Parsons Hill Rehabilitation & Health Care Center

Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#91), out of a total sample of 29 residents. Specifically, for Resident #91, the facility failed to ensure that the oxygen concentrator was set at 2 liters per minute (LPM) as ordered by the Physician, when the Resident was observed with the oxygen concentrator set at 1.5 LPM. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients…

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 provide care and services consistent with professional standards of practice related to renal dialysis (procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly) for two Residents (#93 and #147), out of a total sample of 29 residents. Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident's #93 and #147. Findings include: Review of the facility policy titled Hemodialysis, dated April 2015, included but was not limited to: -Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: >vital signs >Copy of MAR (Medication Administration Record) >any change of condition from last hemodialysis treatment -Documentation will be completed prior to dialysis treatment. -The communication book/sheet will be reviewed upon return from dialysis. 1. 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.

Based on records reviewed and interviews, the Facility, (who had an in-house census of 148 residents) failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit, when their daily occupancy rate was greater than 60 residents. Findings include: Review of the Facility's Job Description for the Director of Nursing Services, with a revision date of 10/2011, indicated the primary purpose of the position is to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Review of the Census Daily Report, dated 07/23/24, indicated the Facility Census was 148. Review of the Nursing Daily Schedule, dated 07/22/24, indicated the DON worked as a charge nurse on a unit, for the 11:00 P.M. through 7:00 A.M. (night) shift. During an interview on 07/23/24 at 3:13 P.M., 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 Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who's Comprehensive Care Plan and Hospital Discharge Summary indicated he/she required supervision with eating, the Facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aides (CNAs) documented that Resident #1 was independent for eating and his/her CNA Care Card (used by the CNAs to determine individual care needs) was incomplete. Findings include: Resident #1 was admitted to the Facility in June 2024, diagnoses included status post mitral valve replacement (surgical procedure to replace a damaged heart valve), Diabetes Mellitus, and Dysphagia (difficulty swallowing). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 was on a minced and moist diet with thin liquids and required supervision with eating. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated 06/13/24, indicated Resident #1 required staff supervision with…

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 interview and record review, the facility failed to provide coverage as required by a Registered Nurse (RN) for at least eight consecutive hours a day for seven days a week. Specifically, the facility was unable to provide evidence that a Registered Nurse (RN) was scheduled and worked for a minimum of eight hours during the 24-hour period on Monday 1/1/2024, when no staffing waivers were in place. Findings include: Review of the facility's daily Nurse Staff Schedule provided to the surveyor by Administration for the period of 12/16/23 to 1/16/24, indicated that no RN had been scheduled to work on Monday 1/1/24 and there were no licensed nursing staff call-outs reported. During an interview on 1/17/24 at 3:22 P.M., the Scheduler said the facility does not use agency staff. She said if there is a call out by a scheduled Registered Nurse and another RN was not available in the facility, she will contact the Director of Nurses (DON) to come in and cover as the DON lives nearby. The scheduler stated that no calls were placed to the DON requesting coverage on 1/1/24. The surveyor…

