Future Care Sandtown-Winchester

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and facility record reviews, it was determined that the facility failed to provide residents with a homelike environment in good repair. This was evident for resident bathrooms observed during the survey. The findings include: On 01/29/25 at 08:28 AM during observation rounds, room [ROOM NUMBER] bathroom was observed to have a cracked toilet seat. On 01/29/25 at 08:37 AM during observation rounds, room [ROOM NUMBER] bathroom was observed to have cracked caulking around the bathroom sink where it meets the wall. On 01/29/25 at 08:44 AM during observation rounds, room [ROOM NUMBER] bathroom was observed to have a hole in the wall behind the toilet, the cove base was separated and peeling from the wall, and the wall directly in front of the toilet had large pieces of dry wall missing. On 02/04/25 at 09:34 AM, the facility's pest control records were reviewed. The facility's pest control records revealed that when Orkin Pest Control services treated the facility on 02/03/25, they recommended…

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, medical record reviews, and record review, the facility failed to protect the residents' right to be free from neglect and failed to notify the medical staff, the facility administrative staff, and the resident's representative of a resident's change in condition in a timely manner. This was found to be true for 1 of 1 (#134) investigated for neglect during the survey. The findings include: On 01.30.25 at 3:00 PM the surveyor reviewed the complaint MD00197046 submitted to OHCQ on 09.18.23. The complainant addressed the late notification by the facility to the resident representative related to resident # 134's fall on 09.08.23 and delay in immediate care status post a fall. On 01.31.25 at 09:45 AM the regional district RN #17 provided the surveyor with the facility incident documents related to resident # 134. On one page of the hard copy facility incident report Resident had a fall on 09.08.23 without complaint of pain/visible injury was written by the director of nursing (DON). with a date of 09.10.23. Further review of the facility incident report included an…

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

Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of an allegation of abuse. This deficient practice was evidenced in 1 (#66) of 1 Facility Reported Incident (FRI) reviewed during the survey. The findings include: On 02/06/25 at 10:30 am a review of the Facility Reported Incident (FRI) involving Resident #66 revealed the alleged incident occurred on 01/30/25 during the 3:00 pm - 11:00 pm shift. The surveyor requested and received a copy of the staffing sheets for Unit #5 when the alleged incident occurred. On 02/06/25 at 12:15 pm review of the staffing sheet 01/30/25 for the 3 pm- 11 pm shift revealed the alleged perpetrator's name was not on the assignment sheet. At 12:35 pm the surveyor received the staffing sheet for 7 am - 3 pm shift and the alleged perpetrator's name was present. Received a copy of Registered Nurse # 37 time sheet for 01/30/25 day shift which revealed he/she clocked out at 4:24 pm. Review of the interviews conducted by Director of Nursing #2 revealed all the staff who worked on Unit #5…

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

Based on record review and interviews it was determined that the facility staff failed to practice according to professional nursing standards as evidenced by failing to complete a narcotic count prior to their shift and failing to sign the narcotic sheet after completing the narcotic count. This deficient practice was discovered during the survey. The findings include: On 02/04/25 at 1:45 pm the surveyor asked Licensed Practical Nurse (LPN) #30 who completed the narcotic count with them when their shift started. LPN #30 verbalized the narcotic count was completed with Unit Manager #34. The surveyor looked at the narcotic sign off sheet and did not see Unit Manager #34's name. The surveyor asked who signed the narcotic sheet. LPN #30 verbalized, oh that's right I did the count with Registered Nurse #33. The controlled narcotics sheet was signed by LPN #30 and RN #33. On 02/04/25 at 2:00 pm while on the third floor, the surveyor asked Registered Nurse # 33 who completed the narcotic count. RN #33 verbalized they completed the narcotic count with Registered Nurse #49 on the third 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, record review, and interview with staff, it was determined that the facility failed to ensure a resident had the opportunity to participate in daily activity programs and maintain documentation of resident participation. This was evident for 1 (Resident #10) out of 4 residents investigated for activities during the survey. The findings include: On 1/30/2025 at 9:08AM, the Surveyor conducted an interview with Resident #10 which revealed that the resident was not offered activities every day. The resident also stated that they used to participate in activities at the facility, but now it takes the staff too long to bring him/her back to their room when ready. BIMS stands for Brief Interview for Mental Status, a cognitive screening tool used to assess a person's mental status and scored from 0-15. During a review of Resident #10's electronic medical record, the Surveyor discovered that the resident had a BIMS score 15 indicating the resident was cognitively intact. Further review revealed the resident was dependent on nursing staff for activities of daily living…

