Dade City Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to adhere to the smoking assessment of one resident (#79) out of the twenty smoking residents, and allowed three residents (#79, #9, and #213) to possess unsecured smoking paraphernalia outside of the supervised smoking times. Findings included: 1. On 4/22/24 at 6:30 a.m., Resident #79 was observed sitting at the main entrance of the facility, next to a trash bin/ashtray alone. The resident informed team of having to use the doorbell to get back into the facility. The entrance area smelled of fresh cigarette smoke and a pack of cigarettes was observed sitting on top of the trash bin. The resident entered the building with the survey team. On 4/23/24 at 3:02 p.m., Resident #79 was observed lying in bed and stated the facility started taking away smoking materials about 7-8 months ago, but have gotten lax about it. The resident stated Staff P, Activity Assistant, informed residents' today of having to take the cigarettes away again, saying…

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 interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and six (6) errors were identified for four residents (#67, #48, #415, and #24) of six residents observed. These errors constituted a 20% medication error rate. Findings included: 1) On 4/23/24 at 4:51 p.m., an observation of medication administration with Staff O, Licensed Practical Nurse (LPN), was conducted with Resident #67. The staff member scanned the resident's implantable glucose monitor and received a blood glucose level of 190. Staff O, LPN dispensed the following medications: - Insulin Aspart - Staff O applied needle to insulin pen, primed the pen with 2 units holding it parallel to the floor, applied another needle due to insulin not coming out, dialed the pen to 2 units, while holding the pen at approximately 45 degrees tapped the cartridge. The staff member returned to Resident #67's room, obtained a pulse of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to ensure two residents (#79 and #213) were assessed for self-administration of treatments and medications out of forty sampled residents. Findings included: An interview was conducted with the Director of Nursing (DON) on 4/24/24 at 5:01 p.m., the DON stated she did not believe any residents in the facility were able to self-administer medications. 1. Review of Resident #79's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus with diabetic chronic kidney disease, cellulitis of left lower limb, and End Stage Renal Disease. An observation on 4/23/24 at 3:02 p.m. revealed Resident #79 lying in bed after returning from dialysis. The observation showed a bottle of nasal spray, a spray bottle of wound cleanser, and a bottle of a dark liquid the resident stated was Betadine. The resident reported an undated foam dressing on 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 observations, interviews, and record review, the facility failed to complete the smoking assessment for one resident (#364) out of four residents sampled. Findings included: An observation on 04/22/24 at 9:45 a.m. revealed Resident #364 actively smoking a cigarette on the designated smoking patio during a facility specified smoking time. An interview was conducted on 04/24/24 at 12:09 p.m. with Resident #364. She stated she smokes during designated smoking times daily and has been smoking at the facility since she was admitted on [DATE]. An interview was conducted on 04/25/24 at 10:43 a.m. with the Director of Nursing (DON). She stated the smoking assessment process is completed when residents are admitted to the facility. She said there is a section in the admission assessments to address smoking. She stated the expectation is for staff to complete the smoking assessment immediately along with all assessments that are part of the admission. She said smoking assessments are completed at admission to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to assess, obtain physician orders, and provide treatments for one resident (#79) out of one resident sampled for skin conditions unrelated to pressure injuries. Findings included: On 4/23/24 at 3:02 p.m., Resident #79 was observed lying in bed with a bottle of wound cleanser and a bottle of dark liquid, which the resident stated was Betadine, on the over-bed table within reach of the resident. The observation revealed an undated foam dressing located to the outer aspect of the resident's upper left arm. The resident was observed with two areas on the upper left thigh, one area was approximately dime-size, opened with yellowish-white substance attached to the indented wound bed, and the other area was raised, approximately quarter-sized, with a purplish-red coloration to it. The open area to left thigh had a knuckle bandage next to the area. The resident reported dressing the left thigh by himself, having wound cleanser, Betadine, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one resident (#416) out of two residents sampled for pressure ulcers, received necessary care and services to promote healing, prevent infection, and prevent new ulcers from developing. Findings included: During an interview on 04/22/24 at 9:05 a.m., Resident #416 stated, My heel hurt last night so I asked {Staff B, Licensed Practical Nurse, (LPN)} if she could put the pressure ulcer medicine and bandage on my heel so it could sooth the pain. Resident #416 stated Staff B, LPN responded, No she did not do this at night as she was the only nurse in the facility, she was too busy and the facility was understaffed. Resident #416 stated there should be a bandage on my pressure ulcer at all times. Resident #416's right heel did not have a bandage over the pressure ulcer. Resident #416 gave permission to take photographic evidence of the pressure ulcer located on her right heel. (Photographic evidence obtained). A second observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to provide medications ordered by the physician at the time of admission for one resident (#212) out of one resident sampled for new admissions and failed to notify the physician of the unavailability of the those medications. Findings included: During an interview on 4/22/24 at 12:51 p.m. with Resident #212 and a family member, the family member stated the facility could not get a nebulizer medication from the pharmacy. The resident was lying in bed and wearing oxygen via nasal cannula at the time of the interview. Review of Resident #212's admission Record revealed the resident was admitted on [DATE] with the primary diagnosis of Chronic Obstructive Pulmonary Disease with (acute) exacerbation (COPD). The record included additional diagnoses of acute and chronic respiratory failure unspecified whether hypoxia or hypercapnia and personal history of other malignant neoplasm of bronchus and lung. Review of Resident #212's Admit/Readmit…

