Willow Point Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 31 residents. The sample included three residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on record review and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented R1 had diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication 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 33 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to report an allegation of resident-to-resident abuse between R1 and R2 to the State Agency (SA) within the mandated timeframe. This deficient practice placed R2 at risk for unresolved and ongoing abuse. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and dementia progressive mental disorder characterized by failing memory, confusion) with other behavioral disturbance. The Significant Change Minimum Data Set (MDS) dated 10/09/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R1 had hallucinations (sensing things while awake that appear to be…

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 45 residents. The facility had one main kitchen. Based on observations, record review, and interviews, the facility failed to properly label and store food, failed to store clean dishes inverted, failed to prevent cross-contamination during puree (mechanically altered diet) and mechanical soft (mechanically altered diet) diet preparation, and failed to ensure staff wore hair nets appropriately in the kitchen. This deficient practice had the risk to spread foodborne illness to all affected residents. Findings included: - On 05/01/23 at 07:17 AM, the refrigerator revealed two uncovered pudding cups and an Italian dressing bottle with the lid partially on and dressing crusted around the opening. Plates were stored at the end of the steam table, not inverted, or covered to prevent contamination. On 05/01/23 at 07:19 AM, the freezers revealed a bag of strawberries that leaked to the shelf below it and a bag of unidentified meat patties, opened and not dated. On 05/01/23 at 07:19 AM, the dry storage revealed a bag of beans, opened and not dated; a bag…

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 45 residents. The sample included 13 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for four residents who required assistance from staff to complete the care. This deficient practice placed resident (R)103, R29, R4 and R18 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R103's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of failure to thrive and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, with a staff interview which revealed R103 had modified independence with cognitive skills, with some difficulty in new situations. The MDS documented R103 was independent with set up assistance for ADL.…

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 45 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends and failed to provide activities for residents in isolation. This deficient practice placed 45 residents at risk for decreased psychosocial wellbeing. Findings Included: - The facility's Activity Calendar for February, March, and April of 2023 revealed the activities schedule for Saturdays and Sundays lacked activities listed on the activity calendar. On 05/01/23 at 08:45 AM Resident (R)46 reported she just got out of isolation due to COVID-19 (highly contagious, potentially life-threatening respiratory virus). She stated she is grateful for being out of isolation because she was bored in her room. She stated she was not provided activities or entertainment for over ten days in isolation. She stated she got bored of watching television but could not be around other residents. She stated the facility did not provide her with any type of human interaction or companionship…

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 45 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 05/02/23 at 07:38 AM an inspection of the medication cart in the 100 Hall revealed one Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured and one Lispro Flexpen (injectable long-acting hormone which regulates blood sugar) left unsecured on top of the medication storage cart. On 05/04/23 at 01:05 PM an inspection of the Nurses medication storage room was completed. The inspection revealed the medication storage refrigerator temperature log was not being completed. An open cup pudding labeled March 2023 was inside the refrigerator. Licensed Nurse (LN) G stated the refrigerator temperature and contents should be checked each shift. LN G immediately threw away the expired pudding. On 05/04/23 at 01:40 PM an inspection of the…

