Stoddard Baptist Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to provide Resident #66's representative with written information that specified the duration of the state bed-hold policy before transfer to the hospital. The findings included: Review of the facility's Bed Hold policy, last reviewed on 04/26/23, documented that: - The admissions office will mail out the Bed Hold notification form to each resident/point of contact each time they are out of the facility. - The form will be mailed out the next business day. - The notification shall provide the number of [bed-hold] days remaining. Resident #66 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Hypertension and Hyperlipidemia. Review of the Resident #66's medical record revealed the following: It was noted that the face sheet documented Resident #66's wife as his responsible party and emergency contact. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to complete a quarterly (every 3 months) assessment for Resident #72. The findings included: Review of the facility's contracts showed that [Company name], effective on 02/12/24, was responsible for completing the facility's Minimum Data Set (MDS) assessments. The contract documented: - [Company Name] shall provide the facility with ongoing MDS department support, specifically, to organize, review, encode and confirm timely completion of all admission, quarterly, annual and significant change in status MDS assessments. Resident #72 was admitted to the facility on [DATE] with diagnoses that included: Pressure Ulcer of Sacral Region, Stage 3, Dysphagia, Aphasia, Pain, and Cerebral Infarction. Review of Resident #72's MDS transmittal sheet provided to this surveyor on 03/08/24 documented: - Annual MDS assessment - dated 10/03/23 showed Accepted, indicating that it was accepted by Center for Medicare and Medicaid…

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 41 sampled residents, facility staff failed to have documented evidence a resident's admission Minimum Data Set (MDS) Assessment was completed as evidenced by not coding the resident's cognitive patterns in Section C. Resident #89. The findings included: Resident #89 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction and Multiple Sclerosis. Review of Resident #89's medical record revealed: An Annual MDS assessment dated [DATE] documented: Section C - Cognitive Patterns, Should Brief Interview for Mental Status (BIMS) (C0200-C0500) be conducted? 1. Yes. However, there was no documented evidence that facility staff conducted the BIMS, as evidenced by Sections C0200, C0400 and C0500 were blank. Additionally, there was no documented evidence of the resident's BIMS summary score that indicated the resident's cognitive status. During a face-to-face interview conducted on 03/07/24 at 2:07 PM, Employee #4 (Director…

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 41 sampled residents, facility staff failed to develop a care plan with goals and approaches to address a resident's use of a central intravenous (IV) line and a cholecystectomy tube and failed to implement a resident's care plan intervention for falls. Resident #66 and Resident #71. The findings included: Review of the facility's Interdisciplinary Care Plans policy, last reviewed on 11/10/22, it documented: - An individualized interdisciplinary care plan will be maintained for each resident. - Information recorded on the care plan includes date problems and/or needs first addressed, active problems and current needs of the resident. 1. Facility staff failed to develop care plans with goals and approaches for Resident #66's use of a central intravenous (IV) line and a cholecystectomy tube. Resident #66 was admitted to the facility on [DATE] with multiple diagnoses that included: Retention of Urine, Hypertension and Dementia. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, staff interviews, and a family interview, for one (1) of 41 sampled residents, the facility's staff failed to provide adequate supervision for a resident. As a result, the resident left the facility without staff knowledge (Resident #192). The findings included: Review of the policy titled, Missing Resident #99M-010, documented, A resident is considered missing from the facility whenever their whereabouts cannot be ascertained. This situation is an elopement. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A care plan dated 01/01/23 that documented, Problem: [Resident #192] has risk for Elopement related to wandering evidenced by trying to enter the elevator. Goal: Resident will not elope. Approach: Monitor resident's movements closely while out of bed. Encourage resident to verbalize feelings of boredom/loneliness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to follow the physician's order to change Resident #66's peripherally inserted central catheter (PICC) line dressing every Friday. The findings included: Review of the facility's PICC/Midline/CVAD (central venous access device) Dressing Change policy dated 10/05/22, it documented: - It is the policy of this facility to change PICC, midline or CVAD dressing weekly or if soiled, in a manner to decrease potential for infection. - Physician's orders will specify type of dressing and frequency of change. Resident #66 was admitted to the facility on [DATE] with multiple diagnoses that included: Retention of Urine, Hypertension and Dementia. Review of Resident #66's medical record revealed: A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 03, indicating severely impaired cognitive status. A…