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 interviews and record review, the facility failed to ensure physician ordered lab work was completed accurately and in a timely manner for one resident (#33) out of five sampled residents. Findings included: Review of Resident #33's Power of Attorney (POA) correspondence on 04/20/24 at 12:20 p.m. revealed she made nursing staff aware of Resident #33 not acting herself and requested urinalysis (UA) be completed due to resident's history of recurrent urinary tract infections (UTI). The medical record revealed it took over a week to have the UA completed and when it was, the culture and sensitivity (C&S) was not requested as ordered and had to be redone, delaying treatment. An interview was conducted on 04/25/24 at 10:43 a.m. with the Director of Nursing (DON). She stated the process for receiving physician orders is I expect any order to be acted upon immediately, documented and followed through when received. She said if the resident refused the lab there needs to be documentation in the medical record…

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

Based on observations, interviews, and record review, the facility failed to ensure the accuracy of documentation presented for two of two pantry refrigerator temperature logs. Findings included: An observation on 04/22/24 at 11:30 a.m., revealed a Refrigerator/Freezer temperature log that hung on the wall next the free standing refrigerator in the [NAME] Dietary Pantry. The temperature log was incomplete with blank spaces on the form for the dates 04/05/24-04/14/24 and 04/16/24- 04/21/24. Photographic evidence obtained. An observation on 04/22/24 at approximately 12:00 p.m., revealed a a Refrigerator/Freezer temperature log that hung on the refrigerator in the East Dietary Pantry. The temperature log was incomplete with blank spaces on the form for the dates of 04/06/24, 04/12/24, 04/13/24, 04/17/24, 04/18/24 and 04/19/24. An observation on 04/22/24 at 10:30 a.m., revealed the Refrigerator/Freezer temperature log located in the East Dietary Pantry was now fully completed with no blank spaces. Photographic evidence obtained. An observation on 04/23/24 at 12:05 p.m., revealed 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, interviews, and record review, the facility failed to ensure all grievances were tracked through to their conclusion for 1) voiced concerns by residents from the Resident Council and the Food Committee Council meetings between April 2023 and September 2023, and 2) voiced concerns from three residents (#11, #14, and #17) related to their specific diet out of seventeen residents sampled during survey. Findings included: A review was conducted of the Resident Council Meeting Minutes, from April 2023 through September 2023 after speaking with the Resident Council President (Resident #14). An interview was conducted with the Resident Council President (RCP) on 10/03/2023 at 8:50 a.m. The RCP reported the Activities Director (AD) ran the meetings and the RCP was not provided with the minutes from the prior meetings. She reported she did not remember the AD reporting on old business and the status of resolving concerns. The RCP reported the dietary department had not updated likes and dislikes for her and she was aware that new residents are not interviewed about…