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

The facility identified a census of 45 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 cognitively impaired, dependent R38 (moderately cognitively impaired resident) remained free from abuse when the facility failed to prevent an episode of staff to resident physical abuse. (Refer to F600) The facility failed to ensure staff effectively communicated with R38 (moderately cognitively impaired resident the uses gestures and sign language to communicate) during ADL care. (Refer to F676) The facility failed to ensure bathing was provided for four residents who required assistance from staff to complete the care. This deficient practice placed resident (R)103, R29, R4 and R18 at risk for potential skin breakdown and/or skin complications from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with five residents sampled for immunization review. Based on record review and interviews, the facility failed to obtain pneumococcal (infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination signed consents or declinations for Resident (R) 4, R41, and R44 and the facility failed to administer pneumococcal vaccination after signed consent was obtained for R29. This deficient practice had the risk for physical complications and the risk to spread illness among residents, a high-risk population. Findings included: - R4 admitted to the facility on [DATE]. He received Pneumovax on 02/26/18. R4's medical record lacked evidence a Prevnar vaccination was offered upon admission and/or evidence of a signed consent or declination for the Prevnar vaccination for R4. R41 admitted to the facility on [DATE]. R41's medical record lacked evidence a pneumococcal vaccination was offered upon admission and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to assess and document resident-centered dietary and mealtime preferences for Resident (R) 18. This deficient practice had the risk for weight loss, and declines in psychosocial well-being and independence for R18. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of major depressive disorder (major mood disorder), need for assistance with personal care, open wound to right foot, pressure ulcer of left heel, pressure ulcer of sacral region (large triangular bone between the two hip bones), stage four (full thickness tissue loss with exposed bone, tendon or muscle.Dead tissue may be present on some parts of the wound bed. Often includes undermining and tunneling), malnutrition, and quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord).…

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 45 residents. The sample included 13 residents. Based on interview and record review the facility failed to issue the Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123, which contained the required information for Resident (R) 45. This failure placed the resident at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R45's Electronic Medical Record (EMR) documented the resident had a Medicare Part A episode, which ended on 04/14/23. R45 did not remain in the facility and the facility did not issue a NOMNC 10123 to R45. On 05/04/23 at 03:15 PM Social Services X stated she was responsible for providing the NOMNC forms to the residents that discharged from Medicare Part A services. Social Services X stated she kept copies of the documents that were provided to the residents. The facility did not provide a policy on beneficiary notification. The facility failed to issue the NOMNC form 10123, 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 45 residents. The sample included 13 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to complete a baseline care plan for R103, which placed him at risk of impaired care related to unidentified or uncommunicated care needs. Findings included: - R103's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of failure to thrive and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, with a staff interview which revealed R103 had modified independence with cognitive skills, with some difficulty in new situations. The MDS documented R103 was independent with set up assistance for ADLs. The MDS documented bathing activity did not occur for R103 during the look back period. R103's ADL Functional/Rehabilitation Potential Care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for discharge. Based on record review and interviews, the facility failed to ensure active discharge planning occurred for Resident (R) 51. This deficient practice had the risk for miscommunication of discharge goals and missed services for R51. Findings included: - R51 admitted to facility on 12/02/22 and discharged on 03/11/23. The Diagnoses tab of R43's Electronic Medical Record (EMR) documented diagnoses of pulmonary cryptococcosis (fungal lung infection), malnutrition, hereditary ataxia (impaired ability to coordinate movement). The admission Minimum Data Set (MDS) dated [DATE], documented R51 had a Brief Interview for Mental Status (BIMS) score of 14, which indicates R51 was cognitively intact. The MDS further documented R51 required limited assistance with activities of daily living (ADLs), he was expected to remain in the facility, and no active discharge planning had occurred. The ADL…

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 45 residents. The sample included 13 residents, with one resident reviewed for discharge. Based on record review and interviews, the facility failed to complete a discharge summary including a recapitulation of stay for Resident (R) 51. This deficient practice placed the resident risk for miscommunication of services received during a stay in the facility and of post discharge care needs. Findings included: - R51 admitted to facility on 12/02/22 and discharged on 03/11/23. The Diagnoses tab of R43's Electronic Medical Record (EMR) documented diagnoses of pulmonary cryptococcosis (fungal lung infection), malnutrition, hereditary ataxia (impaired ability to coordinate movement). The admission Minimum Data Set (MDS) dated [DATE], documented R51 had a Brief Interview for Mental Status (BIMS) score of 14, which indicates R51 was cognitively intact. The MDS further documented R51 required limited assistance with activities of daily living (ADLs), he was expected to remain in 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 45 residents. The sample included 13 residents with four reviewed for maintaining activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to ensure staff effectively communicated with R38 during ADL care. This deficient practice placed R38 at risk for a decline in her ADLs and decreased psycho-social wellbeing. Findings Included: -The Medical Diagnosis section within R38's Electronic Medical Records (EMR) included diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), aphasia (condition with disordered or absent language function), fracture of left humerus (broken bone of the left upper arm), need for assistance with personal hygiene, and dysphagia (swallowing difficulty). A review of R38's Quarterly Minimum Data Set (MDS) completed 03/09/23 indicated a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for treatment of pressure injuries. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 18, who was on an antibiotic (medication used to treat bacterial infections) for a wound infection. This deficient practice placed R18 at risk of wound worsening and complications related to infections. Findings included: - R18's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder), need for assistance with personal care, open wound to right foot, pressure wound of left heel, pressure injuries of sacral region (large triangular bone between the two hip bones), stage four (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling),…