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

Based on observations and staff interviews, for two (2) of two (2) oxygen storage rooms, facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks intended for patient use. The findings included: According to the Joint Commission: - Storing oxygen cylinders, as per the National Fire Protection Association (NFPA) 99-2012, 11.6. 5.2, is about ensuring full and empty cylinders are not comingled. - Those cylinders defined as 'empty' by the organization shall be segregated from all other cylinders that are intended for patient care use. https://www.jointcommission.org/standards/standard-faqs/home-care/environment-of-care-ec/000001261/#:~:text=Storing%20oxygen%20cylinders%2C%20as%20per,intended%20for%20patient%20care%20use. 1. An observation on 03/05/24 at 10:09 AM of the 2nd floor oxygen storage room, with Employee #22 (Licensed Practical Nurse/LPN) showed, one (1) empty oxygen tank was stored in the same area with four (4) full oxygen tanks that were stored for resident use. At the time of the observation, Employee #22 stated, I'm not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to promptly notify the ordering physician of radiology results that fell outside of clinical reference range. Resident #243. The findings included: Resident #243 was admitted to the facility on [DATE] with diagnoses that included: Muscle Weakness, Other Abnormalities of Gait and Balance and Age-Related Physical Debility. Review of Resident #243's medical record revealed the following: An Annual MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 12, indicating mild cognitive impairment and had no falls since the prior assessment. A Facility Reported Incident (FRI), DC~11996, received by the State Agency on 05/29/23 at 6:30 PM documented: - At 4:40 PM, the resident got up on her seat to give another resident a hug and she missed her step and fell on her left side. - The physician was called and gave an order for an x-ray of the affected leg. - Resident RP was called and was made…

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 provide documented evidence that the Nurse Staffing Agency used to supplement the facility's nursing staff was operating in compliance with applicable Federal, State, and local laws and regulations, as evidenced by providing services in the District of Columbia (D.C.) on an expired business license. The facility's census on the first day of the survey was 90. The findings included: A review of a letter addressed to [Nurse Staffing Agency's Name] dated [DATE] from the D.C. Department of Health documented, Enclosed is your Certificate of Licensure that covers the period [DATE], through [DATE]. A review of the Staffing Agency's business license issued by the District of Columbia revealed a license number with an expiration date of [DATE]. A review of the Service Contract between Nurse Staffing Agency and the facility, signed on [DATE] by Employee #19 (Chief Human Resources Officer) documented, Thank you for choosing [Nurse Staffing Agency's Name]…

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 three (3) of 41 sampled residents, facility staff failed to accurately document in the residents' medical record. Resident #66, The findings included: Review of the Documentation Criteria policy last reviewed on 07/22/22, documented: - The objective is to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized. 1. Facility staff failed to accurately document n Resident #66's Treatment Administration Record (TAR). Resident #66 was admitted to the facility on [DATE] with multiple diagnoses that included: Retention of Urine, Hypertension and Dementia. Review of Resident #66's medical record revealed: A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 03, indicating severely impaired cognitive status. A Health Status…