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 interviews and record reviews, the facility failed to ensure residents were free from unnecessary medications by 1) not ensuring proper behavioral and side effect monitoring for psychotropic medications for four residents (#2, #5, #6, and #14) of four residents sampled and, 2) not ensuring use of as needed (PRN) psychotropic medications were limited to 14 days for one resident (#5) of four residents sampled. Findings included: A review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of insomnia and wedge compression fracture of the first lumbar vertebra. Resident #2 was discharged from the facility on 5/29/2023. A review of Resident #2's physician's orders revealed the following orders: - An order, dated 5/18/2023 for Zolpidem Tartrate 10 milligrams (mg) by mouth (PO) as needed at bedtime for insomnia. The order was discontinued on 5/18/2023 and restarted on 5/19/2023 with an order duration limited to 14 days. - An order, dated 5/19/2023 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility 1) failed to ensure the planned menu was followed for three of three observed meals during lunch, 2) failed to ensure residents received an alternate meal when they were absent from the facility for three residents (#11, #14, and #17) out of seventeen sampled, and 3) failed to ensure residents were provided their preferences at meals for four residents (#11, #17, #13, and #6) of seventeen residents sampled during survey. Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, unspecified protein-calorie malnutrition, Chronic Kidney Disease, and Dementia. At admission the physician ordered a Mechanical Soft, Renal diet. A review of the Minimum Data Set (MDS) admission Assessment, dated 07/24/2023, revealed the resident's Brief Interview for Mental Status (BIMS) was coded as a 99, indicating the resident was cognitively not able to complete the interview. On 10/02/2023 at 1:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the Patient-Centered Care Plan was followed for one resident (#10) out of 16 residents sampled. Findings included: Resident #10 was admitted on [DATE] and readmitted on [DATE]. Record review showed diagnoses included but were not limited to neurocognitive disorder with Lewy bodies; brief psychotic disorder; adjustment disorder with anxiety; generalized anxiety disorder; unspecified lack of coordination; Diabetes; muscle weakness (generalized); other abnormalities of gait and mobility; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent moderate; and essential hypertension. Record review of the annual, Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Function, a Brief Interview Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section G: Functional Status showed the resident required extensive assistance of two for bed mobility, extensive assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interviews and record review, the facility failed to ensure one resident (# 11) received an antibiotic ordered for a urinary tract infection out of 17 residents sampled during the survey. Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, chronic kidney disease and dementia. A review of the nurses' progress notes revealed the resident was exhibiting aggressive behaviors toward the staff. On 09/08/23 at 4:05 p.m., the nurse documented, Resident has refused all medications since overnight shift, attempted multiple times to encourage with no success. On 09/13/23 at 11:55 a.m. the nurse documented, Resident having behavior issues. resident noncompliant with care plan. attempting to walk with no assistance. biting and refusing care from staff. Doctor notified. On 09/13/23 the nurse documented, Resident attempting to ambulate without assist. Aide attempted to assist resident. Resident bit into aide's arm. Resident continued to throw items…

