Stratford Commons Rehab & Health Care Center

The facility identified a census of 54 residents. Based on record review and interview, the facility failed to ensure Licensed Nurse (LN) staff possessed the required skills and competencies to administer medication intravenously (IV- administered through a vein directly into the bloodstream). This placed all residents with IV medications at risk for medication errors and adverse outcomes. (Refer to F760) Findings included: - An SBAR Communication Form and progress note -V 2 under the Assessments tab in R47's EMR recorded in the Situation section, documented the wrong IV antibiotic was administered on 12/13/24. The form was signed by Administrative Nurse F on 12/15/24. The facility's report #74 Med Error, dated 12/13/23, documented the wrong IV antibiotic medication was administered to R47. The document further recorded R47 received Unasyn (antibiotic) instead of the ordered Rocephin. The document recorded that the IV medication was stopped, R47's provider was notified and R47 went to the hospital. The report documented None to the predisposing environment, physiological 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 identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for care plans. Based on observation, record review, and interviews, the facility failed to revise the care plan with the relevant hospice information for Resident (R) 29. The facility also failed to revise R10's care plan with the unsuccessful attempts for nonpharmacological interventions that had been tried prior to the administration of as-needed psychotropic (alters mood or thoughts) medication. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The admission Minimum Data Set (MDS) dated [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified as census of 54 residents. The sample included 14 residents with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's discharge summary included medication reconciliation and instructions. This placed R24 at risk for not receiving timely and appropriate care. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses of atrial fibrillation (A-fib: a rapid, irregular heartbeat), hypertension (HTN- an elevated blood pressure), syncope (fainting or passing out), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). The admission Minimum Data Set (MDS) dated [DATE] documented R24 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The Functional Care Area Assessment (CAA) dated 01/25/24 for R24 documented she was receiving skilled services and was seen by therapy with the goal 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 identified a census of 54 residents. The sample included 14 residents with one sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 32 received supportive care and services to promote and maintain his quality of life when the facility did not implement tools and/or strategies to allow R32, who had aphasia (a condition with disordered or absent language function), to communicate his wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings included: - R32's Electronic Medical Record (EMR) from the Diagnoses tab documented cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia following cerebral infraction, hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following…

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 54 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL care including trimming his fingernails/toenails for Resident (R) 5. The facility also failed to provide ADL care and assistance to R9. This deficient practice placed the residents at risk for poor hygiene, decreased self-esteem, and impaired health. Findings included: - The Diagnoses tab of R5's Electronic Medical Record (EMR) documented diagnoses of chronic inflammatory demyelinating polyneuropathy (CIDP - a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), generalized muscle weakness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). 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 identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for quality of care. Based on observation, record review, and interview, the facility failed to apply Geri Sleeves (sleeves used to protect the skin on the arms and legs against damage caused by friction and shearing) to Resident (R) 23 per her care plan and the facility failed to follow physician ordered daily weights for R10 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R23 at risk for skin injury and placed R10 at risk for excess fluid accumulation and physical complications. Findings included: - R23's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). 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 identified a census of 54 residents. The sample included 14 residents with two sampled for 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, interviews, and record reviews the facility failed to ensure staff implemented the care plan interventions for Resident (R) 9 who had multiple pressure-related injuries and remained at risk for the development of pressure ulcers. This deficient practice placed R9 at risk for delayed healing, new pressure injuries, and related complications. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of chronic osteomyelitis (local or generalized infection of the bone and bone marrow) of the left tibia (bone of the lower leg )and fibula (one of the two bones of the lower leg), repeated falls, symptoms and signs involving cognitive functions and awareness, acquired absence of the right toe,…

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 54 residents. The sample included 14 residents with three reviewed for range of motion. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5 received services/interventions to prevent a reduction of range of motion (ROM) and contractures (abnormal permanent fixation of a joint or muscle). This deficient practice left R5 at risk for further decline and decreased ROM or mobility. Findings included: - The Diagnoses tab of R5's Electronic Medical Record (EMR) documented diagnoses of chronic inflammatory demyelinating polyneuropathy (CIDP - a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), generalized muscle weakness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated 08/15/23, documented a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 54 residents. The sample included 14 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff followed the care plan for safe transfers for Resident (R) 29 and the facility also failed to ensure staff placed a fall mat next to R9's bed per his plan of care. These deficient practices placed these residents at risk for falls and possible injuries related to falls. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R29 was…

