Serenity Rehabilitation And Health Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Facility staff failed to accurately code Resident #11's Quarterly Minimum Data Set (MDS) assessment to reflect that she was receiving opioid medications. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Type 2 Diabetes Mellitus (DM), Bipolar Disorder, and Edema. Review of the resident's medical record revealed the following: A care plan focus area last reviewed on 11/20/24: [Resident #11] is on pain medication therapy Oxycodone (type of narcotic pain reliever) r/t (related to) osteoarthritis and polyneuropathy. A physician's order dated 01/12/25 that directed, Oxycodone HCl (Hydrochloride)Tablet 5 MG (milligrams), give 1 tablet by mouth two times a day for severe pain (#7-10). A physician's order dated 01/14/25 that directed, Tramadol (type of narcotic pain reliever) HCl Tablet 50 MG, give 1 tablet by mouth every 8 hours as needed for moderate pain (#4-6). A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 15,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to refer a resident to the appropriate state-designated authority, known as PASRR Level II, for evaluation and determination to ensure a resident received specialized services to meet the resident's needs. Resident #34. The findings included: A Level I Preadmission Screen/Resident Review (PASRR) dated 09/06/24 documented, Beneficiary is likely to require less than 30 days nursing facility services? No and Does the beneficiary have a known diagnosis of a major mental disorder? Yes and If yes, list diagnosis: Schizophrenia and Does the beneficiary have a diagnosis or evidence of a major mental illness limited to the following disorders: schizophrenia: Yes and Specify diagnosis based on DSM (Diagnostic and Statistical Manual of Mental Disorders)-5: Schizophrenia and Notice of referral for Level II, if applicable, distributed to Beneficiary/Representative? Yes. It should also be noted that, on the Level I PASRR,…

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, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to implement Resident #5's care plan intervention to have the resident have access to functioning hearing aids. The findings included: A care plan with a last reviewed date of 06/07/23: (Resident #5) has a communication problem r/t (related to) bilateral hearing impairment AEB (as evidenced by) use of bilateral hearing aid had interventions that included: (Resident #5) requires hearing aid to communicate. Ensure availability and functioning of adaptive communication equipment. Ensure hearing aid(s) on bilateral ear is in place. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Hearing Loss Bilateral, Vascular Dementia, and Paroxysmal Atrial Fibrillation. A physician's order dated 07/16/24 directed, Audiology eval (evaluation) and treat as needed. A Complaint DC~13174 submitted to the State Agency on 10/02/24 documented in part, The resident has…

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 56 sampled residents, the facility staff failed to revise interventions on a resident's comprehensive care plan to address the resident's behavior of wearing gloves and two masks throughout the facility. Resident #332. The findings included: Resident #332 was admitted to the facility on [DATE] with diagnoses that included Depressive Disorder, Anxiety Disorder, Dementia, Peripheral Vascular Disease, and Substance Abuse History A review of Resident #332's medical record included: A care plan initiated on 10/23/23 documented: Focus/Problem: [Resident #337] has non-compliance behavioral concerns by putting on gloves and putting on double (two) masks despite staff redirection provided. Goal: [Resident #337] will have fewer episodes of non-compliant behavior with putting on gloves and double mask through the next review date x 90 days with Target Date: 02/11/2025; Interventions (Initiated on: 10/23/23): Approach [Resident #337] with a soft and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to provide Resident #5 with the necessary care and service to ensure that their ability to perform activities of daily living do not diminish as evidenced by the facility staff failing to ensure the residents malfunctioning hearing aides were replaced. The findings included: A review of a Social Work Progress Note dated 01/24/23 at 4:33 PM: The daughter stated that one of resident's hearing aids is broken and she will follow up with the doctor at (facility name) to schedule an appointment for the repair and will notify the facility. A care plan last reviewed on 06/07/23: (Resident #5) has a communication problem r/t (related to) bilateral hearing impairment AEB (as evidenced by) use of bilateral hearing aid. Interventions: Anticipate and meet needs, (Resident #5) requires hearing aid to communicate. Ensure availability and functioning of adaptive communication equipment. Ensure hearing…

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 56 sampled residents, facility staff failed to ensure that Resident #67, who had limited range of motion, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The findings included: Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia, Hemiparesis, and Muscle Weakness. Review of the resident's medical record revealed the following: A care plan focus area last reviewed on 11/13/24: [Resident #67] is on Restorative nursing program for active assistive range of motion of bilateral lower extremities and strength of bilateral lower extremities of all joints in supine/sitting in wheeled chair 3 x 10 reps for 6 days/week for 15 minutes. Goal: The resident will improve current exercise through next review date. Interventions: Restorative Aide staff will assist with daily exercises as per order. Resident on range of motion and 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 review and staff interviews for one of fifty-six (56) sampled residents, the facility staff failed to monitor and supervise a resident with a history of elopement and failed to ensure that all doors were secure in the facility after a fire drill. Subsequently, on 08/14/24, the Resident eloped. Resident #59. The findings included: A review of the facility's Elopement policy documented: Residents that are at risk for elopement must be checked every hour for their location. If they are not found, the supervisor must be notified immediately. Resident #59 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Bipolar Disorder, Behavioral Disturbance, Personal History of Other Mental and Behavioral Disorders, Hypothyroidism, Hypertension, and Congestive Heart Failure. The Department of Health received the following incident on 08/15/24 at 3:55 AM that documented: [Name and date of birth of Resident #59] is reported missing from Serenity Rehab and Health Center. Resident's BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 56 sampled residents, facility staff failed to ensure that Resident #142, who has an indwelling Foley Catheter, received the appropriate care to prevent urinary tract infections. The findings included: Resident #142 was admitted to the facility on [DATE] with multiple diagnoses that included: Benign Prostatic Hyperplasia with Lower Urinary Trach Symptoms. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: severely impaired cognitive skills for decision-making and had an indwelling urinary catheter. A care plan focus area last reviewed on 11/27/24: [Resident #142] has Foley 16 French/ balloon size 10 milliliters (ML) for Neurogenic Bladder, had interventions that included: check for wetness before and after meals, every hour of sleep (qhs) & on rounds during the night; note any changes in amount, frequency, color or odor; and report any abnormalities to Registered Staff. During an observation…