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 the medical records included completed documentation for one resident (#10) out of 16 residents sampled. Findings included: Resident #10 was admitted on [DATE] and readmitted on [DATE]. Record review showed diagnoses included but were not limited to neurocognitive disorder with Lewy bodies; brief psychotic disorder; adjustment disorder with anxiety; generalized anxiety disorder; unspecified lack of coordination; Diabetes; muscle weakness (generalized); other abnormalities of gait and mobility; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent moderate; and essential hypertension. Record review of the annual, Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Function, a Brief Interview Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section G: Functional Status the resident required extensive assistance of two for bed mobility, extensive assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review it was determined the facility failed to provide Quality Assessment and Assurance (QAA) practices that demonstrated identification, monitoring, and implementation of an effective Action Plan regarding assessing and ensuring two residents (#10 and #12) out of 11 sampled residents with wandering and exit-seeking behaviors was provided supervision and services to prevent elopement. Findings included: Review of the facility's policy entitled, QAPI Change Process, revised on 07/12/2023, showed the following: Policy: the facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. Policy Explanation and Compliance Guidelines: 1. The facility has in operation a Quality Assessment and Assurance (QAA) Committee that is responsible for coordinating and evaluating activities under the facility's QAPI program. 2. The QAA Committee utilizes a systematic approach to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to notify five (#22, #32, #41, #85, and #186) out of five sampled residents and their representatives in a timely manner of the positive COVID-19 results within the facility. Findings included: A review of the positive COVID-19 cases within the facility identified that Resident #32 tested positive on 1/29/22. A review of Resident #22's Quarterly Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 10, indicating a moderate impairment of cognition. The clinical record indicated that a call had been placed, on 2/1/22 at 3:02 p.m., to family member to notify of the most recent COVID 19 number in the facility. A review of Resident #32's admission Record identified the residents' responsible party was a family member. The clinical record indicated that on 2/1/22 at 3:55 p.m. a message left for family member to notify of the most recent COVID-19 numbers in the facility. The review of Resident #41's Annual 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 review of test results, review of the staff schedule for 2/8/22, and interviews, the facility failed to test 26 out of 65 staff members twice weekly for COVID-19 per the community transmission rate (high) for the period of 2/3 - 2/9/22. Findings included: A cross reference review of the staff roster, 2/7 and 2/8/22 staff COVID-19 test results, the working schedule for staff members in all departments for 2/8/22, and the logs of COVID positive staff from November 2021 through January 2022 indicated that the following staff members did not test on 2/7 or 2/8/22 prior to working their shift on 2/8/22: - Staff Member E, Licensed Practical Nurse (LPN) - Staff Member F, Certified Nursing Assistant (CNA) - Staff Member R, Maintenance Assistant - Staff Member T, Speech Language Pathologist (SLP) - Staff Member Y, Housekeeping - Staff Member Z, Housekeeping - Staff Member AA, Housekeeping - Staff Member BB, Certified Occupational Therapy Assistant/Director of Rehab (DOR) - Staff Member CC, Chef - Staff Member DD, Chef - Staff Member EE, Dietary - Staff Member FF, Dietary - Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate three (Residents #49, #56 and #74) of 96 residents by failing to provide beds that were long enough so their feet could extend without hanging over the footboard. Findings Included: 1. Observation and interview of Resident #49 on 2/08/22 at 10:38 a.m., revealed the resident sitting up at the top of his air mattress with his right knee up toward the ceiling, under the covers. The resident straightened his right leg and his foot was observed over the foot board of the bed. The resident stated he was 6 foot 5 inches tall and he had to keep his legs bent or they rub over the footboard and hurt. The footboard of the bed was observed peeling. Observation of the resident on 2/8/22 at 12:00 p.m., revealed the resident lying toward the top of the bed with his right foot hanging over the footboard. During an interview and observation with Staff Nurse I, LPN (Licensed Practical Nurse) on 2/10/22 at 1:18 p.m., she confirmed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to 1. ensure privacy of resident medical information for seven (Residents #4, #11, #50, #54, #55, #74, and #336) of 45 residents and 2. ensure privacy during a shower for one (Resident #37) of 45 residents. Findings included: 1. On 2/8/2022 at 10:30 a.m., the main dining room was observed with eight tables that were used for both activities and dining. The room door was wide open and two residents self propelled their wheelchairs into the room and positioned themselves at various tables. The first table when entering the room was observed with a stack of papers, a notebook electronic device, an electronic mobile phone device, and a computer mouse device. The stack of paperwork and electronic devices were found to be unattended by staff. The stack of papers and devices were within reach and visible to anyone who entered the room. Observations revealed the paperwork included Medication Administration Records, Medication Order sheets,…