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

Based on record review and staff interview, for 12 out of 25 Infection Control policies and procedures, facility staff failed to have documented evidence that they were reviewed at least annually. The findings included: A review of the facility's Infection Control Policy and Procedure binder on 03/19/24 revealed that the following policies lacked review dates: admission of Residents During an Outbreak Control of Methicillin-Resistant Staphylococcus Aureus (MRSA) Colonization (#11-015) Control of Vancomycin-Resistant Enterococcus (VRE) Infection (#06-003) Discharge Room Cleaning (Non-Isolation/Infection Precaution Room) Handling Infectious Waste Infection Outbreak Response and Investigation Infectious Waste Material Exposure Control (#99-013) Multiple Drug Resistant Organisms (MDRO) (#06-002) Reporting of In-House Infection and Communicable Disease (#99-01) Treatment of Urinary Tract Infection Visitation During a Communicable Disease Outbreak. This binder also showed a policy titled, Antibiotic Stewardship (#19-007) that had a review date of 07/22/22. During a face-to-face interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 41 sampled residents, facility staff failed to have documented evidence that the residents or their responsible party received education on Influenza vaccination. (Resident #4 and Resident #49). The findings included: Review of the Immunization of Residents for Flu (Influenza) and Pneumococcal (#10-00) Policy with a review date of 07/20/23 documented the following but not limited to, The resident or the resident's legal representative is provided education regarding the benefits and potential side effect of immunizations. 1. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including Dementia. A review of the face sheet showed that Resident #4's son was her responsible party. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 3, indicating the resident had a severely impaired cognitive status. A review of a document titled, Preventive Health Care…

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

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) defective food pellet warmer, and two (2) of four (4) burners from one (1) of one (1) gas stove that did not function when tested. The findings include: During a walkthrough of dietary services on March 4, 2024, at approximately 9:00 am: One (1) of one (1) food pellet warmer was inoperative. Two (2) of four (4) burners from one (1) of two (2) gas stoves did not light up when the knob was activated. These observations were acknowledged by Employee #9 during a face-to-face interview on March 11, 2024, at approximately 3:30 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews for four (4) of 41 sampled residents, facility staff failed to develop and implement comprehensive patient-centered care plans that included goals and approaches to meet resident's medical, physical, mental and psychosocial needs. Residents' #350, #32, #299, and #26. The findings included: 1. Facility staff failed to implement daily skin assessments per Resident #350's care plan. Resident #350 was admitted to the facility admitted [DATE] with diagnoses including Cerebral Vascular Accident, Peripheral Vascular Disease, Dysphagia, Gastrostomy Status, Lower Extremity Contracture, and Generalized Muscle Weakness. A complaint, DC00010482, received by the State Agency on 12/30/21 documented, [Hospital Social Worker ] explained that the physician asked her to file a report due to the condition of the pressure wounds .a call was placed to the niece who also wanted to file a complaint (attach). Since, both [Local Hospital] and the niece wanted to file a complaint about 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 staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to identify areas for improvement and to develop and implement corrective and preventive actions. The resident census during the survey was 101. The findings included: Facility staff failed to develop and implement appropriate plans of action to correct identified quality deficiencies as follows: Under §483.12(b)(2), F 607 Develop/Implement Abuse/Neglect Policies Under §483.12(c)(2), F 610 Investigate/Prevent/Correct Alleged Violations Under §483.21(b)(1), F 656 Develop/Implement Plan of Care Under §483.21(b)(3)(i), F 657 Plan of Care Timing and Revision Under §483.24, F 684 Quality of Care Under §483.25(b)(1) (i)(ii), F 686 Treatment/Services to Prevent/Heal Pressure Ulcers On 11/08/22 at 2:16 PM, a face-to-face interview was conducted with Employees #1 (Administrator) and #12 (Director of Quality Improvement) regarding the Quality Assurance and Performance Improvement…

