North Dade Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that menus were followed for nutritional adequacy to meet special dietary needs for one diabetic (Resident #1) out of three residents sampled. There were 40 diabetic residents out of the 211 residents present in the facility at the time of the survey. The findings included: Observation and interview of Resident #1 on 6/30/25 at 7:43 AM, revealed the resident sitting in a chair in his room and received his breakfast tray. The breakfast tray consisted of: Boiled egg (1), Oatmeal (1 bowl), Toast (2 slices), Regular Sugar (3 packets), Regular grape jelly (1 packet), Coffee (1 cup). The tray did not include a meat, a choice of Vitamin C juice, sugar substitutes and sugar-free jelly. The resident revealed via a Spanish translator that he eats what his roommate tells him to eat on the food tray because he is diabetic. He doesn't use the regular sugar or regular jelly. They don't send him a diabetic sugar or jelly on his food tray.…

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 and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F689 Accidents Hazards and F803 Menus Meet Resident Needs and Followed. These deficient practices have the potential to affect 211 residents residing in the facility at the time of the survey. The findings included: Record review of Quality Assurance and Performance Improvement (QAPI) policy and procedure (issue date June 2021). The purpose of the committees is to review and analyze facility related data, evaluate improvement plans effectiveness and direct appropriate actions for the facility response. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure and implementation of corrective actions. Review of the facility's survey history revealed, during a recertification survey with exit dated August 1, 2024, F689…

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 interviews the facility failed to ensure residents' medical records are accurate in accordance with accepted professional standards and practices for two (Resident #1 and Resident #3) out of three residents sampled, as evidenced by an Elopement Risk Assessment information for Resident#1 was struck out by the Director of Nursing (DON) when written by the Assistant Director of Nursing (ADON); and a progress note for Resident #1 that indicated Resident #1 left Against Medical Advice (AMA) without staff observation of Resident #1 exiting the facility and an Elopement Care Plan for Resident #3 noted with interventions that included a monthly [wander management system] check inconsistent with an attestation from the facility stating [wander management systems] are not used, These practices has the potential to affect any of the residents residing in the facility. 1) Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] 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.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents and was cited for Free of Accident Hazards, Supervision, Devices and Quality Assurance and Assessment (QA&A).during survey with Event ID # 4HN11, exit date 08/02/2024 with noncompliance cited at a scope and severity (S/S) of No actual harm with potential for more than minimal harm that is not immediate jeopardy (D). Additional during survey Event ID # 8CDC11, exit date 06/04/2024 QA&A with noncompliance cited at a S/S of D. During survey Event ID # 4E6811, exit date 09/20/2023 Administration was cited at S/S of Actual harm that is not immediate jeopardy (G). On 8/22/2024, the facility was negligent and failed to provide adequate supervision and effective services to prevent harm resulting in the death of one (Resident #1) out of three sampled residents 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.

Based on observations, interview and record review, the facility's quality assurance and assessment committee (QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem areas related to repeated deficient practices; as evidenced by, review of the facility's history revealed during the survey with exit dated 03/24/2023 the facility was cited for these repeated deficiencies identified during this survey with exit dated 08/01/24 related to: F584 Safe/ Clean/ Comfortable/ Homelike Environment, F641 Accuracy of Assessments, F645 PASRR Screening for Mental Disorder/ Intellectual Disability, F656 Develop/implement comprehensive care plan, F684 Quality of Care, F791 Routine/Emergency Dental Services, F761 Label/Store Drugs & Biologicals and F867 QAPI/QAA Improvement Activities. This pattern of repeated deficient practice has the potential to affect any of the 208 residents residing in the facility at the time of the survey. The findings included: Review of the Quality Assurance and Performance Improvement (QAPI) Committee…

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, interview, and record review the facility failed to promote and ensure residents are treated in a dignified manner and treated with respect; for four out of the 36 residents sampled. (Resident #201, Resident #159, Resident #48 and Resident #76). As evidenced by 1) staff observed standing while feeding Resident #201 with breakfast. 2)Resident #201 and 159 did not receive their food tray until half an hour after the other two roommates. 3) Staff referred to the residents that need assistance with eating as feeders and 4) Resident #48 in view of staff and other residents was wearing no pants with genitals exposed and Resident # 76 was wearing no socks or shoes propelling in wheelchair around the facility. There were 208 residents residing in the facility at the time of the survey. The findings included: 1) Observation on 07/29/2024 at 12:26 PM trays arrived for residents that ate in rooms, one nurse and three Certified Nursing Assistants (CNAs) started serving trays immediately. Further…