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

Based on observations and interviews it was determined that the facility staff failed to monitor a resident's oxygen saturation as ordered and failed to follow a physician's order for oxygen therapy. This deficient practice was evidenced in 1 (#80) of 1 resident assessed for oxygen therapy during the survey. The findings include: On 01/29/25 at 9:03 am the surveyor observed Resident #80 in bed receiving 3L of oxygen therapy via NC. On 01/30/25 at 12:58 pm the surveyor observed Resident #80 receiving 3 liters of oxygen (02) therapy via nasal cannula (NC). On 01/31/25 9:29 am a review of the electronic medical record revealed an order was written on 11/24/24 for Resident #80 to receive 3L of oxygen via NC as needed (PRN) for shortness of breath (SOB) and pulse ox below 95%. A review of the resident's medication and treatment administration records for November 24, December 24, and January 25 revealed there was no documentation to support the resident was receiving oxygen therapy. A review of the resident's vital signs revealed the resident's oxygen saturation was not being checked…

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 interviews, it was determined that the facility staff failed to ensure a resident who smokes did not have readily available cigarettes. This deficient practice was evidenced in 1 (#6) of 1 residents assessed for safe smoking monitoring during the survey. The findings include: On 02/06/25 at 1:17 pm while the surveyor was on Unit #5 the surveyor noticed something on the floor in Resident #6's room. The surveyor walked into the room and observed a cigarette on the floor next to the bed in front of a black tennis shoe. Another cigarette along with unsmoked tobacco was on the floor in the walking path. The surveyor asked Registered Nurse #37 if Resident #6 was supposed to have their cigarettes. Registered Nurse #37 verbalized the resident was care planned for having their cigarettes. Review of Resident #6 care plans revealed, four separate care plans were initiated related to the resident smoking including adhering to the smoking policy. No interventions included monitoring the resident for smoking paraphernalia. On 02/06/25 at 2:50 pm the surveyor reported 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 observation, medical record review, and interview with staff, it was determined that the facility staff failed to provide care, treatment, and appropriate and sufficient services for a resident with an indwelling urinary catheter. This was evident for 2 (Resident #52, #50) of 3 residents reviewed for Urinary Catheters during the survey. The findings include: An indwelling urinary catheter is a thin flexible tube inserted through the urethra into the bladder to drain urine. The catheter is held in the bladder by a water-filled balloon, which prevents it falling out. These types of catheters are often known as Foley catheters. 1. On 1/30/2025 at 11:52AM, during an interview with Resident #52, the Surveyor observed the indwelling catheter bag with cloudy urine, hanging from the side bed frame facing the wall. On 2/3/2025 at 12:56PM, a review of Resident #52's electronic medical record failed to reveal physician orders for an indwelling catheter or for catheter care. The Treatment Administration Record (TAR) had no provision for the staff to sign off the presence 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 record review and interviews it was determined that the facility staff failed to ensure the controlled substance count was completed and the records were accurate. This was evident for 2 medication carts out of 4 medication carts reviewed during the survey. The findings include: 1. On 02/04/25 at 1:45 pm the surveyor asked Licensed Practical Nurse (LPN) #30 who completed the narcotic count with them when their shift started. LPN #30 verbalized the narcotic count was completed with Unit Manager #34. The surveyor looked at the narcotic sign off sheet and did not see Unit Manager #34 name. The surveyor asked who signed the narcotic sheet. LPN #30 verbalized, oh that's right I did the narcotic count with Registered Nurse #33. On 02/04/25 at 2:00 pm while on the third floor, the surveyor asked Registered Nurse # 33 who completed the narcotic count. RN #33 verbalized they completed the narcotic count with Registered Nurse #49 on the third and fifth floors. Registered Nurse #33 worked on the fifth floor during the 11 pm - 7 am on 02/03/25. On 02/04/25 at 2:08 pm Director 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 observation and interview it was determined that the facility staff failed to store medication in the refrigerator, discard expired intravenous tubing kits, discard an opened gastrostomy tube, discard expired COVID-19 Rapid Test Kits, and an open vial of medication. This deficient practice was evidenced in 1 (Unit #5) of 2 medication storage units reviewed during the survey. The findings include: On [DATE] at 1:18 pm the surveyor reviewed the medication storage room on Unit 5. There was a pack of [NAME] cigarettes that belonged to a resident per RN Unit Manager #34 who the cigarettes were given to. A bag of 5 vials of Lorazepam was in the left upper cabinet on the second shelf behind a box. The bag had a label indicating the medication should have been refrigerated. The cap was removed from one vial and the vial was almost empty. The medication was prescribed for Resident #37. An opened package with a gastrostomy tube 14F/5ml was in the cabinet along with two packages of COVID 19 Rapid Test Kits that…

