Legacy At Herington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)25's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R25 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where 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.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)6, R14, and R26s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with opened and discard dates. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 10/29/24 at 09:00 AM, observation of the facility's treatment cart revealed the following: R6's Basaglar (long-acting insulin) flex pen was not labeled with an open or discard date. R14's Lantus (long-acting insulin) flex pen was not labeled with an open or discard date. R26's Basaglar flex pen was not labeled with an open or discard date. On 10/29/24 at 08:35 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened and the expiration date. On 10/30/24 at 08:30 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the date opened and the expiration date. Medlineplus.gov directs open,…

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 had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for three residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life. Findings included: - On 10/30/24 at 10:00 AM, observation revealed the lunch meal included cheesy macaroni hamburger helper, carrots, pears, and garlic bread. On 10/30/24 at 10:30 AM, observation revealed Dietary Staff (DS) CC prepared three pureed diets. DS CC placed three servings of cheesy macaroni hamburger helper in the Robot-coup blender (a food processor) and added four ounces of beef base. DS CC blended the macaroni to a thin consistency and emptied the blended food into a metal pan and placed the pan into the hot water well in the hot holding cart. Observation revealed DS CC then placed three - four-ounce servings of pears in the Robot coup, with four squirts of simply thick easy mix and blended the food to a pureed texture. DS…

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 30 residents. The sample included three residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth. Findings included: - The Diagnoses tab of R3's Electronic Medical Record (EMR) documented a diagnosis of nontraumatic intracerebral hemorrhage (an emergency condition in which a blood vessel in the brain ruptures and causes bleeding inside the brain). The Significant Change Minimum Data Set (MDS) dated 02/16/24 documented that R3 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 02/26/24, documented R3 had physical and verbal behaviors directed at staff. R3's Care Plan dated 11/15/23, documented R3's preference to vape (using a device to inhale an aerosol, typically…

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 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 1 and R2 were able to exercise their right to receive visitors of their choosing at the time of the residents' choice. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented 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) and weakness. The Annual Minimum Data Set (MDS) dated 10/05/23, documented that R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated 01/05/24, documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive…

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 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to inform Resident (R) 1 and R2 and/or their representative of their visitation rights and any visitation restrictions placed on them. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented 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) and weakness. The Annual Minimum Data Set (MDS) dated 10/05/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated 01/05/24, documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder…

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 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse. On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and caalled her a derogatory name.This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated 08/10/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated moderately impaired cognition. The MDS…

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

The facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported verbal abuse to the facility administrator (LNHA). On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and called her a derogatory name. CNA N did not report the incident until 09/19/23 in an e-mail to the Human Resources GG. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated 08/10/23, documented…

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 32 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 05/17/23 at 11:50 AM Administrative Staff A stated that Dietary BB was currently enrolled in class to become their CDM; she reported that the facility did not currently have a CDM. She further stated that the facility's registered dietitian comes to the facility about once per month. On 05/22/23 at 11:33 AM Dietary BB stated that the facility's registered dietitian comes to the facility once a month. He further stated that he can call the dietitian when needed for assistance. The facility failed to provide a policy related to a CDM. The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed all residents at risk for unmet dietary 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 identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 05/17/23 at 07:42 AM an observation revealed plates and bowls stored on top of a cart were not covered or inverted. On 05/17/23 at 07:43 AM an observation revealed plates and bowls stored in a metal bin under a table. The dishes were stored below waist level and the side of the bin was open leaving the plates and bowls exposed. The plates and bowls were uncovered and not inverted. On 05/17/23 at 07:45 AM review of the Dish Machine and Temperature Log for April 2023 revealed a lack of evidence that dishwasher temperatures were monitored for 79 out of 90 scheduled times. Review of the Dish Machine and Temperature Log for May 2023 revealed a lack of evidence that dishwasher temperatures were monitored for 17 out of 51…