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 interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the status for six Residents (#97, #141, #39, #40, #24 and #13), in a total sample of 31 residents. Specifically, the facility staff failed to accurately reflect on the MDS assessment that: 1. For Resident #97, that he/she was not receiving dialysis services (a treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) while residing in the facility. 2. For Resident #141, to document, Not Rated instead of continence (ability to control bladder movements), when the Resident had a foley catheter (a tube inserted to drain urine from the bladder). 3. For Resident #39, that he/she did not have a diagnosis of Pneumonia and Septicemia during the MDS assessment time frame 4. For Resident #40, that criteria had been met for Serious Mental Illness (SMI) when the Resident had been identified as having SMI through 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 interview, policy and record review, the facility failed to ensure that three licensed nursing staff (Unit Manager #2, Nurse #5 and Nurse #6), out of a sample of five licensed nursing staff, completed the specific competencies and skill sets necessary to care for residents' needs as identified for one Resident (#102). Specifically, the facility failed to ensure: 1. that nursing staff competencies for three licensed nursing staff (Unit Manager [UM] #2, Nurse #5 and Nurse #6) were completed as necessary to provide safe nursing and related services for facility residents. 2. that Resident #102 could receive dialysis catheter care from licensed nursing staff who were able to demonstrate that they possess the competency to use emergency dialysis equipment in a manner that accomplishes their purpose. Findings include: 1. Review of the Facility Assessment, dated November 2023 indicated: Staff Training/Education included but not limited to the following Nurse Competencies: -Cardiovascular, Respiratory assessment and monitoring -Gastrointestinal (GI),Gastrocult testing, use 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 Based on observation, interview, and National Standards reviewed, the facility failed to provide a safe, sanitary environment for all residents, staff, and visitors and failed to control the source of potential infection on one Unit (Tatnuck) out of five units observed and the rooms of three Residents (#115, #12, and #248). Specifically, the facility failed to: 1. Adequately clean Resident's #115, #12, and #248 rooms of rodent droppings when rodent infestation in the rooms was well known to the facility. 2. Implement cleaning techniques for rodent droppings according to National Standards in order to reduce the risk of infection for all individuals on the Unit. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines, titled How to Clean up After Rodents, dated 1/3/23, indicated the following: -Diseases are mainly spread to people from rodents when they breathe in contaminated air. -CDC recommends you NOT vacuum (even vacuums with a HEPA filter) or sweep rodent urine,…

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 observation, interview, and record review, the facility failed to ensure that one Resident (#40) out of a total sample of 31 residents was treated with dignity and respect. Specifically, the facility staff failed to intervene as needed when residents on the Tatnuck Unit directed yelling, using profane language, and name-calling at Resident #40. Findings include: Resident #40 was admitted to the facility in February 2018 with diagnoses including Schizoaffective Disorder (mental disorder characterized by abnormal thought process and unstable mood), Bipolar Disorder (mental health condition that can cause extreme mood swings), and Dementia (loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of Resident #40's Minimum Data Set Assessment (MDS), dated [DATE], indicated the following: -The Resident was severely cognitively impaired, as evidenced by a total score of three out of 15 possible points on the Brief Interview for Mental Status (BIMS)…

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

Based on observation, interview, record and policy review, the facility failed to prohibit and prevent abuse and retaliation following the reporting of an alleged violation to law enforcement for two Residents (#77 and #248) . Specifically, the facility staff failed to intervene when Resident #248 used verbal threats and threatening physical gestures towards Resident #77, after Resident #77 filed charges with law enforcement against Resident #248, relative to a previous physical altercation between the two Residents that resulted in right eye injury to Resident #77. Findings include: Review of the facility's policy, titled Resident to Resident Altercation, dated April 2015, indicated the following: -It was the facility's policy to create and maintain a safe environment for all residents. -The resident pre-admission screening process will include an evaluation of the person's physical, emotional and behavioral history and present status. -Care plans should include behavior management strategies that utilize the least restrictive intervention before and after any incident 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.

Based on interview and record review, the facility failed to re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#15) out of a total sample of 31 residents, had a serious mental illness (SMI). Finding include: Resident #15 was admitted to the facility in March 2022. Review of Resident #15's Diagnosis Report dated 1/17/24, indicated that on 5/5/22 a diagnosis of Undifferentiated Schizophrenia (a mental disorder that may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) was added to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely development and implementation of care plans relative to fall prevention and trauma informed care for two Residents (#66 and #28) out of a total sample of 31 residents. Specifically, the facility staff failed: 1. For Resident #66, to develop a fall prevention care plan when the Resident had been identified on admission to the facility, on a fall risk assessment, as being at risk for falls, and the Resident also sustained two separate falls in the facility. 2. For Resident #28, to develop and implement a care plan for the Resident who had a known history of trauma, and account for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident. Findings include: 1. Review of the facility policy titled Falls Management, revised August 2018, indicated the following: -Residents who are identified to be at risk on the admission fall risk evaluation will have a fall…

