Franklin Woods Center

Based on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 2 (Resident #38 & #65) out of 33 residents reviewed during the survey. The findings include: 1a) On 5/7/25 at 9:43 AM, the surveyor conducted an interview with Resident #38. During the interview Resident #38 stated that he/she washed him/herself up at the bedside and was never offered to be set up for a shower. On 5/8/25 at 12:46 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated that shower days are established on admission. She further stated that the Geriatric Nursing Assistants GNA's utilize shower book to document the showers. The surveyor requested the documented showers for Resident #38. On 5/13/25 at 6:44 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON stated that she had spoken to the GNA's and that Resident #38 refused…

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 employee files and staff interviews, it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) were evaluated annually. This was found to be evident for 5 out of 5 GNA employees (GNA #31, #32, #33, #34, #35) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility. The findings include: During review of the employee files on 08/16/2021 at 10:02 AM, the surveyor was unable to locate annual evaluations for GNA #31, 32, 33, 34, and #35. During an interview conducted on 08/16/2021 at 11:45 AM, the DON stated that he/she was unable to confirm that annual evaluations had been conducted for GNAs #31, #32, #33, #34, and #35. During an interview conducted on 08/16/2021 at 12:02 PM, the Workforce Coordinator #38 stated that the facility policy required that he/she send a list to management for each department. The list provided staff names and due dates for annual performance evaluations. The Workforce Coordinator stated that the list had been sent…

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 of the facility's kitchen food services, and staff interview, it was determined that 1.) The facility failed to maintain food service equipment in a manner that ensured sanitary food service operations, and 2.) The facility staff failed to serve beverages in a manner that ensured sanitary food distribution during meal service to rooms. This was identified while observing the facility's dish washing machine in operation and meal distribution service to residents' rooms. The findings include. 1.) On 8/11/21 at 10:45 AM, during an observation of the facility dishwasher with the food service director, it was revealed that the temperature of the wash water was not reaching the minimum requirement of 160 degrees Fahrenheit (F). The food service director acknowledged that the wash temperature gauge was only reading 140 degrees F and indicated that the facility's maintenance man was notified. On 8/13/21 at 12:16 PM, review of the Machine Warewashing Sanitizing Log and the Manual Warewashing…

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 of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the resident's in the facility have the potential to be affected by not having a qualified nutritional profession with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: On an initial tour of the facilities kitchen on 8/10/21 at 9:05 AM, it was revealed that the full time Food Service Director (staff # 4) was not clinically qualified as per Federal and state regulations. The food service director indicated that his predecessor had abruptly left and he was placed in-charge. Upon interview, he indicated that he was not a Certified Dietary Manager (CDM). He indicated that he has completed some of the educational course work towards becoming a CDM. Upon request for written documentation of the foodservice director's credentials on 8/11/21, no documentation was provided.

Based on observations and interviews, it was determined that the facility failed to ensure residents received their meal in a timely manner. This was found to be evident for 1 (resident #21) out of 7 residents observed for dining. The findings include: During a tour conducted on 08/10/21 at 12:22 PM, surveyors observed the lunch cart arrive to the 2nd floor nursing unit. At 12:48 pm, the surveyor observed Resident# 21 lying in his/her bed, and their roommate (resident #40) was sitting in a wheel chair. Resident# 40 stated that he/she had already eaen lunch and that their lunch tray had been removed from the room. Resident #21 stated that he/she had not yet received a lunch tray. During an interview on 08/10/2021 at 12:49 PM, the Unit Manager (UM) #10 stated that Resident #21's tray was not delivered to their room, because he/she normally ate lunch in the dining room. The UM went on to say that the kitchen was contacted 4 times to request that resident #21's lunch tray be delivered to their room. At 12:52 PM, The surveyor observed that resident #21's tray was delivered. Afterward,…