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 32 residents. Based on observation, interview, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 32 residents who reside in the facility. Findings included: The facility failed to ensure a surety bond was in place to protect resident's trust accounts. This deficient practice placed 30 residents at risk for complication related to monetary issues. (Refer to F570) The facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to provide the necessary number of qualified staff members along with the required medical equipment to provide appropriate assistive cares for R7. (Refer to F600) The facility failed to provide written notification of the reason and location for the transfer to the hospital for R16 or her representative. This deficient practice placed R11 at risk of delayed care. (Refer to F623) The facility failed to ensure staff provided and documented consistent…

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 32 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: The facility failed to ensure a surety bond was in place to protect resident's trust accounts. This deficient practice placed 30 residents at risk for complication related to monetary issues. (Refer to F570) The facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to provide the necessary number of qualified staff members along with the required medical equipment to provide appropriate assistive cares for R7. (Refer to F600) The facility failed to provide written notification of the reason and location for the transfer to the hospital for R16 or her representative. This deficient practice placed R11 at risk of delayed care. (Refer to F623) 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.

The facility census totaled 32 residents. Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required personnel in attendance. This deficient practice placed all the residents at risk for ineffective care. Findings Included: - A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet indicated a QAPI meetings were held 02/08/22, 03/08/22, 04/12/22, 07/27/22, and 10/26/22. The facility was unable to provide documentation showing meetings held after October 2022. The review indicated no quality measures, concerns, monitoring, performance improvement plans (PIPs), or QAPI guidance/education occurred after 10/26/22. On 05/22/23 at 04:10PM Administrative Staff A reported that she was not aware she was supposed to be running the QAPI program at the facility. She reported the facility will have a QAPI meeting on 05/24/23. She stated that going forward the facility will meet monthly and quarterly to identify facility concerns and create…

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 32 residents. The sample included 17 residents. Based on interview and record review, the facility failed to ensure the principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner when the facility Infection Preventionist (IP) failed to document and maintain an accurate antibiotic stewardship log monthly. This placed the residents who resided in the facility at risk for unnecessary side effects of antibiotics and antibiotic resistance. Findings included: - Review of the facilities Infection Control Tracking Log for tracking and trending infections from January 2022 through May 2023, revealed lack of Infection Control Logs for May 2022 was missing. The November 2022 and December 2022, January 2023, February 2023, March 2023, April 2023 logs lacked any infection/antibiotic tracking. The Infection Control logs reviewed had incomplete data for analysis of adherence with an evidenced-based…

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 32 residents. The sample included 17 residents. Five residents were reviewed for activities of daily living (ADLs) care. Based on observation, record review and interview the facility failed to ensure staff provided consistent bathing cares for Resident (R) 29, R7, R11, and R30 who required extensive assistance from staff with bathing. This deficient practice placed the residents at risk for complications due to poor personal hygiene and impaired psychosocial wellbeing. Findings included: - The electronic medical record (EMR) for R29 documented diagnoses of hypertension (an elevated blood pressure), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), and dementia (a progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] for R29 documented a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. R29 required…

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 32 residents. The sample included 17 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to implement a system to ensure the monthly Consultant Pharmacist (CP) recommendations were addressed/followed up by the physician and facility staff for the five residents sampled for medication review. Resident (R) 5, R9, R12, R29, and R30's chart lacked physician responses to the monthly pharmacy recommendations. This placed the residents at risk for complcations related to unecessary medications. Findings included: - Review of the electronic medical record (EMR) for R5, R9, R12, R29, and R30 lacked evidence that monthly medication regimen review (MRR) were addressed by the physicians and facilty staff. The facility was unable to provide the CP's MRR's including recomemndations since the last onsite annual survey on 09/27/21. On 05/22/23 at 02:56 PM Administrative Nurse F stated that on 05/13/23 the pharmacist came to the facility to do the monthly MRR. Administrative Nurse F…

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 32 residents. The sample included 17 residents. Based on observation, record review and interview, the facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - An observation on 05/18/23 at 07:36 AM revealed Administrative Nurse D entered Resident (R) 5's room to obtain his fingerstick blood sugar (FSBS). Administrative Nurse D placed items on the bedside table without placing a barrier down. Administrative Nurse D donned gloves that were in her scrub top pocket; she cleansed R5's finger with an alcohol wipe, then applied the lancet (a device that punctures the skin to obtain a blood sample). She…

