Westview Of Derby Rehabilitation & Health Care Cen

- The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R57's admission Minimum Data Set (MDS) dated 12/19/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS noted he required substantial to maximal assistance with transfers, toileting, bed mobility, bathing, and personal hygiene. The MDS noted he took anxiolytic medication. R57's Psychotropic Drug Use Area Assessment (CAA) completed 12/28/24 indicated he was on hospice services and took antianxiety medication. The CAA instructed staff to monitor him for side effects. The CAA noted the consultant pharmacist (CO) would recommend a gradual dose reduction…

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.

The facility identified a census of 69 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to store oxygen saturation equipment and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) tubing in a sanitary manner and further failed to ensure the required personal protective equipment (PPE) was worn while doing tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 03/03/25 at 07:08 AM, during the walk-through of the facility, Resident (R) 225's oxygen tubing and cannula were wrapped over her walker and her nebulizer tubing was on her side table, the tubing for R225 was not stored in a sanitary manner. On 03/04/25 at 01:26 PM,…

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 The facility identified a census of 69 residents. The sample included 18 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's call light was within her reach and further failed to provide foot pedals for R25 while pushing her in the hall. This deficient practice left R24 vulnerable to unmet care needs due to the inability to call for staff assistance and placed R25 at an increased risk for preventable falls and injuries. Findings Included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of heart failure (a condition with low heart output), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), effecting the left nondominant side, muscle weakness…

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 The facility reported a census of 69 residents. The sample included 18 residents, with one reviewed for personal funds. Based on record review, interviews, and observations, the facility failed to prevent unnecessary charges to Resident (R) 218 bank account resulting in multiple charges to his bank account. This deficient practice placed R218 at risk for misappropriation of funds. Findings Included: - The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Chronic obstructive pulmonary disorder (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), senile degeneration of the brain, and dementia (a progressive mental disorder characterized by failing memory and confusion). R218's EMR indicated he was admitted to the facility on [DATE]. R218's admission Minimum Data Set (MDS) completed 09/19/24 noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive…

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

The facility identified a census of 69 with 18 residents included in the sample. The facility identified 12 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 63. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - Review of R63's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 11/13/24 and ended on 012/06/24. R12 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued the SNF ABN 10055. On 03/02/25 at 11:25 AM, Social Service X stated she had never given an SNF ABN for residents ending Medicare part that were staying in the facility. She stated she was not trained to give SNF ABN. The facility's 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 The facility identified a census of 69 residents. The sample included 18 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24's heels were offloading, heel protectors were applied to both heels and further failed to monitor R24's low air loss mattress. This placed R24 at increased risk for developing pressure ulcers. Findings Included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of heart failure (a condition with low heart output), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery 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.

The facility identified a census of 69 residents. The sample included 18 residents, with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently monitor and document Resident (R) 54's dialysis (a procedure where impurities or wastes were removed from the blood), shunt for bruit (blowing or swishing sound heard when blood flows through a shunt), thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt), and dressing. This deficient practice placed R54 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dialysis hypertension (HTN - elevated blood pressure),…

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

The facility identified a census of 69 residents. The sample included 18 residents, with seven reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure R4's Diclofenac (topical medicated ointment used to treat pain) medication had a dosage administration amount. This deficient practice placed both residents at risk for unnecessary medications and potential side effects. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, aphasia (difficulty speaking), chronic kidney disease, and heart failure. R4's admission Minimum Data Set (MDS) dated 12/16/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she required substantial to maximal assistance with transfers, bed mobility, dressing, toileting,…

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.

