Autumn Lake Healthcare At Loch Raven

Based on interviews and record review, it was determined that the facility failed to protect residents' clothing from loss. This was evident for 1 (Resident #13) out of 3 residents reviewed for loss of personal property during the recertification survey.The findings include:On 9/04/2025 at 9:04 AM An interview was conducted with Resident #13's representative. They reported that the resident was admitted into the facility with gray sweatpants, 1 pair of jeans, funnel pajamas and 1 sweater and that these items were lost during laundry. The representative also stated that they had communicated these concerns to the laundry staff, Staff #12, but the facility had not found the missing clothes or replaced the items. On 9/04/2025 at 9:24 AM A review of Resident #13's admission records was conducted. The review revealed an inventory list that was dated 5/16/25. The inventory list included a sweater and 1 pair of jeans. On 9/04/2025 at 9:44 AM An interview with the Assistant Director of Nursing (ADON) was conducted. She reported that the facility process is to update each resident'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, it was determined that facility staff failed to ensure that residents were free of exploitation. This was evident for 1 (#114) of 5 residents reviewed for misappropriation of resident property. The findings include:A complaint was received alleging the facility applied for Medicaid for Resident #114 without proper consent and had not used the resident's veteran benefits. They alleged that because the resident was approved for Medicaid, money was removed from the resident's personal bank accounts. On 9/4/25 at 12:11 PM an attempt to reach the complainant was unsuccessful. An email was sent to the complainant with no response received. A review of Resident #114's medical record on 9/8/25 at 9:47 AM revealed under the census tab the resident was admitted on [DATE] and had Medicare A until 1/4/24 when the resident's payment changed to Medicaid. A review of the resident's profile tab revealed the resident had 2 people listed on his/her account. Review of the admission 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.

Based on medical record review and staff interview, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during the annual survey.The findings include:On 09/08/2025 at 9:28 AM, review of Resident #7's medical record revealed the resident had an order for Dasatinib (a chemotherapy medication pill by mouth) for everyday administration. Further review of the medical record revealed the resident received the medication everyday in August of 2025. On 9/10/25 at 1:17 PM, review of section O of the MDS assessment with an Assessment Reference Date (ARD) of 8/9/25 failed to reveal that the chemotherapy medication was coded on the assessment.The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process.On 09/11/2025 at 9:01 AM, an interview with MDS coordinator (Staff #33) revealed that if a resident were receiving chemotherapy medication within the ARD 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 Based on record review and staff interviews, it was determined that the facility failed to create and implement a baseline care plan for 1) a resident with a stage 4 sacrum pressure ulcer and 2) a resident with Chronic Myeloid Leukemia (CML) requiring chemotherapy medication. This was found to be evident for 2 (Resident #73 and Resident #7) of 5 residents reviewed for care planning during the recertification survey.The findings include: 1) On 09/05/2025 at 09:00 AM, a review of the resident #73's admission MDS from 08/16/2024, revealed that the resident was admitted with a stage 4 pressure ulcer on their sacrum. On 09/05/2025 at 09:09 AM, review of the resident #73's weekly wound assessment from admission, dated 08/12/2025, revealed that the resident was admitted to the facility with the stage 4 sacrum pressure ulcer that was present on admission. On 09/05/2025 at 09:48 AM, a review of the resident #73's care plan from admission revealed a focus on a stage 4 sacrum pressure ulcer. On 09/05/2025 at 10:04 AM, a…

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

Based on record reviews and interviews, it was determined that the facility failed to revise resident's care plan after a change in condition. This was evident for 1 resident (Resident #3) out of 2 residents reviewed for hospitalization after a change in condition during the recertification survey. The findings include:The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan.Blood glucose refers to the level of sugar (glucose) in the bloodstream. It is the primary source of energy for the body's cells, including the brain, muscles, and organs. On 09/04/2025 at 11:33 AM, review of Resident #3's electronic health record showed a progress note dated 06/21/2025 at 8:20 PM documenting that the resident was found unresponsive. Vital signs were within normal limits; blood glucose was 157 mg/dL; the resident was administered oxygen via non-rebreather mask, and oxygen saturation was 100%. Emergency…

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, it was determined that facility staff failed to follow a physician's order. This was evident for 1 (#111) of 2 residents reviewed for pain management.The findings include:A medical record review for Resident #111 on 9/9/25 at 9:43 AM revealed a medication administration record (MAR) for May of 2025, which noted the resident was ordered an opioid 10 mg as needed every 4 hours for a pain level of 7-10. However, on the following dates and times facility staff failed to follow the physicians orders and gave the medications for a pain level less than 7; 5/7 at 9:00 PM for pain level of 6, 5/9 at 1:22 PM for a pain level of 0, 5/13 at 12:09 AM for a pain level of 0, 5/14 at 6:30 PM for a pain level of 6, 5/17 at 1:18 PM for a pain level of 0, 5/27 at 9:44 PM for a pain level of 6, 5/28 at 6:00 PM for a pain level of 0, 5/28 at 11:59 PM of a pain level of 6, 5/29 at 2:15 PM for a pain level of 0, 5/30 at 8:41 PM for a pain level of 6, and 5/31 at 10:10 AM for a pain level of 4. The following dates were for June 2025; 6/2 at 2:17 PM for a pain level 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.

Based on surveyor observation, review of the medical records, and interview with facility staff, it was determined the facility failed to provide quality care to residents by 1) not following physician orders for oxygen therapy and 2) not reporting a change in condition. This was found to be evident for 2 residents (Residents #45 and #47) out of 4 residents observed on oxygen therapy and 1 resident (Resident #115) of 2 residents reviewed for pressure ulcer complaints during the facility's recertification survey.The findings include:1) Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. Oxygen saturation or SpO2, is a medical measurement that indicates the percentage of oxygen-carrying hemoglobin in the blood compared to the total amount of hemoglobin. It is a key indicator of how well oxygen is being distributed from the lungs to the rest of the body. An oxygen flow rate is the volume of oxygen delivered to a patient per minute, usually…

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, record review, and staff interviews, it was determined that the facility 1) failed to provide services for pressure ulcer for a new admission and 2) to document and provide ordered treatment to promote healing of pressure injuries. This was found to be evident for 2 (Resident #115 and Resident #113) of 4 residents reviewed for pressure injuries during the survey. The findings include:1) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident's wounds had worsened, and s/he was diagnosed with sepsis because the wounds were infected. A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital after being bedbound at home with a sacral pressure ulcer. The wound care was ordered as follows; clean daily with normal saline, pat dry, and apply medihoney (a wound treatment…