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 and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident #145) out of the 36 sampled residents. There were 56 residents residing in the facility that are smokers. The finding included: Review of Resident # 145's admission records an initial admission date of 11/28/2022. Record review of the Annual Minimum Data Set (MDS) dated [DATE] Sections C-Cognitive Patterns/Brief Interview for Mental Status (BIMS) was 05 out of 15, indicating severe cognitive impact. Section J-Health Conditions item J1300. Current Tobacco Use was checked No. Record review of Care plan dated Date 6/16/2024, Target Completion Date 9/14/2024 revealed that the facility had not done a care plan for the resident. Interview with MDS Coordinator on 07/31/24 at 02:23 PM. she stated: This was coded by my assistance who is no longer working in the facility. If the residents is not coded properly in the MDS it would not create the care plan thus the reason why there is not a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to readmission and failed to revise the screening following admission for one (1) Resident (#107). There were 208 residents residing in the facility at the time of the survey. The findings Included: During observations on 07/29/24 at 08:10 AM Resident #107 was in bed asleep. On 07/30/24 at 08:58 AM Resident # 107 was in bed awake. On 07/31/24 at 09:31 AM resident in bed asleep. Review of the medical records for Resident #107 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Major depressive Disorder and Anxiety Disorder and Unspecified psychosis not due to a substance or known physiological condition. Record Review of Resident #107's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check…

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 and record review, facility failed to develop a Smoking care plan for Resident # 145 out of one resident reviewed for discharge care plan at the time of the survey. there were 208 residents residing in the facility at the time of survey. The findings included: Record review of admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Anemia, Hypertension, Arthritis, Cataracts, glaucoma, or macular degeneration and insomnia, Record review of Care plan dated Date 6/16/2024, Target Completion Date 9/14/2024 revealed that the facility had not done a care plan for resident Interview with MDS Coordinator on 07/31/24 at 02:23 PM, she reported the Minimum Data Set (MDS) was coded by her assistance who is no longer working in the facility. If the residents is not coded properly in the MDS it would not create the care plan thus the reason why there is no smoker care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews facility failed to provide treatment and care for a skin condition for one resident (Resident #8) out of eleven residents sampled as evidenced by Resident # 8's right foot was noted to be dry and scaly while in bed. There were 208 residents residing in the facility at the time of survey. The findings included: On 07/29/24 at 8:50 AM an observation was made of Resident #8 in bed and the right foot exposed from under linens. Resident #8's right foot appeared dry and scaly. Record review of demographic sheet for Resident #8 revealed an admission date of 3/19/2012 and readmission date of 1/1/20222 with diagnosis that included Hemiplegia and Hemiparesis affecting left non-dominant side and Peripheral Vascular Disease. Record review of physician order sheet revealed orders dated 12/27/23 for Weekly Skin Check. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C (cognitive status) revealed a Brief Mental Status Score of 15 out of 15 indicated…

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 the safety of two vulnerable residents (Resident #12 and Resident # 84) out of 40 residents sampled. As evidenced by an open toiletry bag full of shaving razors was observed on Resident #12's overbed table and a shaving razor was observed on Resident # 84's bedside table. Failed to ensure two Soiled Utility/Biohazard rooms, were locked. There were 208 residents residing in the facility at the time of survey. The findings Included: During observation 7/29/24 at 08:15 AM Resident #12 was in bed watching television, an open toiletry bag full of razors was on the overbed table, (Photo available). On 07/30/24 at 07:56 AM Resident #12 was in bed awake he revealed the Director of Nursing (DON) took away his bag of razors from him and it has his money in it, he wants the bag back, when Resident #12 was asked if he is allowed to have a bag of razors with him, the resident refused to answer and reported he wanted to see the DON. Interview 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.