The facility identified a census of 69 residents. The sample included 18 residents, three medication carts, and one medication room. Based on observation, record review, and interviews, the facility failed to properly label medication in one of the three medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 03/05/25 at 09:06 AM the licensed nurse medication cart on the 400 hallway contained one opened, undated insulin (a hormone that lowers the level of glucose in the blood) pen. On 03/05/25 at 09:06 AM, Licensed Nurse (LN) G stated all insulin pens should be labeled once they are removed from the refrigerator and placed into the medication cart. On 03/05/25 at 01:17 PM, Administrative Nurse D stated she expected all insulin pens to be dated and labeled once the pens were opened. The facility failed to provide a policy related to medication storage. The facility failed to properly label medications. This deficient practice could potentially cause adverse consequences or ineffective treatment to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 70 residents with three selected for review for bathing services. Based on observation, record review, and interview, the facility failed to provide adequate bathing services for the three residents reviewed, Resident (R)1, R2, and R3. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for Resident (R)1 included diagnoses of muscle weakness and need for assistance with personal care. The admission Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R1 required a wheelchair and walker for mobility, set-up or clean-up assistance for bathing and getting in/out of tub/shower. The Functional Abilities Care Area Assessment dated 12/27/23 revealed R1's self-care and mobility will be addressed in the care plan. The Quarterly MDS dated 03/25/24 assessed R1 with a BIMS score of 15, indicating intact cognition and R1 had no changes to mobility devices used or…

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.

The facility reported a census of 60 residents which included two residents sampled for allegations of abuse. Based on interview and record review, the facility failed to suspend alleged perpetrator in response to an allegation of abuse, neglect, exploitation, or mistreatment, to prevent further potential abuse for the residents of the facility on one of four halls (400 hall) of the facility while an investigation of abuse was in progress related to Resident (R)1. Findings included: - On 03/04/24 at 02:46 PM, Administrative Nurse A stated she received a report of an allegation of abuse on 02/27/24 from Certified Nurse Aide (CNA) B. The allegation included CNA C and Licensed nurse (LN) D restrained and dragged Resident (R)1 to her room and forced her to take medication on 02/25/24. Administrative Nurse A confirmed she suspended LN D and CNA C on 02/28/24, the next day. She allowed CNA C to work the night shift on 02/27/24, 10:00 PM to 06:00 AM after she received the allegation of abuse. Administrative Nurse A stated she should have suspended CNA C to ensure the residents where safe…

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.

The facility reported a census of 56 residents. The facility had one main kitchen. The kitchen served food to one main dining area. Based on observation, interview, and record review, the facility failed to properly store food in the main kitchen refrigerators due to foods left uncovered, boxes placed directly on the floor in the kitchen area, and staff failed to discard expired foods in accordance with professional standards for food service safety, to prevent food borne illness to the residents. Findings included: - During the brief initial tour of the kitchen, on 05/15/23 at 07:46 AM, observation revealed the following concerns: 1. The walk-in refrigerator had one large bowl of undated green jello with fruit in it, with the plastic wrap falling into the jello. 2. The kitchen dry storage area had one 500-piece box of foam cups, one box of lids for the cups, one large bag of potatoes, and five boxes of oil stored directly on the floor. Also, one undated 10-pound (lbs.) bag of dry spaghetti noodles stored on the shelf. Furthermore, 24 four ounce containers of prune juice with a use…

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.

The facility reported a census of 56 residents. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for the residents and staff related to items/areas in the facility laundry. Findings included: - The laundry tour on 05/18/23 at 09:22 AM, with Housekeeping/Maintenance Staff V and W identified the following areas of concern: 1. A one foot section of cove base dislodged along an interior wall in the soiled linen area with dirt and debris present. 2. An approximate five-foot section of cove base missing on the back wall of the soiled laundry area. 3. A door with a metal plate protruding from the wooden door at the entrance of the washer room. 4. A washing machine with a white lime deposit build-up that covered the exterior of the machine. 5. A missing panel on the wall behind the washing machine. 6. The platform for the washing machine was made of unsealed concrete, which was not sanitizable. 7. The hopper with brown stain and build-up around the parameter of the bowl 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.