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, interview with staff, and record review, it was determined that the facility failed to implement an intervention, determined to be necessary, for residents who were identified as a fall risk. This was evident of 2 of 5 residents (Resident #11 and Resident #55) reviewed for accidents during the annual survey.The findings include:A fall mat is a cushioned, low-profile floor mat designed to reduce the impact and severity of injuries from falls, particularly for elderly or at-risk individuals, by absorbing the force of impact. A fall risk assessment is an evaluation used to determine an individual's likelihood of experiencing a fall. 1) On 09/04/25 at 9:09 AM, during an interview with Resident #55, the surveyor observed the resident sitting in a recliner positioned to the left of the bed. A catheter was connected to the resident and attached to a peritoneal dialysis machine located on the right side of the bed. The resident's legs were elevated, and the surveyor observed scabs that appeared 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 Number of residents sampled: Number of residents cited: Based on observations, record reviews, and interviews, it was determined that facility staff to 1.) ensure safe and sanitary storage of dialysis equipment and supplies, 2.) establish dialysis specific infection control policy, and 3.) assess and document care of peritoneal catheter access site. This deficient practice was evident for 2 (#17, #55) of 2 residents reviewed for dialysis during the annual survey.The findings include: Dialysis - A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semi-permeable membrane. The two types of dialysis that are currently in common use are hemodialysis (HD) and peritoneal dialysis (PD)1.) On 09/04/25 at 9:18 AM, during an interview at the entryway of Resident #55's room with the licensed Practical Nurse (LPN) #2, the surveyor observed a delivery person bringing multiple boxes of PD supplies. The delivery person stacked and stored the boxes…

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 and administrative record reviews, it was determined that the facility staff failed to conduct annual nursing aide performance reviews. This deficient practice was evident for 2 out of 5 nursing aide annual performance reviews, reviewed during the annual survey.The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #11, GNA #21, and GNA #22 failed to reveal nurse aide annual performance review. On 09/09/2025 at 9:00 AM, the surveyor informed the DON about the missing nurse aide annual performance reviews. On 09/9/2025 at 9:03 AM, during an interview with Human Resources (HR) #17, the surveyor asked who was responsible for maintaining nursing aide annual performance reviews. The HR #17 stated that she was responsible. When asked…

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, it was determined that staff failed to ensure that a resident did not have unnecessary medications. This was evident for 1 (#111) of 6 residents reviewed for unnecessary medications.The findings include:A pain level score of 1-10 is used to determine the resident's level of pain, 1 being the lowest amount of pain and 10 being the greatest amount of pain. A medical record review for Resident #111 on 9/9/25 at 4:30 PM revealed physician's order summary that the resident was ordered an opioid 10 mg as needed every 4 hours for a pain level of 7-10 dated 5/7/25. However, on the following dates and times facility staff administered the pain medication for no pain (as indicated by a 0): 5/9 at 1:22 PM, 5/13 at 12:09 AM, 5/17 at 1:18 PM, 5/28 at 6:00 PM, and 5/29 at 2:15 PM. On the following dates in June 2025, it was administered for no pain: 6/2 at 2:17 PM and 6/5 at 5:08 PM. During an interview with the attending physician on 9/10/25 at 1:03 PM he reported he was aware that Resident #111 had an opioid addiction and was on methadone. He stated that he…

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 review and interviews, it was determined that the facility failed to serve residents meals based on their meal tickets. This was evidence for 3 residents (Resident #6, #40, and #14) out of 8 residents observed during dining.The findings include:A Magic Cup is a fortified nutritional supplement. It is designed to add calories and protein to the diets of individuals experiencing malnutrition or involuntary weight loss. Each serving of magic cup provides a significant amount of calories and protein, along with essential vitamins and minerals. On 9/04/2025 at 8:24 AM Resident #6 was served breakfast while the surveyor was at the bedside, the breakfast included a pureed meal but there was no magic cup. The resident reported the facility often failed to serve them magic cups during breakfast. The meal ticket that was on the resident's food tray stated Resident #6 should have a magic cup with all meals.On 9/04/2025 at 9:45 AM a review of Resident #6's medical record was conducted. The review revealed an order entered on 7/21/25 that stated the resident should…

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 staff interviews, it was determined the facility failed to 1) maintain medical records on residents that are complete and accurately documented and 2) validate the signature on a bed hold policy form and included conflicting information regarding the resident's ability to sign the document. This was evident for 1 resident (Resident #3) out of 2 residents reviewed for hospitalization and 1 (Resident #111) of 6 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include:1a) On 09/04/2025 at 11:33 AM, review of Resident #3's electronic health record revealed that his/her quarterly BIMS score on 07/03/2025 was 15 which showed that the resident was cognitively intact. The health record also showed a progress note dated 06/21/2025 at 8:20 PM documenting that the resident was found unresponsive. Vital signs were within normal limits; blood glucose was 157 mg/dL; the resident was administered oxygen via non-rebreather mask, and oxygen saturation was 100%. Emergency medical services were called, and 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.

Based on interviews and administrative record reviews, it was determined that the facility failed to provide the required Quality Assurance and Performance Improvement (QAPI) training to staff. This deficient practice was evident in 5 of 5 employee files reviewed during the annual survey. The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #9, GNA #11, GNA #20, GNA#21, and GNA #22 failed to reveal QAPI training. On 09/09/2025 at 9:00 AM, the surveyor informed the DON and the Assistant Director of Nursing (ADON) #1 about missing QAPI training. The DON explained that the facility's previous nurse educator had been responsible for maintaining nursing staff education record. Since the educator's departure, she is having difficulty locating employee…

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 and administrative record reviews, it was determined that the facility failed to provide the required Infection Control training to staff. This deficient practice was evident in 3 of 5 employee files reviewed during the annual survey. The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #11, GNA #21, and GNA #22 failed to reveal infection control training. On 09/09/2025 at 9:00 AM, the surveyor informed the DON and the Assistant Director of Nursing (ADON) #1 about missing infection control training. The DON explained that the facility's previous nurse educator had been responsible for maintaining nursing staff education record. Since the educator's departure, she is having difficulty locating employee education records. When…

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 and administrative record reviews, it was determined that the facility failed to provide the required Compliance and Ethics training to staff. This deficient practice was evident in 3 of 5 employee files reviewed during the annual survey. The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #11, GNA#21, and GNA #22 failed to reveal compliance and ethics training. On 09/09/2025 at 9:00 AM, the surveyor informed the DON and the Assistant Director of Nursing (ADON) #1 about missing compliance and ethics training. The DON explained that the facility's previous nurse educator had been responsible for maintaining nursing staff education record. Since the educator's departure, she is having difficulty locating employee education…

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 and administrative record reviews, it was determined that the facility failed to provide geriatric nursing assistants (GNA) with the required minimum of 12 hours of annual in-service training. This deficient practice was evident in 5 out of 5 GNA employee files reviewed during the annual survey.The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22 failed to reveal 12 hours of nurse aide in-service training. On 09/09/2025 at 9:00 AM, the surveyor informed the DON and the Assistant Director of Nursing (ADON) #1 about missing nurse aide in-service training. The DON explained that the facility's previous nurse educator had been responsible for maintaining nursing staff education record.…