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 four (4) of 41 sampled residents, facility staff failed to determine whether residents had Advanced Directives (AD) and failed to provide residents or their representatives the right to formulate or refuse an AD. Residents' #55, #67, #69 and #248. The findings included: 1. Facility staff failed to provide documented evidence that Resident #55 had advanced directives or were given the opportunity to formulate or refuse an advanced directive. Resident #55 was admitted to the facility on [DATE] with diagnoses that included: Presence of Right Hip Artificial Joint, Pressure Ulcer of Right Heel, Hypothyroidism, and Tachycardia. A review of Resident #55's electronic record revealed: A Quarterly Minimum Data set (MDS) dated [DATE] documented that the resident had moderately impaired cognition. Review of Resident #55's physical record revealed: A green colored piece of paper read: Full Code Face sheet that listed a family member as Resident #55's emergency contact. Under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for three (3) of 41 sampled residents, facility staff failed to ensure that residents Minimum Data Set (MDS) assessments were coded to reflect of their status at the time of the assessments. Residents' #348, #69, and #68. The findings included: 1. Facility staff failed to code Resident #348 as being at risk for developing pressure ulcers on an admission MDS. Resident #348 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Hemiplegia and Hemiparesis, Generalized Muscle Weakness, and Mixed Receptive-expressive Language Disorder. A review of Resident #348's medical record revealed: Physician's orders: 08/12/22 Apply Barrier Cream To Sacral Buttocks and Peri-area Every shift. 08/12/22 Monitor for Bruising/Bleeding every shift. 08/12/22 Turn and Repositioning Q (every) 2 hours. 08/12/22 at 8:36 PM [Braden Scale for Prediction of Pressure Sore Risk] Calculate Points and Record Totals [Blank] .Interpretation of Score: 15-18 -At Risk .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for five (5) of 41 sampled residents, facility staff failed to revise the comprehensive care plans with new goals and approaches for: one resident who had a urinary tract infection (UTI); two residents who sustained falls; one resident's right foot cellulitis and gangrene; and one resident's new dialysis access site. Residents' #25, #80, #26, #68 and #79. The findings included: 1. Facility staff failed to revise Resident #25's care plan for a diagnosis of Urinary Tract Infection (UTI) on 08/11/22. Resident #25 was admitted to the facility on [DATE] with the following diagnoses: Chronic Kidney Disease, Non-Alzheimer's Dementia, Ventricular Tachycardia, Depression, and Generalized Muscle Weakness. Review of Resident #25 medical record showed the following: Care plan focus area initiated on 01/27/22 [Resident #25] has likelihood for altered urine pattern related to disease process manifested by: Dx (diagnosis) UTI . goal no complication within 90 days. Approach Provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to store and prepare foods under sanitary conditions as evidenced by food items including one (1) of one (1) container of potato salad, five (5) of five (5) containers of mashed potatoes, one (1) of one (1) pan of vegetable mix noodles, one (1) of one (1) pack of turkey bologna, one (1) of one (1) box of American cheese, and one (1) of one (1) pack of roast beef, that were not labeled or dated in one (1) of one (1) walk-in refrigerator, two (2) of two (2) soiled convection ovens, one (1) of one (1) [NAME]-Shaam oven that was soiled on the interior and exterior, one (1) of one (1) flat top grill that was stained on both sides, and food temperatures that tested below 135 degrees Fahrenheit (F) on five (5) of six (6) observations. The findings included: During a walkthrough of dietary services on October 31, 2022, at approximately 9:30 AM, the following were observed: 1. Food items such as one (1) of one (1) container of potato salad, five (5) of five…

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 41 sampled residents, facility staff failed to ensure a resident's dignity and privacy as evidenced by failing to place a privacy cover over the resident's urine collection bag. Resident #298. The findings included: During a facility tour conducted on 10/31/22 at approximately 3:15 PM, Resident #298 was observed in her room with her urine collection bag uncovered, visible to visitors and other residents from hallway. Resident #298 was admitted to the facility on [DATE] with multiple diagnoses that included Overactive Bladder and Change in Bowel Habit. A review of the medical record revealed the following: 10/28/22 [Nursing Progress Note] .[Resident #298] .newly admitted from [Hospital name] .Catheter was placed with improvement. Resident however failed void trial and catheter was replaced and is to be on until next follow up with urology . 10/29/22 [History and Physical] . Patient has an indwelling Foley inserted in the hospital due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to implement its policies for conducting investigations of facility reported incidents as evidenced by failure to conduct a thorough investigation of: one resident's allegation of abuse; and one resident's unwitnessed fall, allegation of abuse, and elopement. Residents' #4 and #82. The findings included: Review of the policy entitled, Social Service Resident Abuse, Grievance and Complaints revised 09/20/21 documented, . All suspected abuse will be investigated, with a report of such investigation give in writing to the Administrator . A review of the facility's policy titled Prohibition of Resident Abuse/Abuse Prevention with s revision date of 09/24/22, revealed the following, .Abuse means willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Neglect means failure to provide goods and services necessary to avoid physical harm,…

