Rossville Healthcare And Rehabilitation Center

The facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction…

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 74 residents. The sample included 19 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's footrest was down on her wheelchair and her feet had appropriate footwear, and further failed to ensure R6 was provided with assistance while eating. This defiant practice placed R10 and R6 at risk of impaired activities of daily living (ADL) and unmet care needs. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels),…

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 74 residents. The sample included 19 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 6 and R10, who were at risk for the development of pressure ulcers. This deficient practice placed R6 and R10 at risk for complications related to skin breakdown. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), dysphagia (swallowing difficulty), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 08/01/24 documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated…

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 74 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's resting splint and R41's cockup splint were applied for contractures (abnormal permanent fixation of a joint or muscle) and dysphagia (swallowing difficulty). This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or 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 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction…

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 74 residents. The sample included 18 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 13's continuous positive airway pressure (CPAP - a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner. This placed R13 at an increased risk for respiratory infection and complications. Findings included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of personal history of nicotine dependence, major depressive disorder (major mood disorder that causes persistent feelings of sadness), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), kidney failure, hypertension (high blood pressure), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), anxiety (mental 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 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address Resident (R) 37's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis. This deficient practice placed R37 at risk of ineffective treatment and decreased quality of care. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia, major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R37's admission Minimum Data Set (MDS) dated 01/21/25 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 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 2, R37, and R67 antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication lacked a Centers for Medicare and Medicaid (CMS) approved indication for use. These deficient practices placed R2, R37, and R67 at risk of unnecessary medication administration and related complications. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), major depressive disorder (major mood disorder that causes persistent…

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 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the physician provided an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use of Resident (R) 2 and R67's prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. These deficient practices placed R2 and R67 at risk of unnecessary medication administration and related complications. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may…

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 71 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required effective communication education. This deficient practice placed residents at risk for impaired care. Findings included: - The facility's Entity Reports and Complaint Data Collection, not dated, documented on 08/12/24 at approximately 08:00 PM, LN G heard CNA M talking to Resident (R) 1 in her room. CNA M asked R1 how she was doing and if she needed anything. R1 responded by telling CNA M to just leave, she was making a fool out of herself. CNA M left R1's room without any incidents. Later, R1 had her call light on and LN G answered it. R1 requested a cup of ice. When CNA M returned to R1's room with the ice, LN G heard yelling in R1's room from R1 and CNA M. LN G entered R1's room and R1 appeared noticeably upset after CNA M exited her room. R1 stated that CNA M threw the cup of ice. LN G observed water and ice on the floor, side table, and bed. Upset, CNA M stated R1 used racial slurs towards her. R1 and CNA M…

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 71 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from staff to resident verbal abuse. This deficient practice placed R1 at risk for further abuse and a decline in her psychosocial well-being. Findings included: - 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 borderline personality disorder (a disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior). The Annual Minimum Data Set (MDS) dated 06/04/24, documented R1's short-term and long-term memory were okay, and she made decisions regarding daily life independently. R1 had verbal behaviors directed toward others…

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 70 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure the required information was provided on an involuntary notification of discharge to Resident (R) 1 and/or his representative. This deficient practice placed R1 at risk for an inappropriate discharge and impaired resident rights. Findings included: - R1 admitted to the facility on [DATE] and discharged from the facility on 06/02/24. R1's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion) with other behavioral disturbances. The admission Minimum Data Set (MDS) dated 02/26/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R1 experienced delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) during the assessment period. The Quarterly MDS…

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

The facility had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, for the 70 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and assessment. Findings included: - Review of the Registered Nursing Staffing Schedule for May, June and September 2022, recorded the facility lacked a registered nurse on the following days: Three day in April (04/05/22. 04/10/22, 04/17/22) Two days in June (06/25/22, and 06/26/22) On 08/21/23 at 08:50 AM, Administrative Nurse D verified the facility did not have a registered nurse in the building or working as a charge nurse for the above documented dates. The facility's Nursing Services and Sufficient Staff policy dated 02/01/20 recorded the facility would provide sufficient staff with appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical, mental 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 had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year. Findings included: - The facility's employment records documented five nurse aides were employed at the facility for at least one year. The facility's in-service records documented all five of those nurse aides had not completed the required 12 hours of in-service training in the past year. On 08/21/23 at 10:45 AM, Administrative Staff A and Administrative Nurse D stated there was no system in place to monitor completion of in-service hours by nurse aide staff and stated they were aware of the mandatory topics for in-services. They said they were recently hired a few weeks ago and they, along with corporate office, were unable to find a system in place to monitor completion of in-service hours, and they did not find completed…

