Rossville Rehabilitation And Healthcare Center

Based on record review and interviews, it was determined that the facility failed to notify the resident's physician and resident representatives of a facility acquired pressure ulcer. This was true for 1 (Resident #9) of 2 residents reviewed for pressure ulcer during the recertification/complaint survey process.Findings included:According to the Center for Medicare and Medicaid services (CMS), a stage 1 wound is describe as, an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.Change of Condition (CoC) is a standardized tool for health professionals to communicate important details about resident's care to include significant changes in a resident's physical, mental, or psychological status. This tool/form helps ensure early detection and timely intervention, as unaddressed changes can lead to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews it was determined that the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold, including reserve bed payment. This was evident for 1(Resident #10) of 3 residents reviewed for hospitalization during the recertification/complaint survey.The findings include:On 11/17/2025 at 12:06 PM during the initial tour of the facility, Resident #10 was asked if he has been sent out to the hospital emergently and he said he went sent out recently but was not sure if he was given a bed hold policy at the time.Review of the facility census on 11/19/25 at 1:42 PM revealed that Resident #10 was hospitalized on [DATE] due to abnormal MRI result and came back to the facility on [DATE]. Notice of facility-initiated transfer was given to the residents and was signed and dated 10/2/25. Further review however did not show that a bed hold policy was given to the resident or their representatives.On 11/9/25 at 2:02 PM, the administrator was…

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

Based on Observation, record review and facility staff interviews, it was determined that the facility 1) failed to update the care plan of Resident #2 who is on isolation precaution to reflect the actual status of the isolation and, 2) failed to conduct care plan meetings of the interdisciplinary team for Resident #11 at the time of the quarterly revision of their care plan. This was evident for 2 (Resident #2 and #11) out of 56 residents reviewed for care plans during this recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's health status, functional abilities, and needs. It is administered to all residents upon admission, quarterly, yearly, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. Care plans are developed for residents to guide the care that residents receive in the facility. They are…

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 a complaint, record review and staff interviews, it was determined that the facility failed to administer medications to a resident timely, and as ordered by the physician. This was evident for 1 (Resident #105) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.The findings include,On 11/18/25 at 10:15 AM in an interview with a complainant, they revealed that a hospital physician told them that Resident #105 had a stroke because s/he was not getting their blood thinning medications as prescribed. The complainant also stated that the blood thinner was later switched to a different one that required closer monitoring.A review of the residents ordered medication on 11/18/25 at 10:29AM revealed that Resident #105 was prescribed on 1/30/25 a blood thinning medication Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Deep vein thrombosis (DVT) a blood clot to the lower extremities. This medication was later switched on 10/7/25 to a different brand - Warfarin Sodium Oral Tablet 5 MG (Warfarin Sodium) Give…