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 56 sampled residents, facility staff failed to demonstrate the competencies and skills to provide appropriate nursing services to ensure resident safety and well-being. Resident #89. The findings included: Review of the facility's Administering Medications policy, dated January 2025, documented: - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - Insulin pens containing multiple doses of insulin are for single-resident use only. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for two (2) of 56 sampled residents, facility staff failed to show documented evidence in the resident's medical records that the pharmacist's monthly medication regimen reviews and recommendations were reviewed and acted upon by the physician. Resident's #40 and #30. The findings included: A review of the facility's policy titled Medication Regimen Review with a revision date of 01/2024 documents . Actual and potential clinically significant medication issues identified will be communicated to the physician for clarification. Documentation will be maintained in the resident ' s medical record. 1. The facility staff failed to show documented evidence in Resident #40's medical record that the pharmacist recommendations were reviewed by the physician for three (3) out of 12 months in the year 2024. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Heart Failure and Dementia. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to administer medications or biologicals in accordance with the physician's order and the manufacturer's specifications. Resident #89. The findings included: Review of the facility's Administering Medications policy, dated January 2025, documented: - Medications are administered in accordance with?prescriber orders, including any required time frame. - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - Insulin pens containing multiple doses of insulin are for single-resident use only. Insulin pens?are clearly labeled with the resident's name or other identifying information. Prior 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 observations, record reviews, staff and resident interviews for one (1) of 56 sampled residents, facility staff failed to provide Resident #77 with a diet that met the residents' daily nutritional and special dietary needs while taking into consideration the residents' preferences for fresh fruits and vegetables. Resident #77 The findings included: Resident #77 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2 with Unspecified Diabetic Retinopathy without Macular Edema, Sickle Cell Trait, Anemia and Constipation. It is noted that on 01/31/25 at 1:38 PM, the survey team received a forwarded email from the ombudsman requesting that a surveyor reach out to Resident #77 concerning food at the nursing facility. A review of Resident #77's medical record revealed the following: A review of a physician's order dated 08/07/20 documented Regular diet regular texture, thin liquids consistency, (Double portion) per preference Review of a care plan…

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

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by one (1) of one (1) ice machine that was soiled on the inside, eight (8) of eight (8) four-inch pans and ten (10) of ten (10) six-inch pans that were stacked wet, torn air curtains in one (1) of one (1) walk-in freezer, one (1) of one (1) flour bin and one (1) of one (1) sugar bin without scoops, and one (1) of one (1) milk box that lacked a thermometer. The findings include: 1. One (1) of one (1) ice machine was soiled on the inside. The ice machine was emptied and cleaned on the day of observation. 2. Eight (8) of eight (8) four-inch pans and ten (10) of ten (10) six-inch pans were stored wet, one on top of the other, on a clean and ready-for-use shelf. 3. Air curtains located at the entrance of one (1) of one (1) walk-in freezer were torn throughout. 4. One (1) of one (1) flour bin and one (1) of one (1) rice bin were not equipped with a scoop. 5. One (1) of one (1) refrigerator box, used for milk storage, did not have a thermometer. Employee #13…

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 eight (8) of 57 sampled residents, facility staff failed to report allegations abuse to the State Agency immediately (within 2 hours of the incident); and failed to send the results/follow-up of all investigations to the State Survey Agency within five (5) working days of the incident. Residents' #103, #46, #366, #91, #54, #99, #22 and #63. The findings included: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating documented: - All reports of resident abuse 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 -If resident abuse is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law - Immediately is defined as within 2 hours of an allegation involving abuse. 1. Facility staff failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for four (4) out of 57 sampled residents, facility staff failed to have documented evidence that they conducted thorough investigations of allegations of abuse by failing to have interviews or statements of all staff represent at the time of the alleged incidents. Residents' #103, #46, #366, and #91. The findings included: The facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating documented: -All reports of resident abuse are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. 1A. Resident #103 was admitted to the facility on [DATE] with diagnoses that included: Aphasia, Major Depressive Disorder and Muscle Weakness. Review of Resident #103's medical record revealed the following: A census tracking that documented Resident #103 resided in room [ROOM NUMBER], bed A. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, resident and staff interviews, for one (1) of 57 sampled residents, the facility staff failed to treat Resident #102 with respect and dignity and care for the resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, as evidenced by staff not closing the privacy curtain before opening the resident's door that opens to a public hallway. Resident #102. The findings included: Resident #102 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Paraplegia, Complete, Pressure Ulcer of Sacral Region Stage 4, and Major Depressive Disorder Recurrent. A review of Resident #102's medical record revealed the following: [Quarterly Minimum Data Set Assessment] 09/28/23 revealed that the facility staff coded the resident as having a Brief Interview for Mental Status (BIMS) Score of 15 indicating intact cognition. Facility staff coded that the resident has an indwelling catheter. [Physicians 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.