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 interviews and record review the facility failed to response to a grievance in a timely manner for one (Resident #61) of forty five sampled residents. Finding Included: An interview on 02/08/22 at 10:37 a.m. with Resident #61 revealed that when she went to the hospital back in December, came back to the facility, and was in isolation for 2 weeks, she wrote a check for $450. She reported that she gave the check to social services in December 2021, and had been given multiple excuses like because of COVID they were not going to the bank. She stated she had been relying on her friend to get things for her because she had not been able to get her money. The resident reported that she spoke with the Business Office Manager (BOM) about her money in January 2022 who stated that she had no money. The resident reported that her statement indicated that the check had been cashed on January 13th 2022. Resident #61 said the Assistant Business Office Manager (ABOM) recently had come to apologize to the resident 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 interview, the facility failed to provide Activities of daily Living (ADL) tasks for one (Resident #41) of 45 sampled residents related to unwanted facial hair. Findings included: Review of Resident #41's medical record revealed that the resident was admitted to the facility on [DATE] and had diagnoses that included Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, dementia without behavioral disturbances, and traumatic amputation at level between knee and ankle. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assist of 1-person physical assist to complete personal care. Review of the quarterly MDS dated [DATE] revealed that the resident required extensive assist of 2-person physical assist to complete personal care. Review of Resident #41's care plan dated 6/24/20, with the most recent revision date of 3/9/21, indicated a risk for ADL related declines or complications due to hx DM…

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, and record review, the facility failed to ensure one (Resident #74) of 45 residents observed received care and services related to a brace and dry flaky feet. Findings Included: During observation and an interview with Resident #74 on 2/9/22 at 1:00 p.m., he stated he had not had a shower in a couple of weeks and no one took his socks off or checked his skin under his brace. Resident #74 stated that the therapist put something under his brace at the bottom of his leg to assist with the rubbing he was getting from the brace, but it had not been checked since then and his feet were extremely itchy. During an interview with Staff F, CNA on 2/9/22 at 1:10 p.m., she confirmed she had not given the resident a shower and had not removed his socks to check his feet or apply lotion as he had not asked her do that. Staff F, CNA removed his socks and white flaky skin dropped to the floor. Staff F, CNA confirmed the residents feet were really dry and needed lotion. During an interview 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, interview, and record review, the facility failed to ensure one (Resident #49) of three sampled residents received catheter care related to a urinary catheter that was cloudy with sediment observed stuck to the tubing. Findings Included: On 2/8/22 at 12:00 p.m., an observation of Resident #49 revealed his urinary catheter tubing was cloudy, gray, and not dated. The resident stated it had not been changed for at least two months and he was currently being treated for a urinary tract infection. The resident said his catheter had not been flushed or changed and he was worried about the way the tubing looked. Observation of Resident #49's tubing on 2/10/22 at 1:10 p.m. revealed the tubing cloudy and gray with sediment. The resident stated no one had looked at the catheter or flushed it. During an interview and observation on 2/10/22 at 1:18 p.m. with Staff I, LPN, she confirmed the catheter did not have orders as to when to change it and she was unaware of the facility policy. Staff I, LPN…

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, and record review, the facility failed to ensure one (Resident # 81) of three residents observed on oxygen, received oxygen as ordered and in a sanitary manner Findings Included: On 2/8/22 at 10:15 a.m., an observation of Resident #81 revealed her sitting in a wheel chair with her oxygen tubing stuck under her wheel chair and dragging across her bedroom floor. On 2/10/22 at 3:05 p.m., an observation of Resident #81 revealed her oxygen tubing bunched up under the wheel chair wheel and under her feet. The resident stated she was unsure why she had so much tubing and said she got stuck in the tubing with her wheel chair. The oxygen setting was observed set at three liters. During an interview with Staff member F, CNA on 2/10/22 at 10:43 a.m., she confirmed the extra long tubing was new for the resident and stated Resident #81 usually did not use the oxygen but had been lately. Staff F, CNA confirmed the setting at 3 liters. Review of the physician's order dated 1/20/22 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 observations, record reviews, and interviews, the facility failed to ensure one (Resident #238) of one resident sampled for Dialysis was monitored pre and post Dialysis services. Findings included: Resident #238 was admitted on [DATE]. The admission Record identified diagnoses not limited to End Stage Renal Disease, Type 2 Diabetes Mellitus with hyperglycemia, and chronic pulmonary edema. Resident #238 was observed, on 2/9/22 at 2:57 p.m. lying in bed and was able to reposition self without assistance. The resident was observed, on 2/10/22 at 1:51 p.m., sitting on the side of the bed speaking on the telephone. The Order Summary Report, active as of 2/10/22, indicated Resident #238 was to receive Dialysis treatments on Tuesday, Thursday, and Saturdays at 4:00 p.m. A review of the calendar for February 2022 indicated that the resident was to receive Dialysis on 2/8 and 2/10/22. The Assessments tab of the electronic record indicated that a skilled nurse's note was last completed on 2/8/22. The skilled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record reviews, the facility did not act upon grievances and recommendations made by resident council. The facility did not consistently provide responses, actions and rationale regarding resident concerns. Four (#46, 151, 50, and 74) of eight residents, participating in interviews expressed concerns with meals and food service. Findings included: 1. A resident council meeting was facilitated by the Council President on 11/18/20 at 11 a.m., attended by 8 regular members. During the meeting, members reported that the facility does not respond to their grievances and that they request the same thing over and over. It was reported that food issues are always the same, including meals passed without silverware, meals are always late, food is served cold and eggs are horrible. The council president reported that the facility ran out of milk the previous week and a request to clean gutters that cause of flooding in the patio has been reported during the last three meetings…