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 interviews it was determined that the facility staff failed to ensure a resident received dental care. This deficient practice was evidenced in 1 (#121) of 2 residents assessed for dental care during the survey. The findings include: On 01/30/25 at 10:23 am while speaking with Resident #121 the surveyor noticed the resident had two teeth; one in the right lower quadrant and one in the left lower quadrant. On 01/30/25 at 11:30 am the reported to the management team Resident #121 had poor dentition and asked if the resident had dental care since being admitted to the facility. On 02/03/25 at 8:45 am the surveyor received a copy of Health Drive request for Services/Consultation form for Resident #121. After surveyor intervention, the resident was ordered a consultation for dental care services. On 02/06/25 at 2:56 pm during an interview with Assistant Director of Nursing #3 he/she reported there was a referral process for prophylactic dental measures. The residents are seen but if they have pain or other issues they are referred as well and Long Term Care…

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

Based on resident interview, observation and staff interview, it was determined that the facility failed to provide food in accordance with the resident's preferences. This was evident in 1 of 1 (Resident #1) resident selected for review during the survey. The findings include: The surveyor interviewed resident #1 on 2/3/2025 at approximately 12:15 pm regarding their lunch tray. The resident stated that they never got what they wanted to eat. They also stated that I don't get to choose what I want on a daily basis. I was asked what I liked and didn't like when I first got here, but when the food gets to me, it usually nothing like what I said I liked. The surveyor observed the tray and reviewed the dietary slip on the tray. The tray had a very small hot dog on a plain piece of bread with no condiments available. According to the dietary sheet, there was supposed to be steamed broccoli but instead there was zucchini squash, which the resident had identified as a dislike. For dessert the resident had a plain unfrosted piece of cake that on the dietary slip was supposed to be 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, record review, and interview with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 2 (Resident #10 and Resident #86) out of 34 resident's paper medical record reviewed during the survey. The findings include: On 1/30/2025 at 12:17PM during a review of Resident #10's paper medical record, the Surveyor discovered an Anticoagulation Record form for Resident #86. On 1/30/2025 at 12:20PM, the Surveyor informed Unit Manager (UM) #44 of their observation. UM #44 was unable to explain how Resident #86's document was placed into Resident #10's paper medical record. UM #44 removed Resident #86's Anticoagulation Record form from Resident #10's paper medical record and placed in it the correct medical record for Resident #86.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews during the environmental tour. It was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This is evident for 6 out of 40 residents reviewed during the survey process. The findings include: The facilities Maintenance Director accompanied this surveyor on an environmental tour and verified all of the environmental concerns addressed. On 02/05/20 11:26 AM during Resident #128's interview, it was observed that the bed side tray table was unclean with black stains. The entire tray table was dirty. The exterior door of the same room was observed to have a panel corner of the room's door detaching and in disrepair with a circular shape cut out from the door. On 02/13/20 at 8:34 A.M. during an observation with resident's (R#13, R#38, R#100 and R#111), who share the same bathroom, it was observed on the bathroom interior wall that a hole in the interior bathroom wall was exposed 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, staff # 9 failed to follow infection control practices, during medication pass on 2/14/20 for Resident # 286. The facility staff also failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to store resident care equipment in a sanitary manner for Resident # 72. This was evident for 2 out of 41 residents during the survey process. Findings include: 1. The resident's medical record review was conducted on 2/14/20. Resident #286 was admitted in February 2020. He/SHE has a history of (H/O) smoking. On 2/8/2020 at 6 PM the physician ordered Nicotine step 1 patch 21 mg/24 hr., apply 1 application transdermally one time per day for smoking cessation and remove per schedule. On 2/14/120 at 8:40 AM, during medication pass observation for Resident #286, it was noted that nurse ( RN # 9) took off a Nicotine patch from Resident # 286's left shoulder without gloves on, twisted the patch with her bare hands and later disposed of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#132) of 5 residents reviewed for hospitalization. The findings include: The MDS (minimum data set) 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. A review of the medical record for Resident #132 was conducted on 2/12/20, documents that Resident #132 was discharged to the community/home on [DATE]. A nursing progress note was written on 12/20/19 by a Licensed Practical Nurse indicating that the resident was discharged home 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 medical record review and staff interview it was determined that the facility failed to develop and implement a comprehensive person-centered care plan, that included measurable objectives to meet the residents medical, nursing, mental and psychosocial needs. This was evident for 1 (#72) of 5 residents reviewed for unnecessary medications. 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: Review of Resident # 72's care plans on 2/13/20, revealed an intervention was written for a Coronary artery disease problem as Encourage resident to refrain from smoking. This plan of care was created on 5/16/18 and last revised on 9/17/19. Review of the resident's annual comprehensive assessments (9/17/17, 9/18/18 and 9/19/19) indicated that the resident was not a tobacco user. Review of the facility's smoker list did not include Resident #72. Review of the care plan problem Limited physical mobility related to (r/t) Cerebrovascular Accident (CVA) lower extremity…