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 41 sampled residents, facility staff failed to conduct a thorough investigation of one resident's allegation of abuse and one resident's unwitnessed fall, allegation of abuse, and elopement. Residents' #82 and #4. The findings included: Review of the policy entitled, Social Service Resident Abuse, Grievance and Complaints revised 09/20/21 documented, . All suspected abuse will be investigated, with a report of such investigation give in writing to the Administrator . A review of the facility's policy titled Prohibition of Resident Abuse/Abuse Prevention with s revision date of 09/24/22, revealed the following, .Abuse means willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .Investigate different types of incidents, and Identify the staff member…

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 41 sampled residents, facility staff failed to ensure that one resident had a physician's order for an indwelling catheter. Resident #298. The findings included: During a facility tour conducted on 10/31/22 at approximately 3:15 PM, Resident #298 was observed in her room with her urine collection bag uncovered, visible to visitors and other residents from hallway. Resident #298 was admitted to the facility on [DATE] with multiple diagnoses that included Overactive Bladder and Change in Bowel Habit. A review of the medical record revealed the following: 10/28/22 [Nursing Progress Note] . [Resident #298] .newly admitted from [Hospital name] .Catheter was placed with improvement. Resident however failed void trial and catheter was replaced and is to be on until next follow up with urology . 10/29/22 [History and Physical] . Patient has an indwelling Foley inserted in the hospital due to urinary retention . Care plan focus area Indwelling catheter .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, for one (1) of 41 sampled residents, facility staff failed to administer medications within the professional standards of practice. Resident #99. The findings included: According to the Long-Term Care Nursing: Medication Pass, .pre-pouring medications is unacceptable because the medications: cannot accurately be compared to the Medications Administration Record (MAR) and violates at least two of the seven rights of medication administration (right patient & right medication), dramatically increasing the probability of medication errors . https://ceufast.com/course/long-term-care-nursing-medication-pass During an observation on 11/09/22 starting at 8:42 AM, Employee #13 (Licensed Practical Nurse) was observed retrieving a white paper cup that was located in the medication cart and contained unwrapped loose tablets to administer to Resident #99. Employee #13 was stopped by the surveyor before she could administer the unidentified, loose tablets. The employee stated I 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 one (1) of 41 sampled residents, facility staff failed to ensure that residents received care to promote the healing of existing pressure ulcers for Resident #350. The findings included: Resident #350 was admitted to the facility admitted [DATE] with diagnoses including Cerebral Vascular Accident, Peripheral Vascular Disease, Dysphagia, Gastrostomy Status, Lower Extremity Contracture, and Generalized Muscle Weakness. A complaint, DC00010482, received by the State Agency on 12/30/21 documented, [Hospital Social Worker ] explained that the physician asked her to file a report due to the condition of the pressure wounds .a call was placed to the niece who also wanted to file a complaint (attach). Since, both [Local Hospital] and the niece wanted to file a complaint about the condition of and care that the member was receiving, our office is submitting the complaints together to your office for review and investigation as appropriate. A review of Resident #350's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 41 sampled resident, facility staff failed to identify and implement measures or approaches to reduce the risk of accidents (falls). Residents' #80 and #68. The findings included: 1. Facility staff failed to identify and implement measures or approaches to reduce the risk of Resident # 80 who had multiple falls having an injury of unknown origin to the left forehead. Resident #80 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebrovascular Accident (CVA), Seizures, Diabetes Mellitus, Hypertension, and Respiratory Distress. Review of Resident #80's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognition and used a wheelchair for mobility. 03/21/22 at 4:30 PM [Nurses Progress Note] resident was seen by charge nurse and other residents suddenly slipped from her wheelchair and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to: develop and implement interventions for care and monitoring of his dialysis access site; and have an emergency kit (pressure bandage) at the bedside of Resident #79. The findings included: Review of the policy Care of Residents Receiving Dialysis last reviewed on 03/22/22 directed, .residents who are dialysis dependent will receive nursing care appropriate to their individualized needs: the existence type (i.e., shunt, fistula, or graft) and location of the residents access will be noted and referenced in subsequent nursing notes . care provided to the dialysis resident will be documented in the care plan . During an observation of Resident #79 on 11/07/22 at 9:22 AM, he was noted with a right chest permacath and a dressing to his left lower arm. In a face-to-face interview conducted at the resident's bedside with Employee #18 (Licensed Practical Nurse/ LPN) at the time of the observation, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for two (2) of 41 sampled residents, the physician failed to adequately evaluate resident's condition and total program of care as evidenced by: no physician's order for an indwelling catheter for one resident and a physician progress note that inaccurately documented the physician's involvement in the assessment and care of one resident. Residents' #298 and #79. The findings included: Review of the policy Health Record Documentation last revised on 02/10/20 showed, . Each resident who is assessed by the medical, clinical and other staff at [Facility Name]] and/or who receives clinical care must have a complete and accurate medical documentation record kept at all times .Health care services should be documented while they are being provided or as soon as possible after they are completed . Review of the policy Documentation Criteria last reviewed on 07/22/22 directed, Clinical notes are written by a licensed nurse in the medical record. Clinical notes are randomly…

