Berlin Nursing And Rehabilitation Center

Based on observation, record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met in accordance with the residents' plan of care. This was evident in 1 (Resident# 69) of 1 resident reviewed for Activities of Daily Living (ADL).The findings include: Resident # 69 was admitted to the facility in February 2024 with Diagnoses which included Atherosclerotic Heart Disease, Dementia and End Stage Renal Disease. On 07/15/2025 at 10:25 AM and on 07/18/25 at 7:40 AM the surveyor observed Resident #69 lying in bed with unshaven facial hair. On 07/20/25 at 06:30 PM the surveyor again observed the resident with unshaven facial hair approximately I/8 inch long sitting in a wheelchair in his/her room. During an interview on 07/20/2025 at 06:30 PM the Resident #69 stated I need assistance with shaving because I cannot do it myselfOn 07/17/25 at 08:55 AM a review of Resident 69's clinical record revealed a care plan initiated on 08/06/24 which stated Resident #69 had limited ability to maintain grooming/personal hygiene. 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 interview, it was determined that the facility failed to 1) obtain an order for the use of a splint and 2) properly assess and address the resident's condition prior to hospital transfer. This was evident for 2 (Resident #44 and #96) of 2 resident reviewed for position and mobility and 1 resident reviewed for hospitalization during the recertification survey.The findings include:1) According to the Mayo Clinic, a contracture is a condition where muscles, tendons ligaments, or skin tighten, restricting the normal movement of the body part. This can lead to a joint being stuck in a bent or flexed position.A splint is a device that supports or immobilizes a joint to prevent or correct the tightening and shortening of soft tissues (like muscles, tendons and ligaments) that restricts movements.On 7/15/2025 at 9:50 AM, during the initial facility tour, Resident #44 was observed in bed with contractures of the left elbow, left hand and right hand and was not wearing any splints…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews it was determined that the facility failed to ensure a Resident received audiology services. This was found to be evident for 1 (Resident #74) out of 1 Resident reviewed for treatment to maintain hearing during the annual recertification survey. The findings include: During an observation and interviews conducted on 07/15/2025 at 2:19 PM, it was discovered Resident # 74 was hard of hearing. When this Surveyor asked Resident #74 a question the Resident responded, you must use the whiteboard on the table because I cannot hear. When asked if the Resident had hearing aids by writing my question on the whiteboard, Resident #74 read the question and responded no. When asked if he/she had seen an Audiologist for the loss of hearing via the whiteboard, the Resident responded no, not since he/she had been at the facility. A review of Resident #74's medical records was conducted on 07/18/2025 at 6:16 AM. The medical records revealed a diagnosis for Unspecified Hearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews it was determined that the facility failed to ensure Residents received proper dialysis care. This was found to be evident for 2 (Resident #6 & #69) out of 2 Residents observed for dialysis care during the recertification survey. The findings include: 1) Hemodialysis is a treatment that filters waste and excess fluid from the blood when kidneys are not functioning properly. During an interview with Resident #6 on 7/15/25 at 3:09 PM it was discovered that the Resident has dialysis three times a week. During a review of the Treatment Administration Record (TAR) for Resident #6 on 07/21/2025 at 8:25 AM it was discovered that the Resident had several orders pertaining to dialysis care and monitoring. There was an order for “Dialysis three times per week”, “Once a Day on Monday, Wednesday, Friday.” Dialysis visits for July included 7/02/25, 7/04/25, 7/07/25, 7/09/25, 7/11/25, 7/14/25, 7/16/25, 7/18/25 and 7/21/25. There was an order for “Dialysis Communication Sheet Returned…

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 Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months for 1 (Staff#21) of 5 staff members reviewed. The findings included:Performance reviews are to be completed at least every 12 months to identify what in-service education the geriatric nursing assistants need to address their competencies. On 07/16/25 at 2:30 PM the surveyor conducted a review of 5 Geriatric Nursing Assistants' personnel files. The records revealed that the facility failed to conduct a performance review for the calendar year 2023 for Staff #21 who had been employed by the facility for over 8 years.During an interview with the surveyor on 07/17/25 at 8:34 AM, the Director of Nursing (DON) stated that annual performance reviews for geriatric nursing assistants were conducted annually in keeping with the facility's policy. The DON reviewed the records and confirmed the surveyor's findings.