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, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. The was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for any given time. The findings include: Tour of the facility on 2/14/20 did not reveal a facility wide staff posting indicating the total number and actual hours worked by categories of Registered nurses (RN), Licensed practical nurses (LPN), and Certified nursing aides (CAN) per shift. It was noted that the facility was posting staffing data/information on the units. On 2/14/20 at 9:40 AM the posting of staffing on the 5th floor was not accurate as the facility used a pre-filled staffing sheets that did not reflect the actual hours worked for the Geriatric Nursing Assistant (GNA)…

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, the facility failed to keep the medication error rate under 5%. A total of 35 med's were given and 2 errors were found which made the med error rate of 5.71 %. According to the regulation, the medication error rate cannot be greater than 5 %. This was evident for 2 (R#286 and R#72) out of 5 residents receiving medication during med pass. The findings include: 1. According to medical record review, Resident # 286 was admitted in February 2020. He/She has a history of (H/O) smoking. On 2/8/2020 at 6 PM the Doctor ordered Nicotine step 1 patch 21 mg/24 hr., apply 1 application transdermally one time per day for smoking cessation and remove per schedule. On 2/14/20 at 8:40 AM, during a med pass observation for Resident #286, it was noted that nurse ( RN # 9) took off a Nicotine patch from Resident # 286's left shoulder without gloves on, twisted the patch with her bare hands and later disposed of the patch into the trash. Immediately after, the same nurse, (RN # 9) without implementing any hand hygiene techniques administered a new Nicotine patch on the right…

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 interviews, it was determined that the facility staff failed to accurately document the respiratory status of Resident #117 . This was evident for 1 Resident investigated during the complaint survey process. The findings include: Resident #117 was placed on Isolation droplet precautions for RSV (Respiratory Syncytial Virus) a viral infection of the respiratory tract that is transmitted through airborne exposure from 01/30/20 until 2/12/20. On 02/12/20 around 02:58 PM, while reviewing the resident's record, it was noted that on 2/2/20 @ 19:36 (7:36 PM) and on 2/10/20 @ 8:16 AM nursing documented that the resident was not on isolation. The Director of Nursing (DON) was made aware.