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 and administrative record reviews, it was determined that the facility failed to provide the required Dementia training to staff. This deficient practice was evident in 4 of 5 employee files reviewed during the annual survey. The findings include: On 09/08/2025 at 1:34 PM, the surveyor requested employee files from the Director of Nursing (DON) for Geriatric Nursing Assistant (GNA) #9, GNA #11, GNA #20, GNA #21, and GNA #22. The surveyor requested that each file include documentation of the employee's annual review, annual training, and immunizations.On 09/09/2025 at 7:30 AM, a review of the employee files for GNA #11, GNA #20, GNA #21, and GNA #22 failed to reveal dementia training. On 09/09/2025 at 9:00 AM, the surveyor informed the DON and the Assistant Director of Nursing (ADON) #1 about missing dementia training. The DON explained that the facility's previous nurse educator had been responsible for maintaining nursing staff education record. Since the educator's departure, she is having difficulty locating employee education records. When asked who is…

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 complaint, observations, staff interview, and record review, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for when individual room air conditioning systems failed to cool resident rooms. Residents were exposed to ambient temperatures above 81 degrees Fahrenheit. This was evident for 4 (Residents #1, #2, #3, #4) of 4 residents reviewed during a complaint survey. The findings include: Review of complaint MD00196573 on 09/06/23 at 12:30 PM that revealed an allegation from emergency services and local law enforcement that on 09/05/23 at 10:30 PM, the residents in the facility did not have a functioning air condition system and that one resident room, room [ROOM NUMBER], was subject to temperatures of up 92.4 degrees Fahrenheit. During an observational tour of the facility with the director of maintenance on 09/06/23 at 12:58 PM, observation of room [ROOM NUMBER] revealed that Resident #1 and #2 had been transferred to a different room in 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 observation and staff interview, it was determined that the facility failed to ensure that resident room hand sanitizing dispensers were functioning properly. This was evident for 8 of 56 rooms reviewed during a complaint survey. The findings include: During a tour of the facility on 09/06/2023 at 12:58 PM with the Director of Maintenance, the nurse surveyor observed and tested the facility rooms for functioning hand sanitizer receptacles. Each resident room has a hand sanitizer receptacle at the doorway to each room. The purpose of these alcohol-based hand sanitizer is to help prevent the spread of germs. 8 (rooms 5, 10, 28, 34, 48, 50, 55, and 57) of 56 rooms failed to have functioning hand sanitizer receptacles. In an interview with staff member #6 on 09/06/23 at 5 PM, staff member #6 stated that the hand sanitizer receptacles were functioning but the gel in the receptacles may be old and can become sticky. Staff member #6 stated the staff just need to clean the tip of the dispenser and the hand sanitizer will function.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, family interview and clinical record reviews, it was determined that the facility staff failed to ensure that wound care was provided to a resident (#274) as ordered, that a resident (#2) received the size catheter that was ordered, that a resident (#225) was provided transportation for an appointment, that a resident (#227) was administered medications on time, that consultant recommendations were followed for a resident (#45), that a resident (#16) received insulin on time as per physician order, and that vital signs were discontinued as ordered for a hospice resident (#57). These deficient practices were evident for 7 (#274, #2, #225, #227, #45, #16, #57) of 43 residents reviewed during the recertification process. The findings include: 1. A wound vac is a type of therapy to help heal wounds. During the treatment, a device decreases air pressure on the wound which can help the wound heal faster. On 06/09/2023, a clinical record review was conducted…

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 medical record review and interview, it was determined that the facility staff failed to provide showers per a resident's request (Resident #223). This was evident for 1 of 43 residents reviewed during an annual survey. The findings include: During interview with Resident #223 on 5/30/23 at 10:34 AM, Resident #223 was asked if he/she chooses how many times a week he/she gets a shower. Resident #223 stated no, he/she would like to receive more showers and has only had one shower since admission to the facility. Review of Resident #223's medical record on 6/5/23 revealed the Resident was admitted to the facility on [DATE] and has only one documented shower on 5/5/23. Interview with the Regional Director of Nursing on 6/5/23 at 2:10 PM confirmed Resident #223 has only one documented shower from 5/2/23 until 6/5/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #19). This was evident for 1 of 43 residents reviewed during an annual survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: During interview with Resident #19 on 5/31/23 at 8:34 AM, Resident #19 stated he could not find his/her dentures and was actively looking in his/her dresser drawers for them. Observation of the Resident at that time revealed the Resident to be edentulous and not wearing dentures. Review of Resident #19's medical record on 6/2/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident'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 medical record review and interview, it was determined the facility staff failed to hold a care plan meeting to include the interdisciplinary team, resident and resident's representative quarterly (Resident #45). This was evident for 1 out of 43 residents reviewed during an annual survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. During interview 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 observations, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that dependent residents were provided with the necessary services to maintain clean and trimmed fingernails. This was evident for 1 (#14) of 6 residents reviewed for activities of daily living (ADL). ADLs are tasks of everyday life. Examples of ADLs include dressing, bathing, grooming, and toileting. Nail care would fall under this category. The findings include: On 05/31/23 at 09:43 AM, resident #14 was observed to have long fingernails. Several fingernails had a dark substance under the nails. Resident #14 stated that he/she would like their fingernails to be trimmed. On 06/01/2023 at 2:30 PM, resident #14 was observed to still have long fingernails with a dark substance beneath several of the nails. A subsequent review of the resident ' s care plan revealed that the resident required assistance with ADLs. On 06/02/2023 at 8:50 AM, an interview with Geriatric Nursing Assistant (GNA) #14. The GNA stated that residents ' nails should be trimmed twice a week…

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 medical record review and interview, the facility staff failed to obtain ophthalmology services for a resident (Resident #45). This was evident for 1 of 43 residents reviewed during the annual survey. The findings include: During interview with Resident #45's Emergency Contact on 5/30/23 at 3:37 PM, the Emergency Contact stated the Resident was in need of eye glasses. Review of Resident #45's medical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident's care plans revealed a care plan entitled impaired visual function related to disease process initiated on 6/23/22 with 2 interventions: 1. arrange consultation with eye care practitioner as required 2. able to wear glasses and see large print. Review of Resident #45's Annual MDS (Minimum Data Set) assessment on 11/13/21 Section B1200 Corrective Lenses revealed the facility staff coded Yes. Review of Resident #45's Annual MDS assessment on 2/20/23 Section B1200 Corrective Lenses revealed the facility staff coded 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 medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #15, #45 and #324). This is evident for 3 of 5 residents reviewed for pressure ulcers during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. 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 clinical record review and staff interview, it was determined that the facility staff failed to ensure that a dietary consult was obtained after a significant weight loss. This was evident for 1 (#10) of 8 residents reviewed for nutritional status. The findings include: On 06/05/2023 at 9:35 AM, a clinical record review revealed that resident #10 had dysphagia, a condition that makes it difficult to swallow. From 12/07/2022 to 01/03/2023, resident #10 lost 12% of his/her body weight. On 01/05/2023, both a dietary and speech consult had been ordered by physician. Resident #10 was seen by speech therapy however, he/she was not seen by a dietician as per order. A dietician is a health professional who has special training in diet and nutrition. For a resident with significant weight loss, having a dietary consult would have been important as the dietician would have recommended additional interventions and would have provided an individualized nutrition plan of care for the resident. On 01/10/2023 resident #10 was examined by staff #15, a nurse practitioner (NP). The notes…

