Kentmere Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to ensure three of six residents (Resident (R) 103, R39, R105) reviewed for abuse was free from abuse. Findings include: Review of the facility's undated policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, deprivation of goods or services, or punishment with resulting physical harm' pain or mental anguish, including such conduct facilitated or enabled through the use of technology. Physical abuse was unnecessarily inflicting pain or injury on a resident. 1. Review of R103's Resident Profile located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, acute embolism and thrombosis of left…

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, interview, and facility policy review, the facility failed to protect two of two residents (Residents (R) 17 and R95) from misappropriation of property of 40 sample residents. This failure has the potential to affect all residents who choose to keep money and/or credit cards in their rooms. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime indicated the following: .Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 1. Review of R17's Resident Profile located in the electronic medical record (EMR) under the Resident tab, indicated R17 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, obstructive sleep apnea, diabetes mellitus due to underlying…

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 interview, record review, and review of facility policy, the facility failed to ensure that an allegation of potential abuse was reported to the State Survey Agency (SSA) in a timely manner for one of five residents (Resident (R) 108) reviewed for abuse/neglect of 40 sample residents. This failure had the potential for other allegations of abuse/neglect not to be reported in a timely manner. (Cross Reference F741) Findings include: Review of a facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime dated 10/19 indicated .Witnessed or suspected incidents of abuse are to be reported immediately .neglect, mistreatment . Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours . Review of R108's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R108's EMR…

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, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R) 36) of 40 sample residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. Findings include: Review of the RAI manual, dated 10/24 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate…

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, interviews, and record review, the facility failed to ensure activities of daily living (ADLs) were provided consistently according to the plan of care for two of six residents (Residents (R) 93 and R23) reviewed for ADLs of 40 sample residents. The facility failed to ensure R23 was provided with oral hygiene and R93 was provided with consistent showers twice weekly. This failure placed the residents at risk of a diminished quality of life. Findings include: 1. Review of R93's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R93 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/26/24 revealed that R93 had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R93 was severely impaired in cognition. Review of the ADL Care Plan located in the Care Plan tab of the EMR,…

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, interview, record review, and facility policy review, the facility failed to ensure one Licensed Practical Nurse (LPN) 1, who identified a skin alteration for one of two residents (Resident (R) 36's) reviewed for wound care, notified the Primary Care Physician (PCP) for treatment orders. In addition, the facility failed to ensure a physician ordered blood pressure was obtained prior to administering a hypertensive medication for one of five residents (Resident (R) 109) observed during the medication pass of 40 sample residents. This failure placed residents at risk for health complications. Findings include: Review of the facility's policy titled, Provider Notification of Resident Change in Medical Condition, dated 04/17, indicated .It is the policy of [Facility Name] Rehabilitation and Healthcare Center that staff communicate changes in a resident's medical condition to providers in a timely and accurate manner . Review of the facility's undated policy titled, Pressure Ulcer Identification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure nail care was provided to one of one resident (Resident (R) 1) reviewed for nail care of 40 sample residents. This had the potential to limit mobility for R1 or cause R1 pain if the nails were left untreated. Findings include: Review of the facility's policy titled, Nails, Care of Finger and Toe, dated May 2023, indicated . PURPOSE . To provide cleanliness . To prevent spread of infection . Review of an undated Face Sheet, provided by the facility, indicated R1 was admitted to the facility on [DATE], with diagnoses of abnormalities gait, muscle weakness, and lack of mobility. Review of the five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. The assessment revealed R1 required limited assistance of one staff member for personal hygiene. During an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews, and review of facility policies, the facility failed to ensure one resident (Resident (R) 36) was provided adaptive equipment (padded footrest) that was attached to her wheelchair and failed to ensure one of two residents (R23) was consistently provided with a physician ordered splint to her right arm/hand of 40 sample residents. This failure placed the residents at risk of improper support, positioning, and at risk of further decreased range of motion (ROM) and worsening contractures (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints). Findings include: Review of the facility's policy titled, Repositioning, dated 03/16, indicated .Lifting/handling and other assistive devices will be used whenever determined based on the practitioner order . Review of the facility's policy titled, Splints and Position Devices, dated 05/16, indicated .All residents are screened by therapy on admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, facility document review, and facility policy review, the facility failed to ensure residents were provided with appropriate dementia care interventions from one of one Certified Nurse Aide (CNA) 1 resulting in one of one resident (Resident (R) 108) sustaining harm with visible bruising, skin tears, and complaints of pain of 40 sample residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of a facility's document titled Facility Assessment, dated 10/22/24 and provided by the facility, indicated under a section titled Staff Competencies revealed .Competencies for Certified Nurse's Aides (CNA) include the following .Behavioral Management . Review of a facility's policy titled, Dementia Care, dated 2023, indicated .It is the policy of this facility to provide the appropriate treatment and services to every resident who has signs of, or is diagnosed with dementia, to meet his or her highest practicable physical,…

