Waters Edge Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection control program as evidenced by failure to use Personal Protective Equipment (PPE) while providing care for 1 of 1 sampled residents on Enhanced Barrier Precautions (EBP) observed for catheter care, Resident #29. The findings included: Review of the Centers for Disease Control and Prevention (CDC) guidance recommends wearing PPE for resident on EBP. The article titled Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states, Enhanced Barrier Precautions [EBP] are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The guidance can be found at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Review of the policy titled Enhanced Barrier Precautions documented, 1. Enhanced barrier precautions…

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 policy review, Centers for Disease Control (CDC) recommendation review, observation, interview, and record review, the facility failed to ensure appropriate infection control practices as evidenced by the failure to ensure PPE (personal protective equipment) use during COVID outbreak testing for 2 of 2 sampled residents observed, Residents #1 and #11; failed to fully implement their Enhanced Barrier Precautions (EBP) policy for 3 of 3 sampled residents who were not on EBP (Residents #2, #17, and #138), and 2 additional random residents (Residents #25 and #188); failed to implement appropriate infection prevention practices for eye drop administration and blood glucose monitoring for 3 of 7 sampled residents observed during the medication pass observation, Resident #3, #18 and #28; and failed to assist 11 of 11 residents, who ate independently or with minimal assistance, with hand hygiene prior to meals in the main dining room, that included random residents and sampled residents, Residents #15, #20, 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, record review, and policy review, the facility failed to ensure appropriate respiratory assessment or knowledge of possible medication side effects for 1 of 1 sampled resident, Resident #24, who received a nebulizer treatment. The findings included: Review of the policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, documented, in part, Steps in the Procedure: . 6. Obtain baseline pulse, respiratory rate and lung sounds. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. Documentation: The following information should be recorded in the resident's medical record. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment.…

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 care plans were developed for activities and anticoagulant for 3 of 11 sampled residents, Resident #8, Resident #24 and Resident#12, reviewed for care plans. The findings included: 1. Review of Resident #8's records revealed Resident #8 was admitted to the facility on [DATE] with diagnoses to include: Malignant Neoplasm, Cognitive Communication, Major Depressive Disorder, Epilepsy, Anxiety Disorder, Muscle Weakness and Dementia. Review of the quarterly MDS (Minimum Data Set) documented the resident did not have a Brief Interview for Mental Status (BIMS) Score, indicating the resident's cognition was severely impaired. Review of Resident #8's progress notes documented: activities is spending 1:1 time with the resident. Review of the care plans revealed he did not have a care plan for activities. 2. Review of Resident #24's records revealed the resident was admitted to the facility on [DATE] with diagnoses to include: Parkinson's Disease, Atrial…

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 ongoing activities were provided for 1 of 3 sampled residents, Resident#24, reviewed for activities. The findings included: Review of Resident #24 records revealed an admission to the facility on [DATE] with diagnoses to include Parkinson's Disease, Atrial Fibrillation, Coronary Heart Disease, Major Depressive Disorder, Short of Breath, Marasmic Kwashiorkor, and Dementia. Resident #24 was currently on Hospice care. Review of her comprehensive MDS (Minimum Data Set), dated 11/25/22, revealed a Brief Interview for Mental Status (BIMs) Score of 99, indicating her cognition was severely impaired. Further review of her section F: Activity Preferences documented: Very Important: Listening to music is very important to her; Books, newspapers, and magazines to read; be around animals such as pets, to do favorite activities; and go outside and get fresh air is somewhat important to her. Review of her care plans revealed she did not have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and services for residents with limited range of motion (ROM) was provided for 2 of 2 sampled residents reviewed, Residents #14 and #18. The findings included: 1. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included: Non-traumatic Brain Dysfunction and Alzheimer's disease. The quarterly minimum data set (MDS) assessment, reference date 08/18/22, revealed there was no Brief Interview for Mental Status (BIMS) score, indicating Resident #14 was rarely/never understood. There were no behaviors recorded in this MDS. The MDS recorded Resident #14 required total assistance by staff for activity of daily living (ADLs) care. Review of care plan, effective date of 10/18/22, documented Resident #14 had stiffness to bilateral hands. The intervention included: Resident #14 was to have palm guards in place daily, may remove for skin checks and hygiene. On 11/07/22 at 1:50 PM, Resident #14…

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 proper positioning of a catheter bag and tubing for 1 of 1 sampled resident reviewed with a history of urinary tract infection (UTI), Resident #1. The findings included: On 11/14/22 at 10:17 AM, Resident #1 was observed lying in bed, the bed was at low position, and the catheter bag at the bedside was observed with scant hematuria (bloody urine). The catheter bag and tubing were observed touching the floor. When Resident #1 was asked if she had lowered the bed to low position, she stated, 'no, they did' (referring to the staff). On 11/15/22 at 09:07 AM, Resident #1 was observed lying in bed, and the catheter bag was positioned on the floor without protection. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included: Neurogenic Bladder (a urinary condition due to lack of bladder control). The significant change minimum data set (MDS) assessment, reference date 09/11/22, recorded a Brief…

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 act upon a decline in eating ability, ensure consistent meal intake information, and failed to assist and encourage 1 of 1 sampled resident reviewed for weight loss (Resident #16). The findings included: Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 4 on a 0 to 15 scale, indicating the resident was severely cognitively impaired. Further review of this assessment revealed the resident needed the limited assist of one person for eating. Review of the previous MDS dated [DATE] revealed Resident #16 needed only supervision and set up of meals, indicating a decline in ability to feed herself. Review of the current care plans for Resident #16 revealed the following: Effective 02/20/21 to present, the resident had a noted functional decline in self-care, 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 policy review, observation and interview, the facility failed to ensure proper storage of medications in 1 of 2 medication carts observed on the Gardenia Hall and 1 of 1 treatment carts observed on the Gardenia Hall. The findings included: 1. The Policy, Storage of Medications, revised November 2020, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Under policy interpretation and implementation, #6 revealed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. On 11/07/22 at 9:13 AM, while standing at the Gardenia unit, the medication cart was observed left opened, and unlock, while unattended. Several staff walked by the medication cart without acknowledging it. At that time, the attending nurse, Staff B, Registered Nurse (RN) was in room [ROOM NUMBER]. The medication cart was facing forward…

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.