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 it was determined the facility failed to assist with feeding for a resident at risk for aspiration. This was evident for 1 (Resident #16) of 2 residents reviewed for Nutrition during the recertification/complaint survey.The findings include:According to guidelines from the Centers for Disease Control and Prevention (CDC) Aspiration is the inhalation of foreign material such as food, liquids, saliva, stomach contents (including acid/vomit), or foreign objects/airborne particles into the respiratory tract or lungs. Aspiration precautions are the practices used to prevent these substances from entering the airway and lungs instead of the esophagus and stomach.On 11/18/2025 at 8:43 AM, an observation was made of Resident #16 attempting to feed his/herself while lying in bed, there was no staff member present.On 11/18/2025 at 3:21 PM, a review of Resident #16's medical record revealed a physician order for Aspiration Precautions, dated 06/23/2025. Instructions included: position patient upright during meals, provide oral care before 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, medical record review, and interviews, it was determined that the facility failed to 1) maintain a nasal cannula in a sanitary manner and administer Oxygen according to the prescribed physician order (Residents #6), and 2) failed to provide necessary respiratory care services for Resident #30. This was evident for 2 (Residents #6 and #30) of 3 residents reviewed for respiratory care during the recertification/complaint survey.The findings include: 1) On 11/17/2025 at 11:20 AM, during an observation and interview, Resident #6 was seated in a wheelchair. The oxygen tubing was on the floor next to the bed, not dated, and not connected to the oxygen concentrator. Resident #6 was observed without oxygen and stated that oxygen causes his/her nose to bleed. On 11/17/2025 at approximately 11:25 AM, during an interview, Staff #3, Registered Nurse (RN), confirmed that Resident #6 was not receiving Oxygen (O2) as ordered by the physician. Staff #3 verified that the oxygen tubing was on the floor, was not bagged or dated, and was disconnected from the oxygen concentrator.…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure parameters used to determine if a resident was to be administered pain medication was adhered to by nursing staff, and failed to have a physician's order for non- pharmacological interventions for residents on pain medications. This was evident for 3 (Resident #6 and #84, #4) out of 3 residents reviewed for pain during the recertification/complaint survey. The findings include: A pain scale is a numerical scale, usually 0-10, used to determine the severity of a person's pain. Parameters (Instructions in order on when a medication can be given) for a pain scale are used to determine which pain medication would be given according to a person's severity of pain. Non-pharmacological interventions are methods that manage or reduce pain without the use of pain medication. 1) On 11/17/2025 at 11:09 AM, during an interview with Resident #6 he/she reported pain and inadequate pain medication, noting he/she had informed multiple staff members. On 11/18/2025 at 9:37 AM, review 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 record review and staff interviews, it was determined that the facility failed to report irregularities identified by the pharmacist to the attending physician for follow up. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medication during the recertification/complaint survey.The findings includeOn 11/19/2025 at 9:22 AM review of the physician's order revealed orders for pain medication written as: Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug*give 1 tablet by mouth every 8 hours for Pain and Oxycodone HCl Oral Capsule 5 MG (Oxycodone HCl) *Controlled Drug*Give 1 tablet by mouth every 3 hours as needed for breakthrough pain. The facility was asked to provide a monthly pharmacy review from January to October 2025.On 11/20/2025 at 9:02 AM review of the pharmacist monthly report revealed that the pharmacist recommended in March 2025 to add Narcan, a drug used to reverse the effect of narcotics. Resident #7 was on oxycodone which is a narcotic medication used to treat moderate to severe pain. The facility did not follow the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility staff failed to 1) ensure treatment carts were locked and secure, and 2) failed to store all drugs in a locked compartment as required. This was evident for 1 out of the 4 nursing units observed in the facility during the recertification/complaint survey.The findings include: 1) This surveyor observed on 11/17/25 at 8:23 AM the treatment cart across from room [ROOM NUMBER] was unlocked. The contents included: gauze pads, a tube of triple antibiotic ointment, a tube of hydrocortisone ointment, a container of wound cleanser solution, a tube of Lidocaine cream (name of resident was worn out), a container of hydrogel, a tube of Mupirocin ointment labelled for Resident #145, Medi honey wound and burn dressing patches sizes 4x5 and 2x2, one pair of bandage scissors, a tube of Vitamin A&D ointment, a tube of antifungal cream, a tube of Santyl ointment labelled for Resident #102, a tube of Nystatin cream, a tube of ketoconazole cream, a tube 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, it was determined the facility staff failed to 1) maintain a medical record in the most accurate form for residents and 2) maintain medical records for residents from other licenses professionals. This was evident for 2 (Resident #12 and #11) out of 46 residents reviewed during the facility's recertification/complaint survey. The findings include:A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.1) On 11/21/25 at11:27 AM review of Resident #12's medical record revealed his/her profile documented him/her as his/her own responsible party (RP); however, further review of the medical record revealed 2 certificates of incapacity that were signed and dated 5/9/25 and 5/13/25 by two different physicians as required and a surrogate document which was uploaded into the electronic medical record (EMR) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility staff failed to ensure residents and/or residents' representative (RP) were provided education regarding the benefits and potential side effects of the pneumococcal and/or influenza immunization. This was evident for 2 (Resident #26 and #12) out of the 5 residents reviewed for immunizations during the facility's recertification/complaint survey.The findings include:The Centers for Disease Control and Prevention (CDC) recommend a pneumococcal vaccine for adults age [AGE] and older, as well as for younger adults (19-49) with certain risk conditions including, but not limited to, diabetes, chronic liver disease, alcoholism, cigarette smoking, chronic heart disease, chronic lung disease, and/or sickle cell anemia. It is important for nursing home residents to get a pneumococcal vaccine because they are at a higher risk of developing serious complications from pneumococcal disease, which can spread easily in the close 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 record review and interview with facility staff, it was determined that the facility failed to ensure staff were provided education regarding the benefits and potential side effects associated with the COVID-19 vaccine. This was evident for 1 (Staff #30) out of 5 staff members reviewed for immunizations during the facility's recertification/complaint survey.The findings include:COVID-19 is an infectious disease leading to a range of respiratory illnesses from mild to severe. It can be very contagious and spread quickly. Some people are more likely than others to get very sick if they get COVID-19. This includes people who are older, are immunocompromised (have a weakened immune system), have certain disabilities, or have underlying health conditions. While most people recover without special treatment, some may become seriously ill, particularly older people and those with underlying conditions like heart disease, diabetes, or cancer. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death.On 11/21/25 at 9:13 AM review of Staff #30's 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 record review and interviews, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for residents within the regulatory time frames to facilitate appropriate care planning and maintain current assessment records. This was evident for 11 (#85, #28, #65, #183, #59, #54, #43, #77, #18, #63, #3) of 67 residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool nursing home staff use to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The completion date of the Quarterly assessment must be within 92 days of the MDS Completion Date of the last OBRA assessment. The Quarterly assessment must be completed no later than 14 days after the ARD. That is the ARD + 14 days. The last day of this observation period is the Assessment Reference Date (ARD). This is the end date of the observation period and provides a common reference point for all team members participating in the assessment. In completing sections of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to have an effective system in place to ensure that maintenance concerns are reported and addressed. This was found to be evident for rooms in 3 out of the 4 units in the facility. The findings include: During an initial tour of the facility, the surveyors made the following observations: - On 1/10/24 at 11:54 AM in room [ROOM NUMBER], the lower part of the wall, under the window, beside the A/C unit had 2 areas damaged, each measuring about 4x4 inches. This damage could be seen from the hallway. - On 1/10/24 at 1:50 PM in room [ROOM NUMBER], cracks were noted on several floor tiles and a broken corner guard on the left side under the sink. - On 1/11/24 at 9:47 AM in room [ROOM NUMBER], a broken corner guard was noted on the right side under the sink. - On 1/10/24 at 9:16 AM in room [ROOM NUMBER], Resident #32 complained that the clock had stopped working. The surveyor observed that the clock read 3:15 and the current time was 9:16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility staff 1) failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records, and 2) failed to failed to assess a resident's cognition and mood on comprehensive and quarterly MDS assessments. This was evident for 8 (#98, #281, #130, #245, #282, #235, #241 and #54) of 67 residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool nursing home staff use to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The admission MDS assessment is a comprehensive assessment for new residents and, under some circumstances, returning residents. It must be completed by the end of day 14, counting the date of admission to the facility as day 1. The Annual MDS assessment is a comprehensive assessment for 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.