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 45 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)40, and R6. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses muscle weakness, history of falls, dementia (progressive mental disorder characterized by failing memory, confusion), reduced mobility, cognitive communication deficit, anxiety (progressive mental disorder characterized by failing memory, confusion), and left femur fracture (broken bone in left upper leg). A review of R40's Significant Change Minimum Data Set (MDS) completed 02/16/23 indicated a brief Interview for Mental Status (BIMS) score of eight noting moderate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) in a sanitary manner for Resident (R) 33. This deficient practice placed R33 at increased risk to develop a respiratory infection. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide and the lungs are unable to carry the blood to the organs) with hypoxia (inadequate supply of oxygen), hypertension (elevated blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and chronic obstructive pulmonary disease (COPD-…

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 45 residents. The sample included 13 residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide adequate dementia care and services for Resident (R) 38 (a cognitively impaired resident displaying dementia related symptoms). This deficient practice placed R38 at risk for preventable injuries and accidents as well as impaired quality of life. Findings Included: - The Medical Diagnosis section within R38's Electronic Medical Records (EMR) included diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), aphasia (condition with disordered or absent language function), fracture of left humerus (broken bone of the left upper arm), need for assistance…

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 45 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were followed up for Resident (R) 33 related to an antihypertensive medication (class of medication used to treat hypertension (high blood pressure) which was held, and the physician was not notified. The facility failed to follow CP recommendations for antihypertensive medication administered outside of physician ordered parameters for R33 and R4. The facility also failed to notify the physician of blood sugars outside of ordered parameters for R33. This deficient practice had the potential for unnecessary medication use and possible adverse consequences and side effects. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure (condition in which the blood does not have enough…

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 45 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow physician orders for Resident (R) 33's antihypertensive medication (class of medication used to treat hypertension (high blood pressure)), when staff held the medication and did not notify the physician, as ordered The facility failed to follow the consultant pharmacist recommendations for antihypertensive medication administered outside of physician ordered parameters for R33 and R4. The facility also failed to notify the physician of blood sugars outside of ordered parameters for R33. This deficient practice had the potential for unnecessary medication use and possible adverse consequences and side effects. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure (condition in which the blood does not have enough oxygen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 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 to obtain signed consents or declinations for COVID-19 vaccinations for Resident (R) 44. This deficient practice had the risk for unwarranted physical complications and the risk to spread illness among residents, a high-risk population. Findings included: - R44 admitted to the facility on [DATE]. His medical record lacked evidence a COVID-19 vaccination was offered upon admission. There was a lack of evidence of a signed consent or declination for COVID-19 vaccination for R44. On 05/04/23 at 02:14 PM, Administrative Nurse D stated when a resident admitted to the facility, she and medical records reviewed the resident's history for vaccination status and obtained consents. She stated she and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents. Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of the residents residing in the facility. Findings Included: - On [DATE] at 11:35 AM, Resident (R)6, who was alert and oriented, reported the facility staff tell him they did not have enough staff to provide him with his scheduled showers three nights a week on Monday, Wednesday, and Fridays. The resident reported he was lucky to get one bath a week. He stated the staff had to use a full body lift to transfer him and there has to be two staff present while they use the full body lift and they only have one CNA on each of the three halls and sometimes they did not even have that. There have been nights where there have only been one Certified Nurse Aide (CNA) on for all three halls. Review of R6's Electronic Medical Record (EMR) revealed R6…