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 41 sampled residents, facility staff failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for a resident's needs and assure resident safety when administering medications. Resident #99. The findings included: Review of the policy titled General Guidelines for Medications Administration with a revision date of October 2018, instructed, .Cleanse hands as appropriate .Read the label three times before pouring the medication .Never touch any of the medication with fingers .Identify the resident before administering any medication. Check the arm band or photograph, call resident by name, or check with other staff members if necessary. Explain to the resident the type of medication to be administered. The resident has the right to be informed of all medications that are administered .Administer medication and remain with resident while medication is swallowed .Once removed from the package or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, for one (1) of 41 sampled residents, facility staff failed to: properly waste a discontinued narcotic and reconcile narcotics. Resident #24. The findings included: Review of the facility's policy titled Administration of Schedule II Medications with a revision date of October 2018, instructed .The nurse will then count or measure the remaining drug quantity in stock and enter the amount remaining onto the narcotics inventory sheet. Review of the policy titled Disposal of Controlled Substances with a revision date of October 2018, instructed .For all residents' schedule II-V medications, it is the responsibility of the facility to destroy all discontinued controlled drugs at the facility and complete the same documentation . 1. Facility staff failed to properly discard Resident #24's controlled medication after it was discontinued by the prescriber. During an observation on 11/08/22 at 9:20 AM, on the first-floor unit of medication cart A, two blister…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) of 41 residents, facility staff failed to take the action of notifying the psychiatrist as ordered, in response to a monthly MRR (medication regimen review) and to have an established, consistent location for the MRR forms to facilitate communication with the State Surveyors. Resident #60. The findings included: A. Facility staff failed to take the action of notifying the psychiatrist as ordered, in response to the monthly MRR (medication regimen review) for a gradual dose reduction for Resident #60. Resident #60 was admitted to the facility on [DATE] with multiple diagnoses that included: Insomnia, Thyroid Disorder, Tobacco Use, Anemia, Orthopedic Conditions and Thyroid Disorder, Review of Resident #60's medical record revealed the following: 10/14/21 [Physician's order] Trazadone (antidepressant) 25mg (milligram) tab (tablet) po (by mouth) qhs (every night) for insomnia . 10/13/22 at 12:41 PM [Pharmacist Note] MRR completed. Recommendation made to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, in two (2) observations, facility staff failed to: store medications in accordance with professional standards of practice; and to date and initial Insulin vials. The findings included: A review of the facility's policy titled Medication Labels revised in October 2018, instructed, .To decrease the potential of medication errors .properly labeling medications, all medications dispensed . will be labeled according to Federal, State, and Local laws .Containers having no label should be destroyed . A review of the facility's policy titled Returning Medications to the Pharmacy revised in October 2018, instructed, .Unused medications that are not a controlled substance nor require refrigeration may be returned to [Pharmacy name] if they are in a manufacturer's sealed container . 1. Facility staff failed to properly discard Resident #62's and #35's medications from the isolation medication cart. During an observation on 11/08/22 at 9:25 AM on the first-floor,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to promptly notify the ordering physician of Resident #248's laboratory results that were outside of the clinical reference ranges. Resident #248. The findings included: Review of the policy titled Microbiology Culturing of Residents and Staff dated 09/14/11 directed, . Culture reports- attending physicians is notified when culture and sensitivity results are obtained . Review of the policy titled, Lab Results revised on 03/15/22 documented, All lab results should be reported to the physician and recorded in a timely manner .the night charge nurse is responsible for ensuring that all requested labs were drawn and results returned . Resident #248 was admitted to the facility on [DATE] with multiple diagnoses that included: Sepsis, Urinary Tract Infection (UTI) and Benign Prostatic Hyperplasia (BPH). Review of Resident #248's medical record revealed the following: 10/19/22 at 9:56 PM [Nursing Note] . newly…