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 Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#91) of 2 residents reviewed for dental status, 1 (#98) of 3 residents reviewed for resident assessment, 2 (#65, #54) of 5 residents reviewed for unnecessary medications and 1 (#129) of 4 residents reviewed for hospitalization. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Active diagnoses documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of…

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

Based on medical record review and staff interview, it was determined that facility staff failed to develop and implement comprehensive, person-centered care plans, with measurable goals and non-pharmacological approaches. This was found to be evident for for 1 (#63) of 4 residents reviewed for position and mobility, and 2 (#54, #21) of 5 residents reviewed for unnecessary medications The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 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 Resident #63's medical record revealed that the resident…

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

Based on medical record review and staff interview, it was determined that facility 1) failed to ensure interdisciplinary team meetings to review and revise the care plans following each assessment, 2) failed to evaluate and update a resident's plan of care after each assessment and 3) failed to ensure that a resident and resident representative, if applicable, had the opportunity to participate in the development, review, and revision of his/her care plan after each assessment. This was evident for 4 (#53, #59, #54, #235) of 6 residents reviewed for care plan timing and revision, 1 (#68) of 6 residents reviewed for communication and sensory problems, and 1 (#106) of 2 residents reviewed for behavioral and emotional status and 1 (#21) of 5 residents reviewed for unnecessary medications. The findings include: The Minimum Data Set (MDS) is part of the Resident Assessment Instrument, 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…

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, medical record review, and interviews with the staff, it was determined that the facility failed to develop and implement an activities program to meet the needs and preferences of residents. This was evident for 4(#43, #71, #63, #91) of 6 residents reviewed for activites. 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. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. 1) Observations made of Resident #43 on 1/9/24 at 11:55 AM, 1/10/24 at 1:30 PM, and 1/10/24 at 3:16 PM revealed that Resident #43 was lying in bed and not involved in any meaningful activity program. A medical record review completed on 1/16/24 at 10:30 AM revealed a care plan for Resident #43, initiated on 9/25/2020. The focus 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, it was determined that the facility failed to have an effective system in place to ensure that the attending physician reviewed and responded to pharmacist identified irregularities and recommendations in a timely manner. This was evident for 1 (#65) of 5 residents reviewed for unnecessary medications, and 1 (#53) of 2 residents reviewed for insulin The findings include: 1) On 1/11/24 at 1:14 PM, a medical record review was conducted for Resident # 65.The review revealed pharmacy progress notes that indicated a medication regimen review (MRR) was completed on 8/9/23 for Resident #65 with the recommendation to attempt a gradual dose reduction of an antidepressant. Continued record review revealed that Resident #65 was visited by attending physician # 51 on 8/25/23. However, the review did not show that attending Physician# 51 had reviewed or responded to the pharmacy recommendation for Resident #65. Further review of Resident #51's physician orders revealed that Resident #51's antidepressant dose had never decreased since the MRR was…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that primary care and specialty provider notes were placed in the medical record for review by other health care professionals. This was found to be evident for 1 (#106) of 2 residents reviewed for behavioral and emotional status, 2 (#63, #59) of 6 residents reveiwed for communication and sensory problems, 1 (#53) of 2 residents reviewed for insulin, and 2 (#184, #183) of 20 residents reviewed for facility reported incidents. The findings include: 1) Review of Resident #106 medical record revealed an admission date in April 2023 with diagnoses that included, but were not limited to, history of stroke, high blood pressure, diabetes, lung disease and dementia. Review of the medical record on 1/17/24 revealed an order dated 7/26/23 for a psychiatric consult. On 1/17/23 at 12:32 PM surveyor reviewed with the unit nurse manager (Staff #23) that there was an order for a psychiatric consult in July but no documentation was found to indicate the resident was seen as a result of the July order.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure that a dependent resident was groomed in a manner that preserved the resident's dignity. This was evident for 1 (# 71) of 2 residents reviewed for dignity. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Observations of Resident #71 on 1/9/24 at 9:40 AM and 1/16/24 at 9:42 AM showed that Resident #71 was lying in bed with facial hair on the chin and upper lip. On 1/24/24 at 11:17 AM, a medical record review revealed a Minimum Data Set (MDS) assessment, dated 7/18/23, which documented that Resident #71 depended on staff for all their self-care needs, including grooming and personal hygiene. Further record review showed…

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 1) failed to ensure that the resident was informed of their right to formulate an advance directive. This was evident for 2 (#54, and #235) of 5 residents reviewed for advance directives. The findings include: Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. 1) On 1/24/24 at 11:22 AM, a review of Resident #54's medical record revealed Resident #54 was admitted to the facility in August 2023 following an acute hospital stay. Resident #54's admission assessment with an assessment reference date (ARD) of 8/12/23, documented Resident #54's Brief Interview for Mental Status summary score was 13, indicating Resident #54 was cognitively intact. Further review of Resident #54's electronic medical record (EMR) and paper medical record failed to reveal evidence that Resident 54 had an advance directive in place, and no…

