Unique Rehabilitation And Health Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 75 sampled residents, facility staff failed to follow the physician's order for narcotic pain administration. Resident #229. The findings included: Review of the facility's Physician Medication Orders policy dated 11/01/24 documented: - Medications shall be administered only upon the written order of a person licensed to prescribe such medications. Resident #229 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Malignant Neoplasm of Left Female Breast, and Neoplasm Related Pain. Review of the resident's medical record revealed the following an admission Minimum Data Set (MDS) assessment dated [DATE] showing facility staff coded: clear speech; clear comprehension of others; able to make self-understood; received scheduled and as needed pain medication and received opioid medications in the last seven (7) days. A physician's order dated 11/25/24 directed, Hydromorphone (narcotic pain reliever) 2 milligrams (mg), give one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record reviews and staff interviews for one (1) of 75 sampled residents, the facility staff failed to ensure that a resident who is fed by enteral means received appropriate treatment and services to prevent complications as evidenced by an observation in which Resident #39's enteral tubing was observed tied in a knot. Resident #39. The findings included: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Gastrostomy Status, Schizophrenia, Seizures, Pressure Ulcer of Sacral Region Stage 4 and Anemia. A review of a Facility Reported Incident (FRI) DC#00012152, submitted to the State Agency on 08/01/23, documented the following: On rounds resident was observed lying on the floor in her room beside her bed with nonskid socks on. Upon assessment, the resident was noted with a small laceration on the left eyebrow measuring 7 x (times) 4 cm (centimeters) with moderate bleeding. The area was cleaned with normal saline, pat dry and pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 75 sampled residents, facility staff failed to ensure that Resident #362 received care and services, consistent with professional standards of practice for her right upper chest central venous intravenous (IV) catheter\line. The findings included: According to the Centers for Disease Control (CDC): Replace dressings used on short-term central venous catheter sites at least every seven (7) days. https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html Review of the facility's Central Line Dressing Change policy dated 11/2024 documented: - Dressing changes for central lines will be performed weekly, on Wednesdays, or as clinically indicated based on the patient's conditions. - Nurses are responsible for performing the dressing change according to the established protocols. - Each dressing change, including any observations (signs of infection, condition of the catheter), must be…

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

Based on observation and staff interview, facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks in one (1) of five (5) clean utility rooms observed. The findings included: According to the National Fire Protection Association (NFPA): - Per NFPA 99-2012, 11.6. 5.2, is about ensuring full and empty cylinders are not commingled. Those cylinders defined as 'empty' by the organization shall be segregated from all other cylinders that are intended for patient care use. https://www.nfpa.org/ During an observation of unit 2 north's clean utility room on 11/22/24 at 11:30 AM with Employee #17 (2 north Unit Manager), three (3) oxygen tanks were noted stored for use. Upon closer inspection, it was noted that one of the oxygen tanks showed empty. The evidence showed that facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks. Employee #17 acknowledged the finding at the time of the observation and removed the empty oxygen tank from the utility room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews for one (1) of 75, sampled residents, facility staff failed to schedule a gynecology follow-up appointment for a resident. Resident #215. The findings included: Resident #215 was admitted to the facility on [DATE] with the following diagnoses: Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Lymphedema, Diabetes Mellitus Type 2, Atrial Fibrillation, Vitamin B12 Deficiency, Vitamin D deficiency, and Anemia. A review of Resident #215's medical record revealed a face sheet that showed the Resident as his/her own responsible party. A Physician's Order dated 06/09/23 documented: Resident has gynecology appointment at [Name of Local Hospital] on 06/9/2023 at 10:00 am one time only for appointment until 06/09/2023. A Physician's Order dated 06/09/23 from the gynecologist that documented: Admitting Diagnosis: Post [NAME] (menopause) vag (vaginal) bleeding/eb (endometrial biopsy) .Ultrasound (US) Pelvis non-OB (obstetric) -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 75 sampled residents, facility staff failed to ensure that the system for accurate reconciliation and accounting for all controlled medications was followed. Resident #229. The findings included: Review of the facility's Narcotic Reconciliation and Storage policy dated 11/01/24 documented: - The facility will ensure that controlled pain medications are accounted for by the licensed nurses dispensing or administering the medications. - As soon as a narcotic is removed from the package, the narcotic book must be signed off. Resident #229 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Malignant Neoplasm of Left Female Breast, and Neoplasm Related Pain. Review of the resident's medical record revealed the following an admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech; clear comprehension of others; able to make self-understood; received scheduled and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that medical supplies and medications (vaccines) stored for use were not expired. The findings included: 1. During an observation of the unit 2 north code cart on 11/22/24 at 11:33 AM with Employee #20 (Licensed Practical Nurse/LPN), the following expired items were found: - Two (2) Yankaur (oral suctioning tool used in medical procedure) devices stored for use that had an expiration date of 07/12/23. - One (1) Yankaur attached to the suction machine that had an expiration date of 11/28/23. - Two suction connection tubes stored for use with an expiration date of 07/12/23. During a face-to-face interview at the time of the observation, Employee #20 stated that she was the staff who signed off that the code cart was checked at the start of the shift that day. When asked about the expired supplies, Employee #20 stated, I didn't look at the expiration dates on the supplies when I checked the [code] cart this morning. 