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 observation, interview, and record review, the facility failed to provide activities as scheduled, on the Tatnuck Unit and to meet the needs of three Residents (#12, #40, and #248), in a total sample of 31 residents, based on their comprehensive assessments and preferences. Specifically, the facility failed to: 1. Provide an activity to Residents on the Tatnuck Unit during the time an activity was scheduled to occur. 2. Alert Residents #12, #40, and #248 of a change in the activity schedule from a group discussion activity to a food social group activity. 3. Invite Residents #12, #40, and #248 to participate in a food social group activity when the Residents had preferences for food related activities. Findings include: 1. Resident #12 was admitted to the facility in November 2016 with a diagnosis of Dementia. Review of Resident #12's Minimum Data Set (MDS) Assessment, dated 12/12/23, indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points. Review of Resident #12'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide proper assistive devices to maintain hearing abilities for one Resident (#28) out of a total sample of 31 Residents. Specifically, for Resident #28, the facility failed to follow-up on an Audiology recommendation for hearing aids. Findings include: Resident #28 was admitted to the facility in December 2017, with diagnoses including: Unspecified Hearing Loss, Unspecified Ear and Sensorineural (a type of hearing loss caused by damage to the inner ear or auditory nerve) Hearing Loss Bilateral (hearing loss in both ears). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #28 was cognitively intact as evidenced by a score a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS). During an interview on 1/16/24 at 9:15 A.M., Resident #28 said that his/her hearing is bad in his/her left ear and that he/she has been waiting for a hearing aid for years and was not sure why it has taken so long. Review…

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 observation, interview and record review, the facility failed to provide adequate nutritional care and services for one Resident (#79), out of a total sample of 31 residents. Specifically, the facility staff failed to identify and address an unplanned significant weight loss for Resident #79 when the Resident had been identified as being at risk for nutritional decline. Findings include: Review of the facility policy titled Weights dated August 2015 indicated the following: -Residents will be weighed monthly unless clinically indicated. -All weight loss/gain of three pounds or more for a resident weighing 100 pounds or less and weight loss/gain of five pounds or more for residents weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present. -If a significant weight loss/gain is identified (greater than five percent in 30 days or greater than ten percent in six months), the IDT (Interdisciplinary Team), Dietitian, Physician 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.

Based on interview, policy and record review, the facility failed to ensure that one Resident (#102) out of a total sample of 31 Residents, received dialysis care consistent with professional standards of practice. Specifically, the facility failed to: 1. monitor and track the Resident's actual fluid intake as ordered. 2. to provide bedside equipment and supplies necessary to manage a medical emergency for a hemodialysis (machine that filters waste, salt and fluid from the blood when the kidneys can no longer function) access site. Findings include: Resident #102 was admitted to the facility in March 2022 with a diagnosis of End Stage Renal Disease (ESRD - a condition in which the kidneys stop functioning on a permanent basis). 1.Review of the facility policy titled Hemodialysis, dated April 2015, indicated but was not limited to: -Fluid Balance >If a Resident is placed on fluid restriction, monitor intake. >Allocate fluids to be given by nursing and dietary with amounts per shift. Review of the January 2024 Physician's orders included the following: -Fluid restriction to 1500…

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 interview, record and policy review, the facility failed to ensure that performance reviews were completed every 12 months and regular in-service education was provided based on the outcome of the reviews, for two Certified Nurses Aides (CNAs #6 and #7) out of a sample of three CNAs. Specifically, the facility failed to ensure that expectations, individual performance, and training requirements were communicated to CNA #6 and CNA #7 through the annual performance appraisal process as required. Findings Include: Review of the Facility Assessment, dated November 2023, indicated: -Staff Training/Education included the following: >Required in-service training for nurse aides. >In-service training must address areas of weakness as determined in Nurse Aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff. Review of the facility policy titled Performance Appraisals, last revised February 2010, indicated: -The facility will evaluate the job performance of each employee on a periodic basis. -Department Heads…

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 observation, interview, policy and record review, the facility failed to meet the nutritional needs for one resident (Resident #348) out of a total sample of 31 residents. Specifically, the facility staff failed to communicate and implement the Registered Dietitian (RD) recommendations to ensure that additional sandwiches were added to Resident #348's meal trays for improved nutritional intake and weight gain. Findings include: Review of the facility policy titled Food and Dining Service, dated April 2015, indicated the following: -The objective of food service is to supply to the resident/patient a diet comparable with his/her needs. -The responsibility of determining the residents/patients' dietary needs is the Physician, the Nurse in charge, and the Dietitian. -Cycle menus are prepared by the Dietitian for all diets. -Therapeutic diets are planned by a qualified Registered Dietitian. Resident #348 was admitted to the facility in January 2023 with the following diagnoses: Sepsis (presence of harmful microorganisms in the blood) and Cutaneous Abscess (localized collection…