The facility reported a census of 56 residents. Based on interview and record review, the facility failed to develop, implement and permanently maintain an in-service training program for nurses aides that is appropriate and effective as to ensure the continuing competence of nurse aides with no less than 12 hours per year. Five of five nurse aides also lacked dementia management training, resident abuse prevention training Findings included: - The following hour totaled for the last 12 months indicated the following concerns: 1. Certified Nurse's aide (CNA) I had a total of in-service hours of one and a half total hours. The training record lacked dementia or abuse training. 2. CNA J had a total of in-service hours of three hours The training record lacked dementia or abuse training. 3. CNA K had a total of in-service hours equaled nine hours and fifty minutes of training. The training record lacked dementia and abuse training. 4. CNA L had a total of in-service hours equaled three hours. The training record lacked dementia and abuse training. 5. CNA M lacked indication of any…

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 The facility reported a census of 56 residents with 14 residents included in the sample. Based on interview and record review, the facility failed to provide a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfers to the hospital. This included Resident (R) 14, R 13, R 47, R 164. Findings included: - Review of R47's Electronic Medical Record dated 04/24/23, revealed the facility lacked a signed bed hold with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital on [DATE]. On 05/17/23 at 09:55 AM, Social Service staff D stated the charge nurse would send a copy of the bed-hold policy with the resident upon the discharge to the hospital. Interview with Administrative Nurse B on 05/17/23 at 10:01 AM revealed it was the expectation of the nursing staff that with each hospitalization the bed hold policy should be sent with the resident and scanned into the resident's chart. On 05/17/23…

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 The facility reported a census of 56 residents with 14 sampled which included two residents reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for Resident (R)39 related to her preferences for waking up in the morning. Findings included: - Review of Resident (R)39's Physician Orders, dated 04/25/23, the resident had diagnoses that included hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (CVA/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain affecting left non-dominant side, difficulty walking, muscle weakness, and need for assistance with personal care). The admission Minimum Data Set, (MDS), dated [DATE], documentation revealed the Brief Interview for Mental Status, (BIMS) score of 15, indicating intact cognition. She did not exhibit behaviors or rejection 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 The facility reported a census of 56 residents with 14 sampled that included three for hospitalization. Based on observation, record review, and interview the facility failed to notify/ send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman of the reason for the transfers for Resident (R) 13, R14, and R47's required hospitalizations. - Review of R13's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Furthermore, the resident discharged to the hospital again on 04/30/23 and returned to the facility on [DATE]. Review of R13's Medical Record lacked evidence of a written notification of the facility-initiated hospitalizations transfer/discharges to the Office of the State Long-Term Care Ombudsman. On 05/17/23 at 09:55 AM, Social Service staff D confirmed she did not send a notice to the Office of the State Long Term Care Ombudsman…

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.

The facility reported a census of 56 residents, with 14 sampled including two residents sampled for Preadmission Screening and Resident Review (PASARR). Based on interview and record review the facility failed to coordinate an assessment with the PASARR program for a level II screening as recommended for Resident (R) 22. Findings Included: - The Electronic Health Record (EHR) for R22 revealed the following diagnoses included anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and schizoaffective disorder (mental health disorder characterized by a combination of symptoms of schizophrenia). The 11/13/19 Preadmission Screening and Resident Review (PASARR) Determination Letter indicated a need for further evaluation and would be referred for a Level II screening. The 05/09/23 Care Plan lacked documentation of PASARR Level II requirements. The 05/17/23 EHR for R22 lacked documentation of a PASARR Level II assessment. On 05/17/23 at 10:25 AM, Licensed Nurse E stated R22 could make her needs known and was able to do most things for herself.…

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.

The facility reported a census of 56 residents, with 14 residents sampled for review. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 13 and R15 which included oxygen use and care. Findings included: - R13's pertinent diagnoses from the Electronic Health Record (EHR) included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and dementia (progressive mental disorder characterized by failing memory, confusion). The 05/12/22 admission Minimum Data Set (MDS) documented R13 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment documented no oxygen use. The 02/10/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition and documented R13 had not used oxygen. The 05/15/23 Care Plan lacked documentation of nebulizer medication or oxygen use or the care of the equipment. The Physicians…