2. During an observation of the facility's medication storage room on 11/26/24 at 2:15 PM with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to maintain handrails in safe condition, as evidenced by a loose handrail on one (1) of eight (8) resident care units. The findings included: The handrail located on unit 4 South, next to resident room [ROOM NUMBER] was loose and slightly detached from the wall and needed to be secured. Employee #10 acknowledged the findings during a face-to-face interview on November 20, 2024, at approximately 4:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) out of 75 sampled residents, facility staff failed to ensure that they took the steps to investigate Resident #56's grievance that an aide handled him roughly during ADL care. The findings included: Review of the facility's Grievance Policy (not dated) documented: - This policy ensures acknowledgement of grievance procedures and fair and timely resolution of grievances. - Grievances can include behavior of staff, care and treatment provided by the staff or other concerns regarding their long-term or short-term stay. - The facility has 72 hours to investigate and resolve the grievance. - The following grievances are reported to Department of Health (DOH) - abuse and neglect. - The facility must ensure that all written grievance decisions include steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 75 sampled residents, facility staff failed to provide adequate supervision and intervention to prevent one resident's aggressive behavior towards others from escalating as evidenced by a resident-to-resident altercation in the courtyard and subsequently, one resident sustaining an injury. (Residents #220 and #222) Findings include: Review of a facility-reported incidents showed the following altercations involving Resident #222 and #220. A. Resident #222 was admitted to the facility on [DATE] with the diagnosis of COPD [Chronic Obstructive Pulmonary Disease], HIV [Human Immunodeficiency Virus], Chronic Viral Hepatitis C, Asthma, Vitamin D Deficiency, Unspecified, Malignant Neoplasm of Endocervix, Low Back Pain, Muscle Weakness, Anemia, and Hypertension. Review of Resident #222's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a BIMS [Brief Interview for Mental Status] summary score of 11, indicating moderate cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 75 sampled residents, the facility staff failed to implement its own written policies and procedures for reporting allegations of abuse or neglect in the required timeframes for three residents. (Residents' #24, #216, and #412) The findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and investigations with a revision date of 01/24 documented the following: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for four (4) of 75 sampled residents the facility staff failed to notify the State agency of allegations of abuse or neglect as evidenced by the following: a resident to resident altercation with injuries not being reported in the required 2-hour timeframe,a report of an unusual incident involving a resident who was found unresponsive and administered Naloxone by staff and an incident where a resident alleged he was handled roughly by a certified nurse aide. (Residents #24, #216, #412 and #56) The findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and investigations with a revision date of 01/24 documented the following: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews for one (1) of 75 sampled residents, the facility staff failed to implement a comprehensive person-centered care plan for Resident #175 as evidenced by the staff failing to implement the residents falls care plan intervention to place the residents bed in the lowest position. (Resident #175) The findings included: Resident #175 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Displaced Fracture of Base of Neck of Right Femur, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Right Dominant Side, and Repeated Falls. Review of Resident #175's medical record revealed the following: [Care Plan] focus area initiated on 03/27/24 documented (Resident #175) is at risk for falls r/t (related to) muscle wasting and atrophy not elsewhere classified, multiple sites, muscle weakness, had the following interventions initiated on 03/27/24 anticipate and meet the residents needs, bed in lower position and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 75 sampled residents, facility staff failed to provide ongoing in-service training related to abuse, neglect, and exploitation, per the facilities policy when there are allegations of abuse. (Resident #12) The findings included: A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy documented, All reports of resident abuse, including injury of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported and Corrective Action: 5. The employee will obtain education for the incident prior to returning to work. Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Aphasia and Seizure Disorder. A Quarterly Minimum Data Set…

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

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by ceiling vent covers that were soiled throughout on six (6) of eight (8) resident care units, and ceiling tiles that were stained on five (5) of eight resident care units. The findings included: During an environmental walkthrough of the facility on September 12, 2022, between 10:00 AM and 1:00 PM the following were observed: 1. Ceiling vent covers were soiled with dust in common areas including: Three (3) of five (5) in the hallway on 4 South Three (3) of three (3) in the hallway on 4 North Four (4) of four (4) in the hallway on 3 South Seven (7) of seven (7) in the dayroom on 3 South Three (3) of three (3) in the hallway on 3 North Four (4) of five (5) in the Rehab Department on 3 North One (1) of two (1) in the dayroom on 3 North One (1) of two (2) in the hallway on 2 South One (1) of one (1) in the dayroom on 2 South One (1) of one (1) in the hallway on 1 South 2. Ceiling tiles were stained in common areas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for four (4) of 63 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS) for one resident's functional impairment, one resident's bowel status, one resident's fall and one resident's fall and oxygen use. Residents' #20, #102, #133, and #158. The findings included: 1. Facility staff failed to accurately code Resident #20's functional impairment. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Hemiplegia and Hemiparesis, Hypertension and Type 2 Diabetes Mellitus. Review of the resident's medical record revealed the following: A Quarterly MDS dated [DATE] showed facility staff coded: functional impairment on one side for upper and lower extremities. Care plan focus area [Resident #20] has limited physical mobility r/t (related to) right sided weakness reviewed on 06/02/22. Care plan focus area [Resident #20] will maintain optimal status and quality of life within limitations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eight (8) nursing units, the facility staff failed to account for the receipt, usage, disposition, and reconciliation of controlled medications. The findings included: Review of the Receiving Controlled Substances policy revised August 2020 showed, .The following information is completed .upon receipt of the controlled substance: name of resident . drug name, strength and dosage, date received, quantity received, name of person receiving medication . Review of the Controlled Substances policy revised August 2020 showed, . Accurate inventory of all controlled medications is maintained t all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record . date and time of administration; amount administered, remaining quantity, signature of the nursing personnel administering the dose . 1. A review of the Shift count Narcotic records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, facility staff failed to provide laboratory services in a timely manner to meet resident needs. Residents' #158 and #204. The findings included: 1. Resident #158 was admitted to the facility on [DATE] with multiple diagnoses including Sarcoidosis, Hypertension, Chronic respiratory failure, Diabetes Mellitus, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #158's medical record revealed the following: Care plans focus area, [Resident #158] has a diagnosis of painful urination (dysuria) initiated on 04/30/22. 04/30/22 at 3:41 PM Nurses Note .Complaining of pain in vagina when she urinates. Writer called out to [MD name] to make her aware. Order given to increase fluids and monitor notify Md if condition changes after pushing fluids . 04/30/22 [physician's order] Please push fluids q shift complain of burning in vagina when urinating every shift for burning when urinating for 3 days call MD with updates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, serve, and distribute foods under sanitary conditions as evidenced by 16 of 16 six-inch half-pans that were stored wet and ready for use, soiled equipment such as two (2) of two (2) convection ovens, two (2) of two (2) grease fryers, one (1) of one (1) meat slicer, and six (6) of seven (7) cutting boards, dishwasher temperature logs that were improperly documented, six (6) of six (6) stained fire suppression nozzle covers , and food temperatures that tested below 135 degrees Fahrenheit on two (2) of two (2) food trays assessment. The findings included: 1. 16 of 16 six-inch half-pans were stored wet, on a shelf, ready for use. 2. Two (2) of two (2) convection ovens, two (2) of two (2) grease fryers, one (1) of one (1) meat slicer, and six (6) of seven (7) cutting boards were soiled throughout with food deposits. 3. Dishwashing machine daily temperature logs were improperly documented and failed to show a final rinse temperature of at least 180 degrees Fahrenheit (F) from January 2022 to present. 4. Six (6)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) dishwashing machine that did not reach 180 degrees Fahrenheit and failed to complete the fill cycle during start-up, one (1) of six (6) steam well covers with no handle, four (4) of six (6) steam well covers with a loose handle, one (1) of eight (8) unsecured baffle from the kitchen hood system, and four (4) of four (4) curtains from the dishwasher that were marred. The findings included: 1. Dishwasher final rinse temperatures failed to reach 180 degrees Fahrenheit on numerous consecutive cycles. 2. The dishwasher failed to automatically complete the fill cycle during start-up. Staff was observed filling the machine manually with water. 3. One (1) of six (6) steam well pan cover was missing a handle and four (4) of six (6) steam well pans cover had a loose handle. 4. One (1) of eight (8) baffles form the kitchen hood located above the fryers was hanging loose due to a missing locking pin. 5. Four (4) of four (4) dishwasher curtains…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, and staff interviews, for three (3) of 63 sampled residents, the facility's staff failed to ensure that they were provided dignity and privacy. Residents' #193, #132, and #158. The findings included: 1. The facility staff failed to ensure that Resident #193 was provided dignity and privacy as evidenced by staff exiting the room and leaving the privacy curtain open while resident was partially naked and receiving a bed bath. Resident #193 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Hemiplegia Affecting Left Nondominant Side, Post Traumatic Stress Disorder and Major Depressive Disorder. A Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility's staff coded the following: intact cognition; totally dependent for toilet use and personal hygiene requiring 1 staff assist; totally dependent on staff and requiring the support of 2 staff. 05/18/22 [Physician Order] Shower twice a week per patient request . 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 staff interview, for two (2) of 63 sampled residents, facility staff failed to ensure that residents or their representatives were provided the Notice of Medicare Non-Coverage (NOMNC) form no later than noon of the day before the effective date listed for discontinuance of skilled services. Residents' #202 and #203. The findings included: The Notice of Medicare Non-Coverage form stipulates that .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily . 1. Resident #202 was readmitted to the facility on [DATE] with diagnoses that included Severe Protein-Calorie Malnutrition and Pneumoconiosis. Review of Resident #202's NOMNC form showed an effective last day of skilled nursing services was on 06/19/22. The form also showed that facility staff provided Resident #202's legal guardian notification on 06/20/22. The evidence showed that facility staff failed to ensure that 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 reviews and staff and resident interviews, for three (3) of 63 sampled residents, facility staff failed to implement its abuse policies and procedures. Residents' #505, #148, and #191. The findings included: Review of the facility's policy entitled, Prohibition of Abuse revised 02/2022, read: .Policy: Sexual abuse is non-consensual sexual contact of any type with a resident includes but is not limited to sexual harassment coercion or sexual assault. Procedure .E. Protection .3. In the case of a resident abusing another resident, the facility will separate the resident (s) as appropriate during the investigation .F. Reporting 1.