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, comfortable environment as evidenced by a window blind in one (1) of 34 resident's rooms with a broken chain. The findings include: During a walkthrough of the facility on October 10, 2023, at approximately 1:15 PM, the window blind in one (1) of 34 residents' room (#128) would not open due to a broken pull chain. Employee #14 acknowledged the finding on October 11, 2023, at approximately 11:00 AM, and replaced the broken chain.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 57 sampled residents, facility staff failed to accurately code the residents Quarterly Minimum Data Set (MDS) assessment to accurately reflect the resident's fall that occurred on 08/17/23. Resident #415. The findings included: Resident #415 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Dementia in other Diseases Unspecified Severity With Behavioral Disturbance, and Insomnia. A Facility Reported Incident (FRI) DC00012210, was received by the State Agency on 08/17/23, and documented the following: .Writer notified by CNA (Certified Nurse Aide) that the resident was on the floor in his room. Writer immediately went to the resident room and observed the resident on the floor in a supine position beside his bed. Assigned CNA stated that the resident slid off his bed and got out of her grip while she tried to assist the resident with morning care . Review of Resident #415's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview for (3) of 57 sampled residents, facility staff failed to do the following: follow an intervention included in a residents fall care plan, perform a weekly skin assessment as ordered by the physician for Resident #418, and use a 2 person physical assist when transferring Resident #102 from a wheelchair to the bed using a Hoyer lift. Resident #57, #418, and #102. The findings included: Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including Generalized Muscle Weakness. A review of the policy titled, Fall and Fall Management with a review date of 05/23 instructed, When a fall occurs, referral to rehabilitation or other disciplines depending on the reason for the fall. The staff, with the input of the interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the attending physician 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, resident interview and staff interviews for one of (1) of 57 sampled residents, facility staff failed to assist a resident in gaining access to vision services by failing to ensure that the resident was able to have an appointment with an ophthalmologist for evaluation for cataract surgery as recommended by the physician on 07/24/2023. Resident #145. The findings included: Resident #145 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hypertension, History of Falling and Heart Failure. A review of Resident #145's medical record revealed the following: [Physician Order] 03/17/23 Ophthalmology consult as needed . [admission Minimum Data Assessment (MDS)] 03/23/23 revealed that the facility staff coded the resident as having adequate vision and not requiring corrective lenses. The facility staff coded the resident as having severe cognitive impairment. [Quarterly Minimum Data Set assessment] 09/22/23 revealed that the facility staff coded the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, record review, staff interview and resident interview, for two (2) of 57 sampled residents, the facility's nursing staff failed to ensure a Customer Service Representative did not administer Vitamin C (supplement) to one resident; and failed to demonstrate competent nursing skills as evidenced by failing to ensure that one resident's medication orders were clarified to indicate specific administration times. Residents' #18 and #159. The findings included: 1. Facility nursing staff failed to ensure that a Customer Service Representative did not administer Vitamin C (supplement) to Resident #18. Resident #18 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Hemiplegia, Muscle Weakness, and Contracture of Right Hand. A review of the policy titled, Administering Medications with a review date of 01/23 that instructed, Only persons licensed or permitted by this state to prepare, administer of medications may do so. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of 57 sampled residents, facility staff failed to maintain accurate and complete medical records. Residents' #23 and 418. The findings included: Review of the facility policy Clinical Documentation/Record documented: - It is the policy of this facility to ensure accurate documentation of important elements contributing to high quality care of our residents - Clinical documentation is required to record pertinent facts, findings, and observations about resident's health history - Documentation entries into organization documents or the health record must be accurate and valid. 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included: Peripheral Vascular Disease, Anemia and Hypertension. Review of Resident #23's medical record revealed the following: A physician's order dated 09/05/23 that directed, Gentamicin (antibiotic) Sulfate External Cream, apply to BLE (bilateral lower extremities) topically one time a day every Monday,…

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) out of 57 sampled residents, facility staff failed to have evidence in Resident #132's medical record of an established communication process between the hospice provider and the nursing home; and failed to have in writing, a designated member of the nursing home's interdisciplinary team who is responsible for working with hospice to coordinate care for its residents. The findings included: 1A. Facility staff failed to have evidence in Resident #132's medical record of an established communication process between the hospice provider and the nursing home. Resident #132 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy; Vascular Dementia and Adult Failure to Thrive. Review of Resident #132's medical record revealed the following: A physician's order dated 05/23/23 that directed, Admit resident to [Facility name] Hospice An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, record review and staff interview, the facility's staff failed to maintain Infection Control and Prevention Practices during wound care for one (1) of 57 sampled residents. (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including Lower Back Stage 4 Pressure Ulcer and Paraplegia. A physician's order dated 06/08/23 at 5:37 PM instructed, Cleanse lower back with normal saline pat dry apply collagen with silver and cover with bordered foam dressing daily every day shift for wound care. A care plan with a review date of 07/19/23 documented the following but not limited to: Focus- [Resident #5] has a pressure ulcer to lower back. Interventions-administer treatments as ordered and monitor effectiveness. A Quarterly Minimum Data Set assessment dated [DATE] documented the following but not limited to the resident had a Brief Interview for Mental Status summary score of 14, indicating the resident's cognitive status was intact, 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 seven (7) of 67 sampled residents, facility staff failed to implement: their Prohibition of Abuse policy by not reporting allegations of sexual abuse to the State Survey Agency within two (2) hours for Residents #108 and #145; and their Investigation Process policy by not interviewing or obtaining statements from all potential witnesses with knowledge of an incident for Residents' #108, #145, #86, #112, #121, #303 and #304. The findings included: Review of the facility's policy titled, Prohibition of Abuse, with a revision date of 05/22, defined sexual abuse as non-consensual sexual contact of any type with a resident includes but is not limited to sexual harassment coercion or sexual assault .All alleged violations, the Administrator, Director of Nursing, or designee shall notify the Department of Health [State Agency] via the Event Reporting System electronically .within two (2) hours if seriously bodily injury occurred . 1. The facility's staff failed to follow…

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 nine (9) of 67 sampled residents, facility staff failed to: report allegations of resident-to-resident alleged/witness sexual abuse (inappropriate non-consensual sexual touch /willful non-consensual sexual contact) to the State Survey Agency immediately or no later than two hours of the allegation for Residents #108 and #145; report the results of investigations to the State Survey Agency, within 5 working days of the incident for Residents' #8, #84, #86, #108, #145, #112, #303 and #304; and report a resident-to-resident incident involving Resident #121. Residents' #108, #145, #8, #84, #86, #112, #303, #304 and #121. The findings included: 1. The facility's staff failed to report allegations of resident-to-resident alleged/witness sexual abuse (inappropriate non-consensual sexual touch /willful non-consensual sexual contact) to the State Suvey Agency immediately or no later than two hours of the allegation for Residents' #108 and #145. 1a. Resident #108 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for seven (7) of 67 sampled residents, facility staff failed to: conduct thorough investigations evidenced by failure to interview and/or obtain statements from potential witnesses for: Resident #108's allegation of resident-to-resident inappropriate non-consensual sexual touch [sexual abuse]; Resident #86's allegation of a resident-to-resident altercation; Resident #8's allegation of staff-to-resident physical abuse; Resident #112's allegation of sexual abuse; Resident #303's allegation of staff-to-resident physical abuse; Resident #304's allegation of staff neglect; and conduct an investigation of Resident #121's resident-to-resident incident. Residents' #108, #86, #8, #112, #303, #304, #121. The findings included: Review of the facility's policy titled, Prohibition of Abuse, with a revision date of 05/22, defined sexual abuse as . non-consensual sexual contact of any type with a resident includes but is not limited to sexual harassment coercion or sexual assault .…