Based on staff interview and surveyor record review it was determined that the facility failed to act on recommendations from pharmacist drug regimen review reports. This finding was found to be evident in 1 (Resident #12) out of 1 Resident reviewed for unnecessary medication.The findings include:A pharmacist drug regimen review (DRR), also known as a medication regimen review (MRR), is a comprehensive evaluation of all medications a Resident is currently using. This includes prescribed medications, over the counter drugs, herbal products, dietary supplements, and even total parenteral ((intravenous) nutrition and oxygen therapy. The primary purpose of a DRR is to promote positive outcomes and minimize adverse consequences associated with medication use. A pain scale is a tool used to measure and describe the intensity of pain, which is a subjective experience. The pain scale helps individuals communicate their pain levels to healthcare professionals and can be used to track pain over time.The surveyor conducted a record review of Resident #12's electronic medical record 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 surveyor observation and facility staff interview it was determined that the facility failed to 1) label/store drugs and biologicals appropriately and 2) properly secure medications. This finding was found to be evident during the review of medication administration and storage during the annual recertification survey.The findings include: 1) A Certified Medication Aide (CMA) is a healthcare professional who has completed additional training to administer medications in specific settings. They are responsible for ensuring Residents receive the correct medications at the right time and dosage, while also documenting the administration and reporting any adverse reactions or changes in Resident condition. CMAs complete a state-approved training program which included classroom instruction and practical experience in medication administration. After completing the training, CMAs must pass a certification exam. Senna Plus (sennosides-docusate sodium) is in the drug classification of a laxative. The…

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

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure policies and procedures were followed to reduce the risk of infection. This was evident for 2 (Resident #6, #2) out of 4 residents reviewed for infection control procedures. The findings include: A dialysis catheter in the chest is a type of access used for hemodialysis, a treatment that filters waste and excess fluid from the blood when kidneys are not functioning properly. The catheter, a flexible tube, is inserted into a large vein in the neck or chest and is used to connect the patient's blood to the dialysis machine. The dialysis catheter is also known as a Central Line or a Central Venous Catheter. During an interview with Resident #6 on 7/15/25 at 9:43 AM he/she reported having wounds and a lot of problems with his/her right foot. He/she also stated it is infected to a degree. I'm supposedly on an antibiotic. Resident #6 also reported having a catheter in his/her right chest for dialysis. During an observation of the entryway to the room for Resident #6 on 7/15/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's records and interview, it was determined that the facility failed to ensure Residents were free from abuse. This was found to be evident for 2 (Resident #108 & #7) out of 4 Residents reviewed for abuse during the re-certification survey.The findings include: 1) A review of the Facility’s Reported Incident (FRI) #348430 was conducted on 07/17/25 at 11:48 AM. The FRI’s investigation stated that the Resident reported that Geriatric Nursing Assistant (GNA) # 6 pushed him/her by the back of the neck, shoved him/her onto the bed and injured the Resident’s arm. The facility investigated the complaint, suspended GNA #7 on 09/13/24 (the day of the incident) pending the investigation and then terminated her for the allegation of abuse on 09/19/24. During an interview conducted on 07/17/25 at 12:09 PM, the Staff Educator /Infection Control Preventionist stated during the time of the incident she was the acting Director of Nursing (DON) and had conducted the investigation. She advised 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, medical record review and review of facility documents, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This has the potential to affect all the residents in the facility. The findings include: 1) On 9/19/23 at 9:00 AM Staff #26 stated to Staff #25 there is no way she can bathe 20 residents. Review of the staffing board on Unit 1 at that time revealed there were 38 residents with 2 geriatric nursing assistants (GNAs). 2) On 9/20/23 at 7:00 AM tour of the dementia unit with 28 residents revealed one nurse (Staff #29) on the unit and one geriatric nursing assistant (Staff #34) standing at the locked door with her coat on and belongings in hand. Staff #29 was asked if there were any other staff on the unit at that time and they stated no. 3) On 9/21/23 at 11:55 AM on the dementia unit a resident was observed at the nurse's station trying to stand up, Staff #27 was standing next to the resident trying to prevent the…