Based on observation, record review, resident and staff interviews, it was determined that the facility staff failed to inform residents of their rights during their stay at the facility. The findings include: The Surveyor attended a resident council meeting on 8/16/18 at 10:00 AM with 5 residents #72; #47; #78; #31; #26 who regularly attend the monthly resident council meetings. When asked if they were aware of their rights the residents were unclear and stated that no one has ever really told them what their rights are. In an interview with the Activities Director on 8/16/18 at 11:35 AM, who assists residents with facilitating their Resident Council meetings, the surveyor asked if resident rights were presented at the monthly meetings to provide ongoing communication to residents about their rights. The Activities Director confirmed that resident rights are only discussed during the meetings if residents have a specific question or concern regarding one of their rights. Additionally, review of the meeting minutes for February, March, April, May, June and July of 2018 revealed that…

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 ensure that the resident and resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 5 out of the 33 (# 50, # 18, # 94, # 116 and # 65) residents reviewed for hospitalization during the investigative portion of the survey. The finding includes: 1. A medical record review for Resident #50 was conducted on 8/16/18 at 8:30 AM. Review of the nursing note written on December 1, 2017 revealed that Resident #50 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal any documentation that the resident or the responsible party had been provided with a written notification of the transfer or the rationale for the transfer. 2. A medical record review for Resident # 18 was conducted on 8/16/18 at 8:30 AM. Review of the nursing note written on January 11, 2018…

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 record and staff interview, it was determined the facility staff failed to develop a comprehensive care plan for Resident # 18. This was evident for 1 of 33 residents reviewed during the investigative portion of the survey. The findings include: A comprehensive care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the patient. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. On 8/14/18 at 12:35 PM an interview with Resident # 18 stated that his/her teeth are broken and painful. A review of Resident # 18's clinical record revealed on 3/21/18 documentation that the resident had dental problems as indicated by broken natural teeth and or likely cavities on the Minimum Data Set (MDS). The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on 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.

Based on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plan to reveal accurate assessment and interventions for Resident (#9). This was evident for 1 of 41 residents reviewed during the survey process. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gather 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. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the…

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

Based on record review and interview, it was determined the facility failed to follow the physicians' order for blood pressures for Resident # 50, and to flush a suprapubic catheter for Resident # 18. This was evident for 2 of 33 residents selected for review during investigation stage of the survey process. The finding includes: 1. Medical record review for Resident # 50 revealed on the 2/05/18 physicians' order: resident to have blood pressures taken on Wednesday. Blood pressure is the strength of your blood pushing against the sides of your blood vessels. Further record review of staff documentation revealed the facility staff failed to follow the physician order and continue to take residents' blood pressure from February 05, 2018 through August 14, 2018. Interview with the Director of Nursing on 08/14/18 at 10:50 AM confirmed the facility staff failed to follow the physician's ordered for Resident # 50. 2. The facility staff failed to flush a suprapubic catheter (SPC). Medical record review for Resident # 18 revealed on the 4/14/18 physicians' order: resident to have SPC flush…

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, observation and interview with residents and staff, it was determined that the facility failed to asses a resident's reported pain as per the resident's care plan. This was evident during the initial tour and interview process. (Resident #68) The findings include: Interview with Resident #68 on 8/14/18 at 11:40 AM during the initial questioning revealed that s/he does have pain in his/her left thigh. This resident further stated that the staff do medicate him/her, as needed, for pain. Review of the Residents medical record on 8/15/18 at 11:43 AM revealed that the resident has diagnoses to include multiple sclerosis, anemia and chronic pain syndrome. A further review of the residents medical record revealed a care plan in place related to the resident's pain with interventions including to assess the pains location, duration and intensity. A review of the resident's chart failed to show any documentation of pain in the resident's left thigh, or a history of pain in the left thigh. A review of the resident's medication administration record (MAR)…

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 interviews it was determined that the facility staff failed to consistently maintain Resident nourishment, and Medication storage refrigerators at an appropriate temperature. The findings include: Facilities are required to maintain refrigerator temperatures for the safe storage of foods and medications at or below 41 degrees Fahrenheit. On 8/15/18 at 8:50 AM while reviewing the medication storage surveyor observed temperature logs for the medication and resident nourishment refrigerators on the 2nd, 3rd and 4th floors. Review of the 2nd floor log revealed that from 5/29/18 through 8/15/18 a total of 79 days, the temperature was not recorded on either refrigerator on 24 days; the Medication Refrigerator temp was above the safe storage range of 41 degrees on 17 days and the nourishment refrigerator was above 41 degrees on 36 days. Review of the 3rd floor log revealed that from 4/9/18 through 8/15/18 a total of 129 days, the temperature was not recorded on either refrigerator on 37 days; the Medication Refrigerator temp was above the safe storage range of 41…

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.