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 54 residents. The sample included 14 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure there was a physician indication for oxygen administration for Resident (R)29 and failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R29 at increased risk for respiratory infection and complications. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R29 was…

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 54 residents. The sample included 14 residents with two residents reviewed for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to obtain Resident (R) 102's weight before hemodialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) treatment. This placed R102 at risk for complications related to dialysis. Findings included: - The electronic medical record (EMR) for R102 documented diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on renal dialysis. R102's admission Minimum Data Set (MDS) dated 12/21/23 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R102 was on dialysis at the time of admission. R102's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 12/27/23 documented she was skilled and was seen by therapy with the goal…

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 54 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure nonpharmacological attempts of symptom management prior to administering as-needed psychotropic (alters mood or thought) medication for Resident (R) 10. The facility also failed to ensure a duration for an as-needed psychotropic medication for R101. These deficient practices placed these residents at risk for unnecessary psychotropic medication and related complications. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and insomnia (inability to sleep). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview…

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 54 residents. The sample included 14 residents with two reviewed for discharge. Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 47 received an incorrect antibiotic (medication used to treat bacterial infections) intravenously (IV-administered via the vein directly into the bloodstream). This placed the resident at risk for adverse drug effects and ineffective antibiotic therapy. Findings included: - R47's Electronic Medical Record (EMR) documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), fracture of the skull and facial bones, compression of the brain, and generalized muscle weakness. The admission Minimum Data Set (MDS) dated 11/05/23 documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS documented R47 used a walker and was independent for personal hygiene. R47 required substantial…

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 54 residents. The sample included 14 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 29 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R29. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief…

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

The facility identified a census of 54 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to provide Resident (R)39 with the pneumococcal conjugate vaccine (PCV20- vaccination for bacterial lung infections) as consented. This placed R39 at increased risk for complications related to pneumonia ( bacterial infection in the lungs). Findings included: R39's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. R39's EMR under the Misc tab revealed he gave verbal consent on a Pneumococcal Vaccination form to receive the PCV20 vaccination on 10/11/23. The form indicated R39 was provided educational information related to the vaccination but never received the PCV20 vaccination. The facility was unable to provide evidence the PCV20 was administered to R39 upon request. On 02/05/24 at 07:25 AM Administrator Staff A stated Administrative Nurse E was responsible for tracking resident vaccinations. On 02/08/24 at…

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 55 residents. Based on interview and record review, the facility failed to ensure 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. Findings included: - Review of the Infection Control Log for tracking and trending infections from January 2022 through June 2022, revealed the following: January, February and March logs lacked documentation of organism identifications for monitoring trends in infection. The May 2022 log was not done/unavailable for review. The Infection Preventionist (IP) was not available to interview. On 07/28/22 at 06:37 PM Administrative Nurse D stated she had reviewed the monthly infection surveillance book and had noted the lack of organism tracking and facility trending. The facility policy Infection Prevention and Control Program Manual Antibiotic Stewardship and MDROs dated 2019 documented tracking and reporting of antibiotics use and outcomes will 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. The sample included 16 residents with five residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for resident (R)27, R34, R16, R18, and R31. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and increased skin complications. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of muscle weakness, retention of urine (lack of ability to urinate and empty the bladder), dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), chronic kidney disease, and cognitive communication deficit. R27's Significant Change Minimum Data Set (MDS) dated 06/16/22 noted a Brief…

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

The facility identified a census of 55 residents and one facility kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dining services related to food preparation, equipment cleaning and food storage during service. This deficient practice placed the residents at increased risk related to food borne illnesses and food safety concerns. Findings Included: - On 07/26/22 at 07:25 AM an initial kitchen walk-through revealed two staff members prepping food in the kitchen area were not wearing hairnets while working with food during the prepping of breakfast. At 07:26 AM Dietary Staff CC stated that the kitchen did not have any hairnets available at that time. An inspection of the dry food storage area revealed opened containers of pancake syrup, Worcestershire sauce, and peanut butter with no opened dates labeled. An inspection of the dry food mixer revealed dried food residue on the base of the mixer around the buttons. An inspection of the walk-in refrigerator unit revealed heavy dust and debris buildup of the air-conditioning units…