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 The facility reported a census of 56 residents with 14 residents sampled which included two residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to accurately obtain weight and verify weights as needed to monitor and address Resident (R)23's nutritional status/weight loss. Findings included: - Review of Resident (R)23's Physician Orders, (POS) dated 03/21/23, documentation included diagnoses of major depression disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), with behavioral disturbances, acquired absence of limb, hypertension (high blood pressure), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), encephalopathy (condition of the brain), cerebral infarct (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood…

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 The facility reported a census 56 residents with 14 residents sampled which included one resident reviewed for dialysis (a process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 55, who required dialysis, receive services, consistent with professional standards of practice, to monitor for the effectiveness and adverse reactions related to dialysis. Findings included: - Review of Resident (R)55's Physician Orders, (POS) dated 02/24/23, documented diagnoses which included malignant neoplasm (terminal cancer), end stage renal disease, muscle weakness, reduced mobility, and presence of urogenital implant (suprapubic catheter-a surgically place tube through the abdominal wall which drains the bladder. The admission Minimum Data Set, (MDS), dated [DATE], documentation included the resident's Brief Interview for Mental Status, (BIMS)…

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 The facility reported a census of 56 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to Resident (R) 26's urinary catheter, and R13 and R15, related to nubulizer storage. Findings included: - Review of Resident (R) 26 Physician Orders dated 03/09/23 revealed diagnosis that included neurogenic bladder (dysfunction of urinary bladder caused by a lesion of the nervous system) requiring indwelling catheter (a tube placed in the bladder to drain urine into a collection bag). The annual Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 02, indicating severely impaired cognition. The Activities of Daily Living documented the resident required two-person physical assist with toileting and required an indwelling catheter. Review of the Care Plan dated 12/20/22, guided staff to position the catheter bag and tubing below the bladder and away from the entrance room door. Observation…

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

The facility reported a census of 56 residents with 14 residents sampled which included five residents selected for review of influenza, pneumococcal, and COVID vaccines. Based on interview and record review, the facility failed to ensure the resident/resident representative received information/education regarding the benefits, risks, or medical contraindications of influenza, pneumococcal, and/or COVID vaccines for Resident (R)39. Findings included: - Review of Resident (R)39's immunizations records provided by Administrative Nurse B revealed the records lacked documentation of vaccine information/education for influenza, pneumococcal, and COVID vaccines provided to the resident and/or their representatives to demonstrate the benefits verses risks of receiving the vaccines. The facility lacked documentation the resident had been offered or provided an opportunity to receive the vaccine. - On 05/18/23 3:34 PM, Administrative Nurse B, confirmed the records noted above were all inclusive. She stated the provided documentation was all she was able to provide. The facility policy…

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.

The facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure a qualified Dietician or Certified Dietary Manager (CDM) worked in the facility to carry out the functions of food and nutritional services for the 42 residents who resided in the facility and received meals from the facility kitchen. Findings included: - During the annual survey 09/27/21-09/30/21, the facility could not provide documentation of a Dietician evaluating Dietary Manager H or documentation of Dietician in-house to complete assessments and oversee the functions of the kitchen. Additionally, the facility could not provide evidence Dietary Manager H completed or enrolled for the CDM training classes. Interview with Dietary Manager H on 09/27/21 at 10:35 AM revealed she was not a CDM but planned on taking the classes soon. DM H stated a Corporate Dietician worked for the facility, but she has never met that person and did not know the Corporate Dietician's name. Interview with Administrative Nurse B on 09/28/21 at 03:00 PM revealed the facility worked with 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.

The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed ensure the safe and sanitary meal preparation, service, and storage when kitchen staff failed to adequately monitor the daily temperatures of the refrigerators and freezers, failed to monitor the chemical sanitization of the low temperature dishwasher each shift, and failed to test the sanitizing solution used to clean surfaces in the kitchen and dining room. These failures had the ability to affect all residents served meals from the kitchen. Findings included: - Observation on 09/27/21 at 10:35 AM revealed no completed logs for the low temperature dishwasher or chemical sanitizer spray could be found in the kitchen. Further observation revealed no parts per million (ppm) test strips could be found in the kitchen in order to ensure the antimicrobial properties/chemical sanitization desired effect. Observation of temperature logs located on the refrigerators and freezers in the kitchen at the time of observation lacked completion of daily temperatures/were not…

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.

The facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure five Certified Nurse Aide (CNA) staff reviewed, completed 12 hours of required in-service training annually. Findings included: - Review of staff training records for Certified Nurse Aide (CNA) C (hired on 05/01/20), D (hired 03/31/20), CNA E (09/26/17), CNA F (hired on 01/20/15), and CNA G (hired on 10/01/13) lacked documented evidence of in-service hours totaling 12 hours in a one-year period from hire anniversary date. Interview with Administrative Nurse B on 09/29/21 at 12:31 PM revealed she started working for the facility in March of 2021 and did not have documentation of completed in-services for any of the facility staff prior to her arrival. Administrative Nurse B could provide documentation of completed in-services for the CNAs [listed above] from March through September of 2021. Review of the Facility Assessment reviewed in 2021, lacked documentation regarding required in-service hours for each staff member annually. The facility did not provide a policy regarding…

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.

The facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure all facility staff were trained on dementia care and social media annually. Findings included: - Review of the staff training records for Certified Nurse Aide (CNA) C (hired 05/01/20) and CNA G (hired 10/01/13) lacked evidence of dementia care training from 05/01/20 through 09/30/21. Review of the staff training records for CNA E (hired 09/26/17), CNA F (hired 01/20/15), and CNA G (hired 10/01/13) lacked evidence of social media training since hire date through 09/30/21. Interview with Administrative Nurse B on 09/29/21 at 12:31 PM revealed the staff completed social media training only upon hire and not completed each year. Administrative Nurse B said the facility completed all staff in-services in-house and did not utilize online training. The 08/27/21 Facility Assessment documented staff were to complete ANE training, however it did not note the frequency for the training. The Facility Assessment noted the expectation of staff to complete HIPAA training annually and noted…

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.

The facility census totaled 42 residents (R) with 12 included in the sample and two residents reviewed for transfers out of the facility. Based on observation, interview, and record review the facility failed to ensure staff completed notifications to the ombudsman for R38s transfer to the hospital and R45's discharge to another long-term care (LTC) facility. Findings included: - R38's pertinent diagnoses from Physician's Orders in the Electronic Medical Record (EMR) dated 07/19/21 revealed a fracture (broken bone) to his right femur (thigh bone). The 07/16/21 Discharge Assessment Return Anticipated Minimum Data Set (MDS) revealed he discharged to an acute hospital. The 07/16/21 Progress Notes revealed R38 was hospitalized after a fall with fracture due to the resident's non-compliance with ADLs. Review of the facility provided documentation of monthly notifications to the State LTC Ombudsman of transferred/discharged residents from 01/01/20 to 09/01/21, revealed no documentation of ombudsman notification completed for R38's facility-initiated hospitalization transfer. Observation…

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

The facility census totaled 42 residents (R) with 12 residents in the sample and one resident reviewed for hospitalization. Based on observation, interview, and record review the facility failed to notify R38's representative in writing and complete the bed hold for the resident's facility initiated hospitalization transfer. Findings included: - R38's pertinent diagnoses from Physician's Orders and Progress Note for diagnosis in the Electronic Medical Record (EMR) dated 07/19/21 revealed a fracture (broken bone) to his right femur (thighbone). The 06/08/21 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident experienced no falls during the review period. The 07/16/21 Discharge Assessment Return Anticipated MDS revealed he was discharged to an acute hospital. The 09/13/21 Annual MDS revealed a BIMS of 09, indicating moderately impaired cognition. The resident experienced one minor injury fall during the review period. The 09/13/21 ADL Care Area Assessment (CAA) revealed cognitive loss. He may need…

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.