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 53 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - During the initial tour of the kitchen, on 10/06/21 at 08:21 AM, and an environmental tour of the kitchen, on 10/12/21 at 10:05 AM, revealed the following concerns: 1. There were five skillets which lacked the non-stick surfaces, making them uncleanable. 2. Eight cookie sheets had a build-up of a black substance on the cooking surfaces and around the edges of the cookie sheets. 3. Three cutting boards had deep grooves, making them uncleanable. 4. The lids to two trash cans had dried food debris. 5. The inside of the microwave had dried food debris on the top and sides of the inside. 6. The reach-in refrigerator contained six left-over food items which were undated. 7. There were 25 containers of spices with sticky, dusty tops. On 10/12/21 at 10:05 AM, Dietary Staff BB and Administrative Staff A, stated the kitchen…

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 53 residents. Based on observation, interview and record review, the facility failed to ensure sanitary room cleaning in a manner to prevent the spread of infection. The facility failed to track and trend infections and causative organisms on an ongoing consistent manner (December 2020, January 2021, February 2021, July 2021, August 2021, and September 2021) to evaluate for the prevalence of organisms causing infections amongst the residents. Findings included: - Observation, on 10/07/21 at 02:59 PM, revealed housekeeping staff U, provided room cleaning to a room occupied by two residents. Housekeeping staff U donned gloves and sprayed a rag with Stride (a general-purpose cleaner for hard surfaces) and wiped one resident's over the bed table which contained the resident's water and personal items and, and with the same gloved hands and same rag, proceeded to wipe the roommate's over the bed table, which contained her personal items and water pitcher. Housekeeping Staff U proceeded to wipe the heating/cooling unit and windowsill. With the same gloved…

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 53 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship were followed by nursing staff to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance for the residents of the facility. Findings included: - Review of the facility, Infection Control Surveillance Log revealed the following areas of concern for application of antibiotic stewardship: December 2020, lacked an Infection Control Surveillance Log. January 2021, lacked an Infection Control Surveillance Log, but did contain a log of antibiotics used in the facility which lacked organism identification for two residents with urinary tract infections and one resident with an unspecified bacterial infection. The log failed to assess compliance with the McGeer's Criteria (a systematic guide for antibiotic use based on criteria for specific infections which included culture sensitivity to antibiotic prescribed). February 2021, lacked an Infection Control…

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 53 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility for resident rooms on two of the three resident halls. Findings included: - Observations during an environmental tour, on 10/13/21 at 07:56 AM, with Housekeeping and Maintenance staff V, included the following concerns: 1. One resident room had a build-up of grime on the floor around the parameter of the room and bathroom. The baseboards were peeled away from the wall next to the bathroom door. 2. A shared resident bathroom had a heavy build-up of a tannish substance on the base of the toilet. 3. Four shared resident rooms had chipped, peeling paint in the bathroom. The floor around the parameter of the room had a build-up of grime. 4. One resident room had a build-up of dirt in the corners of the floor. There were multiple dirty spots on the carpeting covering the wall. 5. One shared resident bathroom had missing molding…

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 53 residents and identified nine with restorative nursing programs. The 18 residents sampled included one other resident (not identified by the facility) Resident (R) 19 reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide the planned and ongoing restorative nursing services to the one sampled resident and the nine identified residents including R5, R27, R37, R21, R25, R30, R41, R48, and R54, to maintain as much functional range of motion ability as possible. Findings included: - Resident (R)19's physician order sheet, dated 09/07/21, included diagnoses of acquired absence of left leg below knee, dementia without behavioral disturbance, and reduced mobility. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had impairment in range of motion ability on one side of the lower extremities and received no restorative services. The Quarterly MDS, dated [DATE], documented impairment in range 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.