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 interviews, observations and documentation and policy review, the facility did not ensure proper food storage and food service safety for 88 out of 93 residents. The facility failed to ensure the dishwashing machine was operating at the required temperatures, refrigerators were cleaned, and the kitchen and cooking equipment were maintained in a sanitary manner. Findings included: During an initial tour of the kitchen conducted on 11/16/20 at 11:03 a.m. with the Certified Dietary Manager (CDM) and Dietary Manager (DM), the following was confirmed: (photographic evidence was obtained) 1. During the tour at 11:05 a.m., the walk-in refrigerator was noted with dirt, grime on the floor of the cooler and spilled dried matter, caked on the bottom shelf. CDM stated that they should clean the refrigerators more often. The refrigerator door was noted with black- like matter on the rubber sealing of the door. CDM confirmed that the black matter was not sanitary and stated that they would get it cleaned. 2. At 11:10 a.m., the deep fryer was observed with dark brown oil and crumbs 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 reviews and interviews, the facility failed to ensure resident rights were maintained related to not providing transportation to an outside appointment for one resident (Resident #50) out of the sampled forty residents. Findings included: A review of the admission Record for Resident #50 revealed that the resident was initially admitted into the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set (MDS) dated [DATE] found that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. A review of the Order Recap Report with a date of 11/01/20 to 11/30/20 found that the resident had an order for a stress test on 11/11/20 at 7:40 a.m. with pick up at 7:15 a.m. one time a day for cardiac clearance. A review of the calendar provided by the facility, however, revealed that Resident #50 had an appointment scheduled for November 16. During an interview on 11/18/20 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 observations, policy review, and interviews the facility failed to ensure one (#92) of two residents reviewed was able to visit with a family member(s) in privacy and without a staff presence during the visit. Findings included: On the afternoon of 11/17/20 an outdoor visitation, which included three (3) persons, was observed ongoing on the front porch. The persons were assembled in a social distancing fashion, with the participants six (6) feet from each other. On 11/18/20 at approximately 11:00 a.m., another observation indicated one of the participants from 11/17/20 sitting on the front porch during an ongoing family/resident visitation. The participants were socially distanced in a triangular formation and within hearing distance of each other. On 11/18/20, Resident #92 was interviewed regarding concerns of lack of visitation privacy voiced during the facility task of Resident Council. At 1:42 p.m., the resident was observed in her room, sitting in a wheelchair between the two beds. She stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a care plan was developed for one (#38) out of 40 sampled residents regarding the application of a neck brace and failed to implement the plan of care for one (#9) out of 40 sampled residents in regards to the 1-on-1 activities. Findings included: 1. Resident #38 was originally admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and abnormal posture. On 11/16/20 at 12:12 p.m., an observation was made of Resident #38 sitting in a Broda wheelchair. The resident was wearing a type of neck brace and her head was resting past shoulder level in the opposite side of the brace. At 9:45 a.m. on 11/19/20, the resident was observed lying in bed, bilateral mid-torso side rails were raised, and the resident's head was positioned on the right shoulder. The resident was not wearing the neck brace, as it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to revise a resident's care plan to include interventions following falls for one (Resident #33) of two residents sampled for accidents and hazards Findings included: A review of Resident #33's medical record revealed that Resident #33 was admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, low back pain, abnormalities of gait and mobility, difficulty walking, pain in right leg, presence of right artificial hip joint, syncope and collapse, and chronic pain, per the admission record. A review of Resident #33's Care Plan, initiated on 8/14/2020, found that Resident #33 was at risk for falls related to weakness, lack of coordination, low back pain, neck pain, right leg pain, neuropathy, insomnia, artificial right hip joint, syncope, restless legs, and chronic pain, and documented falls on the following dates: - 10/23/2020: Observed hanging from railing sitting on floor, no injury. -…