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, interviews, and review of facility policy, the facility failed to ensure one of one resident's (Resident (R) 36) wheelchair was functioning properly. This had the potential for the resident to use a wheelchair that might not properly fit her body. Findings include: Review of a facility's policy titled, Maintenance Service, dated 12/09, indicated . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Review of R36's electronic medical record (EMR) admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. During an observation on 11/19/24 at 3:46 PM, R36 was seated in a high back wheelchair. During an observation on 11/20/24 at 1:55 PM, R36 was seated in a standard wheelchair. During an observation on 11/20/24 at 5:19 PM with the Director of Rehabilitation (DOR) R36's high back wheelchair was in the resident's bathroom. The DOR stated this was the resident's original wheelchair. During…

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, staff interview, documentation review, and facility policy review, the facility failed to ensure food was stored in a sanitary manner; failed to ensure the dishwasher was at the correct temperature level to sanitize the residents' dishes; failed to ensure sanitizer was at the correct level, and failed to ensure a food storage container was maintained in a clean and sanitary manner. This had the potential to affect 98 of the 99 residents who receive meals from the kitchen. The facility identified one resident who received nothing by mouth (NPO). Findings include: 1. Observation on 10/09/23 at 9:15 AM revealed there was an undated/unlabeled plate of food (a bun with chopped meat on it and some other item) covered with another plate and a bag from a restaurant with leftover food that was not dated or labeled in the third-floor resident refrigerator. The Dietary Manager (DM) was present and verified the observation and stated the items should have been dated and labeled. 2. Observation on 10/09/23 at 9:18 AM revealed the second-floor resident refrigerator contained…

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 5. Review of R65's clinical record revealed: 5/14/21 - R65 is admitted to the facility with multiple diagnoses including a stroke with hemiparesis (weakness or paralysis on one side of the body). 10/21/21 - A Physician's order was written for R65 to receive range of motion activity to both shoulders, elbows, wrists, hands knees and ankles twice a day, every day and evening shift. 10/11/23 - A review of R65's CNA task list in the facility Electronic Medical Record (Emr) revealed the task to perform range of motion activity to both shoulders, elbows, wrists, hands knees and ankles twice a day every day and evening shift. The Range of motion task was not documented as done on the day shift on the following days: 10/2/23, 10/3/23, 10/4/23, 10/6/23, 10/7/23, 10/8/23 and 10/10/23. 10/11/23 1:20 PM - During an interview, CNA6 confirmed that that the CNA range of motion documentation was not present for the day shifts on the following days: 10/2/23, 10/3/23, 10/4/23, 10/6/23, 10/7/23, 10/8/23 and 10/10/23. 10/11/23 1:30…

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

Based on interview, review of facility admission paperwork, and facility policy review, the facility failed to ensure that Residents and/or Resident Representatives (RRs) who signed the Arbitration Agreement would be allowed 30 days to rescind their signature, and failed to ensure the Arbitration Agreement was fully explained. This affected 34 (Residents (R)2,R7,R9, R10, R12, R14, R15, R17, R19, R20, R24, R28, R30, R31, R37, R44, R46, R49, R58, R64, R68, R69, R70, R74, R75, R77, R78, R79, R83, R85, R92, R93, R94, and R442 of 99 residents who had signed the Arbitration Agreement, and had the potential to affect any future residents who might sign the agreement. Findings include: Review of the facility admission paperwork that included an Arbitration Agreement showed: .The Resident understands that (1) the Resident should seek legal counsel concerning this Agreement, (2) the Resident does not have to sign this Agreement as a precondition to the Facility providing services to the Resident, and (3) this Agreement may be rescinded by written notice sent to the other party via Certified…