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 medical records and interview with residents, their representatives and facility staff, it was determined that the facility failed to ensure that transportation arrangements were made for a resident who required wheelchair-enabled transport for a known medical appointment. This was evident for 1 (Resident #147) of 43 residents reviewed during the survey. The findings include: The surveyor reviewed Resident #147's medical record on 8/17/21 at 10:18 AM. The review revealed that Resident #147 was admitted to the facility on [DATE] following hospitalization for a complex fracture of the left ankle. Review of discharge paperwork from the hospital indicated that the resident had an orthopedic appointment scheduled for 6/1/21 at 9:42 AM. Review of the resident's physician orders in the electronic medical record system revealed an order, dated 5/27/21, that stated, Follow up appointment, orthopedic 6/1/21 @ 9:40 AM, [physician's name, address, and telephone number]. The surveyor interviewed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and interview with residents, their representatives, and facility staff, it was determined that the facility failed to notify a recently discharged resident or their representative of a positive COVID-19 test. This was evident for 1 (#146) of 43 residents reviewed during the survey. The findings include: In the course of investigating a complaint, the surveyor interviewed Resident #146's responsible party (RP) on 8/18/21 at 12:12 PM. During the interview, the resident's RP stated that the resident was hospitalized on [DATE]. The RP stated that, upon arriving to the hospital, the resident was tested for COVID-19 and the result of the test was positive for COVID-19. The RP stated that s/he had never been told by the facility that Resident #146 had contracted COVID-19. The surveyor reviewed Resident #146's paper medical record on 8/18/21 at 1:20 PM. The review revealed that the resident was admitted to the facility in January, 2021, was hospitalized mid February, 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 observation, interview, and record review, the facility staff failed to provide a clean shower room for the female residents on the first floor. This was evident for the female residents who wanted a shower on the rehabilitation unit. The findings include: On 08/10/21 at 7:50 am, this surveyor checked the women's shower room located on the Long term Care Unit for cleanliness. The surveyor observed dried brown matter on the floor, about 6 inches away from the drain. The second shower stall had a used mask on the shelf, gauze with a piece of tape was on the floor were observed in the left corner of the second stall. The fourth shower stall, near the bathroom, had a pail of standing water underneath a shower chair. The bathroom had a glove turned inside out and another glove on the floor. This surveyor observed a Daily Shower Room Cleaning log taped to the exit door. The cleaning log was removed and Assistant Director of Nursing (ADON) #5 provided this surveyor with a copy. According to the log, the shower room was last cleaned 08/08/21, during the 7:00 am - 3:00 pm shift.…

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 record review and facility report of an incident, the facility failed to protect resident # 246 from verbal abuse. This was evident for 1 out of 2 reports of abuse. Findings include: A record review was conducted for resident # 246 on 8/16/21 at 11:28 AM. Resident # 246 reported in June 2019 that Geriatric Nursing Assistant (GNA) #20 leaned on her wheelchair and looked into her face and stated, 'you need an attitude adjustment. According to GNA# 20, resident # 246 was complaining about her roommate. GNA #20 did admit during an interview with the Director of Nursing held with her/him on 6/13/21 that he /she did make this comment. GNA #20 was placed on suspension until the facilty's investigation was completed and her/his employment was terminated on 6/19/21.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to notify the resident representative in writing for the reason that the resident was transferred to the hospital. This was found to be evident for 1 (resident # 27) out 3 residents reviewed for transfer and discharge. The findings include: Record review of resident # 27's medical records, conducted on 08/13/2021 at 10:32 AM, revealed that resident # 27 was transferred to the hospital on [DATE] and 07/28/2021. Further review of resident # 27's medical records failed to reveal documentation that the resident representative was provided a reason in writing for resident #27's transfer to the hospital on [DATE] and 07/28/2021. During an interview conducted on 08/13/2021 at 11:16 AM, the Unit Manager (UM) #10 confirmed that the resident representative did not receive the reason in writing for resident #27's transfer to the hospital on [DATE] and 07/28/2021. The UM stated the resident's representative resided at the facility, however,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined the facility failed to provide a bed hold for a resident transferred to the hospital. This was found to be evident for 1 (resident #27) out of 3 residents reviewed for transfer and discharge.The findings include: A record review was conducted on 08/13/2021 at 1:25 PM for the Bed Hold Notice of Policy and Authorization form for resident #27's transfer to the hospital on [DATE]. The surveyor was unable to locate the Bed Hold Notice of Policy and Authorization form in the electronic medical record and physical chart. During an interview conducted on 08/13/2021 at 1:32 PM, the Unit Manager (UM) #10 confirmed that resident #27 did not have a Bed Hold Notice of Policy and Authorization form in the electronic medical record or physical chart. During an interview conducted on 08/13/2021 at 2:12 PM, the surveyor advised the Regional Corporate Nurse #13 of the Surveyor findings.