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

Based on record review and interviews, it was determined that the facility staff 1) failed to notify a provider of a blood sugar level outside an order's acceptable range for a resident, and 2) failed to notify the physician immediately following an accident that had the potential for requiring physician intervention. This was evident for 1 (#65) of 5 residents reviewed for unnecessary medications, and 1 (#245) of 5 residents reviewed for accidents. The findings include: 1) On 1/16/24 at 12:56 PM, during a review of an attending provider's note, dated 7/25/23, for Resident #65, it showed that Resident #65 had diagnoses including type 2 diabetes. Continued record review revealed a physician's order summary report as of August 2023 for Resident #65. The order summary report recorded an order initiated on 8/5/23 for Humalog (insulin injection). The order stated the following: Humalog Injection Solution 100 UNIT/ML (Insulin Lispro), inject as per sliding scale: 0 - 69 = 0 if Blood sugar (BS) is less than 70 (Blood sugar is obtained by testing a drop of blood), notify the attending…

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 failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (#31, #106) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The notices include: Notice of Medicare Non-Coverage (NOMNC)- To be issued at least two calendar days before the last covered day of Medicare. Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)- To be issued far enough before delivering potentially noncovered services 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 medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#132) of 5 residents reviewed for accidents, and 1 (#241) of 4 residents reviewed for hospitalization. The findings include: 1) Review of Resident #132's medical record on 1/18/24 at 9:00 AM revealed that, on 4/25/22 and 5/4/22, the resident was transferred to the hospital for an altered mental status. Further review of the medical record failed to reveal that the resident and/or the resident representative were notified in writing of the transfer/discharge of the resident along with the reason for the transfer. During an interview with the Director of Nursing on 1/18/24 at 10:31 AM, she stated that she was unable to locate any documents that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. She stated that the former Administration…

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 failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 1 (#241) of 4 residents reviewed for hospitalization. The findings include: 1) On 1/19/24 at 4:49 PM, a review of Resident #241's medical record revealed the resident was admitted to the facility in December 2023, then transferred to an acute care facility on 12/24/23 and returned to the facility on 1/6/24, then transferred to an acute care facility on 1/18/24. On 12/24/23 at 8:54 PM, in an SBAR (the situation, background, assessment and recommendation) Communication Form, the nurse documented that Resident #241 had a critical low lab, the physician ordered the resident to be sent to the hospital for a blood transfusion, and the resident's representative was aware. Continued review of the medical record failed to reveal any documentation that the resident had received an explanation of why he/she was going to the emergency room and the potential…

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, it was determined the facility failed to notify the resident and/or the resident representative in writing of the bed-hold policy upon transfer of the resident to an acute care facility. This was evident for 1 (#132) of 5 residents reviewed for accidents, and 1 (#241) of 4 residents reviewed for hospitalizations. The findings include: 1) Review of the medical record for Resident #132 on 1/18/24 at 9:00 AM revealed that, on 4/25/22 and 5/4/22, the resident was transferred to an acute care facility for an altered mental status. Medical record documentation revealed that the resident representative was called, however there was no written documentation that the resident and / or the resident representative were notified in writing of the bed-hold policy. During an interview with the Director of Nursing on 1/18/24 at 10:31 AM, she stated that she was unable to locate any documents that the resident and/or the resident representative were notified in writing of the bed hold policy. She stated that a form has now been developed to correct the issue. 2) On…

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

Based on medical record review and interview, it was determined that the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) was completed when it was determined that a resident would remain in the facility for long term care. This was found to be evident for 1 (Resident #63) out of 1 resident reviewed for PASRR during the survey. The findings include: On 1/18/24 review of Resident #63's medical record revealed the resident was originally admitted to the facility in June of 2022. The resident's diagnoses included, but were not limited to, Schizoaffective Disorder Bipolar type. The resident had a brief hospitalization in August 2023, after which s/he was re-admitted to the facility. The PASRR form includes four sections. Section A includes 3 questions: 1. Is the individual admitted to a NF [nursing facility] directly from a hospital after receiving acute inpatient care? 2. Does the individual require NF services for the condition for which he received care in the hospital? and 3. Has the attending physician certified before admission to the NF that 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 resident and staff interview, it was determined the facility failed to provide a resident and/or a resident's representative with a summary of the baseline care plan that included a summary of the resident's medications. This was evident for 2 (#54, #235) of 6 residents reviewed careplanning. The findings include: A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 1/24/24 at 10:20 AM, during an interview, the Director of Nurses (DON) stated that baseline care plans were developed for a resident upon the resident's admission to the facility, that the resident or resident representative was…

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

Based on interviews and pertinent document review, it was determined that the facility failed to provide incontinent care to a dependent resident. This was evident for 1 (#282) of 3 residents reviewed for pressure injury. The findings include: A review of medical records on 1/16/24 at 11:06 AM, revealed that Resident #282 was admitted to the facility for rehabilitation and was dependent on the facility staff for all activities of daily living. On 1/10/24 at 2:38 PM, during an interview with Resident #282's family member s/he reported that Resident #282 was not getting the incontinent care that s/he needed. S/he reported that s/he remembers that this occurred more frequently on holidays and weekends. On 1/24/24 at 11:28 AM, during an interview with nurse, RN, Staff #16 reported that s/he is familiar with Resident #282's daily care and that s/he consistently needs incontinent care twice a shift. On 1/16/24 at 11:00 AM, review of Resident # 282's medical records under Geriatric Nursing Assistant (GNA) tasks, failed to reveal documentation that Resident #282 received incontinent care on…