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 six (6) of 67 sampled residents, facility staff failed to provide written notice of the facility's bed-hold policy to residents or their representative(s). Residents' #35, #54, #93, #97, #110 and #84. The findings include: 1. Resident #35 was re-admitted to the facility on [DATE] with diagnoses including Pneumonia, Type 2 Diabetes Mellitus, Dependence on Renal Dialysis, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarct without Residual Deficits, and Dysphagia. A Quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns) that facility staff documented the resident as having a Brief Interview For Mental Status Summary Score (BIMS) of 15, indicating intact cognition. Review of Resident #35's clinical record revealed: 03/11/22 Transfer/Discharge Report documented: Resident returned from dialysis at 4:30 PM with shortness of breath, chest congestion/discomfort, elevated blood pressure, low oxygen level (88%), 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 12. Facility staff failed to administer Resident #54 supplemental oxygen as ordered. Resident #54 was re-admitted to the facility on [DATE] with diagnoses including, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and Dependence on Supplemental Oxygen. During an observation on 06/23/22 at 12:12 PM, Resident #54 was awake, resting comfortably, with non-labored breathing. The resident was receiving supplemental humidified oxygen via nasal cannula at a rate of 5 liters per minute. A Quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns) that facility staff documented the resident as having a Brief Interview for Mental Status summary score (BIMS) of 00, indicating that the resident had severely impaired cognition. In Section G (Functional Status), facility staff documented that Resident #54 required extensive assistance with one person physical assistance for bed mobility and was totally dependent and required assistance from one staff person…

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 five (5) of 67 sampled residents, facility staff failed to ensure that residents received care consistent with professional standards of practice for pressure ulcers as evidenced by failing to: perform weekly skin assessments for four (4) residents and first observing facility acquired pressure ulcers for two (2) residents at an advanced stage. (Residents' #4, #56, #84, #138, and #257) The findings included: 1. Facility staff failed to perform weekly skin assessments for Resident #4. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Pressure Ulcer Sacral Region Stage 4, Type 2 Diabetes Mellitus with Unspecified Complications, and Muscle Weakness. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed that the facility staff coded the following: Section C (Cognitive Patterns): Brief Interview for Mental Status (BIMS) Summary Score 02 indicating severely impaired cognition. Section G (Functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to provide dignity for a resident as evidenced by not providing incontinent care in a timely manner for one (1) of 67 sampled residents (Resident #256). The findings include: Resident #256 was admitted to the facility on [DATE] with multiple diagnoses including Diarrhea, Recurrent Enterocolitis due to Clostridium Difficile (C Diff) and Generalized Muscle Weakness,. Record review revealed the following: 06/10/22 [admission Nursing Note] - . admitted to the facility at 6:45 PM form [local hospital] .with discharge diagnoses of C Diff Colitis . abdominal pain and diarrhea .discharge summary [Resident's name] is C diff positive on PO (by mouth) Vancomycin [antibiotic] for 14 days . 06/13/22 [Concerns and Comment Form] written by resident's sister - They are not staffed to meet residents' needs. They allowed [resident's name] to lay for hours in her fecese [feces]. They are not answering the call [light] when button pushed. [Resident #256] washed at 3:00…

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 observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in two (2) of 34 resident's rooms, soiled privacy curtains in four (4) of 34 resident's rooms, a worn out, dirty floor in one (1) of 34 resident's bathroom, and one (1) of one (1) dusty oxygen concentrator in one (1) of 34 resident's rooms. The findings include: During an environmental walkthrough of the facility on June 14, 2022, at approximately 11:00 AM, and on June 24, 2022, between 10:50 AM and 1:00 PM the following were observed: 1. Bathroom vents were soiled in resident rooms #115 and #214, two (2) of 34 resident's rooms. 2. Privacy curtains were soiled in four (4) of 34 resident's rooms including rooms #110B, #229, #244A and #313B 3. The floor in the bathroom of one (1) of 34 resident's rooms (#229) was soiled throughout. 4. The oxygen concentrator in Resident room [ROOM NUMBER]A, one (1) of 34 resident's rooms, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 67 sampled residents, facility staff failed to: (1) develop a comprehensive care plan to address Resident #150's use of Plavix (anticoagulant) and (2) implement the care plan intervention for changing Resident #354's central line dressing. The findings included: 1. Facility staff failed to develop a comphrehensive care to address Resident #150's use of Plavix. Resident #150 was admitted to the facility on [DATE] with the multiple diagnoses including Peripheral Vascular Disease and Coronary Atherosclerosis due to Lipid Rich Plasma. Review of the medical record reveals a physician's order dated 05/17/22 instructed, Plavix [anticoagulant] 75 mg (milligrams) give one (1) tablet by mouth one time a day for PAD (Peripheral Arterial Disease). Review of Resident #150's comprehensive care plans lacked documented evidence the of a care plan to address the resident's use of Plavix. During a face-to-face interview on 06/28/22 at 2:30 PM, Employee #21 (RN/Unit…