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 serious bodily injury occurred or there is an allegation of abuse . Review of the facility's policy entitled Dealing With Combative Resident revised 07/01/2022, documented, .In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, for two (2) of 63 sampled residents, facility staff failed to report a reasonable suspicious crime (physical assault of one resident to another) to the appropriate law enforcement entity. Residents' #505 and #148. The findings included: Review of the facility's policy entitled Dealing With Combative Resident revised 07/01/2022, documented, .In case of physical altercation, resident -to- resident, resident- to- staff and staff- to- resident, supervisor or the designee will call and file a complaint with Metropolitan Police Department (MPD) Resident #505 Resident #505 was admitted to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder, Dementia with Behavioral Disturbance, Altered Mental Status, Anxiety Disorder, Other Symptoms and Signs Involving Cognitive Awareness, and Disorientation. On 09/06/22 at 7:42 PM the facility submitted a Department of Health (DOH) Complaint/ Incident Report Form that documented the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, for three (3) of 63 sampled residents the facility staff failed to: report an incident of alleged staff of resident abuse/mistreatment the State Agency; report an unusual incident in which a resident was found unresponsive after going into the facility's courtyard; and report the results of its investigation of one resident's allegation of staff verbal abuse and violation of dignity. Residents' #193, #53, and #403. The findings included: Review of the facility's policy titled Prohibition of Abuse revised on 02/22, stated .Anyone who has knowledge of any kind of abuse should report immediately to their immediate Supervisor. During the Weekend Administrator or Manager on Duty . or in his/her absence, the Nursing Supervisor or his/her designee. Staff will complete an incident/accident form for any unusual occurrences and submit it to the Director of Nursing or designee.All alleged violations, the administrator, Director of Nursing or designee shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three (3) of 63 sampled residents, facility staff failed to: investigate an unusual incident in which a resident was found unresponsive; and to take necessary corrective actions after a resident-to-resident incident. Residents' #53, #148, and #505. The findings included: Review of the facility's policy entitled, Prohibition of Abuse revised 02/2022, read: .Policy: Sexual abuse is non-consensual sexual contact of any type with a resident includes but is not limited to sexual harassment coercion or sexual assault. Procedure .E. Protection .3. In the case of a resident abusing another resident, the facility will separate the resident (s) as appropriate during the investigation .F. Reporting 1.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 serious bodily injury occurred or there is an allegation of abuse .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, the facility's staff failed to ensure the information required for resident-initiated discharge to occur was a part of the medical record. Resident #254. The findings included: Resident #254 was admitted to the facility on [DATE] with diagnoses of unspecified fracture of right Calcaneus, Fracture of Right Femur, Fracture of Facial Bone, Laceration of Other Parts of the Head, Blindness of Left Eye and Gastrostomy Status. A review of the resident's medical record showed the following: Physician's order dated 08/20/21 directed, Admit to skilled level of care. The resident requires SNF [skilled nursing facility] covered care on a daily basis. Care plan initiated 08/25/21 with revision date 11/04/21 Focus: [resident name] shows potential for discharge and his family member expresses wishes for discharge to home. Goal: [resident name] will be discharged to home when rehabilitation/self-care goals are met, and he is medically cleared.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 30 sampled residents, facility staff failed to document/record the specific reason(s) for the notice, the date of discharged , transferred, or relocated, and the destination on the notice before transfer (6-108) form for one (1) resident and failed to record the destination and the correct number of bed-hold days on the 6-108 form for one (1) resident. Residents' #6 and #8. The findings included . Reserved Bed Day- a day for hospitalization or therapeutic leaves of absence, when provided for in the resident's plan of care and when there is a reasonable expectation that the resident will return to the nursing facility. Reserved bed days may not exceed a total of 18 days during any 12- month period that begins on October 1st and ends on September 30th. A therapeutic leave of absence includes visits with relatives and friends and leave to participate in a State-approved therapeutic and rehabilitative 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 interview, for one (1) of 63 sampled residents, facility staff failed to provide Resident #253's responsible party (RP) written notice of the bed-hold policy when he was transferred to the hospital. The findings included: Resident #253 was admitted to the facility on [DATE] with multiple diagnoses that included: Dependence on Renal Dialysis, Chronic Atrial Fibrillation and Hypertension. Review of a Facility Reported Incident (FRI), DC00010324, received by the State Agency on 10/19/21 documented, .Resident was scheduled to dialysis today 9/28/21 by 10am at .Dialysis Center . At 9:10am, Resident was transported out of the facility via a wheelchair . At 3:40pm, Dialysis Nurse .called the unit that resident has been sent to [Hospital Name] ER (emergency room) by Dialysis Center MD (medical doctor) to be evaluated per stroke protocols . Review of Resident #253's medical record revealed the following: The face sheet that documented that Resident #253's responsible party was his sister.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, facility staff failed to complete Resident #1's Minimum Data Set (MDS) assessment within 14 days of the assessment reference date (ARD). The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Liver Cell Carcinoma and Malignant Neoplasm of Prostate. Review of Resident #1's medical record revealed the following: A Quarterly MDS dated [DATE] showed facility staff coded: intact cognition; required supervision and set-up only for activities of daily living; and no functional limitation in range of motion. 03/31/22 at 5:24 PM .Social Service Note/Overnight stay . spoke with resident and his nephew . Resident is going to his nephew college graduation and will be celebrating with his family. Resident will be using 7 of his 18 days of calendar year overnight stay. Resident will be picked up by his family on Saturday, April 2nd and will be returning back to the nursing center 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 staff interview, for one (1) of 63 sampled residents, facility staff knowingly falsified Resident #1's Discharge - Return Anticipated Minimum Data Set (MDS) assessment. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Liver Cell Carcinoma and Malignant Neoplasm of Prostate. Review of Resident #1's medical record revealed the following: A Quarterly MDS dated [DATE] showed facility staff coded: intact cognition; required supervision and set-up only for activities of daily living; and no functional limitation in range of motion. 03/31/22 at 5:24 PM .Social Service Note/Overnight stay . spoke with resident and his nephew . Resident is going to his nephew college graduation and will be celebrating with his family. Resident will be using 7 of his 18 days of calendar year overnight stay. Resident will be picked up by his family on Saturday, April 2nd and will be returning back to the nursing center on Saturday, April 9th…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, for two (2) of 63 sampled residents, facility staff failed to: develop a comprehensive person-centered care plan to address one resident's use of supplemental oxygen; and implement one resident's care plan intervention of having a one to one (1:1) supervision while in the courtyard. Residents' #64, and #176. The findings included: 1. Facility staff failed to develop a comprehensive person-centered care plan to address Resident #64's use of supplemental oxygen. Resident #64 was admitted to the facility on [DATE] with multiple diagnoses that included: Atrioventricular Block Second Degree, Anxiety Disorder Unspecified Fall, and Anemia. During an observation and interview conducted on 09/22/22 at approximately 9:40 AM, Resident #64 was observed with his oxygen tubing and nasal cannula laying on the bed, the tubing was not marked with a date and time and the oxygen was set on 1 liter. Resident #64 stated, I turn my oxygen on and off and take off 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, resident and staff interview, for one (1) of 63 sampled residents, facility staff failed to update Resident #20's fall and skin care plan focus areas with new goals and interventions after he sustained a fall and when he was observed with a bruise on his right cheek. The findings included: Resident #20 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Hemiplegia and Hemiparesis, Hypertension and Type 2 Diabetes Mellitus. Review of Resident #20's medical record revealed the following: A Quarterly MDS dated [DATE] showed facility staff coded: unable to complete the Brief Interview for Mental Status (BIMS); required extensive assistance with one person physical assist for transfers; independent with locomotion on the unit; no functional impairment in upper extremities; functional impairment on one side for lower extremities; wheelchair for mobility; no falls since admission/entry or reentry or the prior assessment. 09/12/22 at 9:20 PM Post Fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, in one (1) of four (4) medication administration observations, facility staff failed to administer medications within the professional standards of practice. 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 a medication administration conducted on 09/12/22 at 9:09 AM on unit 4 South, the following was observed: Employee #11 (Licensed Practical Nurse) pre-poured a resident's medications (6 in total) into a medicine cup, then entered the residents room, checked the resident's blood pressure and was about to administer the medications when the employee was stopped by the State Surveyor. At the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 63 sampled residents, facility staff failed to develop a discharge care plan for Resident #402 that addressed her needs for discharge back to the community. The findings included: Resident #402 was admitted to the facility on [DATE] with multiple diagnoses that included: Multiple Sclerosis, Difficulty in Walking, Heart Failure and Hypertension. Review of a Complaint, DC00010481, received by the State Agency on 12/30/21 documented, . [Resident #402] has been trying to get discharged and service assistance since 09/24/21 . Review of Resident #402's medical record revealed the following: 10/14/21 at 5:29 PM Social Services Assessment Admission showed, Section E (Discharge Assessment/Planning) was left blank; Section F (Care Planning) was left blank. An admission Minimum Data Set (MDS) dated [DATE] showed facility staff coded: moderately impaired cognition; required extensive assistance to total dependence with one person physical assist for bed mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, facility staff failed to ensure: Resident #194 was provided a psychiatric evaluation in a timely manner; and that Resident #253 was administered his blood pressure medications as ordered by the physician. Residents' #194 and #253. The findings included: Review of the Medication/Treatment Administration Record and Initials policy dated February 2022 showed, .Prior to administration of medication and treatment, the licensed nurse assigned to the resident must check am validate . right medication .dosage . assessment, evaluation. Licensed nurses will administer medication and treatment to residents following the physician orders . 1. Facility staff failed to ensure that Resident #194 was provided a psychiatric evaluation in a timely manner. Resident #194 was admitted to the facility on [DATE] with diagnoses that included: Sequelae of Cerebral Infarction, Aphasia and Major Depressive Disorder. Review of a Facility Reported Incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, for one (1) of 63 sampled residents, facility staff failed to ensure that one resident received the proper assistive device to maintain vision. Resident #53. The findings included: Resident #53 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction and History of Falling. During an observation and face-to-face interview conducted on 09/21/22 at approximately 11:30 AM, Resident #53 stated he lost his glasses months ago and he needs them to read. Review of the medical record revealed the following: 06/02/22 [Physician's Order] Ophthalmology Consult Treat as needed 06/16/22 [Ophthalmology Assessment] Documented that Resident #53 required glasses and instructs .Encourage full-time use for distance and reading . A Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the following: In section B (Hearing, Speech, 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 three (3) of 63 sampled residents, facility staff failed to ensure that residents received oxygen/respiratory care in accordance with the physician order. Residents' #123, #132 and #185. The findings included: Review of the policy entitled Oxygen Concentrator Utilization revised 10/01/21 documented, .Procedure and Implementation . Weekly change cannula and tubing as to reduce the risk of respiratory infections and other contamination . 