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 clinical record review, observations, and staff interview, it was determined that the facility staff failed to ensure that a tube feeding container was labeled. This was evident for 1 (#2) of 3 residents reviewed for tube feedings. The findings include: A feeding tube is a device to administer nutrition to a person who cannot safely take food by mouth. On 06/01/2023 at 8:58 AM, a clinical record review revealed that resident #2 had a feeding tube for nutritional support due to having difficulty swallowing. The orders for the resident included receiving nothing by mouth and administering Jevity 1.5 tube feeding, which is calorically dense liquid food, via a pump over 16 hours. On 06/02/2023 at 8:12 AM, an observation of resident #2 revealed that he/she was in the process of receiving his/her tube feeding. It was noted that the tube feeding container with attached tubing was not labeled with information such as the resident's name, the date, or start time. There was a manufacturer's label on the tube feeding container where this information could have been written. 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 Based on medical record review and interview it was determined that the facility staff failed to provide dialysis care consistent with professional standards of practice and ordered by the physician (Resident #231). This was evident of 1 of 3 residents reviewed for dialysis during the annual survey. The findings include: Review of Resident #231's medical record on 6/9/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include end stage renal disease. The Resident was discharged from the facility on 1/21/22. Review of the Resident's orders for peritoneal dialysis revealed the Resident was ordered for pre and post weights, pre and post blood pressure, was receiving two 2.5% green bags. Review of Resident #231's Dialysis record and electronic medical record the facility from 1/12 until 1/20/22 revealed the facility failed to do pre and post dialysis weights, there is only one weight documented daily on the dialysis record. The facility staff failed to do pre 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, it was determined that the Physician failed to provide timely visit notes to the electronic record system following each visit. This was evident for 1 (Resident #40) out of 5 residents reviewed for urinary catheter care. The findings include: Review on 6/01/23 at 8:12 AM of Resident #40's medical record revealed he/her last physician visit by the attending physician (Staff #23) was on 4/25/2023. However, the note's upload date was on 5/25/2023. Further review of Physician #23's visit notes were delayed as followings: 2/20/2023 visit Uploaded on 5/1/2023 4/4/2023 visit Uploaded on 5/25/2023 During an interview on 6/7/23 at 10:03 AM with Regional Nurse #7, she stated that she was to follow up on Physician #23's late uploading of his visiting notes. She thought the Physician gave his notes over to the unit secretary to upload. During an interview on 6/08/23 at 10:50 AM with Regional Nurse #7, she indicated that the Physician was responsible for uploading his regular visit notes and she acknowledged that physician #23 failed to upload his visit…

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, it was determined that the facility staff failed to ensure Resident # 16's preferences were honored and to provide appropriate foods to meet his/hers needs. This was evident for 1 (Resident #16) out of 2 resident reviewed for food preferences and serving proper food. The findings include: On 6/8/2023 at 10:20 AM, a medical record review for Resident #16 was conducted. The resident's diagnosis included acid reflux disease and Gastroparesis (Gastroparesis is a condition in which the stomach muscles do not work properly). The resident's care plan interventions were to; avoid foods or beverages that irritate the esophageal (food pipe) lining such as alcohol, chocolate, caffeine, acidic or spicy foods, and fried or fatty foods. An observation of the Resident's food tray on 6/09/23 at 12:29 PM revealed the fried fish on their plate and the ticket indicated no fish. Further review of the lunch ticket on the tray indicated that the resident should have had chicken tenders per their request. Surveyors showed Resident's #16 lunch meal ticket…

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 medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#324). This was evident for 1 of 43 residents selected for review during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. On 6/12/23 at 9am a review of resident #324's medical record revealed that the Resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's dementia. Alzheimer's is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive…

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 review of resident medical records, it was found that the facility failed to prepare baseline care plans for residents within 48 hours of a resident's admission. This was evident for 7 (#24, #38, #341, #80, #76, #33, #52) of 7 recently admitted residents. This practice had the potential to affect all newly admitted or readmitted residents. A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) Resident #24's medical record was reviewed on 1/2/19 at 10:19 AM. The resident was hospitalized on ce in September and once in October,…

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 resident and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 17 (#86, #35, #63, #72, #45, #47, #58, #341, #64, #70, #24, #78, #189, #74, #76, #33, #52) of 35 residents reviewed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am hard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. It was noted that the resident told the surveyor to sit to the right of the bed, so he/she could hear. On 1/4/19 at 9:21 AM, the unit manager (Staff #5) was asked about the resident's hearing and Staff #5 stated his/her hearing was fine. Staff #5 proceeded to ask the Physical Therapy…

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 6) Resident #71 was interviewed on 1/2/19 at 9:50 AM. During interview, the resident expressed that he/she was uncertain that s/he wasinvited to attend care plan meetings. Resident #71's medical record was reviewed on 1/10/19. The resident was admitted in December of 2017. Information in the medical record related to care plan meetings was sparse. There was not any quarterly care plan meeting documentation for 2/18, 5/18, and 8/18. There was a care plan meeting sign in sheet with three staff and the resident's surrogate decision maker for 11/18. An interview was conducted with the Unit Manager (staff # 5) at 12:54 PM on 1/10/18. Upon discussion and review of the care plan meeting sign in sheets, staff #5 indicated that there was not/or staff #5 did not know of any more documentation or additional information as to what was discussed in the care plan meeting held in November of 2018. Staff # 5 did not know if Resident #71 was invited to attend care plan meetings. Staff #5 was unaware how residents and/or family…

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 with facility staff, it was determined that the facility failed to ensure that the individual designated as the director of food and nutrition services was nationally certified for food service management and safety. This had the potential to affect all residents. The findings include: During interview with the Dietary Manager on 1/4/19 at 11:00 AM, the Dietary Manager was asked if s/he was certified as a dietary manager or a food service manager. The Dietary Manager stated that s/he was not certified in either but that the plan was to get me certified in a few months. It was verified with the business office that no dietician was employed in a full time basis at the facility.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and that kitchen equipment was cleaned and in a sanitary manner. This was evident for 2 of 2 tours of the kitchen performed during the survey. The findings include: During an initial tour of the kitchen that took place on 1/2/19 at 8:42 AM, it was found that records of the concentration of the sanitizer solution in the three compartment sink still only had dates from December. When asked about whether sanitizer solution concentration had been checked for the month of January, the [NAME] was unable to provide any documentation that the solution was documented. During a follow-up kitchen tour that took place on 1/4/19 at 11:10 AM, no temperature logs could be provided for the food being prepared for lunch. The Dietary Manager instructed staff to start over preparing the food item in question.

