Booker T. Washington Skilled Nursing and Rehabilit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to provide documentation regarding the existence of any written advance directives for 3 (#4, #25, #69) of 8 residents reviewed for Advanced Directives. Findings: Review of the facility's Advance Directives policy (revised 05/31/2023) revealed in part: Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Resident #4 Review of Resident #4's record revealed an admit date of 05/07/2026 and 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.

Based on record review and interviews, the facility failed to ensure Safe Smoking Assessments were completed on admit and with each subsequent MDS assessment per policy for 1 (#26) of 1 residents reviewed for smoking. Findings: Review of the facility's Smoking Policy - Residents (revised 03/08/2023) included in part:The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include the ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation or equivalent form. Once a resident is determined to be a smoker, his/her ability to smoke safely will be evaluated upon admission, subsequent MDS and PRN. Based on record review and interviews, the facility failed to ensure Safe Smoking Assessments were completed on admit and with each subsequent MDS per policy for 1 (#26) of 1 residents reviewed for smoking. Findings: Review of the facility's Smoking Policy - Residents (revised 03/08/2023) included in part:The resident will be evaluated on admission to determine if he or she is a smoker 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 Based on record review and interview the facility failed to ensure a significant change assessment was completed for 1 (#15) of 1 reviewed for significant change assessment. Findings: Review of Resident #15's medical record revealed an admission date of 06/13/2022 with diagnosis that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, acute respiratory failure with hypoxia, chronic kidney disease stage two, peripheral vascular disease with heart failure, chronic diastolic congestive heart failure, unspecified systolic congestive heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's MDS dated [DATE], Section C showed that a BIMS was No (resident is rarely/never understood). Resident had memory problem for short term and long term. Cognitive skills for daily decision making was marked 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 Based on record review and interviews, the facility failed to ensure residents' code status wishes for emergency basic life support were consistent and accurate across all areas of residents' medical records for 2 (#4, #78) of 8 residents reviewed for Advanced Directives. The facility failed to ensure the residents' records reflected the residents' wishes to be a DNR. Findings:Review of the facility's Advance Directives policy (revised [DATE]) revealed in part: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive11. The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. 15. Our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, 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 Based on record reviews, observations, and interviews, the facility failed to ensure 2 (#46, #223) of 20 sampled residents received treatment and care in accordance with professional standards of practice by failing to ensure: 1. Resident #46's high blood glucose levels were rechecked as ordered after being administered sliding scale insulin for glucose levels greater than 400, and a Hemoglobin A1C (Glycated hemoglobin- a blood test that measures the average blood sugar level over the past 2-3 months) was obtained every 3 months as ordered; 2. Resident #223's care was coordinated with the Hospice provider regarding the resident's medications. Findings: 1. Review of Resident #46's records revealed an admit date of 04/19/2024 with diagnoses including: Type 2 diabetes mellitus, end stage renal disease, and mild-protein-calorie malnutrition. Review of Resident #46's active Physician's Orders revealed orders including: - 05/06/24 - Humalog Injection Solution 100 unit/ml (milliliters)- Inject subcutaneously as per…

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

Based on record reviews and interviews, the facility failed to provide nutritional and hydration care and services consistent with the resident's comprehensive assessment for 1 (#69) of 4 (#9, #46, #62, #69) residents reviewed for nutrition. The facility failed to consult the Registered Dietician (RD) for Resident #69. Findings: Review of Facility's Nutrition and Hydration to Maintain Skin Integrity Policy (revised October 2010) revealed: Assessment - Purpose: The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. Nutritional Assessment - 1. The dietician and RD, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission/re-admission and as indicated by a change in condition that places the resident at risk for impaired nutrition, 2. Re-assessments will be conducted more often if 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.

Based on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation for 1(#70) of 1(#70) resident reviewed to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide resident #70 or her responsible party with required documents; a discharge summary and plan. Findings: Review of the facility's Transfer or Discharge Preparing a Resident. (Revised December 2016) Policy and Procedure revealed in part: Policy Statement - Residents will be prepared in advance for discharge. Policy interpretation and Implementation 1. When a resident is scheduled for transfer or discharge, office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 3. Nursing, Social Director and Interdisciplinary…

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.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to develop 1 (#69) out of 25 total sampled resident's care plan to include diagnosis and approaches for diabetes mellitus. Findings: Review of Resident #69's medical records revealed an admit date of 02/20/2025 with the following diagnoses, including in part: other sequelae of cerebral infarction, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, and unspecified protein-calorie malnutrition. Type 2 diabetes mellitus diagnosis documented on nurse practitioner progress note. Review of Resident #69's comprehensive care plan failed to reveal a problem and approaches for diagnosis of type 2 diabetes mellitus. Review of Resident #69's Nurse Practitioner (NP) progress notes dated 03/07/2025 revealed: Acute/Follow-Up - Chief…

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.