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

The facility identified a census of 32 residents. The sample included 17 residents with three reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Residents(R)2, R19 and R30 were treated in a dignified manner during meal service. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: On 05/17/23 at 11:40AM R2, R19, and R30 were in the dining room eating lunch. An unidentified staff stood at the table supervising and providing meal assistance with feeding. The staff member held R2's fork and fed R2 her food while standing over her. R2 complained the food was stuck in her upper denture but staff continued to insist she take a bite of her food. While feeding R2, the staff member told R19 to keep eating his meal while she stood over R2. The unidentified staff member moved over to R30 and fed him while standing. From 11:45AM to 11:53AM, during the meal, the staff member left the residents unattended to go to the nursing office. At 11:53 Activities Staff Z arrived in the dining room…

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 32 residents. The sample included 17 residents with three residents reviewed for notice requirements before transfer/discharge. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)11 or her representative. This deficient practice placed R11 at risk of delayed care or uncommunicated care needs. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), artificial openings of urinary tract status, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which…

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 32 residents. The sample included 17 residents with two residents reviewed for treatment/services to prevent /heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to provide physician ordered pressure reducing devices for Resident (R) 10 who had an unstageable pressure injury (base of the sore is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black) to the right heel. This deficient practice placed R10 at increased risk of development and or worsening of pressure related injuries for R10. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 32 residents. The sample included 17 residents with two residents reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) or mobility. Based on observation, record review, and interviews, the facility failed to identify and resolve inappropriate wheelchair positioning for Resident (R)12. This placed R12 at risk for loss of independence, and impaired mobility. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, hemiparesis (muscular weakness of one half of the body) hemiplegia (paralysis of one side of the body) following cerebrovascular accident (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 the right dominant side, and abnormal gait. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status…

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 39 residents. The sample included 17 residents with two residents reviewed for bowel/bladder incontinence and nephrostomy tube (an artificial opening between the kidney and the skin which allows urine to drain from the body). Based on observation, record review, and interviews, the facility failed to provide appropriate hand hygiene during peri-care for Resident (R) 11 who had a foley catheter (tube inserted into the bladder to drain urine) and history of sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) and urinary tract infections (UTI). The facility also failed to evaluate and provide an individualized toileting plan for R7. These deficient practices placed these residents at risk increased infections, catheter related problems, and impaired dignity. Findings…

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 32 residents. The sample included 17 residents with four reviewed for nutrition. Based on observation, record review, and interviews, the facility failed toprovide consistent support during meal services for Resident (R) 19, who had unintended weight loss. This deficient practice placed R19 at risk for further weight loss and impaired nutrition. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction (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, unsteadiness on feet, and chronic kidney disease. A review of R19's Quarterly Minimum Data Set (MDS) completed 01/27/23 noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. The MDS indicated R19 weighed 178 pounds (lbs.). the MDS indicated no weight loss. 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.

The facility identified a census of 32 resident. The sample included 17 residents with one Resident (R) sampled for respiratory care. Based on observation, record review and interview, the facility failed to ensure R10 received her supplemental oxygen (O2) continuously as physician ordered. The facility failed to ensure that R10's O2 tubing and nasal cannula (NC-a hollow tube that helps provide supplemental oxygen) and continuous positive airway pressure (CPAP-machine used to deliver a stream of oxygenated air into the airways through a mask and a tube) mask and tubing were properly stored in a sanitary manner when not in use. This deficient practice placed R10 at risk for increased respiratory infection and complications. Findings included: - The electronic medical record (EMR) for R10 documented diagnoses of lung transplant (a surgical procedure where the diseased lung is replaced with a healthy lung(s) from a donor.) The admission Minimum Data Set dated 04/24/23 documented R10 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R10…