Based on review of facility records, it was determined the facility staff failed to accurately assess the resources necessary to care for its residents during both day-to-day operations and emergencies by failing to accurately assess 1) resident acuity, 2) staffing plan and 3) staff competencies necessary to provide the level and types of care needed for the resident population. This was evident during Sufficient and Competent Nurse Staffing review. The findings include: The facility assessment was reviewed on 1/10/19 at 12:50 PM. The facility's licensed bed capacity was 113. The assessment was dated 10/18/18, and indicated the average daily census was 100. 1) The Acuity section of the assessment provided a table in which the facility recorded the number of residents in the facility on the assessment date divided into 3 levels of assistance needed (independent, assist of 1-2 staff or dependent) for 5 categories of activities of daily living (ADL's). The facility's documentation for the total number of residents for each ADL was inconsistent - Dressing reflected 95 residents, Bathing…

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 surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement effective plans of action to correct quality deficiencies identified during the prior annual quality indicator survey. The findings include: On 1/10/19 at 3:00 PM, the surveyor reviewed the results of the facility's last quality indicator survey. The corrective actions implemented by the facility after the last annual survey failed to effectively correct deficiencies related to failing to notification of changes, failing to administer blood pressure medications according to parameters, MDS (Minimum Data Set) assessment accuracy, develop/implement comprehensive care plans, care plan timing and revision, quality of care, unnecessary drugs and infection control. The Quality Assessment and Improvement program was reviewed with the Staff #9 on 1/10/19 at 3:53 PM. Staff #9 was asked to describe the facility's QAPI plan. He/She indicated that the facility had no…

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 review of facility documentation and interview with staff, it was determined that the facility failed to ensure staff competency by failing to provide required in-service training for nurse aides for no less than 12 hours per year including dementia management, cognitive impairment and resident abuse training. This was evident during Sufficient and Competent Nurse Staffing review. The findings include: The employee files of Staff #42, #43, #27 and #44 were reviewed on 1/10/19 at 12:50 PM. The files for Staff #42, #43 and #27 contained a 72 question Annual Competency test questionnaire and an OSHA Expo Quiz. Staff #44's file did not contain the questionnaire. The questionnaire covered 19 topics that included 5 questions related to Abuse Prohibition and 4 questions related to Psychophysical & Psychosocial Needs of the Aged. The instructions included Please review the information on all annual mandatory in-services and answer all questions in this packet. No documentation was found to indicate what, if any, training had been provided, nor the number of training hours. During…

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.

2) Observation was made on 1/8/19 at 2:00 PM of Staff #3 standing to feed Resident #34 in the resident's room. Resident #34 was lying in bed and Staff #3 was standing to the right side of the bed feeding the resident lunch. 3) Observation was made on 1/8/19 at 4:00 PM of Resident #72 sitting in a geriatric chair on the second floor nursing unit. Staff #1 was observed pulling Resident #72 down the first hallway backwards, turned the corner around the nurse's station and then continued pulling Resident #72 down the next hallway backwards until Staff #1 got to the resident's room. 4) Observation was made on 1/10/18 at 10:06 AM of Staff #14 pulling Resident #17 down the hallway backwards. Resident #17 was sitting in a geriatric chair and Staff #14 was taking the resident outside to smoke. On 1/10/19 at 9:21AM, the Nursing Home Administrator and the Corporate Nurse were advised of the observations. Based on observation and interview with staff, it was determined that 1) the facility failed to ensure that dependent residents were provided with feeding assistance in a manner that preserved…

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 surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 2 of 2 nursing units. The findings include: 1) On 1/2/19 at 10:55 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed that the side rail between the toilet and the sink was loose where it was attached to the wall and the floor. 2) On 1/2/18 at 11:03 AM, observation of room [ROOM NUMBER] (next to the B bed) revealed a suction machine on a bedside table. The bed side table and the base of the suction machine was very dusty. The heating/air conditioner (ac) unit was dusty and the unit's vent grills had a build up of dust. Oxygen supplies, and a nebulizer machine were on top of the heating/ac unit. Observation of room [ROOM NUMBER]'s window revealed a window shade that was soiled and discolored, and the window had a curtain rod that did not have curtains. 3) 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.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 11 (#35, #58, #72, #86, #41, #70, #24, #74, #76, #33, #52) of 35 residents reviewed. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of Resident #35's medical record, on 1/9/19 at 2:34 PM, revealed an order to ensure that the resident's dentures were placed in the mouth in the morning prior to all meals and removed at bedtime. Review of the annual MDS with an Assessment Reference Date (ARD) of 8/25/18, Section K, Oral Status did not capture that the resident was edentulous…

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 family and staff interview, observation and medical record review, it was determined the facility failed to provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 2 (#35, #63, #74) of 7 residents reviewed for activities of daily living and for 1 of 2 dining observations. The findings include: 1) On 1/9/19 at 12:39 PM, an interview was conducted with the family member of Resident #35. The family member expressed concern that the resident's dentures were not being placed in the resident's mouth in the morning before meals. The family member stated, yesterday I took off from work and I washed her clothes up. She was in the dining room and I walked in her room and her dentures were in her cup. She missed breakfast and lunch because she can't eat without her dentures. She does not have the mental capacity to put her dentures in. My other concern is did she get breakfast and lunch. She can't chew her food without her dentures. She is also not capable of taking out the dentures. 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.

Based on observation of the resident, medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional stands of practice by failing to ensure a resident who was dependent on oxygen had accurate physician orders; failing to ensure a resident's respiratory care supplies were stored in a clean and sanitary manner; failing to ensure a resident's oxygen was administered as ordered, failing to ensure emergency respiratory equipment was maintained at a resident's bedside, failing to ensure a prescribed biological was properly stored, failing to ensure Activities of Daily Living care was provided for a dependent resident and failing to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (#74) of 2 residents reviewed for respiratory care. In addition, the staff failed to 1) fully assess a resident for a change in condition, 2) administer blood pressure…

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 medical record review and interview with facility staff, it was determined that the facility failed to ensure that residents remained free from accident hazards and received adequate supervision. This was evidenced by the failure to ensure a resident at risk for elopement received adequate supervision. This was evident for 1 (#10) of 4 residents reviewed for accidents. The findings includes: 1) A facility reported incident involving Resident #10 was reviewed on 1/9/19 at 10:45 AM. The incident involved two elopements that occurred with Resident #10, one in early November and the second in early December, 2018. Both times, the resident had been allowed to pass time outside the facility at a curb about 60 feet away from the front door. And both times, the resident had traveled further than the curb and left the premises without notifying staff. Resident #10 had a Brief Interview of Mental Status (BIMS) score of 15/15 on the most recent Minimum Data Set Assessment, which indicated that the resident had no significant mental impairment. The resident was also his/her own…

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, medical record review, and interviews with facility staff, it was determined that the facility failed to provide residents with respiratory care consistent with professional standards. This was evident for 5 (#24, #63,#74, #52, #189) of 5 residents reviewed for respiratory care during the investigation phase of the survey. The findings include: 1) Resident #24 had a tracheostomy tube, a device that is tunneled directly into a resident's trachea to provide an airway that bypasses the natural airway. Air that is inspired through the tracheostomy tube does not benefit from the humidifying organs in the mouth and nose. In an effort to compensate for this effect, devices that add humidity to air are sometimes used to deliver more humidified air to the resident's tracheostomy tube. Resident #24 was observed in his/her room on 1/2/19 at 10:18 AM. During the observation, a device labeled as an air compressor was noted to be attached to a humidifier bottle that was administering humidified air through corrugated tubing to a cuff placed on top of Resident #24'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.