The facility reported a census of 53 residents and the facility contained two medication rooms. Based on observation, record review, and interview the facility failed to ensure an accurate system to reconcile the discontinued medications from any residents with discontinued medications. Findings included: - Review of medication storage room for the 100 and 200 Halls, on 10/12/21 at 09:30 AM, identified a clear container with 32 medication cards with various medications including examples of Namenda and Potassium: six vials of an antibiotic (Cefazolin) used to mix with fluids and give intravenous (IV), four eye drops, and one inhaler. On 10/21/21 at 09:55 AM, Licensed Nurse L, revealed that the clear container contained medications to be destroyed or sent back to the pharmacy. She confirmed the medications did not have disposition documentation to accurately account for these discontinued medications upon reconciliation. When the medications were discontinued, they were removed from the cart and placed in the clear container without any tracking system. On 10/13/21 at 10:05 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents with 18 residents included in the sample, including one resident reviewed for accommodation of needs. Based on interview, observation and record review, the facility failed to ensure functional accommodation of needs for one Resident (R)19, regarding anti-tip brakes (brakes applied to wheelchair to help prevent falls) on his wheelchair. Findings included: - The Physician Order Sheet (POS), dated 09/07/21, for Resident (R)19, included the following diagnoses: absence of left leg (amputation), dementia (progressive mental disorder characterized by failing memory, confusion) and history of 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. The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. The resident was independent with locomotion on the unit 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents with 18 sampled which included one resident reviewed for choices. Based on observation, interview, and record review the facility failed to provide choices for dependent Resident (R)6 related to his preferences for frequency, time, and type of bath. Findings included: - Review of resident (R) 6's Physician Orders, dated 9/7/21 revealed diagnoses which included quadriplegia (paralysis from the neck down including the trunk, legs, and arms), neurogenic (originating from the nerves or nervous system)bowel and bladder, multiple pressure (left hip, right hip, sacral region, and mid lateral right foot, and contracture (permanent shortening of the muscle, tendon or scar tissue producing deformaty or distortion) of the muscle at the right lower leg. The admission Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. He exhibited no behaviors. The resident reported preferences…

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 53 residents, with 18 residents sampled. Based on observation, interview and record review, the facility failed to develop an individualized comprehensive plan of care for two of the 18 sampled Residents (R)18, regarding toileting and R 19, regarding Activities of Daily Living (ADL). Findings included: - The Physician Order Sheet (POS), dated 09/07/21, for Resident (R)18, documented a diagnosis of contractures (abnormal permanent fixation of a joint) of the bilateral lower extremities (both legs). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required extensive assistance of two staff for toileting, had no toileting program and was always incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/03/21, documented the resident required assistance of staff for toileting and was always incontinent 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 53 residents with two sampled for discharge. Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, reconciliation, and disposition of the medications for resident (R)57. Findings included: - Review of the Resident (R) 57's Physician Orders, dated 07/07/21, revealed diagnoses which included dementia (progressive mental disorder characterized by failing memory, confusion), depression, (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), anxiety, ( mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and urinary tract infection. The admission Minimum Data Set (MDS) dated [DATE], documentation included the resident was admitted on [DATE], with the Brief Interview for Mental Status, (BIMS) not assessed due to the resident being unable to complete the assessment. He was independent with decisions…