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 interview, review of the Arbitration Agreement, and facility policy review, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RR) during admission included a clause that a mutually convenient venue for the Arbitration would be selected. This had the potential to affect the 34 residents (R2, R7,R9, R10, R12, R14, R15, R17, R19, R20, R24, R28, R30, R31, R37, R44, R46, R49, R58, R64, R68, R69, R70, R74, R75, R77, R78, R79, R83, R85, R92, R93, R94, and R442) of 99 residents who had signed the Arbitration Agreement and any future resident who might the agreement. Findings include: Review of the facility provided Arbitration Agreement showed: .Notice that the Resident or the Facility wishes to arbitrate a dispute (''Notice) shall be provided to the other party in writing setting forth the basis of the dispute, including relevant dates, the alleged harm, and the requested relief, via Certified Mail, return receipt requested. The parties shall, within three (3) weeks of receipt of the Notice, mutually agree on an…

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

Based on documentation review and staff interview, the facility failed to ensure each Certified Nursing Aide (CNA) received at least 12 hours of in-service training per year. This involved three CNA5, CNA7, and CNA8 of five CNAs education records reviewed. Findings include: On 10/11/23 at 4:32 PM the training records of five certified nursing assistants (CNA) were reviewed with the Staff Development Coordinator (SD). Review of the training records revealed the following: 1.CNA4 had a hire date of 12/16/20. Review of her untitled list of training dated 12/16/21 through 12/16/22 revealed she received 10 hours of in-service training. The SD Coordinator verified CNA7 had not received 12 hours of in-service training in the last year of her employment. 2. CNA5 had a hire date of 12/15/21. Review of her untitled list of training dated 12/15/21 to 12/15/22 revealed she received four hours of in-service training. The SD Coordinator verified CNA5 had not received 12 hours of in-service training in the last year of her employment. 3. CNA8 had a hire date of 02/05/20. Review of her untitled…

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, interview, and policy review, the facility failed to ensure two of three residents (Rs) and/or their representatives (RR) (R 17 and R79) reviewed for facility initiated emergent hospital transfer were provided with written notice of transfer that contained all required information. This failure had the potential to affect the resident and their RR by not having the knowledge of where and why a resident was transferred. Findings include: 1. Review of the Minimum Data State (MDS) tab of R17's electronic medical record (EMR) revealed she had a quarterly MDS assessment with an assessment reference date (ARD) of 07/12/23 with a Brief Mental Status Interview (BIMS) score of nine out of 15 indicating she was moderately cognitively impaired. Review of the Progress Notes tab of the EMR revealed she had a Nursing Note dated 06/30/23 and timed 11:26 PM stating the resident was unresponsive and she was transferred to the hospital. Review of the Progress Note dated 07/06/23 and timed 10:12 PM revealed…

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, interview, and facility policy review, the facility failed to notify the resident and the resident's representative of the bed hold policy upon transfer/discharge to the hospital. This involved two (Residents (R17 and R64) of three residents reviewed for hospitalization. Findings include: 1. Review of R17's Minimum Data Set (MDS) tab of R17's electronic medical record (EMR) revealed she had a quarterly MDS with an assessment reference date (ARD) of 07/12/23 with a Brief Mental Status Interview (BIMS) score of nine out of 15 indicating she was moderately cognitively impaired. Review of R17's Progress Notes tab of the EMR revealed she had a Nursing Note dated 06/30/23 and timed 11:26 PM revealing the resident was unresponsive and she was transferred to the hospital. Review of R17's Nursing Progress Note dated 07/06/23 and timed 10:12 PM revealed the resident was readmitted to the facility. Review of R17s' entire EMR revealed it was silent for a written bed-hold notice being issued when she…