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

3) Review of Resident #183's medical record revealed the resident was originally admitted in February 2023 with a brief re-hospitalization in March 2023. The resident's diagnosis included, but was not limited to, multiple myeloma (blood cancer), Parkinson's disease, diabetes, heart disease and blindness. Review of the 3/11/23 hospital discharge report revealed one of the medications at the time of discharge was pomalidomide 4 MG take one capsule by mouth daily for 21 days followed by a 7 day rest period. Pomalidomide, also known as Pomalyst, is an anticancer medication used to treat multiple myeloma. Review of the Medication Administration Record (MAR) for March 2023 revealed there was an order to start Pomalidomide 4 mg one time a day for cancer until 4/1/23, take for for 21 days and rest 7 days. This medication was not administered on 3/12/23 and was discontinued on 3/13/23. Review of a 3/14/23 progress note, written by nurse, Staff #16, revealed the resident's responsible representative reported the oncologist (cancer physician) had started the resident on Pomalyst 4 mg, 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 interviews, it was determined that the facility failed to have an effective system in place to ensure that orders for eye doctor and audiology appointments were scheduled in a timely manner. This was found to be evident for 2 (Resident #68 and #59) of 5 residents reviewed for vision and hearing. The findings include: 1) Review of Resident #68's medical record revealed an admission date in 2022. The resident had diagnoses of, but not limited to, dementia, heart failure, hypothyroidism and high cholesterol. Review of a 12/1/23 nurse progress note revealed the resident had an ENT (ear, nose and throat) appointment for a hearing test which revealed bilateral mild to severe hearing loss. The nurse practitioner (NP) was made aware of recommendations with orders for inhouse audiology consult for hearing aide. A corresponding order, by NP, Staff #37, dated 12/1/23 for: Please schedule appt with In-house Audiologist for hearing aides. On 1/10/24, review of the medical record failed to reveal documentation to indicate this audiology appointment had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined that the facility 1) failed to ensure splints for the prevention of contracture development were re-implemented after a resident was re-admitted after a brief hospitalization, and 2) failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 2 (#63, #43) of 4 residents reviewed for position and mobility. The findings include: 1) Review of Resident #63's medical record revealed that the resident was originally admitted to the facility in June of 2022. The resident had a brief hospitalization in August 2023 after which s/he was re-admitted to the facility. On 01/09/24 at 12:03 PM, surveyor observed a sign on the wall near the head of the resident's bed about using a splint. Review of the 12/23/23 Minimum Data Set Assessment Section O 0500 Restorative Nursing revealed no splint or brace assistance was…

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

Based on pertinent document review and interviews, it was determined that the facility failed to accurately document and address a physician's recommendation for a resident to receive a urology consult. This was evident for 1 ( #38) of 1 resident reviewed for urinary catheter. The findings include: On 1/11/24 at 1:54 PM, a review of medical records revealed that the Resident #38 was admitted to the facility with a indwelling urinary catheter in place. On 01/12/24, a review of Resident #38'Ss hard chart revealed the resident had a physician consultation at a local hospital during his/her stay at the facility on 11/29/23. However, further review failed to reveal the facility obtained a written recommendation from the consultation. On 1/12/24 at 2:12 PM, during an interview, second floor unit manager Staff #23, RN, confirmed that the consulting physician written recommendations were not available in Resident #38's medical records. On 1/12/24 at 3:15 PM, review of a nursing progress notes revealed a note dated 11/29/23 which stated, Resident returned from his ORTHO appointment with 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 observation, record review, and interview, it was determined that the facility failed to maintain respiratory care equipment for a resident who required continuous oxygen via nasal cannula. This was evident for 1 (#85) out of 4 residents reviewed for respiratory care. The findings include: A prefilled humidifier with sterile water is used with oxygen concentrators to offer comfortable humidity and moisture to continuous flow oxygen therapy to prevent upper airway dryness. On 1/10/24 at 9:14 AM, an observation was made of Resident #85 receiving 3 Liters (L) of continuous oxygen via nasal cannula. The tubing or nasal cannula was neither initialed nor dated. Continued observation revealed an empty bottle of a prefilled humidifier with sterile water attached to Resident #85's oxygen concentrator, which was neither dated nor initialed. Resident #85 was interviewed at that time. During the interview, he/she said the night shift nurse had told him/her that there were no more prefilled humidifier water bottles. A subsequent observation was made on the same day at 10:55 AM by the…

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

Based on medical record review and staff interview, it was determined that a facility provider failed to make their visit notes available after a visit with a resident (resident #515). This was evident for 1 (#515) of 4 residents reviewed for provider visit note availability during a facility's revisit survey. Findings includes: Review of resident #515's medical records on 4/25/24 at 8:30am revealed resident #515 received a new order for Ativan (.5 mg (milligrams) 1 tablet daily) for Anxiety. Further review of resident #515's medical records on 4/25/24 at 9:00am revealed no evidence of a diagnosis of Anxiety in the resident's list of active diagnosis. An interview with the Director of Nursing (DON) on 4/25/24 at 12:58 pm, the surveyor pointed out that resident #515 received a new order for a medication for Anxiety on 4/23/24 but the medical record had no evidence that the resident was seen by the provider. The DON revealed the Certified Nurse Practitioner (CRNP) #5 saw the resident on 4/23/24. The DON also admitted that CRNP #5 failed to provide a provider note to the facility…

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, it was determined that the facility failed to ensure recommendations from the psychiatric provider was reported to the primary care provider and failed to ensure abnormal behaviors were reported to either the primary care provider or the psychiatric provider in a timely manner. This was found to be evident for 1(#106) of two residents reviewed for behavioral health services during the survey. The findings include: 1) Review of Resident #106's medical record revealed an admission date in April 2023 with diagnoses that included, but were not limited to, history of stroke, high blood pressure, diabetes, lung disease and dementia. On 1/9/24 at 1:39 PM the resident was observed in bed, the resident did not verbally respond to surveyor greeting. Further review of the medical record revealed an order dated 7/26/23 for a psychiatric consult. On 1/17/23 at 12:32 PM, the surveyor reviewed with the unit nurse manager, Staff #23, that there was an order for a psychiatric consult in July, but no documentation was found to indicate the…