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 53 residents with 18 residents sampled, including five residents reviewed for Activities of Daily Living (ADL). Based on interview, record review, and observation, the facility failed to provide necessary assistance to maintain cleanliness for three of the five sampled dependent Residents (R)6, R 18, and R 19, regarding bathing. Findings included: - The Physician Order Sheet (POS), dated 09/07/21, for Resident (R)18, documented a diagnosis of contractures (abnormal permanent fixation of a joint) of the bilateral lower extremities (both legs). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required total assistance of two staff for bathing and had impairment on both sides of her lower extremities. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/03/21, documented the resident required staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents with 18 residents sampled which included one resident reviewed for pressure ulcers care and treatment. Based on observation, interview and record review the facility failed to ensure resident (R)6 with pressure ulcers received necessary treatment and services, to promote healing, and prevent infection or decline in the resident's pressure ulcers. Findings included: - Review of the resident (R) 6's Physician Orders, dated 09/07/21, revealed diagnoses which included quadriplegia (affected by or related to paralysis of all four limbs, iron deficiency anemia ( a condition marked by deficiency of red blod cells), and stage three and four pressure ulcers (PU) of the left hip, right hip, sacral region, and right medial foot. The admission Minimum Data Set (MDS) dated [DATE], documentation the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He required extensive assistance of staff for bed mobility, transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents with 18 residents sampled, which included five residents reviewed for indwelling catheter and incontinence care/treatment. Based on observation, interview, and record review, the facility failed to provide catheter care/and treatment to prevent infection for two residents with indwelling catheters Residents (R)6 and R 9. The facility also failed to provide necessary care and treatment to maintain as much bladder function as possible for two sampled incontinent residents, R18 and R19. Findings included: - Review of Resident's (R)'s 6 Physician Orders, dated 09/07/21, revealed diagnoses which included quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), pressure ulcers, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and chronic urinary tract infections (UTI). The admission Minimum Data Set (MDS) dated [DATE], documented the resident with Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 with 18 residents sampled for review including one resident reviewed for tube feeding. Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent complications including aspiration pneumonia and metabolic abnormalities for the one sampled resident with tube feedings, Resident (R) 51. Findings included: - The Order Summary Report, dated 09/07/21, for Resident (R) 51 included diagnoses of severe protein calorie malnutrition (state of inadequate intake of food), diabetes mellitus (when the body cannot use glucose) and right above the knee amputation. The Annual Minimum Data Set, (MDS), dated [DATE], assessed R51 with a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition, her weight of 79 pounds, and she received 26-50%, 501 ml (milliliters) a day or more in tube feeding. The Care Plan, dated 09/27/21, directed staff to check for tube placement and gastric contents/residual volume per…

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 53 residents, with 18 residents selected for review including one resident reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to provide adequate respiratory services with the failure to label the oxygen tubing when changed, failure to label the distilled water container when opened and store it appropriately. These practices increased the risk for Resident (R)11 of developing a respiratory infection. Findings included: - The Order Summary Report, dated 09/07/21, for Resident (R)11, included diagnoses of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and acute respiratory failure. The Annual Minimum Data Set,(MDS), dated [DATE] assessed R11 with a Brief Interview of Mental Status (BIMS) score of four, indicating severely impaired cognition and received oxygen therapy. The Care Plan, dated 07/09/21, included…

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 53 resident with 18 residents sampled which included five residents for unnecessary medications. Based on interview and record review the facility failed to act upon the pharmacist's recommendation to resolve identified irregularities for Resident (R)16, related to insulin and antihypertensive medication. Findings included: - Review of the Resident (R) 16's Physician Orders, dated 10/7/21, revealed diagnoses which included hypertension (high blood pressure) and type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Care Area Assessment (CAA) for Psychotropic Drug Use, dated 07/09/21, documentation included the resident received psychotropic medications to manage psychiatric illness/condition. A licensed nurse monitors for side effects every shift, and the physician is to be notified of any abnormal findings. A pharmacist consultant will review medications monthly and the Primary care physician (PCP) will review medications with each visit. Contributing factors include…

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 53 resident with 18 residents sampled which included five residents for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the resident's drug regimen was free of unnecessary medications related to the administration, monitoring for effectiveness, and side effects of insulin and antihypertensive medications as ordered by the physician for Resident 16. Findings included: - Review of the Resident (R) 16's Physician Orders, dated 10/7/21, revealed diagnoses which included dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (high blood pressure), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), anxiety disorder mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond 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 53 residents with 18 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure Resident (R)9 was kept free from unnecessary medications, by not reducing the order for Fluoxetine (an antidepressant medication used to treat depression), as ordered, in a timely manner. Findings included: - The Physician Order Sheet (POS), dated 09/07/21, for Resident (R)9, documented a diagnosis of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness emptiness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The resident received an antidepressant medication seven of the seven days of the lookback period. 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.