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) out of 67 sampled residents, facility staff failed to revise Resident #124's comprehensive care plan reflect the resident's preference to not be discharged . The findings include: Review of the facility policy Interdisciplinary Team Meeting (IDT) Care Plan Meeting revised 02/22 documented, It is the policy of [Facility Name] to develop and implement a person-centered care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care . Resident #124 was admitted to the facility on [DATE] with diagnoses that included: Difficulty Walking, Hypothyroidism, Hypertension, Anemia and Dysphagia. Review of Resident #124's medical record revealed the following: Care Plan focus area [Resident #124's] goal and expectation for discharge is to return back to the community initiated on 04/22/21, documented, . 05/2/22 IDT meeting held today. Care plan reviewed and updated. Continue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and resident interview for two (2) of 67 sampled residents, facility staff failed to ensure that residents are given the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living by not providing documented evidence that residents were provided with ADL(activities of daily living) care such as personal hygiene care on multiple days. (Residents' #84 and #4). The findings included: 1. Facility staff failed to provide documented evidence of bathing Resident #84 on multiple days during the month of May 2022. Review of a Facility Reported incident (FRI) received by DOH (Department of Health) on 09/20/21, concerning Resident #84 documented .A complete head to toe assessment done Multiple scars to left upper back and sacral area. Redness to perineal /sacral, area. The incident is categorized as an allegation of Resident/Patient Neglect. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses 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 interviews, for three (4) of 67 sampled residents, facility staff failed to ensure that residents who were unable to independently carry out activities of daily living (ADLs) were provided services necessary to maintain personal hygiene. Residents' #4, #19, #84 and #93. The findings included: 1. Facility staff failed to provide documented evidence of bathing Resident #4, who is dependent on staff for ADL care, on multiple days in May and June 2022. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Pressure Ulcer Sacral Region Stage 4, Type 2 Diabetes Mellitus with Unspecified Complications, Legal Blindness as Defined in USA, Unspecified Glaucoma, and Muscle Weakness. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed that the facility staff coded the following: Section C (Cognitive Patterns): Brief Interview for Mental Status (BIMS) Summery Score 02 Indicating severely impaired cognition. Section G (Functional Status): Bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview for three (3) out of 67 sampled residents, facility staff failed to ensure residents with limited range of motion received the appropriate services to maintain or improve range of motion. Facility staff failed to show evidence that restorative nursing services were provided and failed to ensure that a resident received prescribed orthotics and multi-podus boots as ordered by the physician to prevent worsening contracture. (Residents' #32, #95, and #102) The findings include: Review of the policy Restorative Nursing Care revised 02/22 documented, Restorative nursing is offered to all residents who have completed skilled OT (Occupational Therapy) or PT (Physical Therapy) services . Our facility has an active program of restorative nursing which is developed and coordinated through the resident's care plan .Restorative nursing care is performed for those residents who require such service . initiate point click care list for each resident placed on program .…

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, facility staff failed to ensure that three (3) of 67 sampled residents received adequate monitoring and supervision to prevent avoidable accidents as evidenced by the following occurrences: one resident that left the facility without staff knowledge; one resident who fell out of her wheelchair while being escorted back into the facility; and one resident who fell after receiving assistance from one staff person during a transfer. (Residents' #124, #135, #35). The findings included: Review of the policy Leave of Absence (LOA) for Residents revised on 05/22 documented, .For all authorized leave of absence . Time, date, destination, responsible party, expected return and any special instruction must be documented on LOA form . residents who go on LOA, must return back to facility prior to midnight . Progress note must be completed stating the timeline of event in the resident medical record. Review of the policy, Mobility and Falls . revised 05/22 documented, . It is the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for two (2) of 67 sampled residents, facility staff failed to provide pain management in accordance with the physician's order. Residents' #104 and #133. The findings included: Review of the policy Pain Management revised 02/22, documented, . The licensed nurse will . administer the order as indicated . Review of the policy Medication/Treatment Administration Record and Initials revised 03/2022 documented, . Prior to administration of medication and treatment, the licensed nurse assigned to the resident must check and validated the ten Rights of Medication which includes . right assessment, right evaluation . Licensed nurses will administer medication and treatment to residents following the physician orders . 1. Facility staff failed to administer Resident #104's pain medication in accordance with the physician's order. Resident #104 was re-admitted to the facility on [DATE] with multiple diagnoses, including, Malignant Neoplasm of Prostate, Moderate…

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 one (1) of 67 sampled residents, facility staff failed to remove the pressure dressing from Resident #21's arteriovenous (AV) Fistula site in accordance with the physician's order. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Chronic Kidney Disease. A Quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns) that facility staff documented the resident as having a Brief Interview For Mental Status Summary Score (BIMS) of 13, indicating intact cognition. Review of the physician's order dated 05/05/21 directed, Remove pressure dressing on the left arm 6 hours post dialysis, [Monday, Wednesday, Friday] every evening shift . During a face-to-face interview on 06/21/22 at 11:55 AM, Resident #21 stated, My arm was bleeding this morning. I told [Employee #33]. She came in I showed her this sheet, the resident picked up a white flat sheet (bed linen)…

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 two (2) of 67 sampled residents, facility staff failed to provide nursing and related services to assure resident safety as evidenced by failure to: (1) provide Resident #133 pain management that met professional standards of practice and (2) ensure Resident #257 received care consistent with professional standards of practice to prevent the development of a pressure ulcer (Stage 3). The findings include: Review of the policy Pain Management revised 02/22, documented, . The licensed nurse will obtain order from the attending physician/designee for pain management and administer the order as indicated . Review of the policy Clinical Documentation/Record revised 02/2022 documented, . Clinical documentation is required to record pertinent facts, findings, and observations about the resident . Review of the policy Medication/Treatment Administration Record and Initials revised 03/2022 documented, . Prior to administration of medication and treatment, 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, facility staff failed to ensure that the controlled medications were accurately recorded as given and accurately recorded wasted in the designated location; and accurately reconcile controlled medications for one (1) of three (3) sampled resident controlled drug records reviewed. Residents #256. The findings included: Resident #256 was admitted to the facility on [DATE] with diagnoses that included Osteoarthritis of Hip, Neuromuscular Dysfunction of Bladder and Clostridium Difficile. According to the physician's order dated 06/12/22 the resident is to receive Tramadol HCI (used to relieve moderate to moderately severe pain) 50 mg (milligram) one tablet by mouth every 8 hours as needed for pain 6-10 in scale. During an observation on 06/16/22 at 3:54 PM one (1) of two (2) Medication Carts on unit 3, there was one resident (Resident #256) with a physician's order that directed, Tramadol 50 mg take 1 tablet by mouth every 8 hours as needed for pain 6-10. Review 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 observation, record review, staff and resident interview for two (2) of 67 sampled residents, facility staff failed to provide menus to all the facilities residents so that they could make food choices and the facility's staff failed to update menus periodically and have them reviewed by the facilities dietician. (Residents' #102, and #82) The findings include: 1. Resident #102 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Adult Failure to Thrive, Pressure Ulcer of Sacral Region, Stage 3, Contracture Unspecified Joint, Contracture Right Knee, Contracture Left Knee, Moderate Protein Calorie Malnutrition and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed facility staff coded the following: Section C (Cognitive Patterns): Brief Interview for Mental Status Summary Score 15 indicating intact cognition. Section E (Behavior): Rejection of Care -Presence & Frequency 0 Behavior not exhibited Section G (Functional Status): Bed…