Based on observations, interviews and record review the facility the failed to ensure medications are secured and properly stored on the facility's E wing and medication at bedside for two (Resident #96 and Resident #98) out of eleven sampled residents as evidenced by the E Nursing unit medication cart was observed unlocked and unattended. Observation of a bottle of nasal spray, eye drops, and Ammonium Lactate Lotion at Resident #96's bedside, a bottle of Ammonium Lactate lotion observed on the side table in front of Resident #98. There were 208 residents residing in the facility at the time of survey. On 07/29/24 at 8:57 AM an observation was made of an unlocked medication cart unattended in The E Nursing unit. (photo evidence) On 07/29/24 at 9:02 AM Staff R, Registered Nurse (RN) exited a resident's room and returned to cart. Approached by surveyor. Staff R, RN stated The medication cart should always be locked when unattended for residents' safety, I left it unlocked because I was not a far distance from the cart. On 07/29/24 at 9:04 AM an observation was made of a bottle 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 observation, interview and record review, the facility failed to assure that emergency dental services were provided for one (Resident number186) out of one resident who triggered for dental. This practice has the potential to decrease resident's ability to reach their highest potential. The findings included: Record review of the facility's policy titled Dental Services (issued date 3/2021) documented: Policy-It is the policy of the facility to provide Dental Services in accordance to State and Federal regulations; Procedure: 1) The facility will provide from an outside source routine and emergency dental services to meet the needs of each resident and 2) The facility will provide necessary assist the resident by: a) making appointments and b) arranging for transportation to and from the dentist's office. Observation and interview with Resident number 186 on 7/29/24 at 9:55 AM revealed the resident sitting up in bed, watching television with right leg amputee below the knee and missing teeth were…

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 assure that menus are developed and prepared to meet resident choices including their cultural and ethnic needs for one (Resident number 186) out of one resident who triggered for food. The findings included: Observation and interview with Resident number 186 on 7/29/24 at 9:57 AM revealed the resident sitting up in bed, watching television with right leg amputee below the knee and missing teeth were noted. The resident stated, The food is also lousy. They give us a ham and cheese sandwich on Sundays. Who wants to eat a ham and cheese sandwich on a Sunday. Review of the Demographic Face Sheet for Resident number 186 documented the resident was initially admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, peripheral vascular disease, epilepsy and acquired absence of right leg below knee. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident number 186 documented the resident's Mental…

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 interview the facility failed to ensure food was prepared under sanitary conditions as evidenced by failure to maintain equipment in the nourishment pantry in a clean sanitary manner. This was observed in one of three nourishment pantries and has the potential to affect thirty-five out of forty residents who eat orally residing on the J unit in the facility at the time of the survey. The findings include: Record review of the facility's policy titled Safety Awareness (issued date 3/2021) documented: Policy-It is the policy of the facility to provide Safety Awareness in accordance to State and Federal regulations; Procedure: 2) The facility will maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Observation of the J Unit Floor Nourishment Pantry Room on 7/30/24 at 11:31 AM with Staff S, Licensed Practical Nurse (LPN) revealed the following: Microwave used to warm up resident's foods was not clean, had brown, dried substances and contained brown-like rust stains in the microwave. Photographic…

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, interview and record review, the facility failed to ensure a microwave used for residents was in good repair. The microwave in the Nourishment Pantry Room contained brown-like rust stains. This has the potential to affect thirty-five out of forty residents who eat orally residing on the J unit in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Safety Awareness (issued date 3/2021) documented: Policy-It is the policy of the facility to provide Safety Awareness in accordance to State and Federal regulations; Procedure: 2) The facility will maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Observation of the J Unit Floor Nourishment Pantry Room on 7/30/24 at 11:31 AM with Staff S, Licensed Practical Nurse (LPN) revealed the following: Microwave used to warm up resident's foods was not clean, had brown, dried substances and contained brown-like rust stains in the microwave. Photographic evidence submitted. On 7/30/24 at 11:33 AM, interview with Staff S,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure adequate information was documented in the medical records for one (Resident #2) out of three residents reviewed for admission, transfer and discharge rights. As evidenced by the medical records for Resident #2 was not documented in accordance with accepted professional standards/practices, that require residents' records to be complete, accurate, organized and contain sufficient information. The facility's staff were unable to provide factual information related to Resident # 2's status after leaving the facility to the hospital via emergency services. The findings included: Review of the Demographic Face Sheet for Resident #2 documented Resident #2 was admitted on [DATE] with a diagnosis that include but not limited to diabetes mellitus, bipolar disorder, atherosclerotic heart disease, dementia, cerebral infarction and hypertension. The resident was discharged to the hospital on 8/02/2023. Review of the Minimum Data Set (MDS) 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.

Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns in order to implement effective plans of action related to maintaining accurate medical records resulting in repeated deficient practice. The facility was cited F842- Resident Records ? Identifiable Information in March 2023; again during this survey. The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (issued June 2021) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 1) The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; 2) The QAA Committee shall be interdisciplinary and shall: b) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI 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.

Based on observations and interviews and records reviewed the facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by strong urine odor noted throughout the facility. 2) unclean, disrepair unkempt environment to include disrepair toilet in Resident # 51) unclean ceiling in resident room (Resident # 91). This deficient practice has the potential to affect all residents residing in the facility at the time of this survey. The findings included: 1) On 3/20/23 at 6:00 AM, upon entrance into the facility and during tour of the facility a strong urine ordor was noted. During the tour on Wing A and Wing B of the facility on 03/20/2023 at 06:00 AM, a strong urine odor. During the observational tour of Wing D and E on 03/20/2023 at 06:15 AM, there was a strong urine odor noted. On 03/20/2023 at 06:37 AM a strong urine odor was noted on Wing G during the observational tour. On 03/21/2023 at 07:30 AM there continued to be a strong urine odor noted on Wing D. On 03/21/2023 at 08:00 AM there was a strong urine odor on Wing G. On 03/23/2023 at 07:44 AM…

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, facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for serious mental illness (SMI) or intellectual disability (ID) was completed at the time of admission for one resident (Resident #40) and failed to request Level II PASRR for eight residents (Resident # 40, Resident #63, Resident # 28, Resident # 34, Resident #146, Resident #118 and Resident #120 and Resident #53) out of twelve residents whose PASRR were reviewed. This deficient practice had the potential to affect 207 residents residing in the facility at the time of the survey. The findings included: 1) Observation of Resident #40 on 03/24/2023 at 11:32 AM; revealed the resident lying on his bed, watching television. No distress or anxiety was noted. Resident stated he was doing well. Review of the clinical records for Resident # 40 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Essential (Primary)…