Based on review of training records and interview with facility staff, it was determined that the facility failed to ensure a system was in place to track the training that staff nurses received regarding peritoneal dialysis. This had the potential to affect all residents receiving peritoneal dialysis. The findings include: 1) The facility's resident matrix was reviewed on 1/2/19 at 10:00 AM and it showed that there were five residents (Residents #'s 64, 43, 77, 78, and 189) who were receiving peritoneal dialysis at the time of survey initiation. An interview was performed with the Administrator on 1/4/19 at 11:56 AM. During the interview, the Administrator stated that s/he had been coordinating with the two dialysis services that the facility has contracts with. The coordinating involved having dialysis nurses come to the facility at least monthly to perform dialysis training for facility nursing staff. However, the Administrator stated that no records were kept in the facility of who had received annual dialysis training and who had not. The Staff Scheduler was interviewed 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.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain sufficient staff to provide care to residents to maintain the highest practical physical, mental, and psychosocial well-being of each resident as evidenced by residents failing to receive sufficient help during dining. This was evident for 1 of 2 dining observations. The findings include: A dining observation took place in the upstairs dining area on 1/2/19 between 11:50 AM and 12:45 PM. During the dining observation, it was noted that Residents #33, #35, #38, #11 and #40 were completely dependent on staff to receive nutrition. Resident #50 was noted to require significant cueing to adequately consume the meal served to him/her. Residents began receiving their trays at 11:55 AM. Between 11:57 AM and 12:38 PM, Geriatric Nursing Assistant (GNA) #27 was the only staff member present in the upstairs dining area who was assisting residents with eating. The six residents listed above had all received their trays by 12:09 AM. At that time, GNA #27 was providing a few bites to each…

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 staff interview, it was determined that the facility failed to ensure that staff was properly trained to administer peritoneal dialysis. This had the potential to affect all residents on peritoneal dialysis. The findings include: Review of medical records on 1/10/19, for residents receiving peritoneal dialysis revealed that one RN and 1 LPN were administering peritoneal dialysis without proper training. An interview with the Administrator (NHA), on 1/4/19 at 11:54 AM revealed that he/she was coordinating the Peritoneal Dialysis trainings since the Nurse Practice Educator (NPE), who was the person maintaining these education records, had left in November 2018. The NHA reported that the trainings were offered monthly and he/she was unable to provide proof of the trainings. (Cross reference F698 and F684). NHA and Director of Nursing made aware of deficient practice at the time of exit conference on 1/10/19.

Based on record review and staff interview, it was determined that the facility staff failed to ensure that residents were administered medications that were not necessary by 1) not clarifying physician's orders when a resident had been ordered antihypertensive and anti-hypotensive medications, 2) not clarifying physician's orders when a resident was ordered two medications for pain management, 3) not questioning a medication that was given in excessive doses, and 4) not monitoring behaviors related to antipsychotic medications. This was evident with 3 (#78, #52, #72) of 6 residents reviewed for unnecessary medications. The findings include: 1) A blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through them. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps out the blood into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). Review of the medical record on 1/8/19, revealed on the medication…

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.

5) Review of Resident #58's medical record on 1/3/19 revealed the resident received Risperdal 0.5 mg (antipsychotic medication) at bedtime and Risperdal 0.25 mg in the morning for dementia with behavioral disturbance. The resident also received Mirtazapine (antidepressant) for mood, Escitalopram (antidepressant) for depression and Trileptal (anti-seizure medication) for mood stabilization. Review of a physician's progress note, dated 11/21/18, documented that the resident was being followed for a diagnosis of dementia with behavioral disturbances and was aggressive at times. A psychiatric nurse practitioner's note of 10/3/18 documented the resident's mood was irritable, insight poor and judgement impaired. Behavioral goal was to keep mood neutral. Staff to provide structured socialization and ADL care. Further review of the medical record revealed there were no behavior monitoring notes or flowsheets and there was no documentation that side effects of the medications were being monitored. An interview was conducted with Staff #35 on 1/8/19 at 12:20 PM who confirmed that behavioral…

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, medical record review and staff interview, it was determined the facility failed to keep residents free from significant medication errors as evidenced by 1) failing to give ordered medications, 2) failing to give medications within 1 hour of the ordered time, 3) failing to recognize a resident was receiving too many doses of a medication and 4) failing to follow physician's orders to administer blood pressure medications within parameters. This was evident for 2 (#45, #47) of 5 residents observed during medication administration and 2 (#52, #78) of 6 residents reviewed for unnecessary medications.The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM to watch medication administration for Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc. medication cups. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. After watching…

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, staff interview and facility documentation review, it was determined the facility staff failed to 1) label medications when opened, 2) discard medications when expired 3) lock and secure an unattended medication cart and 4) ensure that medications were not left at the bedside. This was evident for 1 of 2 medication rooms observed, 4 of 8 medication carts observed, 2 random resident room observations and 1 random observation on 1 of 2 nursing units. The findings include: Observation was made on [DATE] at 10:50 AM of the following medications that were observed in the refrigerator in the medication room on the second-floor nursing unit: 1) Resident #52's opened Lantus insulin 100units/ml vial with a fill date of [DATE]. There was no date when opened. Resident #13's opened Humalog insulin 100unit/ml with a fill date of [DATE] with no date when opened. Resident #45's opened Lantus insulin with a fill date of [DATE] with no date opened. Resident #41's opened Humulin R insulin with a fill date of…

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

Based on observation, medical record review and staff interview, it was determined the facility failed to have accurate medical record documentation. This was evident for 12 (#35, #45, #47, #63, #72, #86, #80, #70, #74, #33, #52, #24) of 35 residents reviewed. The findings include: 1) On 1/9/19 at 12:39 PM, an interview was conducted with the family member of Resident #35. The family member expressed concern that the resident's dentures were not being placed in the resident's mouth in the morning before meals. The family member stated, yesterday I took off from work and I washed her clothes up. She was in the dining room and I walked in her room and her dentures were in her cup. She missed breakfast and lunch because she can't eat without her dentures. She does not have the mental capacity to put her dentures in. My other concern is did she get breakfast and lunch. She can't chew her food without her dentures. She is also not capable of taking out the dentures. Staff #1 was asked about the resident's dentures on 1/8/19 and Staff #1 stated, she did not have her dentures in yesterday…