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 32 residents. The sample included 17 residents. Five residents were sampled for unnecessary medication review. Based on observation, record review and interview the facility failed to monitor Resident (R) 29's pulse before administration of the beta blocker (a type of medicine that makes the heart beat more slowly and lower blood pressure) metoprolol (a beta blocker medication used to treat heart conditions). This deficient practice place R29 at risk for unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R29 documented diagnoses of hypertension (an elevated blood pressure), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), and dementia (a progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] for R29 documented a Brief Interview for Mental Status (BIMS) score of four which…

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 39 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered diagnostic laboratory test results were signed and scanned into the clinical record for Resident (R) 10 and R12. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R10's Electronic Medical Record (EMR) under Miscellaneous tab revealed a laboratory test obtained on 05/11/23 had been scanned into the clinical record on 05/14/23 but was not signed and dated. R12's EMR lacked evidence of any laboratory results scanned into the clinical record since 2021. On 05/22/23 at 02:30 PM the facility provided laboratory tests for R12 that had been obtained on 04/13/23 that were dated and signed but not scanned into the EMR. On 05/22/23 at 02:30 PM the facility provided results of laboratory tests that had been obtained 05/03/23 for R12 and not scanned into the EMR. The test results lack a physician signature and was undated. On 05/22/23 at 02:57 PM Administrative…

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 32 residents. The sample included 17 residents with five sample residents reviewed for influenza (a contagious respiratory illness that infect the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interview the facility failed to ensure that sampled Resident (R) 29 and R30 that had consented to receive the influenza and pneumococcal vaccine were administered the vaccinations. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease. Findings included: - Review of R29's Immunization tab in the EMR and a copy of R29's Influenza Immunization Informed Consent dated 09/2010 documented R29's representative signed the form on 11/15/22 for R29 to receive the Influenza Vaccine. R29 did not receive the influenza vaccine. Review of R29's Immunization tab in the EMR and a copy of R29's Pneumococcal…

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 32 residents. The sample included 17 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed toassess and document the COVID-19 vaccination status for Resident (R) 30. The facility failed to offer and obtain signed consents or declinations for COVID-19 vaccinations for R30. This deficient practice had the risk for physical complications and the risk to spread illness among residents, a high-risk population. Findings included: - R30 admitted to the facility on [DATE]. R30's clinical record lacked evidence of the COVID-19 vaccination status or evidence the vaccination was offered including a signed consent or declination of the vaccination. On 05/18/23 at 02:30 PM Administrative Staff B stated the local pharmacy provided all the vaccinations to the residents. Administrative Staff B stated…

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 had a census of 20 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) the Advance Beneficiary Notice (ABN) for skilled services for Resident (R) 2, R7, and R11. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The facility lacked documentation R2 had been provided with Center of Medicare (CMS)-10055 form when the resident skilled services ended 05/21/21, which informed the resident (or their…

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 had a census of 20 residents. The sample included 12 residents with two residents reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services when they failed to ensure staff stored oxygen delivery devices in a sanitary manner for Resident (R) 7. Findings included: - R7's electronic medical record (EMR) documented a diagnosis of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status score of four which indicated impaired cognition. R7 required extensive assistance from staff for all activities of daily living and wore oxygen during the look back period. The Care Plan dated 07/14/21 directed staff that episodes of increased confusion could be a sign of low oxygen level. It directed staff 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 had a census of 20 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to perform adequate infection control during wound care for two residents, Resident (R) 7, R14 and toileting for R10. Findings included: - On 09/22/21 at 03:10 PM, observation revealed Administrative Nurse D used hand gel and a paper towel to wipe off R14's bedside table and set a clean cover on the table for her supplies. Administrative Nurse D washed her hands and put on gloves, set out her wound care supplies, and cleaned the scissors with alcohol. Administrative Nurse D used scissors to remove the moderately soiled dressing. R14's left heel had a large black eschar (dead skin) area. Administrative Nurse D cleansed the heel with foaming wound cleanser and gauze several times, removed her soiled gloves, and donned clean gloves without washing her hands. Administrative Nurse D cleaned R14's left toe wounds with wound cleanser and gauze, changed gloves without washing her hands, and applied a wound treatment with a new gauze for each…

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.