Avita Health And Rehab At Reeds Cove

The facility had a census of 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 6 reviewed during the medication administration pass, remained free of medication errors. Twenty-five medication opportunities were observed with twelve medication errors. This placed the resident at risk for adverse reactions from the medications and resulted in a medication error rate of 48%. Findings Included: - Resident 6's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure) and heart failure (a condition with low heart output and the body becomes congested with fluid). The Electronic Health Record (EHR) revealed the following physician medications: Cholecalciferol (a dietary supplement prescribed for with vitamin D insufficiency or deficiency) tablet 1000-unit tablet, give one tablet, by mouth (po), daily for Vitamin D deficiency, ordered on 06/12/22. Aspirin (a…

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

The facility reported a census of 57 residents. The facility identified 20 residents that resided on the 400 hall on 07/21/24. Based on interview and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible for seven residents when Licensed Nurse I failed to document medications/ treatments/assessments from 07/21/24 at 06:00 PM to 07/22/24 at 06:00 AM. Findings included: - Review of the investigation report dated 07/23/24, revealed the facility employed a licensed nurse from a nursing agency to work from 07/21/24 from 06:00 PM to 07/22/24 06:00 AM shift in one of three houses for 20 residents. Upon review of the resident Electronic Medication Administration records (EMAR) and Electronic Treatment Administration Record (ETAR), multiple medications were not documented or given for a variety of reasons. The facility initiated a review of EMAR, ETAR, and progress notes of the 20 residents that LN I was in charge of medication administration and identified the following concerns: R30 had 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 reported a census of 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the sanitary manner medications administered and lacked proper hand hygiene during medication administration. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - On 08/14/24 at 07:57 AM, Certified Medication Aide (CMA) II prepared medications for R6's morning medication administration. CMA II performed hand hygiene with hand sanitizer located on the medication cart. CMA II spilled the medication cup that contained all R6's by mouth pills except for the Oxycodone (pain medication). Six of the by mouth medications landed on the floor and four landed on the top of the medication cart. CMA II picked up all the medications that fell out and placed them back into the medication cup. She removed the Oxycodone tablet from the blister pack, by popping into the medication cup with all the other pills. CMA…

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 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to include Resident (R)21 for the development and continued planning of the resident's care plan quarterly. This deficient practice placed the residents at risk for impaired care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. Findings included: - Resident 21's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of unspecified shoulder. The 10/30/23 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R21 had a total mood severity score of 02, indicating minimal depression and there were no behaviors. R21 required supervision assistance with 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 reported a census of 57 residents with 17 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R)8's advanced directives (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether or not to withhold medical intervention in the event the resident's heart stops] order). Additionally, the facility failed to obtain proper authorization for a DNR for R3 when the facility allowed the resident's guardian to consent. These deficient practices had the potential to lead to uncommunicated needs specifically to end-of-life care. Findings included: - Review of the Electronic Health Record (EHR) for R8 included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus type 2 (DM2 - a disease when the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents with 17 residents sampled that included one resident reviewed for baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan for one resident, Resident (R) 153. This deficient practice had the potential to lead to uncommunicated needs. Findings included: - The Electronic Health Record (EHR) for Resident (R)153, admitted to the facility on [DATE] with documented diagnoses that included acute pancreatitis (a condition characterized by inflammation of the pancreas that can be accompanied by severe pain with nausea and vomiting), chronic kidney disease (CKD - long term kidney disease with gradual decline in kidney function) and diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) was incomplete and in…

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 57 residents which included 17 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident, Resident (R)30's, regarding oxygen delivery or nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication administration. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical well-being. Findings included: - R30's Electronic Health Record (EHR) included diagnoses of obstructive sleep apnea (OSA - a disorder of sleep characterized by periods without respirations due to anatomical obstructions in the airway) and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (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 reported a census of 57 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise two residents care plans after Resident (R)22 and R9's had a fall. This placed the residents at risk for uncommunicated care needs. Findings included: - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) and dementia (progressive mental disorder characterized by failing memory, confusion). The 03/01/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R22 had a total mood severity score of 00, indicating no depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, and transfers. R22 required supervision assistance with bathing and ambulation. R22 had no falls. The 03/01/24 Functional Abilities Care Area Assessment (CAA)…