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 observation, interview, policy and record review, the facility failed to maintain accurate medical records to reflect the status of the residents for two Residents (#130 and #141) out of a total sample of 31 residents. Specifically, the facility staff completed the following inaccurate documentation on the Treatment Administration Record (TAR): 1. For Resident #130, that his/her oxygen (O2) tubing had been changed. 2. For Resident # 141, that his/her foley catheter (a thin flexible tube placed through the urethra that carries urine from the bladder to outside of the body) had been changed every night shift. Findings include: Review of the facility's policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicated to replace and date the nasal cannula (tubing inserted into the nose to deliver supplemental Oxygen from an Oxygen delivery device) and tubing weekly or when visibly soiled or damaged. Review of the facility's policy titled Nursing Documentation, dated February 2016, indicated: -Notes should be clear, concise, and not subject to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, records reviewed and policy review, the facility failed to ensure that the Pneumococcal Vaccine was offered to and/or administered to two Residents (#87 and #123) out of five applicable residents, in a total sample of 31 Residents, placing them at risk for contracting facility acquired Pneumonia. Findings include: Review of the facility policy titled Immunization of Residents, dated July 2017, indicated the following: -All eligible residents will be offered the .Pneumococcal Vaccine unless medically contraindicated. -Each resident or their responsible party will be asked on admission if they have previously had any Pneumococcal Vaccinations. -The Pneumococcal Conjugate Vaccine (PCV) will be offered to all eligible residents. -Adults who have received PPSV23 (Pneumococcal Polysaccharide Vaccine Version 23) only may receive a PCV greater than a year after their last PPSV23 dose. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults Schedule,…

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 and interviews, the facility failed to ensure that its staff accurately identifed advance directives relative to life sustaining treatment for one Resident (#119) out of a total sample of 30 residents. Specifically, the facility failed to ensure its staff accurately identified the wishes of the Resident and/or his/her invoked healthcare proxy (HCP) relative to whether or not the Resident wished to be a full code (resuscitated - action taken to revive someone from death, and/or intubated/ventilated - action taken to cause air to enter into one's body when they cannot breathe on their own) in the event that his/her heart stopped and/or he/she was in respiratory distress. Findings include: Review of the facility's policy titled, Medical Orders for Life Sustaining Treatment (MOLST- form that converts one's wishes regarding life sustaining treatment into medical orders), dated [DATE], included the following: - The purpose was to provide an outline for the process to follow when a resident was…

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

Based on observations, record reviews, and interviews, the facility failed to ensure that its staff: a) notified the Physician/Non Physician Practitioner (NPP) of changes in the condition of two Residents (#71 and #151) and b) notified the healthcare proxy (HCP) of a change in condition for one Resident (#119) out of 30 total sampled residents. Specifically, the facility failed to ensure that its staff: 1) notified the Physician/NPP that Resident #151 did not receive Suboxone (buprenorphine - nalaxone; medication used to treat opioid dependence) as ordered over two consecutive days, 2) notified the HCP of one Resident's (#119) change in condition after a fall which required medical treatment, and 3) notified the Physician/NPP of a wound on Resident's # 71's hand, and obtained orders for treatment of the wound. Findings include: Review of the facility's policy titled: Condition Significant Change, dated April 2015, included the following: - Staff would communicate with the physician, resident, and family regarding changes in condition and provide timely communication of each 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.

Based on interviews, record review, and policy review, the facility failed to ensure that its staff investigated and reported a resident to resident altercation for one Resident (#10) out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Resident to Resident Altercation, dated April 2015, included but was not limited to the following: -Policies will be in place to investigate and follow up on any incident of resident to resident altercations in an objective, timely, and complete fashion. -All staff are to report any suspected resident to resident altercations immediately to their supervisor. -All staff are to ensure the safety, welfare, and privacy of all residents involved in an altercation during and after the investigation process. -The reporting of resident to resident altercations will adhere to the Department of Public Health (DPH) guidelines which state that any incident which seriously affects the health or safety of the individual needs to be reported. Resident #10 was admitted to the facility in March 2022. Review of Nurse Progress…