Based on record review, observation, and interview, the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 1 (#17) of 1 (#17) residents observed during incontinence care. Findings: Review of Resident #17's medical records revealed an admit date of 11/21/2024 with the following diagnoses, including in part: other idiopathic peripheral autonomic neuropathy, obesity, age-related physical debility, myalgia/unspecified site, and primary generalized osteoarthritis. Review of Resident #17's MDS (Minimum Data Set) Assessment with an assessment reference date of 02/24/2025 revealed in part: -BIMS (Brief Interview for Mental Status = 05 out of 15 indicating severe cognitive impairment; -required extensive assistance with 2+ persons physical assistance for bed mobility and transfers, and total dependence with 2+ persons physical assistance for toilet use, and was frequently incontinent of bowel and bladder. Observation on 04/01/2025 beginning at 11:25 a.m. revealed S7 CNA (Certified Nursing Assistant) performed incontinence 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.

Based on observations, interviews and record reviews, the facility failed to ensure assessments were accurate for 1 (#2) of 3 (#1, #2 and #3) sample residents. The facility failed to ensure resident #2's annual MDS (minimum data set) with ARD (assessment reference date) 04/30/2024 accurately reflected resident #2's self-care abilities. Findings: Review of resident #2's clinical records revealed diagnoses of other sequelae of cerebral infarction, gross hematuria, type 2 diabetes mellitus, and dysphagia following cerebral infarction, unspecified dementia, and moderate with behavioral disturbance, hematuria, acute kidney failure, unspecified, chronic kidney disease, and stage 3 chronic kidney disease Review of resident #2's annual MDS with ARD 04/30/2024 revealed Section GG - Functional Abilities Self-Care assessment indicating Resident #2 is independent in his ability to eat, perform oral hygiene, toileting hygiene, self-showering /bathing and dressing upper and lower body. Review of Occupational Therapy Evaluation & Plan of Treatment with Certification Period: 05/10/2024 - 06/08/2024…

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 Based on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #32) out of 18 (Resident #9, #13, #15, #20, #30, #32, #34, #40, #43, #44, #53, #56, #59, #60, #69, #70, #72, and #73) sampled residents investigated. Findings: Review of Resident #32's medical record revealed Resident #32 was admitted on [DATE] and discharged from the facility on 10/23/2023. Review of Resident #32's Discharge MDS dated [DATE] revealed a completion date of 02/22/2024 and a transmission date of 02/29/2024. Review of Resident #32's medical record failed to reveal a Discharge MDS assessment was completed and transmitted within 14 days after the resident was discharged from the facility. During an interview on 03/06/2024 at 11:20 a.m., S5MDS Coordinator acknowledged Resident #32's 10/23/2023 Discharge MDS was not completed and transmitted within 14 days of discharge and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a plan of care had been developed for 4 (#56, #69, #70 and #72) residents. The facility also failed to ensure a plan of care had been implemented for 1 (#40 ) resident. This was out a total of 24 sampled residents whose plan of care had been reviewed. The facility failed to: 1. Develop a plan of care for Residents #56, #69, #70 and #72. 2. Implement the plan of care for Resident #40. Findings: Resident #56 Review of Resident #56's medical record revealed an admit date of 01/12/2024 with the following diagnoses in part: end stage renal disease, diabetes mellitus type 2 with diabetic chronic kidney disease, dependence on renal dialysis, and congestive heart failure. Review of Resident #56's Quarterly MDS (Minimum Data Set) dated 01/19/2024 revealed Resident #56 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severely impaired cognition. Review of Resident #56's Physician Orders dated 02/29/2024 revealed an…

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.

Based on record review and interview, the facility failed to ensure residents were free of unnecessary medications for 1 (#15) out of 6 (#15, #20, #30, #34, #40, #69) sampled residents reviewed for unnecessary medications. The facility failed to monitor Resident #15 for edema while receiving a diuretic. Findings: Review of Resident #15's Medical Records revealed an admit date of 07/11/2014 with the following diagnoses, in part: type 2 diabetes mellitus without complications, congestive heart failure, other symptoms and signs involving the genitourinary system, obstructive and reflux uropathy/unspecified other viral pneumonia. Review of Resident #15's Physician's Orders revealed orders dated 01/05/2024 - Bumetanide oral tablet 1mg (milligram) give 1 tablet by mouth one time a day and Spironolactone oral tablet 100mg give 1 tablet by mouth one time a day. Review of Resident #15's January - March 2024 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema. During an interview on 03/06/2024 at 10:35 a.m., S2 DON (Director of Nursing)…

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.

Based on record reviews and interviews, the facility failed to ensure a resident's medical record was complete and accurately documented in accordance with accepted professional standards and practices for 3 (Resident #9, #43, #60) of 4 (Resident #9, #40, #43, and #60) residents reviewed for wounds. Findings: Review of facility's Wound Care policy with a revision date of November 2017 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. They type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care. 8. The signature and title of the person recording the data. Resident #9 Review of Resident #9's medical record revealed an admission dated of 03/31/2023 with the following medical diagnoses, in part: restlessness and agitation, mild protein-calorie malnutrition, muscle weakness, and pain. Review of Resident #9's physician order revealed 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.