Larksfield Place

The facility reported a census of 74 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria, by failing to ensure the ice machine had an appropriate drainage air gap from the tubing to the floor drain, as required. Findings included: - During an initial tour of the kitchen on 10/07/24 at 10:35 AM, revealed the facility ice machine, used to supply ice to residents of the facility, did not have appropriate drainage. The draining tube from the ice machine fed directly into the floor drain, which contained small pieces of trash and debris, and lacked an air gap, as required. On 10/07/24 at 10:44 AM, Dietary Staff BB stated the draining tube from the ice machine should go into the floor drain. The facility policy for Ice Machine Safety, undated, included: The ice machine will be maintained and cleaned by the Environmental Service Staff. The facility failed to ensure the ice machine had an appropriate drainage air…

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 74 residents with 20 residents sampled for review, including one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)70, regarding discharge to an acute hospital. Findings included: - Review of Resident (R)70's electronic medical record (EMR) included a diagnosis of type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Modification of admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE], from an acute hospital. She had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident's overall goal was to discharge to the community. The Return to Community Referral Care Area Assessment (CAA), dated 06/23/24, did not trigger. The Discharge MDS, dated 07/09/24, documented the resident…

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 with 20 residents sampled, including two residents reviewed for positioning. Based on observation, interview, and record review, the facility failed to ensure proper wheelchair positioning for one Resident (R)5. Findings included: - Review of Resident (R)5's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. She was dependent on staff for mobility in her wheelchair and all transfers. The Functional Abilities Care Area Assessment (CAA), dated 10/03/23, did not trigger. The Quarterly MDS, dated 07/29/24, documented the staff assessment for cognition revealed severe impairment. She was dependent on staff for mobility in her wheelchair and transfers. The care plan for 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 74 residents with 20 residents sampled, including nine residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)3's toilet safety rail was secure and R 29, related to failure to ensure the resident was safe in the use of his lift chair. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She has no impairment in functional range of motion (ROM) and was dependent on staff for toileting hygiene. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 07/13/24, documented the resident was dependent on staff for toileting cares. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents selected for review, which included two residents reviewed for urinary catheters (a flexible tube inserted through the urethra [the external opening of the urinary tract] and into the bladder). Based on observation, interview, and record review, the facility failed ensure consistent monitoring of one Resident (R)58's penile erosion (a split in the urethra) caused by pressure of a urinary catheter. Findings included: - Review of Resident (R)58's medical record revealed diagnoses that included urinary retention (inability to empty urine from the bladder), renal failure, history of repair of femur (long bone in the upper leg), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident had impairment on…

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 74 residents with 20 residents selected for review, which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for medication for one Resident (R)52 who received a lower dose a chemotherapy (medication used to treat cancer) than ordered by the physician. Findings included: - Review of Resident (R)52's electronic medical record revealed diagnoses that included malignant (cancerous) neoplasm (tumor) of the brain, and post operative repair of femur (bone in upper part of the leg) fracture. The admission Minimum Data Set (MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/30/24, assessed the resident required skilled therapies after a left hip fracture and neoplasm of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents sampled, including five residents reviewed for indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder through the urethra to drain and collect urine). Based on observation, interview and record review, the facility failed to provide appropriate catheter care for two Residents (R)47, and R58 with indwelling urinary catheters, in a clean and sanitary manner. Findings included: - Review of Resident (R)47's electronic medical record (EMR) revealed a diagnosis of 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 Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. He had an indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder through the urethra to drain and collect…

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 59 residents. The facility had a large main kitchen and a satellite kitchen for the long term/skilled branch of the facility. Based on observation, interview, and record review the facility failed to ensure the light fixtures above the food preparation areas in the main facility kitchen were cleaned and the storage shelving without rust. This deficient practice placed residents at risk for food borne illness. Findings included: - On 12/15/22 at 11:00 AM, observation in the main kitchen revealed 19 overhead lights and 10 of the lights had lint on the surface and some small objects inside the cover. On 12/15/22 at 11:20 AM, observation in the main kitchen revealed metal shelving holding steam table pans had a small amount of rust at the edges of three of six of the shelves. The pan were turned upside down directly on the shelves. On 12/15/22 at 11:25 AM, Dietary Staff (DS) BB verified the findings and stated maintenance was responsible for the care and cleaning of the light fixtures and had last checked them in October of this year. The facility's…

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 59 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide two sampled residents, Resident (R)7 and R37 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services. This placed the residents at risk for uniformed decisions regarding skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. Form 10055 was to include the monetary amount it would cost the resident to continue to receive therapy at 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 reported a census of 65 residents, with one main kitchen. Based on observation and interview the facility failed to store foods in a safe and sanitary manner by the failure of staff to date and reseal opened food items, and failure to discard expired food items. Findings included: - On 04/28/21 at 08:18 AM during initial tour of the main kitchen the following are observed: In the dry storeroom there were two bags of spaghetti noodles, opened, with no open date and one bag of chicken fry mix dated but not resealed closed. In the freezer, noted one bag of chicken breasts with ten pieces inside, one bag of fish fillets with 12 pieces, one bag of French fries, and one bag of potato cakes-- all opened and were not resealed and not dated. In the refrigerator, noted one 30 ounce (oz) container of roasted red pepper pesto, five 30 oz. containers of southwest chipotle pesto, all expired on 12/07/20; one five pound tub of whipped whole milk ricotta with a best by 04/28/21 date (Dietary Staff B stated it would not be used today), one 12 oz tub of hollandaise sauce with a best by…

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 was 65 with 16 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R) 10, R157, R48, and R155's Advance Directives (a legal document in which a person specified what actions should be taken for their health), and the facility provided conflicting information regarding the residents code status (decision whether or not to withhold medical intervention in the event the resident's heart stops) to the staff responsible for R10, R157, R48 and R155's care. Findings included: - Review of the [DATE] Care Plan documented R10 had a Do Not Resuscitate (DNR; or no code, a written legal order to withhold cardiopulmonary resuscitation (CPR), in respect of the wishes of a person in case their heart stopped or they stopped breathing) order in chart and staff were to honor R10's decision and would not transfer R10 to the hospital due to the DNR. Review on [DATE] of the Electronic Health Records (EHR) Physician Orders documented no DNR order. Review 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 65 residents with 16 sampled including three for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services to maintain good grooming for Resident (R) 155, who required extensive assistance of two staff with bathing. Findings Included: - Review of R155's Electronic Health Record (EHR) documented the following diagnoses dated 04/20/21: macular degeneration (progressive deterioration of the retina), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and fractures of the right tibia (bone of the lower leg) and fibula (one of the two bones of the lower leg). Review of R155's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident required extensive assistance of two staff with all ADLs, except eating which required supervision of one staff. The MDS…

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

The facility reported a census of 65 residents, with 16 sampled and four for falls. Based on interviews, observations, and record review, the facility failed to adequately ensure R38's fall interventions were in place to prevent future falls and failed to implement new interventions related to two falls with noted lack of appropriate footwear on R38. Findings included: - Review of R38's pertinent diagnoses from 10/07/20 Physician's Order Electronic Medical Records (EMR) documented: overactive bladder, cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), abnormalities of gait and mobility (difficulties in walking), repeated falls, and pain. Review of the 10/14/20 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The resident required extensive one-person assistance for all activities of daily living (ADL) but could eat with limited assistance. R38 was occasionally incontinent of urine and not on a toileting program. The MDS…

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