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 41 sampled residents, facility staff failed to provide a resident with the necessary diagnostic services in a timely manner, resulting in the worsening of a right foot non-pressure related ulcer/wound that extended from the right big toe to midfoot. Resident #26. The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses that included: Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus and Muscle Weakness. Review of Resident #26s medical record revealed the following: An Annual Minimum Data Set (MDS) dated [DATE] showed facility staff coded: severe cognitive impairment; no behavior issues or refusal of care; no functional limitations in range of motion; at risk for pressure ulcers; and no unhealed pressure ulcers or any other skin conditions. 07/14/22 at 11:48 AM [Physician's Assistant Note] .Pt's (patient's) nurse reported that pt complained of big toe pain and redness [right toe] . Order Colchicine…

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 41 sampled residents, facility staff failed to accurately document in Resident #79's medical record. The findings included: Review of the policy Health Record Documentation last revised on 02/10/20 showed, . Each resident who is assessed by the medical, clinical and other staff at [Facility Name] and/or who receives clinical care must have a complete and accurate medical documentation record kept at all times .Health care services should be documented while they are being provided or as soon as possible after they are completed . Resident #79 was admitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure, Pleural Effusion, Chronic Obstructive Pulmonary Disease and Combined Systolic (congestive) and Diastolic (congestive) Heart Failure. Review of Resident #79's medical record showed the following: A. The physician and the Therapeutic Recreation Director documented assessments in Resident #79's medical record at a time when he…

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

Based on observation and staff interview, in one (1) of five (5) medication administration observations, facility staff failed to maintain infection control practices when administering medications. Resident #99. The findings included: During a medication administration observation on 11/09/22 starting at 8:42 AM, Employee #13 (Licensed Practical Nurse) with an ungloved hand picked up the medicine cup with her finger inside the cup. While picking up the cup, the Employee's finger made contact with the loose unwrapped pills. The Employee then entered the resident's room and proceeded to administer the medications to the resident without first sanitizing her hands. Employee #13 was stopped by the State Surveyor before she could give the Resident #99 the medication. In a face-to-face interview at the time of observation, Employee #13 acknowledged that she did not wash or sanitized maintain infection control and prevention practices and made no further comments. Cross reference DCMR 3217.6