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

Based on observations and staff interview, facility staff failed to prepare and serve foods under sanitary conditions as evidenced by food temperatures that tested under 135 degrees fahrenheit (F) during a test tray assessment, a cracked and loose ceiling light in the main kitchen, a damaged wall behind the grease fryer, and staff failure to follow food quality standards of practice. The findings include: During a food test tray assessment on June 21, 2022, at approximately 2:00 PM, hot foods such as ham (117 degrees Fahrenheit), cabbage (105.7 degrees Fahrenheit), and mechanical ham (111.7 degrees Fahrenheit), tested below the minimum required temperature of 140 degrees Fahrenheit (F). These observations were acknowledged by Employee #38 and/or Employee #42 during a face-to-face interview on June 21, 2022, at approximately 2:15 PM. During a walkthrough of dietary services on June 14, 2022, at approximately 10:00 AM, the following were observed: 1. A ceiling light located in a common area of the kitchen was cracked and loose. 2. The wall behind the grease fryer was damaged with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) Facility staff failed to properly minimize or prevent the potential spread of infection by not thoroughly cleaning Resident #406's room prior to their admission. Resident #406 was admitted to the facility on [DATE] with diagnoses including Cervical Stenosis of the Spinal Canal, Fracture of the Left Femur, Cervicalgia (neck pain), Lumbago (low back pain)[https://icd.codes/icd10cm/M542], and S/P (status post) accidental fall. Review of Resident #406's medical record revealed: 06/10/22 at 8:02 PM [Nurses admission Note] documented, .admitted from [Local Hospital] . Resident is alert/oriented x 3, cooperative, able to make needs know(n) .[Name of Physician] made aware of resident admission to the facility . During an observation and interview on 06/16/22 at approximately 9:20 AM, Resident #406 was resting in her bed. The resident reported that facility staff had not thoroughly cleaned her room before she was admitted , because another person's belongings (clothes) were hanging in her closet. The resident added…

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

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) conveyor dishwasher that failed to automatically move peg racks filled with cups, dishes, silverware and/or food trays through the machine. The findings include: During observations in dietary services on June 21, 2022, at approximately 11:00 AM, one (1) of one (1) conveyor dishwasher failed to automatically move soiled items through the machine. to ensure proper wash, proper rinse, and proper final rinse of peg racks filled with cups, dishes, silverware and/or food trays. Consequently, the necessary parts were ordered, and the dishwasher was repaired on June 22, 2022. These observations were acknowledged by Employee #42 during a face-to-face interview on June 21, 2022, at approximately 2:15 PM.

Based on observations and interview, it was determined that facility staff failed to prepare and serve foods under sanitary conditions as evidenced by 12 of 12 baffles from the kitchen hood system that were soiled with grease deposits and hot foods that tested at less than 135 degrees Fahrenheit (F) during a test tray assessment. Findings included . 1. Twelve (12) of twelve (12) baffles from the kitchen exhaust hood system were soiled with grease. 2. Hot food temperatures tested at less than 135 degrees Fahrenheit (F) during a test tray assessment on August 27, 2019, at approximately 1:10 PM. A serving of chicken breast was at 123.6 degrees F and a serving of broccoli and cauliflower mix tested at 112.4 degrees F. Employee #19 acknowledged the above findings during a face-to-face interview on August 27, 2019 at approximately 3:00 PM.

Based on record review and staff interview the facility failed to develop a system of surveillance to identify infections or communicable diseases; and staff failed to maintain a safe, sanitary environment as evidenced by a soiled ice machine on one (1) of three (3) resident care units. The census on the first day of survey was 175. Findings included . 1. Facility failed to develop a system of surveillance to identify infections or communicable diseases. Review of the facility's Infection Control Surveillance logs showed the following: May 2019 there were 25 facility-acquired infections to include chin abscess, vaginitis, boil at right chest, conjunctivitis, urinary tract infections related to E. Coli, resident on isolation for urinary tract infection, skin dermatitis, MRSA of the eyelid, fungal irritation, related to incontinence, and pneumonia. June 2019 there were 23 facility-acquired infections to include vaginitis, boil at right chest, conjunctivitis, urinary tract infections, and fungal irritation - no locations listed. July 2019 there were 21 facility-acquired infections to…

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

Based on record review and staff interview, the facility's staff failed to ensure annual in-services sheets failed to record the mandatory 12 hours of training, the subject, the date, the time/duration, the purpose, and/or who conducted the training in four (4) of four (4) in-service(s) reviewed. Findings included . Record review of the staff annual/mandatory in-service records on 09/03/19 at 1:00 PM showed the facility provided education on four (4) topics, as listed below: Abuse Training - 01/26/19, 01/27/19, 01/30/19, 01/31/19, 02/02/19, and 02/03/19; Dementia/Alzheimer's - 02/04/19 and 05/09/19; Podiatry/Geriatric Foot Care - 04/17/19 and 04/19/19; and Elder Justice, Abuse, and Neglect - 05/09/19. Continued review of the previously mentioned training documents revealed twenty-seven (27) In-Service Training Sign-in Sheets that showed the following: 1.Twenty (27) of 27 sign-in sheets lacked documented evidence of the amount of in-service hours employees received from the previously mentioned in-service training. 2. Two (2) of the 27 sign-in sheets lacked documented evidence 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.