Based on review of resident medical record, the facility failed to develop a care plan for anticoagulant therapy for resident # 45. This was evident for 1 out of 7 records reviewed. Findings include: On 8/13/21 at 1:34PM, a record review was conducted for resident # 45. On 11/7/20, the physician ordered Heparin 5000 units for resident # 45. The instructions stated to give 5000 units of Heparin subcutaneously at 9 AM and 9 PM for clotting prevention. No care plan was initiated to address the use of anticoagulation medication. The corporate nurse manager was made aware and stated on 8/13/21 at 10:45 AM that no care plan was found for anticoagulant therapy.

Based on observation and interviews, the facility staff failed to notify residents receiving rehabilitation services of the activities available during their stay in the facility. This was evident for 3 (#30, #86, #34) of 4 residents reviewed for activities. The findings include: On 08/10/21 at 10:04 am, Resident # 30, who had been in the facility since early June 2021, verbalized that he/she was not aware that there were activities for the rehab residents to participate in. On 08/10/21 at 10:56 am, Resident #86 reported not knowing what activities were being offered at the facility. On 08/12/21 at 9:45 am, Resident #34 verbalized not knowing what activities were being offered. The resident had been in the facility since early June 2021. On 08/13/21 at 12:05 pm, an interview was completed with Staff #11, the Recreation Manager. Staff #11 verbalized that all residents admitted to the facility receive an activity assessment within five (5) days. Staff # 11 stated that an assessment is completed to determine their interests and preferences and the activities staff is responsible for…

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 interviews, it was determined that staff failed to follow physicians' orders for 2 of 2 residents reviewed (Residents #1 and #74). The findings include: 1) On 08/10/21 at 9:55 am, surveyor entered resident #1's room for an interview. The resident requested to speak with surveyor at a later time because he/she was trying to eat his/her breakfast. Resident#1 was observed having difficulty eating. On 08/12/21 at 8:35 am, surveyor entered Resident#1's room for an interview. The resident was observed struggling to eat breakfast due to tremors. No assistance from staff was provided to the resident at the time of the observation. On 08/12/21 1:45 pm, a review of Resident #1's medical record revealed that the resident had a diagnosis of Parkinson's disease. The resident was noted to have tremors. Further review of the record revealed an order, dated 08/03/21 at 7:00 am, for Resident #1 to receive assistance with meals at every shift due to the resident's tremors. On 08/13/21 at 9:08 am, in interview with RN #24 regarding Resident #1's need…

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 resident medical records and interview with facility staff, it was determined that the facility failed to ensure that neurologic checks, following a resident's unwitnessed fall involving a head injury, were completed accurately. This was evident for 1 (Resident #146) of 5 residents reviewed for accidents. The findings include: 'Neuro Check' is a term used to refer to neurological evalutations performed after a patient has had a potential neurological change. It is a standard of nursing practice to complete a neuro check at regular intervals following a resident's unwitnessed fall or a fall involving the resident's head. A Neurological Evaluation Flow Sheet is usually used to conduct these neuro checks. The form identifies the intervals when a neuro check should be performed (most often it is every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every hour for 4 hours, then every 4 or 8 hours for a few days). The purpose of the evaluation is to detect early neurological changes in a resident that may indicate a more significant problem that requires…