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

Based on interview, observation and record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by failing to 1) ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and 2) failing to prevent elopement from the facility by recognizing, analyzing and developing a plan to ensuring all staff are educated on appropriate supervision of a resident and prevent future elopement. The findings include: 1) During interview with the Director of Nursing (DON) on 9/26/23 at 12:30 PM, the DON stated the Assistant Director of Nursing (ADON) is in charge of nursing staff education. The DON stated at that time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility records and interview with staff, it was determined the facility failed to conduct and document an accurate facility-wide assessment. This was evident during the review of the Staff training, education and competencies, staffing and all-hazard assessment during the complaint and the extended survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was provided to the Survey team by the Administrator on 9/25/23. The assessment had a review date of 1/30/23. The Facility Assessment listed the persons involved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and an injury of unknown origin within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 9 (#44, #16, #28, #43, #42, #34, #22, #26, #9) of 43 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 9/14/23 at 12:30 PM a review of facility reported incident MD00196345 revealed on 8/26/23, during routine trach care, the respiratory therapist noticed a wound under the trach collar to the back of Resident #44's neck. The wound/injury of unknown origin was not reported to OHCQ until 8/30/23 at 3:32 PM which was not within 24 hours of finding the injury. On 9/15/23 at 7:30 AM the Director of Nursing (DON) was interviewed about the timely reporting. The DON stated she did not have any further information and confirmed it was not reported within 24 hours. 2) On 9/15/23 at 10:57 AM a review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 6 (#38, #40, #41, #23, #33, #45) of 48 residents reviewed during a complaint survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 9/14/23 at 8:13 PM a review of Resident #38's medical record revealed Resident #38 was admitted to the facility in June 2023 with diagnoses that included Alzheimer's Disease and adult failure to thrive. Resident #38 required total care. There was no baseline 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and observation, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 6 (#38, #37, #28, #39, #23, #45) of 48 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying 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 medical record review and interview, it was determined the facility staff failed to ensure the physician wrote, dated, and signed progress notes at each resident's visit. This was evident for 7 (#38, #42, #31, #32, #39, #41, #23) of 48 residents reviewed during a complaint survey. The findings include: 1) On 9/14/23 at 8:13 PM a review of Resident #38's medical record revealed a physician's history and physical dated 6/12/23 that was not signed and uploaded into the medical record until 6/23/23. Further review revealed physician visits dated 6/19/23, 6/26/23, and 7/3/23 that were not signed and uploaded into the medical record until 7/18/23. Physician visits dated 7/10/23, 7/17/23, 7/24/23, 7/31/23, and 8/14/23 were not signed and uploaded to the medical record until 8/23/23. On 9/25/23 at 12:54 PM an interview of the DON regarding physician's visits. The DON acknowledged that the visits were not put in the medical record timely and stated, when I get the visits, I upload them in the computer. 2) On 9/15/23 at 12:52 PM a review of facility reported incident MD00196023…