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 that its staff completed: a) a fall evaluation assessment following a fall, and b) the Resident's Minimum Data Set (MDS) assessment accurately to reflect the Resident's updated status related to fall history, for one Resident (#23) out of a total sample of 30 residents. Findings include: Resident #23 was admitted to the facility in February 2021. Review of the Resident's clinical record indicated that the Resident fell on 2/7/22. a) Review of the facility policy titled Falls Management, revised August 2018, indicated that: - A fall risk evaluation will be conducted on each resident/patient .following a fall. Review of the Resident's clinical record did not show any evidence of a fall evaluation assessment conducted following the Resident's fall on 2/7/22. During an interview on 7/7/22 at 1:39 P.M., the Director of Nurses (DON) said that a fall risk evaluation should have been completed for the Resident after the Resident fell on 2/7/22 but one…

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 that its staff developed a baseline care plan within 48 hours of admission to the facility for one Resident (#119) out of 30 total sampled residents. Findings include: Review of the facility policy titled, Care Plan - Baseline, dated November 2017, included that the baseline care plan was to be developed within 48 hours of a resident's admission to the facility, as a guide for care until the comprehensive care plan was developed. Resident #119 was admitted to the facility in May 2022. Review of the clinical record indicated that no baseline care plan had been developed for Resident #119 within 48 hours of admission to the facility and that a comprehensive care plan had not been developed in its place. During an interview on 7/6/22 at 4:11 P.M., the Assistant Director of Nursing (ADON) said that baseline care plans were required to be developed for all residents within 48 hours of admission to the facility and that they were pertinent to the residents' immediate care needs until the comprehensive care plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure its staff assisted one Resident (#133) in obtaining an assistive device for hearing, out of a total sample of 30 residents. Findings include: Resident #133 was admitted to the facility in October 2013 with a diagnosis of legal blindness. Review of a Minimum Data Set (MDS) assessment, dated 6/1/22, indicated the Resident to be moderately cognitively impaired, as evidenced by a Brief Interview of Mental Status (BIMS) Score of 10 out of a possible total score of 15. Review of the current Physician Orders indicated an order for Audiology consult as needed, initiated on 5/25/21. Review of a Health Drive Audiology consult, dated 5/4/22, indicated the following reason for referral: Newly decreased participation in social activities including decreased interaction. Presents as HOH (hard of hearing). Further review of the Audiology Consult indicated the Resident exhibited moderately severe to profound sensorineural hearing loss (hearing…

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 review, the facility failed to ensure its staff provided appropriate care and services for one Resident (#71), relative to a wound on the Resident's left hand, in a total sample of 30 residents. Findings include: Resident #71 was admitted to the facility in March 2022. Review of the Minimum Data Set (MDS) assessment, dated 4/4/22, indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15. During an interview on 7/5/22 at 12:53 P.M.with the Resident, the surveyor observed a dressing on Resident #71's left hand. It was a gauze wrap around the palmar (palm) area and dorsal (top) area of the left hand, and anchored around the thumb. The Resident said he/she caught the hand in a door jam and has had the same dressing on it for a week. He/she said it was a blood blister on the top of his/her hand. The dressing had no date/time on it. On 7/6/22 at 11:30 A.M., the surveyor observed Resident #71 in the smoking area. He/she had a dressing on the left hand, with no date/time. 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 observations, record reviews, and interviews, the facility failed to ensure that its staff provided an environment as free of accident hazards as possible for three Residents (#28, #91, and #119), out of 30 total sampled residents. Specifically, the facility failed to ensure its staff: 1) developed a care plan, implemented effective interventions, and provided adequate supervision for Resident #119 when he/she was identified as being at risk for falls, which resulted in a fall where the Resident sustained an abrasion (surface layers of the skin scraped away), 2) assessed Resident #28 for self administration of medication prior to leaving a topical medication with the Resident in his/her room at the bedside for the Resident to self administer, and 3) made certain that Resident #91 did not smoke cigarettes while he/she wore a nicotine transdermal patch (nicotine patch applied to the skin to help one stop smoking). Findings include: 1. For Resident #119, the facility failed to ensure its staff developed a care plan, implemented effective interventions, and provided adequate…