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

The facility identified a census of 57 residents which included 17 residents in the sample. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care related to the unsanitary manner medications administered when CMA II dropped Resident (R)6's medications, picked them up from the floor and the medication cart, and administered the medications to the resident. Findings included: - On 08/14/24 at 07:57 AM, Certified Medication Aide (CMA) II prepared medications for R6's morning medication administration. CMA II spilled the medication cup that contained all R6's by mouth pills except for the Oxycodone (pain medication). Six of the by mouth medications landed on the floor and four landed on the top of the medication cart. CMA II picked up all the medications that fell out and placed them back into the medication cup. She removed the Oxycodone tablet from the blister pack, by popping into the medication cup with all the other pills. CMA II went to R6's table in the dining room and asked R6 if she would like 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.

The facility identified a census of 57 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)19, who was dependent on staff, received care for removal of facial hair. Additionally, the facility failed to ensure (R)40, who was dependent on staff, received care for removal of facial hair and oral care. These deficient practices placed the residents at risk for decreased psychosocial well-being. Findings included: - Resident (R) 19's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiplegia (paralysis of one side of the body), and depression. The 09/25/23 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. Total severity score of one, indicating minimal depression, and there were no behaviors. R19 required maximal assistance with ADL's (activities of daily living such as bed mobility, transfers, dressing, 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 census totaled 57 residents with 17 residents included in the sample, that included five residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to use effective infection control practices when providing wound care to one Resident (R103), who admitted with a pressure ulcer (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) This deficient practice had the potential to inhibit wound healing. Findings included: - Resident (R)103's physician orders identified the following diagnoses that included muscle weakness, need for assistance with personal care, diabetes mellitus type two (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), and disseminated intravascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents, with three residents sampled for urinary catheters. Based on observation, record review and interview, the facility failed to provide proper care to prevent urinary infection for one Resident (R103), when staff failed to properly handle the urinary catheter collection bag to ensure the bag remained below the level of the bladder to prevent urine backflow and the development of urinary tract infection. Findings included: - Resident (R)103's Electronic Health Record (EMR) revealed diagnoses that included hydronephrosis (condition of excess urine accumulation in kidney(s) that causes swelling of kidneys), diabetes mellitus type two (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The admission Minimum Data Set (MDS) dated [DATE] revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents with 17 residents selected for review which included four residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to properly clean and store the nebulizer (a device for administering inhaled medications) for Resident (R)30. Additionally, the facility failed to obtain a physician's order to administer oxygen to R1 and replace a contaminated cannula for R1. These deficient practices had the potential to have a negative impact on the residents' physical and psychosocial well-being. Findings included: - The Electronic Health Records (EHR) documented R1 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), obstructive sleep apnea (OSA - a disorder of sleep characterized by periods without respirations due to anatomical obstructions in the airway) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents. Based on observation, interview and record review, the facility failed to store medications properly for three residents, Resident (R)8, R153 and R22, all of whom had over-the-counter medications stored in their individual bedrooms. The facility failed to screen the residents for safety related to medication storage and safe self-medication administration. Findings included: - The Electronic Health Record (EHR) for Resident (R)153, admitted to the facility on [DATE] with documented diagnoses that included acute pancreatitis (a condition characterized by inflammation of the pancreas that can be accompanied by severe pain with nausea and vomiting), chronic kidney disease (CKD - long term kidney disease with gradual decline in kidney function) and diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin). The admission…

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 49 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care. Findings included: - Review of the nursing schedule from 09/01/22 through 11/28/22 revealed a lack of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 09/19/22, 09/26/22, 10/10/22, 10/15/22, 10/17/22, 10/24/22, 10/31/22, 11/07/22, 11/14/22, 11/21/22, and 11/28/22. On 11/30/22 at 09:22 AM Administrative Staff B stated the salary nurse was the Registered Nurse coverage for the listed dates apart from the 10/15/22. Administrative Staff B stated he was unable to provide the documentation of eight consecutive hours when worked by the salaried Registered Nurse hours. On 11/30/22 at 03:08 PM Administrative Nurse D stated she was responsible for ensuring Registered Nurse coverage for the facility.…