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

Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to ensure orders for a topical anesthetic patch included the duration the patch should be applied, and 2) failing to implement physician orders for blood pressure and pulse parameters prior to administering a blood pressure medication. This was evident for 1 (#21) of 5 residents reviewed for unnecessary medications. The findings include: 1) A Lidocaine (local anesthetic) patch, when applied to the skin, helps reduce pain by causing a temporary loss of feeling in the area where the patch was applied. Depending on the Lidocaine patch product, the patch may be left on the skin for up to 8 or 12 hours. According to MedlinePlus a division of the National Institutes of Health (NIH), Lidocaine 4% patches can be applied up to 3 times daily and for no more than 8 hours per application. Applying too many patches or topical systems or leaving them on for too long may cause serious side effects. 1a) On 1/12/24 at 12:25 PM, a review…

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

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by administering psychotropic medications without adequate monitoring for behavior. This was evident for 2 (#54, #21) of 5 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are any drug that affects brain activities associated with mental process and behavior, and include, but not limited to anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. 1) On 1/18/24 at 12:00 PM, a review of Resident #54's medical record revealed the resident was admitted to the facility in August 2023 with diagnoses which included dementia, depression, mood disorder, and anxiety. Review of Resident #54's January 2024 MAR revealed that the resident received psychotropic medications, which included 2 antipsychotics, an antidepressant and an antianxiety medication. The MAR documented that Resident #54 recieved the following psychotropic medications: - Aripiprazole (Abilify)…

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 pertinent document review, the facility staff failed to ensure a medication error rate of less than 5 percent for 3 (#287, #292, #42) of 5 residents observed with 31 medication administration opportunities which resulted in a error rate of 9.6 percent. The findings include: 1} A medication administration observation of Resident #287 was made on 1/18/24 at 9:39 AM. Nurse, LPN, Staff #12, was observed administering Resident # 287 a Calcium + D 600mg/10mcg(400iu) tablets, with the instructions to chew the tablets. Resident attempted to chew the tablets and reported to the nurse they were not the chewable tablets and spit the medication out. On 1/18/24 at 9:40 AM, during a brief interview with Nurse, Staff #12, s/he reported that s/he was made aware by a nurse on the floor, that the Calcium + D 600mg/10mcg(400iu) tablets s/he provided Resident #287 was not a chewable medication. S/he reported that s/he will notify the physician to obtain the correct form of the medication. On 1/18/24 at 10:30 AM, review of Resident # 287s orders revealed an order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to maintain locked carts where medications were stored. This was evident for 3 carts out of 9 carts observed during the survey. The findings include: 1) On 1/09/24 at 8:31 AM, an observation was made of a unlocked treatment cart near the first floor [NAME] unit nurses' station. A second observation at 8:32 AM revealed that Nurse, RN, Staff #19 was cleaning the top of a medication cart down the hall from the treatment cart. The surveyor requested that Nurse, Staff #19, join her at the treatment cart. The surveyor opened several treatment carts doors in the presence of Nurse, Staff #19. Nurse, Staff #19 confirmed that the treatment cart was unlocked, and s/he immediately locked the cart. 2) On 1/10/23 at 7:44 AM, an observation on the first floor Clear Spring unit revealed that a treatment cart was not locked. The treatment cart was observed to remain unlocked until 7:52 AM and Staff #16, RN, who was working as the unit manager for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined that the facility failed to 1) have a physical barrier between the clean and soiled areas of the laundry room to prevent cross-contamination and 2) clean/replace a dirty nebulizer mask. This was evident for 2 out of 2 observations of the laundry room and 1 ( #65) of 2 residents observed for oxygen use. The findings include: A nebulizer is a small machine that turns liquid medicine into a mist to be inhaled through a mouthpiece or mask and enters the lungs directly. After use, the mask or mouthpiece is washed with mild soap, rinsed under running water, dried on a paper towel, and kept in a sealable plastic bag. 1) On 1/17/24 at 9:35 AM, during a tour of the facility's laundry rooms, an observation was made of an opening between the clean and soiled areas of the laundry room with no door or physical barrier while laundry was being processed. Continued observation showed uncovered soiled linens in bins on the dirty side of the laundry room;…

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

Based on review of facility documents and staff interview, it was determined the facility 1) failed to report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours of the allegation. This was evident for 2 (#235, #383) of 21 residents reviewed for abuse. The findings include: 1) On 1/10/24 at 10:11 AM, during an interview, Resident #235 reported that last night, during the night shift, s/he was belitted by a geriatric nursing assistant (GNA) who accused the resident of messing in his/her diaper on purpose. Resident #235 reported that the GNA slammed him/her around, almost pushing the resident off of the bed. On 1/10/24 at 11:17 AM, following Resident #235's interview, the surveyor reported the resident's allegation of abuse to the Nursing Home Administrator (NHA). In response, the NHA indicated that they would talk to the resident and investigate the allegations. The facility's self reported incident MD00201461 which documented the facility's investigation of Resident #235's abuse allegation was provided to the…