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

The facility had a census of 70 residents. Based on record review and interview the facility failed to employ a designated, certified Infection Preventionist who was responsible for the facility's Infection Prevention and Control Program. This placed the 70 residents of the facility at risk for lack of identification and treatment of infections. Findings included: - The facility's Infection Control Log was completed through July 2023. On 08/23/23 at 12:30 PM, Administrative Staff A verified the facility did not currently employ a certified Infection Preventionist. The facility's Infection Preventionist policy, dated 08/15/22, stated the facility would employ one or more qualified individuals responsible for implementing the facility's infection prevention and control program. The IP must be employed at least part time and the amount of time should be determined by the facility assessment to determine the resources it needs for the Infection Control Program. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the Infection Control Program,…

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

The facility had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to complete ensure certified nurse aides (CNA) received the required 12 hours of in-service which included dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) training and abuse prevention training. This deficient practice placed the residents at risk for impaired quality of care and abuse. Findings included: - The facility's in-service records documented all five CNAs reviewed had not completed the required 12 hours of in-service training which included dementia and abuse pervention in the past year. On 08/21/23 at 10:45 AM, Administrative Staff A and Administrative Nurse D stated there was no system in place to monitor completion of in-service hours by nurse aide staff and stated they were aware of the mandatory topics for in-services. They said they were recently hired a few weeks ago and they, along with corporate office, were unable to find a system in place 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.

- On 08/17/23 at 09:00 AM, observation of Hall 200 medication cart revealed the following: Omeprazole (antacid or used to treat low magnesium) 20 milligrams (mg) 14 tablets expired 06/2023. On 08/17/23 at 09:15AM, observation of the Hall 100 medication cart revealed the following: R40's Humulin R 100 (short acting insulin) vial lacked an open date and expiration date. On 08/17/23 at 09:15 AM, Certified Medication Aide (CMA) S verified the staff were to discard expired stock medications. On 08/23/23 at 09:45 AM, Administrative Nurse D verified the nurses should label and date the vials with the resident's name and discard expired vials and expired medications. The facility's Storage of Medications policy, dated 01/01/20, documented the facility shall store all medications in the medication carts or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature light, ventilation, moisture control, segregation, and security. The medication rooms are routinely inspected by the facility designated for discontinued, outdated,…

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

The facility had a census of 70 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide a CMS form 10055 for Resident (R) 54, R68, and R223. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare Advance Beneficiary Notice (ABN) form 10055 informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. The facility lacked documentation staff provided R54 (or their representative) the CMS form 10055 when the resident's skilled services…

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 70 residents. The sample included 21 residents, with one reviewed for restraints. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 6 was free from physical restraints when they failed to ensure he could release a safety seatbelt while in his wheelchair as directed by the physician. This placed the resident at risk for complications related to physical restraints. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of traumatic brain Injury (sudden injury that causes injury to the brain,) hemiplegia (paralysis of one side of the body,) hemiparesis (muscular weakness of one half of the body,) epilepsy (brain disorder characterized by repeated seizure,) cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), abnormal posture, muscle weakness. R6's Quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 21 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified an unwitnessed fall resulting in a serious head injury as an allegation of potential abuse and/or neglect and report to the state agency as required. This placed the residents at risk for ongoing abuse and/or neglect. Findings included: - R24's Electronic Medical Record (EMR) documented the resident had diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), fracture right femur (thigh bone), and fracture left humerus (bone of the upper arm). R24's Quarterly Minimum Data Set (MDS) dated [DATE], recorded 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 had a census of 70 residents. The sample included 21 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified an unwitnessed fall resulting in a serious head injury as an allegation of potential abuse and/or neglect and intiate an investigation as required. This placed the residents at risk for ongoing abuse and/or neglect. Findings included: - R24's Electronic Medical Record (EMR) documented the resident had diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), fracture right femur (thigh bone), and fracture left humerus (bone of the upper arm). R24's Quarterly Minimum Data Set (MDS) dated [DATE], recorded 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 had a census of 70 residents. The sample included 21 residents with one reviewed for hospitalization. Based on observation, interview and record review the facility failed to provide a Notice of Bed Hold to Resident (R) 5, or their representative, upon transfer/discharge to the hospital. This deficient practice placed R5 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of anxiety disorder (mental conditions characterized by excessive fear of or apprehension about real or perceived threats), chronic pain syndrome, quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epileptic seizures (neurological disorder causing an excessive surge of electrical activity in the brain), history of traumatic brain injury, cognitive communication deficit, acute respiratory failure, encephalopathy (any brain disease that alters brain function or structure), and bacterial…