The facility census totaled 42 residents with 12 residents (R) in the sample. Based on observation, interview, and record review the facility failed to ensure the accuracy of the completed Minimum Data Set (MDS) regarding falls experienced by R9, which were not noted on the MDS. Findings included: - R9's 09/14/20 Quarterly Minimum Data Set (MDS) revealed he experienced no falls in the review period since last Quarterly MDS assessment on 06/07/20. The 06/16/20 at 05:33 AM Fall Investigation and 06/17/20 Fall Risk Data Collection revealed R9 experienced an unwitnessed fall in his bathroom with no injuries. The 06/19/20 at 06:45 PM Fall Investigation and 06/19/20 at 09:50 PM Health Status Note revealed R9 experienced an unwitnessed fall in his room. Observation of 09/27/21 at 01:05 PM revealed R9 sat in his recliner with the call light within reach. Interview with Consultant Nurse staff O on 10/05/21 at 08:43 AM revealed the resident's MDS lookback period for falls was from prior assessment to current assessment and said the 09/14/20 MDS should have indicated two or more non-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.

The facility census totaled 42 residents with 12 residents (R) in the sample. Based on observation, interview, and record review the facility failed to ensure the resident's comprehensive Care Plans reflected the needs of the residents to ensure person-centered care. R10's comprehensive care plan lacked information regarding hospice care, R36's comprehensive care plan lacked information/interventions regarding dialysis (a procedure where impurities or wastes were removed from the blood) services received, and R9's comprehensive care plan lacked revisions related to fall interventions. Findings included: - R10's pertinent diagnoses from Physician's Orders and Progress Note in the Electronic Medical Record (EMR) dated 08/12/21 revealed adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals) and dementia (a progressive mental disorder characterized by failing memory, confusion). The 04/30/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of three, indicating…

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.

The facility reported a census of 42 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 45's stay in the discharge summary. Findings included: - R45's pertinent diagnoses from 06/23/20 Physician Order in the electronic medical record (EMR) documented encephalopathy (damage or disease that affects the brain), Dementia (progressive mental disorder characterized by failing memory, confusion) and major depressive disorder (MDD, major mood disorder). The 07/16/21 Annual Minimum Data Set (MDS) documented no plans for the resident's discharge. The 07/16/21 Care Area Assessment (CAA) did not trigger for discharge to the community. The 04/15/21 Quarterly MDS documented no plans for discharge. The 07/16/21 Care Plan documented R45 would remain long term in the facility. The Electronic Health Records (EHR) Physician Orders documented an order to discharge to another facility and to continue the current medications dated 07/26/21. R45's…

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The facility census totaled 42 residents with 12 residents (R) in the sample and one sampled for hospice care. Based on observation, interview, and record review the facility failed to ensure hospice care/services were documented and communicated to staff for the continuity of care regarding R10. Findings included: - R10's pertinent diagnoses from Physician's Orders and Progress Note in the Electronic Medical Record (EMR) dated 08/12/21 revealed adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals) and dementia (a progressive mental disorder characterized by failing memory, confusion). The 04/30/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of three, indicating severely impaired cognition. The resident required one staff assistance for walking and had a lower extremity (limb) impairment; she used a wheelchair for mobility. Her life expectancy was noted to be less than six months and received hospice care. The 04/30/21 Cognitive Area Assessment (CAA)…

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.

The facility reported a census of 42 residents, with 12 sampled and three reviewed for falls. Based on observation, interview, and record review the facility failed to adequately complete fall investigations, to include identifying causal factors related to falls and implement interventions to prevent further falls for Resident (R) 4, R9, and R26. Findings included: - R4's pertinent diagnoses from 05/20/20 Physician's Order in the electronic medical records (EMR) included documented: dementia (progressive mental disorder characterized by failing memory, confusion), anoxic (lack of oxygen) brain damage, psychosis (any major mental disorder characterized by a gross impairment in reality testing) and delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue). The 12/16/20 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of three, indicating severely impaired cognition. R4 was able to ambulate around the facility independently. R4 had one fall with injury since previous MDS. The 06/23/21…

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.