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 55 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to identify quality issues and develop performance improvement plans. This deficient practice placed the resident's at risk for ineffective care. Findings Included: - The facility failed to ensure residents were provided Notice of Medicare Non-coverage (NOMNC) notices. (Refer to F582) The facility failed to ensure bathing and personal hygiene was provided for residents who required assistance from staff to complete the care. (Refer to F677) The facility failed to implement a physician order for daily weights to monitor for excess weight/fluid retention and failed to implement adequate blood glucose monitoring. (Refer to F684) The facility failed to provide a toileting program to reduce or prevent bladder incontinence. The facility failed to provide consistent catheter (tube inserted into the bladder to drain urine) care of indwelling catheters. (Refer to F690) The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. Based on observation, record review, and interview, the facility failed to ensure that proper hand hygiene was followed during peri-care for Resident (R) 21 and failed to ensure sanitary handling of a sling and disinfection of the Hoyer Lift (total body mechanical lift used to transfer residents) after use for R96. The facility failed to ensure sanitary storage of clean linens. These deficient practices put facility residents at risk for the spread of infections and/or communicable diseases. Findings Included: - On 07/26/22 at 08:00 AM an inspection of the Blue Hallway linen closet revealed clean towels, hospital gowns, sheets, rags, and Hoyer Lift slings stored on a metal rack. The clean linen shared a room with a sink, specimen refrigerator and trash can. No cover was observed over the clean linen rack. An inspection of the Green Hallway linen closet revealed clean towels, hospital gowns, sheets, rags, and Hoyer Lift slings stored on a metal rack. The Hoyer…

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 55 residents. The sample included 16 residents with five reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination and pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Resident (R) 37, R10, and R35, and R18. This placed the residents at increased risk for influenza, pneumonia, and related complications. Findings included: - Review of R37's electronic medical record (EMR) revealed the Annual Minimum Data Set (MDS) dated [DATE] recorded R37 received an influenza vaccination and was offered and declined a pneumococcal vaccine. R37's clinical recorded lacked evidence of an informed declination for pneumococcal. The facility provided a signed declination for the 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.

The facility identified a census of 55 residents with 16 residents included in the sample and three residents reviewed for beneficiary notification. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) 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). The facility failed to complete the NOMNC for Resident (R)150. This placed the resident at risk for being uninformed of his rights for appeal and potential for financial liability related to the end of the Medicare Part A episode. Findings included: - Review of R150's electronic medical record (EMR) documented the Medicare Part A episode began on 06/10/22 and ended on 06/24/22. R150 discharged from the facility on 06/25/22. The facility lacked documentation that staff issued the NOMNC to the resident or resident's Durable Power of Attorney (DPOA). The medical record lacked documentation of notification of the resident's right to appeal the decision of Medicare non-coverage…

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 55 residents. The sample included 16 residents with two residents reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to provide diabetic (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) monitoring for Resident (R)95 who required an acute hospitalization for dangerously low blood glucose levels. The facility also failed to complete daily weights on R37 for her congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R37 at risk for complications related to her CHF. Findings Included: - The Medical Diagnosis section within R95's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, hypertension (high blood pressure), cognitive communication deficit,…

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 55 residents. The sample included 16 residents with one reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff followed Resident (R) 18's plan of care which directed R18 required assistance of one staff with the use of a transfer belt for transfers. This placed R18, who had a history of falls, at increased risk for accidents and related injuries. Findings included: - R18's Electronic Medical Record (EMR), under the Diagnoses' tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), history of falling, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and abnormalities of gait and mobility. 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 identified a census of 55 residents. The sample included 16 residents with four reviewed for bowel and bladder management and two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, record review, and interviews, the facility failed to store Resident (R)11's urinary catheter in a sanitary manner to promoted dependent drainage without backflow. The facility additionally failed to provide R45 with a toileting program to prevent or reduce incontinence of bladder This deficient practice placed the residents at risk for complication related to urinary tract infections (UTI) and increased risk for incontinence. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of hydronephrosis (excess urine accumulation in kidney(s) that causes swelling of kidneys), chronic kidney disease, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate…