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 70 residents. The sample included 21 residents. Based on observation, record review and interview, the facility failed to review and revise Resident (R) 38's care plan with effective interventions to prevent the development of future 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) and promote healing for her right inner heel pressure ulcer. The facility failed to update R45's care plan after a fall and failed to update R4's care plan regarding side rails. These deficient practices placed the residents at risk for decreased quality of care due to uncommunicated care needs. Findings included: - R38's Electronic Medical Record (EMR) documented R38 had diagnoses of absence of left leg below knee, anemia (deficiency of healthy red blood cells in blood), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot…

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

The facility had a census of 70 residents. The sample included 21 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of the resident's dialysis treatment, including monitoring for Resident (R)71. This placed the resident at risk for complications and health decline. Findings included: - R71's Electronic Medical Record (EMR) documented R71 had diagnoses of end stage renal disease (kidney failure). R71's Quarterly Minimum Data Set (MDS), dated 08/10/23, recorded R71 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required limited assistance of one staff for bed mobility, transfers, personal hygiene, and toilet use. The MDS further recorded R71 was occasionally incontinent of urine and recorded the resident received dialysis treatment. The Dialysis Care Plan, dated 07/05/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 21 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)38, R5, R17, R22, R4, and R42. This placed the affected residents at risk for injury. Findings included: - R38's Electronic Medical Record (EMR) documented the resident had diagnoses cirrhosis of liver, diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), absence of left leg below knee, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R38's admission Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview for Mental Status (BIMS) 15, which indicated intact cognition. The MDS documented R38 extensive staff assistance with bed mobility and transfers. The MDS lacked documentation R38 had side rails. R38's Care Plan. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 21 residents with four reviewed for dementia (group of thinking and social symptoms that interferes with daily functioning). Based on observation, interview, and record review the facility failed to provide dementia related psychosocial services to attain the residents highest practicable health and wellbeing, including initial and ongoing mental health assessment for Resident (R) 28 who initiated sexual contact with another impaired resident on the dementia unit. The facility failed to assess the resident for capacity to consent, and failed to initiate ongoing monitoring to ensure the intimate relations did not impact R28 in a negative manner, due to her inability to express her feelings as a result of dementia. This deficient practice placed R28 at risk for decreased quality of life related to unrecognized mental health needs and unidentified negative outcomes. Findings included: - R28's Electronic Medical Record documented diagnoses including…

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 70 residents. The sample included 21 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist (CP) notified the facility of Resident (R) 28's as needed (PRN) lorazepam (medication isued to treat anxious or restless mood) which lacked a stop date as required. This deficient practice placed R28 at risk for adverse side effects related to continued psychotropic (altering mood or mind) medication use beyond 14 days. Findings included: - R28's Electronic Medical Record documented diagnoses including vascular dementia (form of dementia caused by an impaired supply of blood to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS documented R28 required limited staff assistance for dressing, toileting, hygiene, supervision for all other activities of daily living…

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 70 residents. The sample included 21 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure Resident (R) 28's as needed (PRN) lorazepam (medication isued to treat anxious or restless mood) had a stop date as required. This deficient practice placed R28 at risk for adverse side effects related to continued psychotropic (altering mood or mind) medication use beyond 14 days. Findings included: - R28's Electronic Medical Record documented diagnoses including vascular dementia (form of dementia caused by an impaired supply of blood to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS documented R28 required limited staff assistance for dressing, toileting, hygiene, supervision for all other activities of daily living (ADLs) and had wandering behavior daily. The Medication Care Plan,…

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

The facility had a census of 70 residents. The sample included 21 residents. Based on observation, record review and interview the facility failed to serve Resident (R) 60, on the memory unit, food at the appropriate temperature for food safety and palatability. This placed R60 at risk for food borne illness and/or decreased intake and nourishment. Findings included: - On 08/21/23 at 12:20 PM, observation in the memory unit revealed Dietary Staff (DS) CC dished up two plates of resident food from the portable steam table, placed them uncovered on the top shelf of a metal cart, by the dining room. DS CC continued to dish up other plates for residents, then unplugged the steam table, and returned it to the kitchen. DS CC came back at 12:30 PM with covers and placed them on the two plated food items. Continued observation revealed at 12:46 PM, Certified Medication Aide (CMA) R told staff R60 was awake and asked staff to assist R60 to a wheelchair in his room. Continued observation revealed staff propelled R60 to the dining room table, and CMA R started to serve the resident the plated…