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 staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines while performing duties and caring for residents and not verifying evidence of immunity when an employee stated that they never had or been vaccinated for measles, mumps, rubella or was ever tested for evidence of immunity. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. The findings include: 1) During initial interview with Resident #189 on 1/2/19 at 11:35 AM, the surveyor observed that the resident was on oxygen by way of nasal cannula. Further observation revealed the oxygen tubing and nasal cannula was not initialed or dated. In addition, there was a sterile water disposable humidifier connected that was dated 11/18/18. An additional observation made on the following day, revealed the resident receiving oxygen. The tubing and nasal cannula remained undated and un-initialed and humidifier had 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 resident and staff interview and review of the medical record, it was determined that the facility failed to ensure that the resident/resident representative were given the opportunity to participate in his/her care planning process. This was evident for 1 (#86) of 4 residents reviewed for care plan. The findings include: On 1/2/19 at 12:20 PM, an interview was conducted with Resident #86 and the resident was asked if he/she attended his/her care plan meeting. Resident #86 stated, I have not been, and I do not know if anyone goes for me. The resident was alert and oriented and had a BIMS (Brief Interview of Mental Status) score of 14 which indicated the resident was cognitively intact. On 1/4/19 at 9:20 AM, Staff #5 stated that the resident was invited to care plan meetings but had a guardian that came in his/her place. Review of the medical record on 1/4/19 revealed documentation that the last care plan meeting was held on 9/19/18. There was no documentation of a care plan meeting in December 2018. The Director of Social Work (Staff #34) was interviewed on 1/4/19 at 12:23…

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

Based on observation, resident and staff interview, and medical record review,, it was determined that the facility staff failed to ensure access to the nurse call bell, the over the bed tray table, and an ordered snack for a resident who was totally dependent on nursing staff for daily care due to impaired mobility. In addition, the facility failed to provide enough geriatric chairs to ensure that all residents that wanted to get up and out of bed could do this daily. This was evident for 2 (#63, #72) of 35 residents reviewed during the annual survey. The findings include: 1) Observation was made, on 1/2/19 at 12:03 PM, of Resident #63 reclining in a geriatric (geri) next to the resident's bed. The resident's graham cracker snack, which was labeled 1/2, was sitting across from the resident on the bureau next to the television. The resident was unable to walk or get out of the geri chair independently. The chair was approximately 8 to 10 feet away from the bureau. Also observed was the call light cord which was draped around the side rail, which was out of reach for the resident, as…

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 with facility staff, and record review, it was determined that facility staff failed to notify a resident's physician of a change in a residents' conditions. This was evident for 1 (#24) of 5 residents reviewed for respiratory status and 1 (#78) of 5 residents reviewed for unnecessary medications. The findings include: 1) A tracheostomy tube is a device that enables residents with compromised oral airways to bypass the upper airway and ventilate through a hole made in the front of the neck. Residents with tracheostomy tubes have a variety of special needs and challenges, including a greater risk of infectious organisms reaching the lungs. Resident #24 was observed in his/her bed on 1/8/19 at 12:45 PM. During the observation, it was noted that the resident had a significant amount of pink tinged frothy material dribbling out of his/her tracheostomy tube. While some amount of sputum production and expectoration is normal, the amount of sputum that was noted would be abnormal, and the pink tinge would always be considered abnormal. Registered Nurse (RN)…

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 medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident but not limited to for 2 (#29, #189) of 7 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #29 on 1/9/19 revealed documentation that Resident #29 had an unplanned transfer to an acute care facility on 11/21/18. Review of a nursing progress note, dated 11/21/18, did not include any documentation related to preparation and/or orientation to the resident before transferring the resident to an acute care facility. The progress note indicated that Resident #29 had an unplanned transfer and a name and telephone number of the resident's contact person that was notified of the transfer. An interview was conducted with the Director of Nursing on 1/9/19 at 8:42 AM and revealed that he/she was unaware of the regulator requirement 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.

Based on medical record review and staff interview, it was determined the facility staff failed to complete, within 14 days, a significant Minimum Data Set (MDS) comprehensive assessment. This was evident for 1 (#29) of 7 residents reviewed for hospitalization. The findings include: The MDS is part of the Resident Assessment Instrument (RAI) that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #29's medical record on 1/9/19 revealed that the resident had returned from an acute care facility on 12/14/19. At 2:29 PM on 1/9/19, record review revealed that the facility had initiated a significant change assessment with an Assessment Reference Date (ARD) of 12/21/19 however, the assessment was incomplete and should have been completed 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 medication administration observation, medical record review and staff interview, it was determined the facility staff failed to meet professional standards of quality by 1) failing to check placement and residual for residents who received medications and nutrition through a feeding tube, 2) failing to administer all physician ordered medications, 3) failing to accurately document which medications were given or not available, 4) failing to follow physician's orders for the ordered amount of tube feeding flushes and 5) failing to administer medications and a scheduled tube feeding on time. This was evident for 2 (#45, #47) out of 5 residents observed during medication administration by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed. The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM. Staff #2 was preparing to give medications to Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc.…

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, medical record review and staff interview, it was determined that the facility staff 1) failed to provide an activities program to meet the needs and preferences of all residents and 2) failed to revise the care plan when a resident's health and ability to participate in activities declined. This was evident for 2 (#63, #341) of 2 residents reviewed for activities. The findings include: 1) Observation was made, on 1/2/19 at 12:11 PM, of Resident #63 sitting in a reclining geriatric (geri) chair in the resident's room next to the resident's bed. The television, which was sitting directly across from the resident, was off. The room was quiet and there was no radio on. The resident was observed again on 1/2/19 at 2:40 PM, and the resident was sitting in the same position with no radio or television on. Several observations were made of Resident #63 throughout the day on 1/3/19. The resident stayed in bed all day and there was no television or radio playing. Review of Resident #63's Annual MDS assessment with an assessment reference date (ARD) of 6/5/18 documented…