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 it was determined that the facility failed to have a system in place to notify a resident and the resident's representative of the reason for a hospital discharge in writing. This was found to be evident for 5 out of the 6 residents (Resident #13, #77, #35, #59 and #68) reviewed for hospitalization during the investigative portion of the survey. The findings include: 1) On 9/05/18 review of Resident #13's medical record revealed the resident had been discharged to the hospital and re-admitted to the facility on multiple occasions. At 10:19 AM the resident confirmed several hospitalizations but that nothing had been provided in writing in regard to the reasons for the hospitalizations. Further review of the medical record failed to reveal any documentation that a summary of the reason for the hospital discharges had been provided to the resident. 2) On 9/5/18 review of Resident #77's medical record revealed the resident had been discharged to the hospital in August and re-admitted several days later. Further review of the medical 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 medical record review and interview with staff it was determined that the facility failed to have a system in place to provide a written copy of the facility's bed-hold policy to a resident and/or the resident's representative at the time of discharge to the hospital. This was found to be evident for 5 out of the 6 residents (Resident #13, #35. #59, #68 and #77) reviewed for hospitalization during the investigative portion of the survey. The findings include: 1) On 9/05/18 review of Resident #13's medical record revealed the resident had been discharged to the hospital and re-admitted to the facility on multiple occasions. On 9/5/18 at 10:19 AM the resident confirmed several hospitalizations but that nothing had been provided in writing in regard to the bed-hold policy. Further review of the medical record failed to reveal any documentation that a copy of the bed-hold policy had been provided to the resident at time of discharge to the hospital. 2) On 9/5/18 review of Resident #77's medical record revealed the resident had been discharged to the hospital in August and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of medication pass and of medication carts it was determined that the facility failed to maintain and store medications safely and securely. This was determined and evident for 1 medication pass and 3 of 5 medication carts observed. The findings include: Observation of medication pass on [DATE] at 8:57 AM Nurse #15 was observed passing medication to Resident #200. Resident #200 stated that s/he did not want to take his/her Plavix that morning and the nurse left it on the medication cart unattended as the medication pass was completed in the resident's room. A Lidocaine patch for Resident #27 was also observed on the cart left unattended and reported to of been from a previous medication pass according to Nurse #15 Review of medication cart #1 revealed a vial of tuberculin tuberculin test or PPD (purified protein derivative) was found in the medication cart on [DATE] at 9:21 AM. Nurse #15 was asked if any residents were given a PPD test this morning and she stated no. The vial stated 'to be…

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, interview with facility staff and resident it was determined that the facility failed to go to the resident to get consents for treatment when the resident had capacity to make medical decisions based on a physician assessment completed in the facility. This was determined during the investigative portion of the survey and found to be evident for 1 of 52 residents (#36) reviewed during the survey. The findings include: During the initial tour and attempted interview with Resident #36 on 9/4/18 at 9:03 AM Resident #36 was noted in his/her bed attempting to eat breakfast. Screening questions were asked of Resident #36 however, s/he was not able to answer the questions with certainty and therefore was marked as non-interviewable. Surveyor re-attempted to interview the resident on 9/5/18 at 2:57 PM and again the resident was unable to answer the questions that are part of the survey process. Review of Resident #36's medical record on 9/5/18 revealed resident was admitted with a hip fracture status post a fall at home, with noted muscle weakness 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 review of Resident Council minutes, interviews with residents and staff, it was determined that the facility failed to ensure that residents were informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. The findings include: On 9/11/18 the surveyor met with members of the Resident Council. During the meeting it was revealed that they did not remember if the facility gave them a copy of the Resident's [NAME] of Rights. They further revealed that it may have been in the admission packet and they acknowledged if it was given on admission then it was sent with family members and they do not recall what the resident's rights are. The resident council members also revealed that the facility never reviews or discuss the resident's rights at any of the meetings, they further verbalized that reading the resident's rights at each meeting would be a nice way of knowing what rights they have. Review of the minutes from the resident council meeting failed to reveal any documentation indicating…