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 observation, interview, record review, and policy review, the facility failed to ensure that its staff provided care consistent with professional standards, related to the changing of oxygen tubing, for one Resident (#10) out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Oxygen Administration Nasal Cannula, dated November 2020, indicated to replace and date cannula tubing weekly or when visibly soiled or damaged. Resident #10 was admitted to the facility in March 2022, with the following diagnoses: COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypercapnia (excessive carbon dioxide in the blood stream) and Emphysema (a condition in which air is abnormally present within the body tissues). Review of a Minimum Data Set (MDS) assessment, dated 6/6/22, indicated Resident #10 was cognitively intact based on a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). On 7/6/22 at 4:15 P.M., Resident #10 was observed in bed, on 3 liters per minute (L/min) of oxygen administered via nasal…

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 observations, interviews, and record reviews, the facility failed to ensure that its staff: 1) managed the scheduling of medications, including insulin, around one Resident's (#71) dialysis schedule in coordination with the physician orders and, 2) ensured that an emergency kit (Ekit) was provided at the bedside for one Resident (#9) who received dialysis services in the event that there was any leakage from the resident's dialysis port site, out of a total sample of 30 residents. Findings include: 1. Resident #71 was admitted to the facility in March, 2022 with a diagnosis of ESRD (end stage renal disease -when the kidneys no longer function well enough to meet a body's needs). Review of the Physician's orders, active as of 7/7/22, indicated the Resident went to dialysis (the process of removing excess water, solutes, and toxins from the blood through a port from people whose kidneys can no longer perform these functions naturally) on Monday, Wednesday, and Friday with a pickup time of 8:45 A.M. 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.

Based on record reviews and interviews, the facility failed to ensure that its staff documented in the medical record that the recommendations from the Pharmacist's drug regimen review had been reviewed by the Physician and what, if any, action had been taken to address them, for two Residents (#49 and #51) in a total sample of 30 residents. Findings include: 1. Resident #49 was admitted to the facility in October 2020. Review of the record indicated a current order initiated 3/1/21, for Trazodone (antidepressant) 100 milligrams (mg), give two tablets at bedtime for insomnia. Review of a Consultant Pharmacist Recommendation to Prescriber form, dated 5/27/22, indicated the pharmacist recommended the Physician review the use of 200 mg of Trazodone for Resident #49 and consider a gradual dose reduction (GDR) or document the clinical rationale for why a GDR would impair the resident's function or cause psychiatric instability. Further review of the form indicated the section of the form, titled Physician/Prescriber Response, was not completed or signed. Review of the record did not…

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 observation, record review, and interview the facility failed to ensure that its staff implemented the dietary plan of care to provide almond milk, ordered for therapeutic benefit for one Resident (#9) out of a sample of 30 residents. Findings include: Resident #9 was admitted to the facility in June of 2021 with the following diagnoses: ESRD (End Stage Renal Disease) and dependence on renal dialysis. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status Score (BIMS) of 15 out of a possible total score of 15. Review of the Resident's dietician consultant note dated 6/20/22 indicated that the Resident trialed almond milk and he/she liked the unflavored almond milk. Review of the Resident's progress note titled Nutrition Annual assessment dated [DATE] indicated that the Resident's PO4 (phosphate) level was very high (HH) due to high volumes of milk consumed and that the Resident had trialed unsweetened…

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 and interviews, the facility failed to ensure that its staff provided adequate space and furnishings for resident dining on one of four units. Findings include: Review of the census provided to the surveyor team on 7/5/22, day one of survey, indicated the census on the Transitional Care Unit (TCU) was 30 residents. On 7/5/22 at 9:25 A.M., during an observation of breakfast, the surveyor observed six intravenous (IV) medication poles stored in the designated dining area of the TCU. Four residents were seated at a square table. There was an additional empty rectangular table in the room with six chairs. No other tables for dining were observed. Four of the six unoccupied chairs with the rectangular table were loose and wobbled easily, and the formica/ linoleum on top of the table was peeling and lifting along the perimeter of the table. On 7/5/22 at 12:47 P.M., the surveyor observed three residents in the dining area at the square table with coffee and other beverages. All other residents were eating in their rooms. On 7/6/22 at 1:15 P.M., the surveyor observed…

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.