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, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices cited during this survey for: F585-Grievances F623- Notice Requirements Before Transfer/Discharge; F641 Accuracy of Assessments; F645 PASARR Screening; F695 Respiratory/Tracheostomy Care and Suctioning; F761 Label/Store Drugs and Biologicals; F849 Hospice Services. These repeat deficient practices has the potential to affect 207 residents residing in the facility at the time of survey. The finding included: Record review of the facility's survey history revealed, during a recertification conducted on December 6, 2021, through December 9, 2021 the facility was cited F623 Notice Requirement before Transfer/Discharge was cited as the facility failed to provide the Nursing Home Notice of Transfer Discharge to the resident and or representative and the office of the Long-Term Care Ombudsman; F641 Accuracy of Assessments due to failure to accurately code 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 interview, the facility failed to provide documentation of informing two (2) out of 38 sampled residents about advance directives for Resident #9 and Resident #146. The findings included: 1. During the review of the electronic medical record for Resident #9, it was noted the resident was admitted to the facility on [DATE]. The residents diagnoses included but were not limited to Rheumatoid Arthritis, Essential Hypertension and Alzheimers Disease. The resident was documented as a Do Not Resuscitate (DNR) and was receiving Hospice services. The record was reviewed for the residents or family's receipt of advance directive information. This information was not found. During interview on 3/24/2023 at 1:29PM with the Director of Social Services a request was made for the advance directive information for resident #9. On 03/24/2023 at 3:23 PM, a Durable Power of Attorney form dated 3/17/2017 for fiduciary duties and a Physicians Evaluation of capacity to make health care decisions, signed 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 observations, record review and interviews, the facility failed to respond to grievances for one (Resident #120) out of one resident reviewed for grievances. The resident's brother established communication with the facility concerning complaints about the brother's care with rehabilitation and was not informed of the results of the grievance. There were 207 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Grievance (written 3/01/2022) documented the following: Intent: It is the policy of the facility to have a grievance process in accordance to State and Federal regulations; Procedure: 1) The facility will have a grievance procedure available to its residents and their families. The grievance procedure must include: a) An explanation of how to pursue redress of a grievance, e) Each nursing home facility shall maintain records of all grievances and a report, subject to agency inspection, of the total number of grievances…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a notice to the Ombudsman concerning a discharge to the hospital for one (Residet #211) out of three residents reviewed for hospitalization. The findings included: Record review of the facility's policy titled, Transfer and Discharge Requirements (written [DATE]) documented the following: Policy: It is the policy of the facility to transfer and discharge the resident according to State and Federal regulations; Procedure: 2) When the facility transfers or discharges a resident, the resident's clinical record will include documentation related to the reason for the discharge or transfer, 4) When a discharge or transfer is initiated by the nursing home, the nursing home administrator employed by the nursing home that is discharging or transferring the resident or an individual employed by the nursing home who is designated by the nursing home administrator to act on behalf of the administration, must sign the notice of discharge or transfer, 11)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a bed hold policy to the resident concerning a discharge to the hospital for three (Resident # 211, Resident #175 and Resident # 62) out of three residents reviewed for hospitalization. The findings included: 1) Record review of the facility's policy titled, Bed Hold Notice Upon Transfer (written 11/2019) documented the following: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed; Policy Explanation and Compliance Guidelines: 1) Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a) The duration of the state bed-hold policy, if any, during which 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 observation, record review, and interview, the facility failed to document an accurate Minimum Data Set (MDS) related to oxygen use for one (1) out of 61 residents receiving respiratory treatment (Resident #134). The finding included: Observation on 03/21/2023 at 07:29 AM revealed, Resident #134 in bed asleep, the resident had tube feeding Nepro with Carbohydrates, 45 cc(cubic centimeters) per hour, a water flush 40 cc/hr. The resident was receiving oxygen at 1 1/2 liters per minute via nasal cannula, with a humidifier bottle dated 3/12, the bag on oxygen canister was dated 3/12. Observation of Resident #134 on 03/24/23 at 02:00 PM, revealed the resident was receiving oxygen at 1 1/2 liters via nasal cannula. During the review of Resident #134's clinical records it was noted that the resident had a physician order for oxygen at 2 liters via nasal cannula continuous. Review of Residents #134's care plan indicated the resident is at risk for ineffective breathing pattern related to: Pulmonary Edema 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 implement a written care plan related to skin integrity and dental for one resident (Resident # 91) out of 38 sampled residents. The findings included: 1) Observation and interview of Resident # 91 on 3/21/2023 at 9:16 AM revealed the resident lying in bed, wearing glasses and was missing top and lower teeth. The resident was scratching his arms and abdomen area. He lifted the blanket and showed bumps on his arm and abdomen area. He revealed via a Spanish translator that he had been itching and was not receiving anything for it. He revealed he had not seen the dentist and would like to see one. Review of the Demographic Face Sheet for Resident #91 documented the resident was admitted on [DATE] with a diagnoses to include diabetes mellitus, insomnia, hypertension, Hyperlipidemia and major depressive disorder. Review of the Physician's Order Sheets (POS) for Resident # 91 dated January 2023, February 2023, March 2023 documented no orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide treatment and care related to skin integrity for one resident (Resident # 91) out of one resident reviewed for skin conditions. The findings included: Observation and interview of Resident # 91 on 3/21/2023 at 9:16 AM revealed the resident lying in bed. The resident was scratching his arms and abdomen area. He lifted the blanket and showed bumps on his arm and abdomen area. He revealed via a Spanish translator that he had been itching and was not receiving anything for it. Review of the Demographic Face Sheet for Resident # 91 documented the resident was admitted on [DATE] with a diagnoses to include diabetes mellitus, insomnia, hypertension, hyperlipidemia and major depressive disorder. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident # 91 dated 1/08/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating mild cognitive impairment and 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, interviews, and record review the facility failed provide respiratory services to meet professional standards for two residents (Resident #118 and Resident #134) out of the 38 sampled residents. Resident # 118 was receiving oxygen without a physician's order and Resident # 134 oxygen was not being administered at the rate ordered by the physician. The findings included: 1) During observation on 03/20/23 at 07:44 AM Resident #118 was observed in bed asleep with tube feeding in place and infusing. The resident was receiving oxygen at 2 liters per minute via nasal cannula. On 03/20/2023 at 10:19 AM Resident # 118 was observed in room awake and oxygen running at 2 liters per minute via nasal cannula. During an observation on 03/20/23 at 10:21 AM Resident #118 was observed in bed awake. The resident did not respond to questions. On 03/21/2023 at 07:36 AM Resident #118 was observed in bed with 02 running at 2 liters per minute via nasal cannula no distress noted. On 03/22/2023 at 07:39 AM,…