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 it was determined that the facility failed to report and investigate an incident in which a resident, who was cognitively impaired, was found on the floor with a laceration to the head. This was found to be evident for 1 out of 3 residents (Resident #32) reviewed for accidents during the investigative portion of the survey. The findings include: Review of Resident #32's medical record revealed the resident has a diagnosis of dementia and history of falls. Review of the Minimum Data Set (MDS) assessments completed in May 2018 revealed the resident had severe cognitive impairment as evidenced by BIMS (Brief Interview for Mental Status) score of 5 out of 15. A BIMS score of 0 - 7 indicates a severe cognitive impairment. Review of the medical record revealed a Change in Condition Evaluation completed on 6/29/18 which included the following: Had a fall with a cut of 3.5 cm to the right side of [his/her] head. The nurse practitioner was notified at 9:00 PM and ordered the resident sent to the emergency room for evaluation. Further review of the…

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

Based on medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure activity assessments were completed by activity staff during the assessment reference date (ARD) look back time period for the comprehensive Minimum Data Set (MDS) assessment. This was found to be evident for 3 out of 4 residents (Resident #55 and #77) reviewed for completion of section F- Preferences for Customary Routine and Activities for the annual MDS assessment. The findings include: The MDS is a federally mandated assessment tool used to identify resident needs and help with the development of the resident's plan of care. On 9/11/18 review of Resident #55's comprehensive MDS with an ARD of 8/13/18 revealed answers to all of the questions in Section F-Preferences for Customary Routine and Activities to have been marked as not assessed. On 9/11/18 review of Resident #47's comprehensive MDS with an ARD of 5/20/18 revealed answers to all of the questions in Section F-Preferences for Customary Routine and Activities to have been marked…

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, interviews with facility staff and medical record review, it was determined that the facility failed to follow a resident's care plan related to a resident receiving the following medication categories: anticoagulant, sedative and an antibiotic. The facility also failed to develop a care plan for a resident with a Foley catheter and a resident's medical diagnosis and treatment of syncope. This was evident for 3 of 6 residents (#58, #68 and #202) reviewed for unnecessary medications. The findings include: 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. Review of the paper and electronic medical record for Resident #58 on 9/7/18 at 9:42 am revealed hospital discharge diagnosis' including cardiomyopathy (progressive heart disease in which the heart is abnormally enlarged, thickened, and/or stiffened), diabetes, syncope with loss of consciousness and bacterial urinary tract infections. Upon admission to the facility the resident was noted to be on insulin…

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 it was determined that the facility failed to accurately update a residents' care plans after falls resulting in a laceration to the head and failed to accurately reflect the residents' needs and current interventions to be provided. This was found to be evident for 2 out of the 4 residents (Resident #32 and #36) reviewed for accidents during the investigative portion of the survey. The Findings include: 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 9/10/18 review of Resident #32's medical record revealed the resident has diagnosis of dementia and history of falls. Review of the Minimum Data Set (MDS) assessments completed in May 2018 revealed the resident had severe cognitive impairment as evidenced by BIMS (Brief Interview for Mental Status) score of 5 out of 15. A BIMS score of 0 - 7 indicates a severe cognitive impairment. Further review of the medical record revealed the resident sustained falls on 6/29/18 and 7/18/18.…

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, interview with facility staff and observation it was determined that the facility failed to 1. get a physician order for a resident that was using a continuous positive airway pressure (CPAP) machine, and 2. follow a physician order for daily weights on a resident. This was evident for 2 residents (#93 and #198) during the investigative portion of the survey. The findings include: 1. During initial tour observations and interview with Resident #93 on 9/5/18 at 10:12 AM surveyor observed a CPAP (positive airway pressure, which keeps the airways continuously open in people who are able to breathe spontaneously on their own) machine on the resident's night stand. Review of the resident's medical record revealed diagnosis including chronic obstructive pulmonary disease and a care plan in place regarding CPAP use and respiratory therapy notes regarding treatment and care of the resident. Further review of the resident's physician orders failed to reveal a physician order for the use 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 interview with the facility staff, it was determined that the facility failed to complete a discharge summary on a resident to include a review of the resident's medications reconciled with the discharge medications and complete a physician discharge summary in a timely manner. This was evident in 2 of 3 residents (#198, #348) sampled for closed records reviewed during the investigative portion of the survey. The findings include: 1. Review of the closed medical record on 9/10/18 at 1:40 PM for Resident #198 revealed diagnosis including; muscle weakness, chronic kidney disease, and abnormal serum enzymes. Further review of the medical record revealed that the resident's daughter requested for the facility to discharge the resident home prior to the resident's end of skilled care time. A review of the discharge packet and physician summary failed to reveal a list of the medications including dose and frequency the resident was receiving in the facility reconciled with the medications that the resident was provided at time of discharge home. This…