Based on review of the facility's trial balance and staff interview, for 12 of 138 sampled residents with personal fund accounts, facility staff failed to ensure that residents who chose to deposit personal funds with the facility, completed a written authorization form giving the facility permission to act as a fiduciary of the residents' funds. Findings included . Review of the facilities trial balance showed the following residents had asterisk (*) next to their names indicating that the residents' application is missing. The residents, however, had transferring accounts (automatic transfer of care cost payments due the facility): Resident # 7 Resident #14 Resident # 17 Resident # 32 Resident # 37 Resident # 38 Resident # 63 Resident # 65 Resident # 94 Resident # 108 Resident # 119 Resident # 157 A face-to-face interview was conducted with Employee #38, Business Office Representative, on September 3, 2019, at approximately 12:00 PM. She stated the missing application is the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 70 sampled residents, the physician failed to ensure that one (1) resident's order for Humalog Insulin was written correctly. The dosage was written incorrectly x 4 months. Resident #66. Findings Include . Resident #66 was admitted to the facility on [DATE], with diagnoses which included Anemia, Diabetes and End Stage Renal Disease. According to Section I (Diagnoses) of the annual Minimum Data Set (MDS) dated [DATE] and a quarterly MDS dated [DATE] the resident was documented to have a history of diabetes. Review of the physician's order for Humalog Insulin show that for the months of May 2019, June 2019, July 2019 and August 2019 the order was written as: Humalog 100 Unit/ML (3ML vial) Inject 3 ml subcutaneously three times a day for DM (Diabetes Mellitus) . dated 05/07/19. Humalog 100 unit/ML (3ML vial) Inject 3 unit subcutaneously three times a day for DM [Diabetes Mellitus], but the order was discontinued and reordered on May 07, 2019. Employee #30…

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 70 sampled residents, the consultant pharmacist failed to identify and make recommendations to correct the Insulin dosage for Resident #66. Findings include . A review of the Humalog Insulin order for Resident #66 for May 2019 showed that the dosage of the Insulin was documented as 3 ml instead of 3 units. A review of Insulin order for June, July and August were also documented incorrectly as 3 ml instead of 3 units. A review of the facility's policy titled Pharmacy Recommendation Follow-Up /Review Revised 07/2019 depicts the following: 1. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. 2. This review must include a review of the resident's medical chart. 3. The pharmacist must report any irregularities to the attending physician and the facilities medical director and the director of nursing and these reports must be acted upon. Review of the Medication Regimen Review record for Resident #66 showed that the pharmacist reviewed the resident's medical records 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 Based on observation of medications stored and staff interview for one (1) of three (3) medication carts on [DATE], at approximately 12:30 PM the facility staff on the first floor failed to date the labels of seven (7) of 12 multi-dose vials/medication containers when they were first accessed; and to remove an expired medication for one (1) resident from a medication cart on the second floor. Findings included . A. The following medications were opened. All of the containers lacked the dates on which they were initially accessed. Ferrous Sulfate 16 oz. bottle/8 oz. remained Expiration date 01/22 Ranitidine 300 ml bottle/140 ml remaining date of Expiration [DATE] Manantine 150ml bottle/30 ml left Expiration [DATE] Keppra 16 oz. bottle/12 oz. remaining Expiration date 03/22 Ferrous Sulfate 16 oz. bottle/12 oz. left Expiration date 01/20 Chlorhexidine Gluc. (Peridex) 0.2 % solution 16 oz. bottle/4 oz. left Expiration date Feb. 2022 Docusate Sodium 16 oz. bottle/15 oz. left Expiration date 1/21. B. Facility staff…

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 four (4) of 70 sampled residents, facility staff failed to accurately carry over Insulin orders for one (1) resident from one month to another, to complete the dialysis communication form for two (2) dialysis residents, and failed to ensure that recorded weights for one (1) resident were correctly documented in the resident's clinical records. Residents' #8, #66, #71 and #108. Findings include . 1. Review of Resident #8's current medical record showed that the resident was admitted on [DATE] with multiple diagnoses, including End-Stage Renal Disease and Left Arm AV (arteriovenous) Graft. Further review of the record revealed a care plan with an initiated date of 10/16/19. The aforementioned care plan documented that the resident received hemodialysis treatments three times a week (Mondays, Wednesdays, and Fridays). Review of Resident #8's, Dialysis Communication Forms showed that the facility's staff failed to complete the post-dialysis section 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 resident and staff interview and record review for one (1) of 70 sampled residents, facility staff failed to ensure that Resident #112 was free from staff verbal abuse. Findings included . Prohibition of Abuse Policy: .Residents must not be subjected to abuse by anymore, including, but not limited to facility staff . Verbal abuse- is the of oral, written or gestured language, that willfully includes disparaging and derogatory terms to a resident or their families or within their hearing distance . During an interview with Resident #112 on 8/26/19, at 04:08 PM the resident stated that a Certified Nursing Assistant (CNA)/Employee #39 spoke to him rudely a few days ago while providing care with activities of daily living. He cannot remember the date but he reported the matter to the nurse and someone told me they walked her for a few days. She has not come back. Resident #112 was admitted to the facility on [DATE], with diagnoses to include Atrial Fibrillation, Peripheral Vascular Disease, Gout,…

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 70 sampled residents, facility staff failed to develop comprehensive, person centered care plans for use of an antidepressant for one (1) resident, to address dental care t and the use of anticoagulant for one (1) resident. Residents' #54 and #95. Findings include . 1. Facility staff failed to develop comprehensive, a person centered care plan for use of an antidepressant for Resident #54. A review of Section I (Active Diagnoses) of Resident #54's annual Minimum Data Set, dated [DATE] showed that the resident was coded for Depression. Review of Section N (Medications) of the same MDS was coded for use of an Antidepressant (Sertraline). However, review of the resident care plans failed to reveal a care plan for the use of an Antidepressant. A face-to-face interview was conducted with Employee #17 on August 29, 2019, at approximately 3:00 PM. The employee reviewed the record and acknowledged that the care plan for use of an Antidepressant was never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview for one (1) of 70 sampled residents, facility staff failed to update care plan with goals and approaches for resident-centered care for one (1) resident's gastrostomy tube (GT). Resident #53. Findings included . Facility staff failed to update resident-centered care plan to reflect the changes in treatment for Resident #53's gastrostomy tube site care. A review of Resident #53's admission record shows that he was admitted to the facility on [DATE], with diagnoses which included Hypertension, Anemia, Type 2 Diabetes Mellitus, Systemic Lupus Erythematosus, Hyperlipidemia, Gastroesophageal Reflux Disease, Cerebrovascular Disease, Cardiomegaly, Dementia, and Major Depressive Disorder. A review of the Quarterly Minimum Data Set [MDS] dated 6/15/19 showed, Section K 0510 Nutritional Approaches: B Feeding tube -nasogastric or abdominal (PEG), while a resident. A review of Physician Health Status note dated August 7, 2019, showed GT [gastrostomy tube] with no hyper…