1. Facility staff failed to ensure Resident #123's trach mask was positioned over his trach and that the oxygen therapy level was set at the ordered level for administration. Resident #123 was admitted to the facility on [DATE] with diagnoses that included Acute respiratory Failure, Acute Respiratory Distress Syndrome, Tracheostomy and Cerebral Infarct. During an observation on 09/19/22, Resident #123's trach mask was observed placed away from the trach area, on the side of the resident's neck. The humidified oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, facility staff failed to ensure that licensed nurses had the competency and skill sets necessary to implement, assess and document. Resident #204. The findings included: Review of the Change in Condition/Notification of Physician & Responsible Party policy revised on 10/01/21 showed, . [Facility name] must immediately . consult with the resident's physician, and notify responsible party/appointed guardian when there is . a significant change in the resident's physical, mental, or psychosocial status . a need to alter treatment significantly (that is, a need to discontinue or change existing form of treatment . Review of the Wound/Pressure Ulcer Management policy, revised on 10/01/21 showed, . Any alteration in skin integrity will be reported to the physician immediately . Resident #204 was admitted to the facility on [DATE] with multiple diagnoses that included: Mild Protein-Calorie Malnutrition, Dementia, Altered Mental Status,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff and resident interviews for two (2) of 63 sampled residents, facility staff failed to provide food that reflected the resident's food preferences and failed to ensure that the residents' menu was current and posted in plain sight for a resident to review and failed to make a reasonable effort to provide Resident #152 with double portions of food. Residents' #199 and #152. The findings included: 1.Facility staff failed to provide Resident #199 with foods of her choice/preference. Resident #199 was admitted to the facility on [DATE] with diagnoses including Obesity, Diabetes Type 2 Without Complications, Sick-Euthyroid Syndrome, Dysphagia, and Gastroesophageal Reflux Disease. During a face-to-face interview on 09/11/22 at 8:57 AM with Resident #199's she stated, I have to call the kitchen just about every day. I don't eat scrambled eggs because sometimes they upset my stomach. I have asked for two hard-boiled eggs instead. I am also supposed to get fresh fruit like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 63 sampled residents, facility staff failed to accurately document the location where Resident #102's blood pressure was being taken. The findings included: Review of the policy Charting/Documentation Nursing Notes revised 0n 10/02/21 showed, It is the responsibility of licensed nurses to make sure that information relevant to the care of the resident is recorded . Resident #102 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease (ESRD) and Dependence on Dialysis. Review of Resident #102's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: intact cognition and received dialysis while a resident. 09/04/22 [physician's order] No blood pressure, no blood draw, no finger stick, no invasive procedure on right upper arm because of the AV (arteriovenous) graft site every shift . Review of the September 2022 vital signs for Resident #102 showed facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to follow accepted standards of infection control practices to prevent potential contamination and spread of infection related to failure to wear the appropriate shoe and failed to sanitize the blood glucose machine between residents. The resident census on the first day of survey was 208. The findings included: 1. Facility staff failed to follow infection control practices when administering medications. During an observation on 09/11/22 at 9:28 AM, Employee #21 (Registered Nurse) was observed passing medications while wearing open toe sandals. The employee was stopped by the surveyor. In an interview conducted at the time of the observation, the employee was asked why she did not have on proper footwear. Employee #21 stated, I broke my toe and it's been hard for me to put shoes on. Everyone has been aware. I gave the doctor's letter to HR (Human Resources). They said it was okay to wear sandals. During a face-to-face interview on 09/11/22 at…

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

Based on observations and interview, it was determined that facility staff failed to provide housekeeping services necessary to maintain a safe, clean and comfortable environment, as evidenced by torn chairs in one (1) of 33 resident's rooms and in one (1) of two (2) television (TV) rooms on the fourth floor, and bulk trash that was piled up in an area located next to the parking lot. Findings included . During an environmental walkthrough of the facility on October 2, 2020, between 9:51 AM and 1:00 PM the following were observed: 1. One (1) of one (1) chair in resident room's #415A and one (1) of four (4) chairs in the TV room on 4 South were torn throughout. 2. Bulk trash such as mattresses, broken medication cart, chairs, sofas, small trash cans, and different types of defective equipment were stacked on the outside of the building, next to the parking lot and presented an environmental hazard to the community and a harborage site for pests. These findings were acknowledged by Employee #18 on October 2, 2020, at approximately 3:30 PM and/or Employee #1 on October 7, 2020, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for five (5) of 43 sampled residents, facility staff failed to update the care plan with goals and approaches to address one (1) resident who had an accident with injury, to address the removal of the protective dressing of graft/fistula site post dialysis for two (2) residents; to address the use of the wound vacuum-assisted closure (VAC) for one (1) resident, and for one (1) residents refusal to have his weight obtained. Residents' #11, #61, #114, #149 and #158. Findings included . 