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 resident and staff interview and medical record review, it was determined the facility failed to follow up with the resident to ensure the resident received the services necessary to maintain adequate hearing. This was evident for 1 (#86) resident reviewed for communication/sensory. The findings include: On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am hard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. It was noted that the resident told the surveyor to sit to the right of the bed, so he/she could hear. On 1/4/19 at 9:21 AM, the unit manager (Staff #5) was asked about the resident's hearing and Staff #5 stated his/her hearing was fine. Staff #5 proceeded to ask the Physical Therapy Manager who was at the nurse's station if he/she knew anything about the resident's hearing. On 1/4/19 at 9:25 AM the Physical Therapy Manager read an occupation therapy note which stated 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 observation, medical record review and staff interviews, it was determined that the facility staff failed to provide appropriate care for a resident that required total assistance with positioning and was assessed to have a pressure ulcer and continued to be at risk for development of pressure ulcers. This was evident for 1 (#63) of 4 residents reviewed for pressure ulcers. The findings include: Observation was made, on 1/2/19 at 12:05 PM, of Resident #63 sitting in a geriatric (geri) reclining chair with knees towards the window, pillow behind the head and nothing between the resident's knees. The resident was sitting on a Hoyer lift quilted pad. On 1/2/19 at 2:05 PM, the resident was in the same position and on 1/2/19 at 2:41 PM, the resident remained in the same position. A second surveyor observed the positioning of the resident. Observation was made, on 1/3/19 at 7:40 AM, of Resident #63 lying on his/her back with his/her head to the left towards the curtain with 2 pillows around the head. The feet were positioned on a pillow. On 1/3/19 at 11:46 AM, 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.

Based on review of the medical record and interview with the resident and staff, it was determined the facility staff failed to provide services to increase or prevent decline in the resident's range of motion (ROM). This was evident for 1 (#70) of 4 residents reviewed for Position/Mobility. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Review of Resident #70's medical record on 1/9/19 at 10:09 AM revealed a list of diagnoses which included, but was not limited to, monoplegia (paralysis of one limb) of upper limb. Review of the resident's Quarterly MDS with the reference date 12/10/18 Section G Functional limitation on Range of Motion indicated A. Upper extremity = 0. No impairment, B. Lower extremity 2. Impairment on both sides. Section I Diagnoses - did not include monoplegia of upper limb. During an interview and observation of the resident 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.

Based on observation, medical record review and staff interview, it was determined facility staff failed to provide the appropriate treatment and services to prevent complications of enteral feedings by not giving proper tube flushes and by not providing a tube feeding when ordered. This was evident for 2 (#45, #47) of 2 residents observed with tube feedings during medication pass observation. The findings include: 1) Observation was made on 1/8/19 at 9:48 AM of Staff #2 administering medications to Resident #45. Resident #45 was lying in bed and was non-verbal. Staff #2 proceeded to pull on the resident's hospital gown while searching for the end of the tube feeding tube. (A feeding tube is a device that's inserted into the stomach through the abdomen. It is used to supply nutrition for someone that has trouble eating). Once Staff #2 found the end of the tube, Staff #2 removed the cap. Staff #2 then poured water from a large Styrofoam cup into a small 120 cc. plastic cup, filling the cup up with approximately 100 cc. Staff #2 then poured half of the water in the feeding tube as a…

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

Based on observation, family and staff interview and medical record review, it was determined the facility failed to provide coordinated interdisciplinary services for a resident to maintain his or her highest practicable physical, mental and psychosocial well-being. This was evident for 2 (#58, #33) of 2 residents reviewed for dementia care. The findings include: 1) Observation was made on 1/2/19 at 9:19 AM of Resident #58 laying on a visibly, urine stained bedspread. It was also noted the fabric chair in the resident's room was urine stained. On 1/2/19 at 9:44 AM Resident #58's POA (Power of Attorney) was interviewed and stated that he/she didn't feel the staff was properly trained to deal with his/her spouse's dementia. The resident's spouse stated he/she refuses care and will not let anyone change him/her, shower him/her, etc. except for the spouse. The spouse said he/she felt as though he/she should not have to come in to do it. Staff #37 stated on 1/9/19 at 11:31 AM, we try, and we leave and retry to reapproach. He/she will throw a cup of water at us and kick us. He/she cusses…

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, staff interview and medical record review, it was determined that the facility failed to provide residents' medications in a timely manner. This was evident for 2 (#18, #47) of 5 residents observed during medication administration. The findings include: 1) Observation was made, on 1/18/19 at 8:34 AM, of Staff #3 preparing medications for Resident #18. Staff #3 dispensed 8 pills in a medication cup. There were 2 medications that were not in the medication cart; Linzess 72 mcg. and Aldactone 50 mg. Staff #3 proceeded to go to the medication dispensing machine and the medications were not available. Staff #3 stated he/she would have to re-order them from the pharmacy. The Linzess was started on 11/8/17 and the Aldactone was started on 5/14/17. Staff #3 was asked why the medications were not available and the response was someone didn't order them. I will order them and give them when they come in later today. The medications were ordered to be given every day. Resident #18's Medication Administration Record (MAR) was reviewed the next day, on 1/19/19, and 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 medical record review and staff interview, it was determined that the facility failed to have a process in place to ensure that pharmacy recommendations were reviewed and acted upon as necessary. This was evident for 1 (#78, #70) out of 6 reviewed for unnecessary medications. The findings include: Resident #78's medical record was reviewed on 1/9/19 and revealed no evidence that a monthly pharmacy review was done. During an interview with the corporate nurse (Staff #10) on 1/09/19 at 2:22 PM, s/he confirmed that the pharmacy reviews were not kept in the medical record. Staff #10 reported that the pharmacy reviews were sent via the computer as a compiled list of residents which stated, No issues. The list was not placed in resident medical records due to other resident's names being included. When the pharmacy had a recommendation, they are sent for individual residents. An interview with the Director of Nursing (DON) on 1/9/19 at 3:06 PM, revealed an expectation that the pharmacy recommendations were kept in the medical record under the consultation tab. However, he/she…

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 medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#45, #47) of 5 residents observed with 18 errors out of 37 medication administration opportunities which resulted in an error rate of 48.65% by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed. The findings include: 1) The surveyor approached Staff #2 on 1/8/19 at 9:48 AM. Staff #2 was preparing to give medications to Resident #45. Staff #2 poured the medications (1) Metoprolol 50 mg. and (1) Metoprolol 25 mg., (1) Daily Vite and (2) Senna 8.6mg. All medications were crushed and separated into 30 cc. medication cups. The surveyor confirmed with Staff #2 that there were 5 pills in the medication cup prior to Staff #2 crushing the medications. The surveyor and Staff #2 walked into Resident #45's room. Resident #45 was lying in bed and was non-verbal. Staff #2 proceeded to pull on the resident's hospital gown while searching for the end of the tube feeding tube.…

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 and staff interview, it was determined that the facility failed to have quality laboratory supplies for resident diagnostic testing in 1 of 4 medication carts observed. The findings include: Observation was made on [DATE] at 11:02 AM, in the tube feed medication cart on the second- floor nursing unit, of 2 expired blood collection vials in the top drawer of the cart. There was (1) gray top tube lot #5295961 and (1) yellow/red top tube lot #5295961 with an expiration date of [DATE]. Staff #4 was with the surveyor at the time of observation. Staff #4 stated, I didn't know that. To assure accurate test reliability, specimen containers must be used by the expiration date.