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 staff it was determined that the facility failed to ensure physician ordered wound treatment were completed as ordered. This was found to be evident for 1 out of 2 residents (Resident #83) reviewed for pressure ulcers during the investigative portion of the survey. The findings include: On 9/11/18 review of Resident #83's medical record revealed the presence of a facility acquired stage 4 pressure ulcer on the resident's buttocks. Review of the medical record revealed that from 4/26/18 until 6/5/18 the following order was in effect and being completed as ordered: Apply small foam dressing directly to patients sacrum boney prominence to assist with pressure relief to area every day and night shift. This order was discontinued on 6/5/18. Review of the nursing notes revealed on 6/5/18 : Resident found to have pressure area to sacrum, with skin open now and spoke to Hospice Nurse with TX (treatment) changed to hydrogel to sacrum q pm 9 every evening) and PRN as needed. A corresponding 6/5/18 order for: Clean Midline sacrum with Vashe,…

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 it was determined that the facility failed to ensure dietary orders were submitted to the kitchen for implementation. This was found to be evident for 1 out of 5 residents (Resident #13) reviewed for nutrition. The findings include: Review of Resident #13's medical record revealed an order written on 8/28/18 to: Please serve high calorie snacks on each tray: cottage cheese, pudding, or jello three times a day. On 9/10/18 at 12:04 PM review of the resident's meal ticket failed to reveal any documentation about cottage cheese or pudding. Review of the Snack Summary for this resident for the week of 9/10/18 failed to reveal any documentation regarding the order for high calorie snacks on each tray. On 9/11/18 at 11:35 AM the Registered Dietician (RD #18) confirmed that the resident had been losing weight. She reported that she did not think the kitchen received the diet slip regarding the 8/28/18, stating whoever took it (the order) off didn't write the slip. On 9/11/18 at 12:02 PM nurse #17, who entered the order into the electronic health…

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 review of medical records it was determined that the facility failed to document follow-up interventions for a patient when pain medication administered was coded as ineffective. This was evident during the review of 1 of 4 residents (#93) who triggered for pain management. The findings include: During observation of medication pass on 9/5/18 at 9:37 AM, Resident #93 was observed and interviewed. Resident was noted to receive Oxycodone, 15 mg for wound. At this time, surveyor was notified by the resident and the nurse that the resident has a large wound on his/her leg that requires medicinal pain management with additional medication administered prior to wound care. During the interview with Resident #93 regarding the effectiveness of the pain management s/he started to cry and reported to the surveyor that the pain gets so bad and uncomfortable. Surveyor asked the resident for permission to observe the wound care and the resident said that it would be ok. Review of Resident #93's medical record on 9/5/18 10:00 AM revealed diagnosis including encounter for…

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 upon the facility's assessment, record review and staff interview it was determined that the facility failed to have a system in place to assure that there is always enough qualified nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This deficient practice has the potential to affect all residents in the facility. The findings include: The facility assessment is an evaluation of its resident population to identify the resources needed to provide the necessary person-centered care and services the residents require during both day-to-day operations and in emergencies. A review of the facility's assessment for staffing requirements in the facility was conducted on 09/10/18 at 9:13 AM. The assessment tool indicated that the Transitional Care Unit (TCU) and the Long-Term Care (LTC) unit required a specific number of direct care staff; Registered Nurses (RN) License Practical Nurses, and Geriatric Nursing Assistants (GNA) each 8-hour…