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 Medpass observation and staff interview for two (2) of four (4) sampled residents observed during medication administration, the facility staff failed to provide care in accordance with professional nursing standards as evidenced by the staff was observed to incorrectly used the blood pressure cuff to measure one (1) resident's blood pressure and administer one (1) resident eye drops. Residents' #88 and #126. Findings included . 1. Standard of Care for Administering Eye Drops: Ask the patient to tilt his head slightly back and to look toward the ceiling. Turn his head slightly to the side being treated to prevent the solution or tears from flowing toward the opposite eye. Using your non-dominant hand, pull his lower eyelid down with your thumb, exposing the conjunctival sac. Place the medication bottle ½ to ¾ inch above his conjunctival sac, making sure it doesn't touch anything. https://journals.lww.com/nursing/FullText/2007/05000/Administering_eyedrops.14.aspx During Medpass observation on August 27,…

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 staff failed to provide evidence of monitoring or modifying interventions consistent with resident needs and goals to maintain acceptable parameters of nutritional status for one (1) of 70 sampled residents (Resident #132). Findings included . Resident #132 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Hyperlipidemia, Peripheral Vascular Disease and Chronic Kidney Disease. Review of the Annual Minimum Data Set (MDS) dated [DATE] , showed Section C (Cognitive Patterns) C0500 Brief Interview for Mental Status is coded as 15, which indicates cognition intact. Section G Functional Status showed resident is coded as 0 which indicates independent with eating. Section K (Swallowing/Nutritional Status); nutrition approach is coded as therapeutic diet. Reviews of the medical record showed resident weights were recorded as follows: 2/13/19 -132# 3/4/29- 130# 4/3/19- 136# 5/2/19- 135# 6/3/19-136# 7/1/19- 136# 8/1/19- 128 # 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 observation, record review and staff interview for two (2) of 70 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 Residents' #8 and #71 Findings included . 1. 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 #8's medical record. Resident #8 was admitted to the facility on [DATE], with diagnoses, which included Anemia, Cardiomyopathy, Hyperlipidemia, Cerebral Infarction, Hypertension, End-Stage Renal Disease, Arthritis, Cataract, and Presbyopia. Physician orders dated 3/5/19 directed, Resident starts new dialysis hours 6 am on 3/6/19 . Dialysis days remain the same Monday, Wednesday, and Friday . Review of the Resident #8's medical records from July 31, 2019 to August 28, 2019, showed that the resident dialysis record 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 observation, record review and staff interview, the facility staff failed to: (I) adequately assess a wound per professional standards of practice for one (1) of 70 sampled residents (Resident #34); and (II) correctly transcribe an insulin order for one (1) of 70 sampled residents (Resident #66). Findings included . 1. Facility staff failed to adequately assess a wound per professional standards of practice for Resident #34. Resident #34 was admitted on [DATE] (most recent date of admission) with diagnoses that include Cerebral Infarction, Sepsis, Hypertension, Unspecified Dementia, Age-related Debility. Review of the resident's current medical record revealed that the facility's staff initially documented the wound as a Stage 3 medical equipment-induced pressure ulcer. However, after more than 60 days the wound classification was changed to a full-thickness neck wound, as evidenced below: Review of the Annual Minimum Data Set (MDS) dated [DATE], showed Section C (Cognitive Patterns) C0100 Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview for one (1) of 70 sampled residents, the facility staff failed to develop a care plan with individualized, person-centered approaches to address Resident #120 with a diagnosis of Dementia. Findings included . Resident #120 was admitted to the facility on [DATE] with diagnoses to include Dementia, Hypertension, Arthritis, and Diabetes Mellitus. Review of the Annual Minimum Data Set (MDS) dated [DATE] , showed Section C (Cognitive Patterns) C0500 Brief Interview for Mental Status coded as 12, which indicates moderate cognitive impairment. Review of discharge summary from [hospital name] dated 7/22/19 showed patients' mental status was attributed to underlying dementia with frontal lobe component. Hospital course: Altered Mental Status, Dementia with Agitation. Review of physicians order dated 8/12/19 showed psychiatric consultation for resident with Dementia and Behavioral Disturbance . Further review showed monitor resident behavior every 4 hours for Dementia…

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 the facility's staff failed to assist one (1) of 70 sampled resident in obtaining dental care (Resident #95). Findings included . Resident #95 was admitted to the facility on [DATE], with diagnoses which included Human Immunodeficiency Virus Disease, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Anemia, Osteoarthritis, Neuropathic pain, Anxiety, and Major Depressive Disorder. A review of of the Quarterly Minimum Data Set (MDS) completed 07/19/19, showed a Brief Interview for Mental Status (BIMS) score of 11 which is an indication that the resident is moderately impaired cognition and not able to make decisions. A review of the physician's note dated 03/05/19 showed the physician documented, Mouth multiple impacted roots on lower gum and upper gum. No gum bleeding, No oral ulcers. Oral pain due to missing teeth and impacted roots, .dental evaluation as scheduled. Review of the 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 and staff interview facility staff for one (1) of 70 sampled residents facility staff failed to provide Resident #65 with a wheelchair with operable parts (leg rest). Findings included . Resident #65 was admitted on [DATE] with diagnoses that include Dysphagia, Hyperkalemia, Acute Kidney Failure, Constipation, and Type II Diabetes Mellitus. Findings included . During a family interview on 8/26/19 at 11:00 AM resident's wife stated the left pedal on his wheelchair is not working I told them about it. Review of the Annual Minimum Data Set (MDS) dated [DATE], showed Section C Cognitive Patterns C0500 Brief Interview for Mental Status coded as 6, which indicates severe cognitive impairment. Section G Functional Status showed mobility devices wheelchair is selected. Observation on 8/26/19 at 11:30 AM showed a wheelchair in the resident's room with the leg rest in the seat of the wheelchair. The resident was asked would this be your wheelchair the resident responded it don't work if I use it my…

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 the call bell system in good working condition as evidenced by a call bell in three (3) of 38 resident's rooms that did not emit an audio or visual alarm when tested. Findings included . During an environmental walkthrough of the facility on August 27, 2019, between 10:30 AM and 3:00 PM, call bells in resident rooms #209B, #241A and #309A did not alarm when tested , three (3) of 38 resident's rooms. This breakdown could prevent or delay care to residents in an emergency. Employee #8 acknowledged the above findings during a face-to-face interview on August 27, 2019 at approximately 3:00 PM.