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

Based on staff interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide an accurate resident assessment regarding a Level II screening of a Pre-admission Screening and Annual Resident Review (PASARR) on an admission Minimum Data Set (MDS) assessment for one (Resident (R) 67) out of 28 residents reviewed. Findings include: Review of R67's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 08/25/23 with medical diagnoses that included bipolar disorder - severe with psychotic features, panic disorder (episodic paroxysmal anxiety), suicidal ideations, depression, and cognitive communication deficit. Review of R67's EMR MISC (Miscellaneous) tab showed a Level II PASARR was completed on 08/15/23. Review of R67's admission MDS with an assessment reference date (ARD) of 08/31/23 (along with an 08/31/23 modification sent the same day) showed R67 was coded for not having a Level II PASARR completed. During a telephone interview on 10/12/23 at 11:06 AM, the covering MDS…

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 interview, record review, and facility policy review, the facility failed to ensure of one (Resident (R) 14) of 28 sampled residents reviewed had a Pre-admission Screening and Resident Review (PASARR) re-submitted upon a new mental health diagnosis. This had the potential to place the resident at risk for unmet care needs and not receiving appropriate mental health support/services as needed. Findings include: Review of R14's admission Record located in the electronic medical record (EMR) under the Profile tab showed a facility admission date of 04/11/22. Review of R14's Miscellaneous tab of the EMR revealed a PASARR dated 06/04/22. Review of R14's Diagnosis tab located in the EMR revealed medical diagnoses were input with the effective dates of: Schizoaffective Disorder - 06/08/23 Bipolar Disorder- 06/08/23 Review of R14's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 08/17/23 included psychiatric/mood disorder to include schizophrenia (e.g., schizoaffective, and schizophreniform disorders). Review of R14's Care Plan…

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

Based on record review, interview, and facility policy review, the facility failed to ensure that one of two residents (Resident (R) 441) reviewed for bed rail use had documented safety assessment for the use of bed rails and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use. This failure had the potential for the resident or the RR to be uninformed of the risks associated with bed rail use. Findings include: Review of R441's admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admission date of 09/20/23 with medical diagnoses that included hemiplegia and hemiparesis (paralysis) following a cerebral infarction (stroke), muscle wasting and atrophy. A review of R441's EMR Assessments, MISC [Miscellaneous], and Progress Notes tabs on 10/11/23 at 9:40 AM did not reveal any assessments, risk/benefit advisements, or signed consents for the use of the bedrails. Observation and interview on 10/09/23 at 12:05 PM, with R441's RR was asked about the bilateral upper side rails on R441's bed and if they…

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 documentation review and staff interview, the facility failed to ensure a performance review was completed every 12 months for five (Certified Nursing Assistants (CNA)4, CNA7, CNA5, CNA8, CNA1) of five nurse aide performance reviews reviewed. Findings include: On 10/11/23 at 9:07 AM the personnel files and the performance reviews of five CNAs were reviewed with the Human Resources/Payroll Coordinator (HR). Review of the performance reviews revealed the following: 1. CNA4 had a hire date of 05/20/20. The last performance review in her personnel file was a 90-day evaluation dated 08/27/20. 2. CNA7 had a hire date of 12/16/20 and the last performance review was dated 02/05/22. 3. CNA5 had a hire date of 12/15/21 and the last performance review was dated 10/07/19. The HR stated CNA5 was a rehire and she had not had a performance review since she was rehired on 12/25/21. 4. CNA8 had a hire date of 02/05/20 and her last performance review was dated 03/30/22. 5. CNA1 had a hire date of 12/19/21 and her last performance review was dated 04/08/22. During an interview on 10/11/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure there were no loose pills in the medication carts and failed to properly store medication for one (Resident (R) 79) that was located in another resident's room (R16). This had the potential for unauthorized residents or staff to access the medications. Findings include: 1.Review of R79's Order Summary Report located in the EMR under the Orders tab included an order for Voltaren Gel 1% (Diclofenac Sodium) to be applied to the left thumb base topically two times a day for thumb pain as of [DATE]. During an observation on [DATE] at 3:10 PM revealed Voltaren Gel (Diclofenac Sodium) 1% was on R16's over the bed table with a medication label for R79. Review of R16's Order Summary Report located in the EMR under the Orders tab did not include Voltaren Gel (Diclofenac Sodium) 1% (percent) (arthritic pain reliever). During an interview on [DATE] at 3:10 PM with R16 stated she was not aware of the cream on her over the bed…

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