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 49 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to secure 21 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. The facility additionally failed to utilize a gait belt for safe transfers for Resident (R) 6. This deficient practice placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 11/28/22 at 07:15AM an environmental inspection of Reddy Hall was completed. An inspection of the Utility Storage Room revealed the entry door was not securely locked. A sign posted on the door noted Oxygen Storage. The room contained 21 pressurized oxygen cylinder tanks stored with unpressurized tanks. On 11/30/22 at 02:15PM an interview with Licensed Nurse (LN) H, she stated the oxygen tanks and equipment should be stored in a secure and sanitary location. She stated that door should be locked at all times to keep the residents safe. On 11/30/22 at 03:25PM an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to properly store and secure medications on two of three nursing units. This placed the affected residents at risk for complications related to unnecessary medication administration. Finding Included: - On 11/28/22 at 07:17AM an environmental inspection of Berlin-[NAME] Hall was completed. A walk-through of the resident's day room revealed a grey storage bin located outside the medication room. A sign displayed on the box stated, Cycle fill medications - due not start using until the morning of November 24th. An inspection of the unlocked bin revealed around 90 partially used pharmacy bubble cards for multiple residents on the unit. No staff monitored the storage bin during the walk-through. At 07:29AM Licensed Nurse (LN) G reported that the medication bin should not be left unsecured in the common area and moved the box into the locked medication room. On 11/28/22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 15 residents. Five of the sampled residents were reviewed for unnecessary medications. Based on observation, record review and interview the facility failed to ensure the provider ackowledged and responded to the Consultant Pharmacist (CP) recommendation in a timely manner for a prescribed, as needed (PRN) Ativan (lorazepam-an antianxiety medication that calm and relax people with excessive anxiety, nervousness, or tension) had the required 14-day stop date for Resident (R)2, R10, and R32. The CP further failed to identify and report R12's antihypertensive (a medication used to treat elevated blood pressure) medications given outside the physician ordered parameters. This deficient practice placed R2, R10, R32, and R12 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R2 documented diagnoses of quadriplegia (paralysis of the arms, legs and trunk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 49 residents. The facility identified three kitchen/food service areas. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. This placed the affected residents at risk for decreased palatability of food and food-borne illness. Findings included: - Observation of the [NAME] House kitchen, on 11/28/22 at 07:35 AM, with Dietary Staff BB, revealed the following areas of concern: 1. Dietary Staff DD prepared foods with hair retention device only partially covering her hair. 2. In the residential freezer; a large bag of French fries with an open date 11/02/2022 lacked expiration date. 3. In the residential freezer; a large bag of mixed vegetables with an open 09/05/22 use by date 09/15/22. 4. In the residential freezer; three large bags of corn lacked open date or expiration date. 5. In the residential freezer; a medium bag of sliced, grilled chicken with an open date 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 49 residents. Based on observation, record review and interview, the facility failed to ensure staff followed infection control standard of practice. The facility failed to practice proper hand hygiene, failed to ensure a urinary catheter (the insertion of a hollow tube into the bladder to drain the urine into a collection bag) bag was kept off the floor, failed to ensure sanitary storage of oxygen tubing, and failed to ensure face mask covered nose and mouth. This placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - On 11/28/22 08:17 AM, Certified Nurse Aid (CNA) O touched her facemask and pulled it down off her nose for a minute and placed it back on her face, then walked up to the kitchen area and grabbed a plate for a resident without performing hand hygiene after touching her mask. On 11/28/22 at 08:45AM Resident (R) 197 was in the dining room. R197's pants were soaked. His urinary catheter tubing ran down 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 49 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were available and utilized for Resident (R) 11's wheelchair to prevent her feet from dragging on the floor while the staff propelled R11 in the chair. This deficient practice placed R11 at risk for preventable injuries. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cervicalgia (neck pain), other symptoms and signs involving cognitive functions and awareness, low back pain and type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic polyneuropathy (damage or disease to nerves characterized by weakness, numbness and/or pain to the affected area[s]). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS)score of 14, indicating intact cognition.…