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

Based on review of facility investigation documentation, medical records and interviews, it was determined the facility failed to ensure that abuse allegations were thoroughly investigated. This was found to be evident for 2 (Resident #3, #34) of 21 residents reviewed for abuse. The findings include: 1) Review of Resident #3's medical record revealed that the resident was admitted to the facility in June 2023. Review of facility self report MD00194762 revealed that during a meeting with the resident and resident's family member in July 2023 there was a report that the night nurse had squeezed the residents hand. On 1/30/24, review of the facility investigation documentation failed to reveal interviews with potential witnesses other than the resident and nurse involved. There was no documentation of an interview with the geriatric nursing assistant assigned to the resident at the time of the alleged event and no documentation if the resident had a roommate or not. On 1/30/24 at 12:03 PM, surveyor reviewed this concern with the Director of Nursing (DON) and the Nursing Home…

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, the physician failed to show evidence of admission assessment for 4 Residents. This is evident for 4 of 6 resident's (Resident #46, #59, #66 and #82) reviewed during the annual survey for physician services. The findings include: 1a. On 3-27-19 review of Resident #66's medical record did not show evidence that upon admission the physician reviewed the hospital discharge summary and completed an initial H&P. The DON confirmed on 3-27-19 at 12:30 PM that Resident # 66's medical record did not include a completed H&P. 1b. On 3-28-19 review of Resident #46's medical record did not show evidence that upon admission the physician reviewed the hospital discharge summary or completed an initial history and physical (H&P). The Director of Nursing (DON) confirmed on 3-28-19 at 10:00 AM Resident #46's medical record did not include a completed H&P. 1c. On 3-28-19 review of Resident #59's medical record did not show evidence that upon admission the physician reviewed the hospital discharge summary and completed an initial H&P. The DON confirmed on…

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

Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for a resident. This was evident for 1 of 1 resident (Resident #59) reviewed for accurate medical records. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Resident #59 was admitted in 2018 with Alzheimer's disease, a progressive form of dementia. Resident #59 has deteriorated and does not know where they are, the day/month/year, and unable to answer questions appropriately. An interview with Resident #59 on 3-28-19 at 11:30 AM revealed the resident was not oriented to his/her name, where he/she was, or the day or year. Unit Manager #6 confirmed on 3-28-19 at 12:00 PM that Resident #59 is not oriented to person, place, or time. On 8-13-18 Physician #11 documented that Resident…

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

Based on resident interview, staff interview, and observation, it was determined that the facility failed to ensure a resident received meal services at a time that would allow full participation in dialysis treatment. This was true for 1 out of 2 residents (Resident #145) reviewed for dialysis. The findings are: This surveyor interviewed Resident #145 on 3/25/19 at 1:52PM. The resident stated that dialysis treatments have been shortened three times since admission because lunch comes late. This Surveyor observed on 3/26/19 at 11:24 AM the resident eating a tuna salad sandwich and drinking water. Resident #145 said he/she had not received the lunch tray that was supposed to come up at 11:00 AM. The resident requested that a sandwich be sent up in the meantime. A tray arrived at 11:27 AM. The resident was interviewed on 3/28/19 at 11:28 AM. Resident was eating a sandwich. The resident said food was brought up by a nurse at 11:20 AM. Resident also said Dietary sent up 2 hard boiled eggs even though hardboiled eggs were on the resident's dislike list. The Administrator was interviewed…

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 the facility staff failed to notify the physician the results of a potentially toxic Keppra blood level in a timely manner for a resident. This was evident for 1 of 56 residents (Resident #254) selected for review during the survey process. The findings include: The facility staff failed to notify the physician of a high Keppra level of 59.8 mcg/mL in a timely manner as ordered by the physician on 3/28/19. Keppra is used with other medications to treat seizures (epilepsy). Keppra blood levels of 12.0 - 46.0 mcg/mL (mg/L) are within the normal range. Levels above 46 mcg/mL are considered potentially toxic. Medical record review for Resident #254 revealed on 3/28/19 the physician ordered: Keppra level one time only until 03/28/2019 at 23:59. Further record review revealed the facility staff obtained the Keppra level results of 59.8 mcg/mL on 3/29/19 at 1:22 AM. Further review of the resident's clinical records revealed that the resident Medication Administration Record (MAR) revealed that the Resident's received a Keppra…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, staff interview and resident interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 2 of 4 resident units. The findings include: On 3/25/2019 during an initial tour of the facility the following observations were made: 1. At 9:08 AM two holes were observed in the wall of room [ROOM NUMBER] beside the heating/cooling unit. 2. At 9:20 AM in room [ROOM NUMBER], Resident #99's mattress motor was on the floor rather than mounted to the footboard of the bed. It was observed that the motor would impede the bathroom door from being fully opened if mounted on the end of the resident's bed. 3. At 9:51 AM during resident interview, Resident #82 mentioned that the doors in the hallway were opened and closed loudly in the morning. During a Resident Council meeting on 3/28/2019 at 10:30 AM, members of the Resident Council also commented on the slamming 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed in a timely fashion. This was true for 1 out of the 56 residents (Resident #145) selected for review. The findings are: A review of Resident #145's PASARR revealed that only Section A. Exempted Hospital Discharge was completed. At the bottom of the section it reads: If the stay extends for 30 days or more, a new screen and resident review must be performed within 40 days of admission. The form was signed on 2/4/19. The resident had been in the facility for over 40 days. The Director of Nursing (DON) was interviewed on 3/29/19 at 10:17 AM. The DON was shown the PASARR with only Section A completed. She requested that the social worker be consulted to review the PASARR. This surveyor interviewed the DON and the Social Worker (Staff #3). Staff #3 handed me a completed PASARR and confirmed that it had been greater than 40 days since the resident's admission. She said the delay in completing the PASARR was…