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 interviews, observations and record reviews, the facility did not ensure that 1:1 activity therapy was provided per the care plan for one Resident (#9) of forty sampled residents. Findings included: Resident #9 was admitted to the facility with a diagnosis of hemiplegia and hemiparesis following other cerebrovascular disease, major depressive disorder, dementia without behavioral disturbance and anxiety. A review of Resident #9's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 3. Section G, functional status revealed that Resident #9 is totally dependent on staff for all mobility and activities of daily living (ADL) assistance. On 11/17/20 a review of the care plan dated 10/13/20 revealed that Resident #9 is bed bound most of the time. The focus on activity preferences included listening to music, watching westerns, sports and family shows. The interventions included 1:1 room visits to provide with leisure activities, socialization and emotional…

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, record reviews, and review of facility policy, the facility failed to ensure that respiratory equipment was stored and maintained in accordance with professional standards for 2 (Resident #35 and #64) of 2 residents sampled for respiratory care. Findings included: 1. A review of Resident #35's medical record revealed that Resident #35 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis and pneumonia, per the admission record. An observation was made on 11/16/2020 at 11:34 a.m., of Resident #35's room. Resident #35 was resting in bed at the time of the observation. A nebulizer and an EzPAP machine were observed at Resident #35's bedside table. The nebulizer tubing attached to the EzPAP machine was dated 11/09/2020. Resident #35's nebulizer mask was stored inside of a plastic bag, which was also dated 11/09/2020. A follow up observation was made on 11/17/2020 at 09:32 a.m., of Resident #35's room. Resident #35 was sleeping in bed 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure consent for use of bed rails was obtained for one (Resident #33) of one residents sampled for bed rails. Findings included: A review of Resident #33's admission record revealed that Resident #33 was admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, low back pain, abnormalities of gait and mobility, difficulty walking, pain in right leg, presence of right artificial hip joint, syncope and collapse, and chronic pain, per the admission record. A review of Resident #33's Minimum Data Set (MDS) Assessment, dated 11/11/2020, found under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. An observation was made on 11/16/20 at 12:03 p.m., of Resident #33 resting in bed. Resident #33 was observed to have bilateral 1/2 length bed rails installed and in place. A review of Resident #33's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that a PRN (as needed) psychotropic medication was limited to 14 days without a rationale to extend the medication for one resident (Resident #50) and failed to ensure behavior monitoring was documented for two residents (Resident #1 and #48) out of the sampled five residents for unnecessary medications. Findings included: 1. The policy Use of Psychotropic Drugs with a revised dated of November 2017 revealed the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 8. PRN orders for 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.

Based on observations and interviews the facility failed to serve a meal that conserved the flavor and appearance of the food for one of one test trays (11-16-20). Findings included: On 11/16/20 at 11:26 a.m., Resident #46 stated, when asked how the food was at the facility, it _____ lately and reported that the facility changed to a new food vendor. She reported that the poached eggs served for breakfast tasted rubbery. On 11/19/20 at 7:32 a.m., the Kitchen Manager (KM) stated breakfast was scrambled eggs and plain muffins. She reviewed the menu and stated the menu indicated it was cheesy scramble eggs, a choice of eggs and choice of bread. The [NAME] was observed removing a pan of eggs from the steamer and pouring approximately half a bag of grated cheese on top of the eggs. At approximately 7:40 a.m., the breakfast meal began to be plated. A test tray, which contained scrambled eggs, bacon, and oatmeal was delivered to the last hall served breakfast then taken to the Main Dining Room. The eggs were a yellowish color with a gray tint and left an unwanted texture in the mouth. 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.