers' cords in 12 of 20 resident's rooms were frayed. The uncovered, exposed electrical wires created a potential electrical shock hazard to residents, staff and the public. During a face-to-face interview on June 25, 2019, at approximately 12:30 PM, Employee #6 acknowledged the findings.

Based on observations and interview, facility staff failed to maintain electrical equipment in good condition as evidenced by frayed remote bed controller cords in 12 of 20 resident's rooms. Findings included . During an environmental tour of the facility on June 25, 2019, at approximately 11:00 AM, remote bed controllers' cords in 12 of 20 resident's rooms were frayed. During a face-to-face interview on June 25, 2019, at approximately 12:30 PM, Employee #6 acknowledged the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 32 sampled residents, the facility staff failed to ensure that Resident #38's advance directive was placed on her active clinical record. Findings included . Resident #38 was admitted to the facility on [DATE], with diagnoses, which included Chronic Pain, Gastro-Esophageal Reflux Disease, Vascular Dementia with Behavioral Disturbance, Hypertension, and Spinal Stenosis. The Advance Directive/Living Will and Durable Power of Attorney Policy and Procedures signed March 27, 2018, stipulated, Upon admission, the Social Services Department at Knollwood will inquire and document whether a resident has executed an Advance Directive, Living Will or Durable Power of Attorney . Review of the End of-Life Program Planning form dated May 18, 2019, (which serves the staff, residents, responsible parties, and family members in preparation for the time of a resident's passing), stipulated that the resident had Advance Directives, however, the Code Wishes/Preferences 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 three (3) of 32 sampled residents, the facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) resident death, for one (1) resident receiving hospice care and for one (1) resident diagnosis of Macular Degeneration. Residents' #1, #9 and #29 Findings included . 1. Facility staff failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) assessment at the time of the Resident #1's death. Review of the resident's clinical record on [DATE], showed significant change MDS dated [DATE] when the resident entered the Hospice Program. Further review of the record failed to show evidence that an MDS was completed when the resident expired on February 21, 2019. A face-to-face interview was conducted with Employee #9 at approximately 3:30 PM on [DATE]. During the interview, the employee acknowledged that an MDS was not completed at the time of the resident's death. 2. Facility staff failed to accurately code the Minimum Data Set (MDS) 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 record review and staff interview for two (2) of 32 sampled residents facility's staff failed to ensure the resident received treatment and care in accordance with professional standards of practice as evidenced by failing to provide evidence of collaboration with the hospice team for one (1) resident and to develop one (1) residents care plan and to accurately assess a residents neurological status after a fall. Residents' #9 and #32. Findings included . 1.Facility staff failed to devlop a care plan in collaboration with the hospice team. Record review of the facility's undated policy titled Hospice Procedures showed resident's care plan of care is in collaboration with hospice to attain and maintain the resident's highest practical physical, mental and psychological well-being. Resident #9 was admitted to the facility on [DATE] with diagnoses which include: Unspecified Atrial Fibrillation, Retinal Edema, Primary Open-Angle Glaucoma Right Eye and Essential Hypertension. On 6/27/19 at 10:00 AM a review…

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

Based on record review and staff interviews for one (1) of (2) nursing units, the facility staff failed to ensure the system used for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed by staff. The census was 59 on the first day of the survey. Findings included . Review of the Controlled Drug Shift Change Audit Sheet instructions showed controlled drugs (scheduled II to schedule V) must be counted by two nurses at the change of shift, the nurse going off duty and the nurse coming on. Review of the Controlled Drug Shift Change Audit Sheet showed the spaces allotted for nurse signature going off duty to reconcile the narcotic count for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift for 6/20/19 were left blank indicating the reconciliation of controlled medication was Not Done. The evidence showed that the system use for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was not followed by staff. A face-to-face…

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.