The facility census totaled 42 residents (R) with 12 residents in the sample, and one resident sampled for dialysis services. Based on observation, interview, and record review the facility failed to complete pre-dialysis weights and vital signs, assess the dialysis access site, record resident fluid intake, and obtain physician ordered labs for R36. Findings included: - R36's pertinent diagnoses from the Physician's Orders in the Electronic Medical Record (EMR) dated 09/21/21 revealed end-stage renal disease (ESRD, a terminal disease because of irreversible damage to kidneys) and chronic kidney disease (CKD, a condition characterized by a gradual loss of kidney function over time). Review of the 06/10/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. Her diagnosis included ESRD and R36 received dialysis. Review of the 09/10/21 Quarterly MDS revealed a BIMS of 15, indicating intact cognition. Her diagnosis included ESRD, and she received dialysis. Review of 05/22/20 Comprehensive Care Plan revealed a revision 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.

The facility census totaled 42 residents with 12 residents (R) in the sample and five sampled for medication regimen reviews. Based on interview, observation, and record review the facility failed to maintain documentation of the consultant pharmacist's identified recommendations and failed to act upon recommendations for multiple months for R10, R26, and R31. Findings included: - Resident (R) 10's pertinent diagnoses from Physician's Orders and Progress Note in the Electronic Medical Record (EMR) dated 08/12/21 revealed hyperlipidemia (a condition of elevated blood lipid levels) and atherosclerotic heart disease (a condition which affects the arteries that supply the heart with blood, usually caused by atherosclerosis, a buildup of plaque inside the artery walls). The 04/30/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of three, indicating severely impaired cognition. She had diagnoses of hyperlipidemia and coronary artery disease. The Cognitive Loss Care Area Assessment (CAA) revealed a BIMS of three, she had increased confusion,…

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.

The facility reported a census of 42 residents, with 12 sampled and five reviewed for unnecessary medications. Based on interviews and record review, the facility failed to follow the physicians' orders regarding R31's diabetes when staff did not document and notify the provider of blood glucose (BG, blood sugar) values outside the designated parameter. The facility further failed to ensure blood pressure parameters for R26 and R31. Findings included: - Review of R26's pertinent diagnoses from the Physician's Orders in the Electronic Medical Record (EMR) dated 08/20/21 documented pneumonia (inflammation of the lungs), major depressive disorder (MDD, major mood disorder), hypertension (HTN; elevated blood pressure), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). Review of the 01/06/21 Annual Minimum Data Set (MDS) documented R26 had a brief interview for mental status (BIMS) of zero, indicating severely impaired cognition. No…

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.

The facility census totaled 42 residents with 12 residents (R) in the sample and five sampled for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure an appropriate diagnosis for R10s antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications. Findings included: - Resident (R) 10's pertinent diagnoses from Physician's Orders and Progress Note for diagnoses in the Electronic Medical Record (EMR) dated 08/12/21 revealed dementia (a progressive mental disorder characterized by failing memory, confusion) and major depressive disorder (MDD, a major mood disorder). The 04/30/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of three, indicating severely impaired cognition. She exhibited delusions with verbal behavioral symptoms directed toward others and rejection of care one to three days of the review period. R10 received daily routine antipsychotic medications in the seven-day review period. The 04/30/21 Psychotropic Care Area…

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.

The facility reported a census of 42 residents with three residents requiring a pureed diet. Based on observation, interview, and record review the facility failed to ensure the staff prepared foods by methods which conserve nutritive value, flavor, and appearance. Observation of kitchen staff not following a recipe for the preparation of the pureed lunch menu, resulted in unappetizing and runny food, with a change in nutritive value when staff substituted milk in place of other thinning ingredients as listed in the recipe (such as broth and/or butter), and failed to follow the recipe measurements and staff was eyeballing measurements of ingredients used in the purees, meant to thin or thicken the puree, and failed to serve all items on the menu in puree form or offer substitutes for items she did not puree. Findings included: - Review of the Weekly Menu, Day 17 approved on 04/17/21, documented the lunch meal included country ham, herb stuffing, buttered carrots, roasted brussels sprouts, cornbread and Texas sheet cake. Review of the DiningRD.com Pureed Country Ham Recipe for three…

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.