1. Facility staff failed to update the care plan to reflect Resident #11's accident with injury. Resident #11 was admitted to the facility on [DATE], with diagnoses that included Osteoporosis, Parkinson Disease, Hypertension, Encephalopathy, Dysphagia, Major Depressive Disorder, Bipolar Disorder, and Schizophrenia. A review of the progress note dated May 5, 2020, at 5:53PM showed, At approximately 4:55PM writer was called to report to 3 south to assess this resident. Resident was noted 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 43 sampled residents, facility staff failed to minimize potential adverse consequences related to medication therapy for one (1) resident on two occasions and failed to maintain the pharmacy drug regimen review on the active record for one (1) resident. Residents' # 50 and #172. Findings included 1A. Facility staff failed to minimize potential adverse consequences related to medication therapy for Resident #50 who had an elevated thyroid stimulating hormone (TSH) level. Resident #50 was admitted to the facility on [DATE], with diagnoses that included Anemia, Heart Failure, Hypertension (HTN), Renal Insufficiency, Schizophrenia, Hypothyroidism and Depression. Laboratory test results showed the following: Date of test: 02/03/20 Type of test: TSH 16.321(H) [high] (normal range 0.350-4.940). Date of test: 02/04/20 Type of test: TSH 15.512(H) (normal range: 0.350-4.940) ulU [International Units]/mL [milliliters]. A review of the physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 43 sampled residents, facility staff failed to adequately monitor Resident #178 for efficacy and adverse consequences who was prescribed Trazadone Hydrochloride (antidepressant and sedative). Findings included . Resident #178 was admitted to the facility on [DATE], with diagnoses that included Cancer, Orthostatic Hypotension, Benign Prostatic Hyperplasia (BPH), Hyperlipidemia, Retention of Urine and Depression. Review of the Nurse Practitioner's progress note dated 6/29/2020, at 13:36 (1:36 PM), showed, Psych Consult: Insomnia . Diagnosis: Axis1: Adjustment d/o (disorder) with depressed mood, Insomnia. Plan: Start Trazodone 50mg (milligrams) po (by mouth) qhs (every night). Monitor Mood and Behavior. A review of the physician's order dated 6/29/2020, showed, active diagnosis of Major Depressive Disorder, Recurrent Unspecified; Trazadone Hydrochloride tablet 50 mg (milligram) Give 50 mg by mouth in the evening for Depression/insomnia Monitor for SI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview of three (3) of 43 sampled residents, the facility staff failed to consistently document the removal of the protective dressing covering the residents access site post dialysis for two (2) resident's receiving dialysis, to consistently document one (1) resident's treatment on the Treatment Administration Record [TAR]. Residents' #61, #83, and #158. Findings included . 1. Facility staff failed to consistently document the removal of Resident #61's protective dressing post dialysis. According to Fistulafirst, Renal Disease Council, Inc. ESRD (End stage Renal Disease) Network 18 Tool Kit .After bleeding has stopped, dress the site with new gauze and tape or with a Band-Aid. Repeat Steps 3-10 for the second needle. Instruct the patient to remove the dressing 3-4 hours following treatment. Notify the charge nurse if the patient has prolonged bleeding or other abnormal symptoms. www.esrdnetwork18.org > pdfs > QI - FF Tools > FF ToolKit Resident #61 was admitted to the…

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

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by a loose door that failed to close as intended, a broken temperature gauge and a broken temperature adjustment knob from one (1) of two (2) food warmers, and two (2) of six (6) slats from one (1) of one (1) walk-in freezer that were torn. Findings included . 1. The access door to one (1) of two (2) food warmers was loose and failed to close as intended. 2. The temperature gauge and the temperature adjustment knob from one (1) of two (2) food warmers were broken. 3. Two (2) of six (6) slats in the walk-in freezer were torn. During a face-to-face interview on October 9, 2020, at approximately 10:30 AM, Employee #11 acknowledged these findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, for one (1) of 43 sampled residents, facility staff failed to treat residents with dignity and respect during dining observations for one (1) resident. Resident #1 Findings included . Facility staff failed to treat Resident #1 with dignity and respect during two (2) dining observations. Resident #1 was admitted to the facility on [DATE], with diagnoses that included Hypertension (HTN), Benign Prostatic Hyperplasia (BPH), Diabetes Mellitus (DM), Hyperlipidemia and Non-Alzheimer's Dementia. Review of the Minimum Data Set (MDS) dated [DATE], Section G (Functional Status) indicated Resident #1 required one-person physical assist support while eating. During a tour of unit 2 South on 10/5/2020, at 1:32 PM, Resident #1 was observed seated in bed (a semi-sitting position of 45-60 degrees) being fed by Employee # 6 (unit manager) who was standing. At 1:45 PM, Employee #13 (certified nursing aide), who had taken over for Employee #6, was also observed standing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 43 sampled residents, facility staff failed to notify the responsible party of Resident #149's refusal to have his weight obtained by staff. Findings included . Resident #149 was admitted to the facility on [DATE], with diagnoses that included Cirrhosis, End Stage Renal Disease (ESRD), Dementia, Seizure Disorder, Asthma and Respiratory Failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed in Section C (Cognitive Pattern), Resident #149's Brief Interview of Mental Status (BIMS) score was 7, indicating severe cognitive impairment and has a responsible party. The resident's weight was left blank under section K0200 (Height and Weight) on the MDS dated [DATE] and 8/17/20. Review of the Resident's weight record on October 2, 2020, revealed the following: 2/7/2020 178.4 Lbs [pounds] 1/15/2020 176.1 Lbs 12/9/2019 175.7 Lbs 11/5/2019 173.2 Lbs 10/11/2019 176.4 Lbs 9/13/2019 174.2 Lbs The aforementioned weight record shows that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility staff failed to document pertinent discharge information on the Interdisciplinary Discharge Summary form for one (1) of 43 sampled residents, Resident #196. Findings included . Interdisciplinary Discharge Summary form - This document provides information to include a post-discharge plan of care that indicates any arrangements made for follow-up care, any post-discharge medical and non-medical services the resident may require once he/she has transferred to a new setting. Resident #196 was admitted to the facility on [DATE], with diagnoses that included: Pulmonary Hypertension, Cardiomegaly, Hyperlipidemia, Anemia and Vitamin D Deficiency. Review of the Minimum Data Set (MDS) dated [DATE], Section C (Cognitive Pattern) showed Resident #196 had a BIMS score of 15, indicating intact cognitive response. Review of the medical record showed the following: The Care plan section of the electronic health record initiated on June 23, 2020, and closed on August 7, 2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 43 sampled residents, the facility staff failed to code the Minimum Data Set (MDS) to reflect one (1) resident's diagnosis of Malignant Neoplasm of the Prostate, Resident #191. Findings included . Resident #191 was admitted to the facility on [DATE], with diagnoses that included Malignant Neoplasm of the Prostate, Diabetes Mellitus 