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 55 residents. The sample included 16 residents with one resident reviewed for hydration. Based on observation, record review, and interviews, the facility failed to provide consistent intravenous (IV - giving directly through the veins access) fluid therapy as ordered by the physician for Resident (R)11. This deficient practice placed the resident at risk for complication related to dehydration and related complications. Findings Included: -The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of hydronephrosis ( excess urine accumulation in kidney(s) that causes swelling of kidneys), chronic kidney disease, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), retention of urine (lack of ability to urinate and empty the bladder), neuromuscular dysfunction of bladder (bladder- dysfunction of the urinary bladder caused by a lesion of the nervous system), and dementia (progressive mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to ensure that Resident (R) 21's abdominal binder was applied as directed to avoid possible dislodging of his percutaneous endoscopic gastrostomy (PEG-tube placed through abdomen into stomach to allow liquid nutrition) feeding tube. The facility further failed to ensure sanitary care was provided for R31's gravity bag and tubing used to administer enteral (provided directly to the digestive system through an alternative opening such as a feeding tube) nutrition and failed to assess residual as ordered by the physician. This placed the residents at increased risks for complications related to enteral feedings. Findings Included: - The Electronic Medical Record (EMR) for R21 documented diagnoses of cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) , hemiplegia 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 identified a census of 55 residents and identified one resident was positive for Covid (highly contagious, potentially life-threatening respiratory infection). The sample included 16 residents with two reviewed for respiratory services. Based on observation, record review and interviews, staff failed to ensure Resident (R)18's nebulizer tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R18 at increased risk for respiratory infection and complications. Findings included: - R18's Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), history of falling, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort…

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 55 residents. The sample included 16 residents with two reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review the facility failed to obtain communication from the dialysis center regarding Resident (R) 16's and R146 health status with each procedure. The facility further failed to measure weights daily as ordered for R16 and R146, and obtain weekly labs for R16. This deficient practice placed R16 and R146 at risk for complication related to dialysis. Findings Included: - R16's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of a right femur (thigh bone) fracture, end stage renal (kidney) disease, dependence on dialysis, Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and pain. R16's admission Minimum Data Set (MDS) dated [DATE] recorded 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 55 residents. The sample included 16 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services to support Resident (R)18's highest practicable level of well-being. This deficient practice placed R18 at risk for decreased quality of life and impaired well-being due related to dementia. Findings included: - R18's Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), history of falling, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and abnormalities of gait and mobility. The admission Minimum Data…

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 55 residents. The sample included 16 residents with five residents reviewed for medication regimen review. Based on observation, record review, and interviews, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported irregularities found with Resident (R)10's insulin (hormone used to treat/control blood glucose levels) administration and further failed to identify and report inappropriate diagnoses for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]and other mental emotional conditions) medication use for R18 and R37. This placed the affected residents at risk for unecessary medication treatment and related side effects. Findings Included: -The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of type two 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 identified a census of 55 residents. The sample included 16 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate monitor blood glucose (sugar) levels administer physician ordered insulin (medication used to control blood glucose levels) for Resident (R)10 and R37. This deficient practice placed the residents at risk for abnormal blood glucose levels and related complications. Findings Included: -The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), 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), mild cognitive impairment, abnormal gait and mobility, and history of diabetic ketoacidosis (medical emergency were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. The sample included 16 residents with five residents sampled for unnecessary medication review. Based on observation, record review and interview, the facility failed to ensure that Resident (R)37 and R18 had an appropriate diagnosis for their antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medications: Abilify and Seroquel. This place R37 and R18 at risk for unnecessary antipsychotic medication administration and related side effects. Findings included: - The Electronic Medical Record (EMR) for R37 documented diagnoses of type two diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), hypertension (HTN-elevated blood pressure), retention of urine (lack of ability to urinate and empty the bladder), persistent mood 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. The sample included 16 residents with two residents reviewed for hydration. Based on observations, record reviews, and interviews, the facility failed to respond to and provide Resident (R)18, who required thickened liquids, with her requested drinks during meal service. This deficient practice placed R18 at increased risk for dehydration and impaired comfort. Findings Included: - R18's Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), history of falling, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and abnormalities of gait and mobility. The admission Minimum Data Set (MDS) dated…

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.