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 medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure pharmacist review recommendations were addressed and acted on by the physicians. This was found to be evident for 1 out of the 6 residents (Resident #348) sampled for medication regimen review during the investigative portion of the survey. The findings include: On 9/11/18 Resident #348's medical records were reviewed. This review revealed that on May 13, 2018 a pharmacist completed the required monthly medication review. This review revealed irregularities with the resident's medications and recommendations were made. The pharmacist report revealed the following: (Resident #348) has an order for Lorazepam 0.5 milligram TID PRN (three times a day as needed) for anxiety since 4/27/18. Further review revealed that Lorazepam is a psychotropic medication that is ordered PRN which requires an evaluation and documentation of rationale for use of PRN psychotropics beyond 14 days. Pharmacist recommendation: Please review the use of Lorazepam…

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

Based on observations and interviews with the facility staff it was determined the facility failed to store foods properly by ensuring that foods are date labeled upon opening and expired food items are discarded. This was evident during a tour of the facility's main kitchen during the survey. Findings include: On 9/4/18 at 3:23 PM a tour of the kitchen was conducted and the Executive Chef accompanied the surveyor. The following concerns were identified: -Inside of the Walk-In Refrigerator there was 1 gallon of Mayonnaise, 1 plate of tuna fish and there were no date labels on these items as they were stored on the shelf. -Inside of the Walk-In Freezer there was 1 large package of sausage, 1 large sleeve of bagels, 2 large packs of burgers 30 each and there was no date label on these items as they were stored on the shelf. -Inside of the Dry Storage Area there was a box of cream of wheat that was opened, 1 gallon jug of Molasses with a 1/4 remaining in the container,1 gallon jug of Browning Sauce with 1/2 remaining in the container and there were no date labels on these items as they…

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 interviews with facility staff it was determined that the facility failed to ensure accurate medical record documentation as evidenced by Geriatric Nursing Assistants (GNA) documentation of the use of fall mats despite the discontinuation of the use of this intervention. This was found to be evident for 1 out of 3 residents (Resident #32) reviewed for accidents during the investigative portion of the survey. In addition, the facility failed to put a system in place to ensure that documentation for the infection antibiotic stewardship and infection control programs were consistent and accurate. This deficient practice has the potential to affect all residents in the facility. The findings include: 1. Review of Resident #32's medical record revealed the resident has diagnosis of dementia and history of falls. On 9/11/18 review of Resident #32's electronic medical record revealed GNA documentation in the TASKS section of the electronic health record of the use of a Fall Mat on 11 out of the past 14 days. Further review of the medical record failed 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.

Based on record review and staff interview it was determined that the facility failed to put a system in place to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for residents. This deficient practice has the potential to affect all resident, staff and visitors at the facility. Findings include: A line listing is a table in which important information is recorded on each person who is currently or potentially ill with an infection. It can be used to decide if an outbreak has occurred and to monitor the outcomes of persons affected in an outbreak. A review of the facility's Infection Prevention Program was conducted with the Infection Control Nurse (ICN) (staff #1) on 09/10/18 at 01:01 PM. She stated that a line listing is located at every nursing station in the facility and checked daily for new entries. She says the ICN is responsible to review documentation for residents noted with a change in condition, new or revised…

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 put a system in place to ensure that the procedures for the antibiotic stewardship program are put in place. This deficiency has the potential to affect all residents in the facility. Findings include: Antibiotic stewardship is a coordinated program used by healthcare facilities that promote the appropriate use of antibiotics and using the right antibiotic for each infection to improve patient outcomes and decrease the spread of infections caused by multi-drug resistant organisms. On 09/10/18 at 09:00 AM a review of the facilities antibiotic stewardship program was conducted with the Infection Control Nurse (ICN) (staff #1). Review of the facility's line listing revealed that the list failed to document residents' signs and symptoms and any laboratory reports to determine if the antibiotic was indicated or if adjustments were needed for residents receiving antibiotic treatments. Although the line listing provided a section to record the duration of treatment/illness, interview with the ICN…

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.