2, Hypertension, Cerebral Infarction, Gastroesophageal Reflux Disease, Major Depressive Disorder and Anxiety Disorder. A review of Resident #191's quarterly MDS dated [DATE], and significant change MDS dated [DATE], showed no documentation of the resident's type of cancer diagnosis [Malignant Neoplasm of the Prostate] in Section I (Active Diagnosis), under Other I8000 (additional active diagnoses). The evidence showed that the facility staff failed to code the MDS to reflect that Resident #191 had a diagnosis of Malignant Neoplasm of the prostate. During a face-to-face interview with Employee #2 (DON) on October 9, 2020, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility staff failed to develop and implement a comprehensive person-centered care plan with goals and approaches to address the monitoring and side effects of Trazadone (antidepressant and sedative) for one (1) of 43 sampled residents, Resident #178. Findings included . Resident #178 was admitted to the facility on [DATE], with diagnoses that included Cancer, Orthostatic Hypotension, Benign Prostatic Hyperplasia (BPH), Hyperlipidemia, Retention of Urine and Depression. Review of the Nurse Practitioner's progress note dated 6/29/2020, at 13:36 (1:36 PM), showed, Psych Consult: Insomnia . Diagnosis: Axis1: Adjustment d/o (disorder) with depressed mood, Insomnia. Plan: Start Trazodone 50mg (milligrams) po (by mouth) qhs (every night). Monitor Mood and Behavior. A review of the physician's order dated 6/29/2020, showed active diagnosis of Major Depressive Disorder, Recurrent Unspecified; an order for, [Trazadone] HCl (Hydrochloride) tablet 50 MG (milligram) give 50 mg by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, facility staff failed to secure the indwelling catheter tubing and failed to maintain urinary catheter drainage systems below the level of the bladder for two (2) of 43 sampled residents. Residents' #35 and Resident #178. Findings included . A review of the facility's policy entitled, Urinary Catheterization/Foley Care dated 7/15/2020, showed, .Indwelling catheters should be properly secured after insertion to prevent movement and urethral trauma . Drainage bags should always be placed below the level of the patient's bladder to facilitate drainage [allows the urine to drain by gravity and prevents it from flowing back into the bladder] and prevent stasis of urine. According to Cleveland Clinic .Always keep your urine bag below your bladder, which is at the level of your waist. This will prevent urine from flowing back into your bladder from the tubing and urine bag, which could cause an infection.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews for one (1) of 43 sampled residents, the facility staff failed to accurately assess Resident # 244's colostomy site in her progress note. Findings included . Resident #244 was admitted on [DATE], with diagnoses that included Diverticulitis of Intestine, Secondary Hypertension, Peripheral Vascular Disease (PVD), Colostomy Status and Muscle Weakness. A face-to-face interview with Resident #244 was conducted on October 5, 2020, at approximately 2:00 PM. Resident #244 was asked about his condom catheter. Resident #244 explained that he had a condom catheter on admission but it was removed on Friday morning (October 5, 2020) and was told that it would be replaced on Friday afternoon but it was not. Review of the progress notes showed: 9/29/2020, at 19:00 [7:00 PM], Resident is incontinent of both bowel and bladder; has a colostomy bag and uses an [adult brief] . 9/29/2020, at 23:18 [11:18 PM], Resident is alert and verbally responsive .Bowel sound present in all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the attending physician failed to act upon abnormal lab results in a timely manner for one (1) of 43 sampled residents, Resident #50. Findings included . Resident #50 was admitted to the facility on [DATE], with diagnoses that included Anemia, Heart Failure, Hypertension (HTN), Renal Insufficiency, Schizophrenia, Hypothyroidism and Depression. Laboratory test results showed the following: Date of test: 02/03/20 Type of test: TSH [Thyroid-stimulating hormone] 16.321(H) [high] (normal range 0.350-4.940). Date of test: 02/04/20 Type of test: TSH 15.512(H) (normal range: 0.350-4.940) ulU (International Units)/mL (milliliters). A review of the physician's order dated 2/26/2020 at 5:21 [AM] showed, Levothyroxine Sodium Tablet 200 MCG (micrograms) Give 1 tablet by mouth in the morning for [Hypothyroidism]. A review of the document entitled Consultant Pharmacist's Medication Review dated 3/1/2020, For Recommendations Created Between 2/1/2020 And 2/29/2020 showed on page 6, .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 distribute and serve foods under sanitary conditions as evidenced by breakfast food items such as scrambled eggs and ground turkey that were tested below 135 degrees Fahrenheit (F), and inconsistent food temperatures documentation during the months of July, August, and September 2020. Findings included . 1. Facility failed to maintain breakfast food temperatures that were safe and appetizing to Resident #51. During a face-to-face interview with Resident # 51 on 10/01/20, at 11:32 AM, he stated, My food in the morning is cold. On October 7, 2020, at 8:57 AM a test tray containing breakfast foods was measured to determine the food temperatures. The food temperatures were as follows: Ground turkey from the regular diet test tray tested at 119.2 degrees F, and scrambled eggs tested at 123.3 degrees F. Breakfast food temperatures were inadequate and failed to test above 135 degrees Fahrenheit (F). During a face-to-face interview on October 9, 2020, at approximately 10:30 AM, Employee #11 acknowledged these findings. 2. Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, in one (1) of one (1) observation, facility staff failed to wear required personal protective equipment (PPE) while in a resident care area to help minimize the transmission of COVID-19 to residents and other staff in the facility. Findings included . Facility staff failed to wear required personal protective equipment while in a resident care area. During a tour of the third-floor rehabilitation unit on 10/5/2020, at 1:52 PM, Employee #17 (physical therapy assistant, PTA) was observed without a face shield and with facemask pulled down below her chin. A review of the policy entitled, Screening & Use of Personal Protective Equipment (PPE) During An Epidemic dated 9/1/2020, item #12 showed, All employees are required to wear face mask at all times when in the facility. Universal eye protection is required when providing direct patient care or in-patient care areas such as all facility nursing units. During a face-to-face interview conducted on 10/5/2020, at 1:52 PM, Employee #17 (PTA) stated, I took the face shield off because I was just…

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