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 49 residents. The sample included 15 residents with two residents reviewed for notification of changes. Based on observations, interviews, and record reviews, the facility failed to notify Resident (R) 43's resident representative of a change in condition. This deficient practice placed the resident at risk for delayed treatment decisions and decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of hypertensive heart disease (chronic high blood pressure that damages the heart), chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational…

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 49 residents. The sample included 15 residents with 15 reviewed for activities of daily living (ADL). Based on observations, record review, and interviews, the facility failed to provide consistent bathing opportunities for R196. This deficient practice placed R196 at risk for preventable infections and decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R196's Electronic Medical Records (EMR) included diagnoses of hydrocephalus (fluid build-up in the brain's cavities), muscle weakness, cognitive communication deficit, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertensive heart disease (chronic high blood pressure that damages the heart). A review of R196's admission Minimum Data Set (MDS) dated 11/16/22 noted she had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS noted that she required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 15 residents with 15 reviewed for quality of care. Based of observations, record review, and interviews, the facility failed to ensure physician's order were in place for R197's care related to his Wound-Vac (vacuum assisted closure machine used to aid in wound healing). This deficient practice placed R197 at risk for complication related to ineffective wound care. Findings Included: - The Medical Diagnosis section within R197's Electronic Medical Records (EMR) included diagnoses of cellulitis of right lower limb (skin infection caused by bacteria characterized by heat, redness and swelling), atherosclerotic heart disease, atrial fibrillation (rapid, irregular heart beat), acute kidney failure, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), sepsis (a systemic reaction…

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 49 residents. The sample included 15 residents with two reviewed for bowel and bladder management. Based of observations, record review, and interviews, the facility failed to implement an individualized bowel and bladder toileting program for Residents (R)196 and failed to provide sanitary Foley catheter care (tube inserted into the bladder to drain urine into a collection bag) for (R)197. This deficient practice placed the residents at risk for complications related urinary tract infections. Findings Included: - The Medical Diagnosis section within R196's Electronic Medical Records (EMR) included diagnoses of hydrocephalus (fluid build-up in the brain's cavities), muscle weakness, cognitive communication deficit, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertensive heart disease (chronic high blood pressure that damages the heart). A review of R196's admission Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sampled included 15 residents. Based on observation, record review and interview, the facility failed to ensure one resident (R) 12's supplemental oxygen tubing was stored appropriately when not in use. This deficient practice places R12 at risk for respiratory complications and increased infection. Findings included: - The electronic medical record (EMR) for R12 documented diagnoses of respiratory failure with hypoxia (the body does not have enough oxygen), pulmonary hypertension (HTN-when the pressure in the blood vessels leading from the heart to the lungs is too high), and atrial fibrillation (A-fib and irregular, rapid heartbeat). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R12 had a Brief Interview for Mental Status (BIMS) score of seven which indicated a severely impaired cognition. R12 required extensive assistance of one to two staff for her activities of daily living (ADLs). R12 required the use of a walker or a wheelchair…

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 49 residents. The sample included 15 residents. Five sampled residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure nursing staff administered R12's antihypertensive medication (a medication used to lower an elevated blood pressure) metoprolol within physician ordered parameters. The deficient practice placed R12 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R12 documented diagnoses of respiratory failure with hypoxia (the body does not have enough oxygen), pulmonary hypertension (HTN-when the pressure in the blood vessels leading from the heart to the lungs is too high), and atrial fibrillation (A-fib- irregular, rapid heartbeat). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R12 had a Brief Interview for Mental Status (BIMS) score of seven which indicated a severely impaired…

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 49 residents. The sample included 15 residents. Five of the sampled residents were reviewed for unnecessary medications. Based on observation, record review and interview the facility failed to ensure a 14-day stop date or an appropriate rationale for continued use and a duration for as needed (PRN) Ativan (lorazepam, an antianxiety- class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for Resident (R) 2, R10, and R32. This deficient practice placed R2, R10, and R32, at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR)for R2 documented diagnoses of quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mood disorder (category of mental health problems, feelings of sadness,…

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.