Based on record review and interview for one (1) of three (3) sample certified nursing assistants, the facility staff failed to ensure a certified nursing assistant received Dementia Management Training in 2019. Finding included . Record review of Employee #19, CNA, personnel record on 03/11/20 at 3:00 PM showed the employee's date of hire was 02/06/17. Continued review of the record lacked documented evidence Employee #19 had Dementia Management Training in 2019. During a face-to-face interview on 03/11/20 at 3:30 PM, Employee #20, Inservice-Coordinator acknowledged the finding. The facility staff failed to ensure that Employee #19 had annual training on Dementia Management in 2019.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview for one (1) of 34 sampled residents, the facility's staff failed to ensure one (1) was free from physical restraint. (Resident #108) Findings included . The facility's staff failed to ensure Resident #108 was free from physical restraint. Observation on 03/11/20 at 10:00 AM of Resident #108's showed the resident lying in bed in supine position with head of bed elevated at 45-degree angle with both side (long) side rails up. Interview with the resident at the time of observation revealed that he was alert and oriented to name only. A second observation on 03/11/20 at 2:00 PM of Resident #108's room revealed the resident was asleep lying in bed in supine position with head of bed elevated at 45-degree angle with both side (long) side rails up. A third observation with Employee #10, Unit Manager, on 03/11/20 at 3:00 PM of Resident #108's room showed the resident lying in bed with both side (long) side rails up. Review of Resident #108's current medical record 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 record review and interview for one (1) of 34 sampled residents, the facility's staff failed to ensure one (1) resident's Care Plan was revised. (Resident #7). Findings included . Review of Resident #7's current medical record on 03/07/20 at 11:00 AM showed that the resident was admitted [DATE]. The resident was noted to have multiple diagnoses including Right Metastatic Breast Cancer. During an interview on 03/06/20 at 10:00 AM, Resident #7 stated, I have concerns with my transportations arrangements to chemotherapy. The last time I went to my chemotherapy appointment. I had to pay for my transportation, but they [nursing home] paid me back. Further review of the Resident #7's medical record revealed a Care Plan with a last care conference date of 02/28/20. The Care Plan failed to outline who was responsible for making Resident #7's transportation arrangements to and from chemotherapy treatments. During a face-to face interview on 03/07/20 at 2:00 PM, Employee #11, Unit Manager, stated, I did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for three (3) of 34 sampled residents, facility staff failed to show evidence of monitoring one (1) resident for specific behaviors to include: confusion, anxiety, agitation and restlessness, to monitor one (1) resident's side effects with the use of a psychotropic medication, and to provide evidence that one (1) resident was monitored while receiving Antipsychotic medications. Residents' #39, #93 and #120. Findings included . 1.Resident #39 was admitted to the facility on [DATE] with diagnoses which include: Type II Diabetes Mellitus, Hypothyroidism, Congestive Heart Failure, Schizophrenia, Depression and Anxiety. Review of the Comprehensive Minimum Data Set [MDS] dated 1/2/20, showed Section C-Cognitive Patterns: Brief Interview for Mental Status resident was scored as 10 which indicate cognition is moderately intact. Section D [0100] Mood was coded a 1 to indicate resident's mood interview was conducted and there were no symptoms present. Section E: Behavior [E0100.…

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

Based on observation and interview, it was determined that facility staff failed to prepare food in accordance with professional food safety standards as evidenced by two (2) of two (2) grease fryers that were soiled with leftover fried food residue, six (6) of seven (7) soiled, six-inch deep, one-quarter pans that were stored on a clean, ready-for-use shelf, and one (1) of one (1) four-inch deep pan and one (1) of one (1) one-eight pan that were dented throughout. Findings included . 1. Two (2) of two (2) grease fryers were soiled were soiled with fried food residue. 2. Six (6) of seven (7) six-inch deep, one-quarter pans stored on a clean ready-for-use shelf were not thoroughly clean. 3. One (1) of one (1) four-inch deep pan and one (1) one-eight pan were dented throughout. These findings were acknowledged by Employee #18 on March 5, 2020, at approximately 10:30 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that facility staff failed to maintain the call bell system in good condition as evidenced by one (1) of 30 call bell that failed to alarm as expected. Findings included . During an environmental walkthrough of the facility on March 5, 2020, the call bell in resident room [ROOM NUMBER]A did not alarm when tested, one (1) of 30 call bells tested. This deficiency could prevent or delay clinical care to a resident in an emergency. These findings were acknowledged by Employee #16 and Employee #17 on March 6, 2020, at approximately 10:00 AM.