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 70 residents. The sample included 21 residents with one reviewed for urinary catheter (tube inserted into the bladder to drain urine) care. Based on observation, interview, and record review the facility failed to practice proper infection control when providing care for Resident (R)17's urinary catheter. This deficient practice placed R17 at risk for urinary infections. Findings included: - R17's Electronic Medical Record documented diagnoses of obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), kidney failure (condition in which the kidneys lose the ability to remove waste and balance fluids), methicillin resistant staphylococcus aureus (MRSA-infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics), sepsis (life-threatening complication of an infection), and diabetes mellitus (chronic condition that affects the way the body processes blood…

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

The facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards when staff left chemicals in an unlocked cabinet in the activity room. Findings included: - On 12/07/21 at 08:30 AM, observation revealed the following items in an unlocked upper cabinet in the activity room: One full 4 fluid (fl) ounce (oz) bottle of green tempera paint Two full 16 fl oz bottles of red tempera paint One 1/2 full 16 fl oz bottle of blue tempera paint One 1/2 full 16 fl oz bottle of orange tempera paint One full 16 fl oz bottle of black tempera paint One 3/4 full 6 fl oz bottle of nail polish remover with vitamin e and panthenol The tempera (a water based paint that cleans up with soap and water) Material Safety Data Sheet (MSDS), dated 03/30/2007, documented if inhaled remove to uncontaminated area. Give artificial respiration if not breathing. Get immediate medical attention. If skin contact: Wash skin with soap and water for at least 15 minutes while removing…

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

The facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to change gloves during incontinent care, carried unbagged soiled lines against their clothing down the hall to the dirty utility room, and failed to disinfectant a shared glucometer (medical device that helps to measure glucose or sugar levels in the blood). Findings included: - On 12/09/21 at 09:33 AM, observation revealed Certified Nurse Aide (CNA) O and CNA P entered Resident (R) 15's room and told resident they were going to provide incontinent cares. R15 was seated in a rocking recliner, CNA P and CNA O applied gloves, placed lift belt around the resident, moved the sit to stand machine underneath the resident's feet, instructed the resident to hang on to the handles while CNA P used control to stand the resident up, and CNA O placed her hand on the back of the lift…

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 61 residents. The sample included 16 residents with one reviewed for discharge. Based on observation, record review, and interview the facility failed to follow up on Resident (R) 23's request to be transferred to another facility closer to his guardian. Findings included: - The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score 15, which indicated intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, limited staff assistance with locomotion off the unit, and supervision with locomotion on the unit. The MDS documented the resident had no discharge plan. The Discharge Care Plan, revised on 10/14/21, documented the resident expected to remain a permanent resident of the facility, the resident would have an ongoing discharge plan that provided for a safe and effective discharge should the resident 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 had a census of 61 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain grooming, and personal hygiene for two sampled residents, Resident (R) 16 and R42. Findings included: - R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for dressing, toileting and personal hygiene. The ADL Care Area Assessment (CAA), dated 07/04/21, documented the resident required extensive assistance with cares and mobility. The ADL Care Plan, dated 10/07/21, directed staff to offer the resident a choice of whirlpool and shower per individualized wishes on her bathing schedule and provide one staff assistance for bathing and hygiene. On 12/07/21 at 02:40 PM and 12/08/21 at 07:54 AM, observation revealed the resident had multiple facial hairs on her…

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 61 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, physician and medical director medication concerns for one of five sampled residents. Resident (R) 10's medication not held when pulses were out of physician ordered parameters. Findings included: - R10's Physician Order Sheet (POS), dated 11/04/21, documented diagnoses of atrial fibrillation (rapid, irregular heartbeat) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required limited assistance of one staff for bed mobility, transfers, dressing, and toileting. The assessment documented the resident received anticoagulant (medication to inhibit the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The Poly Pharmacy Care…

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 61 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to hold amiodarone hcl (a medication for heart rhythm problems) when pulses were out of parameter for one of five sampled residents, Resident (R) 10. Findings included: - R10's Physician Order Sheet (POS), dated 11/04/21, documented diagnoses of atrial fibrillation (rapid, irregular heartbeat) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required limited assistance of one staff for bed mobility, transfers, dressing, and toileting. The assessment documented the resident received anticoagulant (medication to inhibit the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The Black Box Warning Care Plan, dated 11/01/21, directed staff to administer medications as ordered and monitor for…

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.