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

Based on medical record review and interview, it was determined the facility staff failed to initiate, provide and implement comprehensive care plans for residents. This was evident for 2 of 56 residents (Residents #70 and #93) selected for review of care plans during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. At the time of each MDS assessment, the expectation of the facility staff is 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 medical record review and interview, it was determined the facility staff failed to thoroughly review dental recommendations for Resident #23 and act upon those recommendations. This was evident for 1 of 56 residents selected for dental review. The findings include: Medical record review revealed Resident #23 was seen by the dentist on 10/2/18. At that time, the dentist assessed the resident and determined Resident #23 had poor teeth condition and heavy plaque buildup. Tartar/plaque is a yellow or brown colored deposit that forms when plaque hardens on your teeth. Tartar forms below and above the gum line. It is rough and porous and can lead to receding gums and gum disease. At that time, the dentist stated Resident #23 would benefit from Peridex and consult with physician. Peridex is a medication used along with regular tooth brushing/flossing to treat gingivitis, a gum disease that causes red, swollen, and easily bleeding gums. Peridex oral rinse is used to treat gingivitis, to help reduce the redness and swelling of the gums, and to help control any gum bleeding. Further…

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, medical record review and interview it was determined the facility staff failed to aid with meals for Residents #26 and #29 and failed to provide thorough grooming and personal hygiene services for Resident #68. This is evident for 3 of 3 residents selected for review for ADL care during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. 1. The facility staff failed to aid with a meal for Resident…

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

Based on clinical record review, facility incident report review, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was free from an accident or hazard. This was true for 3 out of 5 residents (Resident #256, #16 and #78) reviewed for a complaint. The findings are: 1. A review of the facility incident report revealed that on 1/1/19 at 2:20 PM the nurse (Staff #5) went into Resident #256's room and provided treatment to a sacral wound. The resident fell to the floor at 2:45 PM. The resident was assessed for pain and injury. Resident #256 did not complain of pain and the nurse observed no injury. The resident was assisted back to bed. The resident was sent to the hospital on 1/1/19 at 5:09 PM. The primary physician was called at 5:12 PM. Staff #4 was interviewed on 3/27/19 at 9:05 AM. He stated he was washing the resident after wound care. He turned the resident to him so he could wash the resident's back. The nurse (Staff #5) went to the bathroom to wash her hands. Staff #4 stated that normally the nurse would not be the one…

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

Based on medical record review, observation and interview, it was determined the facility staff the failed to provide Resident #35 with the physician ordered diet. This was evident for 1 of 10 residents selected for review of nutrition and during the annual survey process. The findings include: 1a. The facility staff failed to provide Resident #35 with the physician ordered diet. Surveyor observation of Resident #35's lunch meal ticket revealed the resident was to have: double portions of meat. Surveyor observation of the resident's lunch on 3/25/19 at 1:00 PM revealed the resident was only served 1 piece of chicken and double portions of cauliflower and spaghetti. The registered dietician was made aware at that time. Subsequent observations of Resident #35's meals revealed the facility staff served the resident double meat portion. Interview with the Director of Nursing on 3/29/19 at 1:30 PM confirmed the facility staff failed to provide Resident #35 with the physician ordered diet. 1b. The facility staff failed to ensure Resident #35 was provided the physician ordered diet.…

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 a review of the clinical records and staff interview it was determined that the facility staff failed to document the administration of pain medication and monitor the effectiveness. This was true for 1 out of the 6 residents (Resident #255) reviewed for pain management during an annual recertification survey. The findings include: 1. A review of Resident #255's clinical record revealed that the resident's primary physician ordered oxycodone 5 mg every six hours as needed for pain. Oxycodone is a strong narcotic pain-reliever. A review of the March Control Medication Utilization Record revealed oxycodone 5 mg on the following days and times were removed from the controlled lock box on 3/27/19 at 6:25 PM and 3/28/19 at 10 PM. Further review of the resident's clinical records revealed that the resident March Medication Administration Record (MAR) revealed that the oxycodone medication on 3/27/19 at 6:25 PM and 3/28/19 at 10 PM, was not documented as given to the Resident. The facility staff failed to administered pain medication as ordered by the physician. Interview with 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 upon staff interview and medical record review it was determined the facility staff failed to assist a resident in obtaining routine dental care and failed to ensure the recommendations of the dentist were carried out. This was evident for 1 of 3 residents (Resident #29) selected for review of dental services during the annual survey. The findings include: 1a. The facility staff failed to thoroughly follow-up with the recommendations of the consultant dentist. Medical record review for Resident #29 revealed the resident was seen by the dentist on 7/18/18. At that time, the dentist documented the resident was assessed and documented: resident has plaque and calculus. Resident is thriving but is concerned about the condition of his/her teeth. Tooth #9 is broken to the gum along with several others. Resident stated that she/he occasionally has a hard time eating certain foods because of the broken and missing teeth that has created spaces. The Dentist recommended: the extraction of tooth #9 and the possible restoration of the tooth #14. After all the teeth that need to be removed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review it was determined that the facility failed to maintain kitchen equipment in safe operating condition. The findings include: On 3/25/2019 at 8:00 AM during an initial tour of the facility's kitchen the following observations were made: 1. The walk-in freezer door was observed slightly ajar and incapable of closing properly as designed. 2. A metal panel on the right side of the dishwasher was observed [NAME] out from the machine itself, potentially exposing the inside wiring to splashes and debris. 3. The drain pipe for the dishwasher was not adequately air gapped to prevent backflow in the event of a sewage back up. These findings were acknowledged by the Food Service Manager during a kitchen walk-through on 3/27/2019.