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 ensure dental service was provided for one resident (Resident # 91) out of one resident reviewed. This practice has the potential to affect all 207 residents present in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Dental Services (written 3/2021) documented the following: Policy: It is the policy of the facility to provide Dental Services in accordance to State and Federal regulations; Procedure: 1) The facility will provide from an outside source routine and emergency dental services to meet the needs of each resident; 2) The facility will provide necessary assist the resident by: a) making appointments and b) arranging for transportation to and from the dentist's office. Review of the facility's policy titled, Social Services (written 3/2021) documented the following: Policy: It is the policy of the facility to provide Social Services in accordance to State and Federal…

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, interview and policy review the facility failed to assure the garbage and refuse area was clean and flattened cardboard boxes were properly disposed and contained on the facility grounds. The findings included: Record review of the Dietary Disposal of Garbage and Rubbish Policy and Procedure (dated 3/01/2021) documented: Policy: It is the policy of the facility to provide care and services related to the disposal of garbage and rubbish in accordance with State Requirements; Procedure: 7) Garbage should not accumulate or be left outside the dumpster. Observation of the outside of the facility near the garbage and refuse area with the Food Service Director (FSD) on 3/20/2023 at 6:28 AM. The area had two garbage bins with one used for garbage and one for recyclables. There were fourteen flattened cardboard boxes leaning against the wall on the ground and not contained in the recycling bin. Photographic evidence submitted. Interview with the FSD on 3/20/2023 at 6:29 AM. She stated, We are not responsible for these boxes on the ground.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure complete and accurate documentation of resident's Advanced Directives for 1 (Resident #175) out of 38 sampled residents. The findings included: During observation on 03/20/23 at 07:55 AM Resident # 175 was observed in bed. The head of bed the bed was elevated, tube feeding was running at 50 milliliters per hour (ml/hr.), flush at 50 ml. Oxygen (02) was in place and running at 2 Liters per minute (LPM)via nasal cannula. On 03/21/23 at 08:26 AM Resident # 175 was observed in bed, with the head of the bed elevated, the tube feeding was off, and oxygen was running at 2 LPM via nasal cannula. No distress noted. On 03/22/23 at 07:36 AM Resident #175 was observed in bed asleep, the tube feeding was running, and oxygen was in place at 2 LPM via nasal cannula. Review of the medical records for Resident #175 revealed Resident #175 was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Osteomyelitis, unspecified. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #153) out of 6 residents on hospice care, as evidenced by no updated hospice communication notes available in Resident #153's medical records. This had the potential to affect the 207 residents residing in the facility at the time of this survey. The Findings Included: During observation on 03/20/2023 at 06:47 AM resident in bed asleep, call light on bed, no distress noted. On 03/21/2023 at 08:25 AM Resident #153 was observed in bed asleep, no distress noted. On 03/22/2023 at 07:30 AM Resident #153 was observed in bed asleep, no distress noted. On 03/22/2023 10:42 AM Resident #153 observed in wheelchair in room, rolling around, no distress noted. On 01/18/2023 at 08:36 AM Resident #153 was observed in bed asleep. Tube feeding running at correct rate, no distress noted. Review of Resident #153's hospice contract documented: 11/14/2014 hospice contract…

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.