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 Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 5 out of 5 personnel files (GNA #9, #35, #40, #41 and #42) reviewed during a complaint survey. The findings include: The outcome of performance reviews are used to provide regular in-service education to GNAs. A review was conducted of GNA personnel files on 9/25/23: 1. A review of GNA #9's personnel file revealed GNA #9 was hired on 9/2/2008 with a last performance review on 4/13/2020. 2. A review of GNA #35's personnel file revealed GNA #35 was hired on 4/22/1991 with a last performance review of 4/15/2021. 3. A review of GNA #40's personnel file revealed GNA #40 was hired on 7/2/2009 with a last performance review of 7/2/2021. 4. A review of GNA #41's personnel file revealed GNA #41 was hired on 4/23/1988 with a last performance review on 4/5/2021. 5. A review of GNA #42's personnel file revealed GNA #42 was hired on 11/11/1992 and did not have a performance review. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#37, #41, #39, #1) of 48 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of 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 9/14/23 at 8:46 PM a review of facility reported incident MD00193528 revealed Resident #37 was asked to roll over in bed during care and the resident rolled too fast and fell off the side of the bed. Review of September 2023 physician's orders documented the order, floor mats to side of bed for patient safety. Review of Resident #37's Treatment Administration Record (TAR) documented the order and there were places 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 review of a complaint, observation of resident rooms, and interviews, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. This was evident on 2 of 3 nursing units observed. The findings include: On 9/18/23 at 11:59 AM a review of complaint MD00194719 for Resident #40 was reviewed and alleged the resident was in a room with two other people, using the same bathing tools and basin. The complainant alleged the geriatric nursing assistant (GNA) left a basin for Resident #40 to use for bathing and noticed the basin was not Resident #40's, it was the roommates. The complaint alleged that despite labeling Resident #40's basin, the GNA did the same thing the next day. On 9/18/23 at 3:54 PM a tour was taken of the facility. The following observations were made: In room [ROOM NUMBER], the room Resident #40 was in, there were 2 gray basins, one on each side of the sink bowl that were not labeled.…

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

Based on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous flies seen throughout the facility. This was evident on 2 of 3 nursing units observed during a complaint survey. The findings include: On 9/21/23 at 4:07 PM observation was made of Geriatric Nursing Assistant (GNA) #30 washing Resident #49. The surveyor walked over to Resident #49 and observed him/her lying in bed on a urine soaked sheet. The surveyor observed a fly crawling on Resident #49's face by the resident's mouth. The surveyor pointed that out to GNA #30 who stated, isn't that disgusting. GNA #30 then swatted at the fly. On 9/22/23 at 7:56 AM observation was made of Resident #37 lying in bed on his/her left side. Resident #37 was sleeping. Observation was made of a fly on Resident #37's forehead. Also observed was a green fly swatter sitting on the resident's dresser. Resident #37's roommate was awake at the time and stated, the flies are bad when food is out. Resident #37 had a yellow fly swatter that 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 facility documentation review and interview, it was determined the facility failed to develop, implement and maintain an effective training program for all new and existing staff. This has the potential to affect all residents in the facility. The findings include: During interview with the Director of Nursing (DON) on 9/26/23 at 12:30 PM, the DON stated the Assistant Director of Nursing (ADON) is in charge of nursing staff education. The DON stated at that time the facility has not held any yearly in person competencies for the nursing staff but does use an online education system. During interview with the ADON on 9/26/23 at 12:45 PM, the ADON states the facility uses an online education system but she doesn't have access to track the nursing staff's education only Human Resources does. The ADON states doesn't keep record of the nursing staff's yearly education and the facility hasn't held any yearly in person competencies for the nursing staff. During interview with Human Resources (HR) on 9/26/23 at 1:00 PM, HR stated she began working at the facility in March 2023 but…

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 a review of a complaint and facility reported incident, medical record review, and interview, it was determined the facility staff failed to notify the physician in a timely manner for a resident's acquisition of pressure ulcers, a change in condition, and abnormal vital signs. This was evident for 3 (#39, #41, #13) of 48 residents reviewed during a complaint survey. The findings include: 1) On 9/18/23 at 10:30 AM a review of complaint MD00194233 revealed an allegation that Resident #39 obtained a stage 4 pressure sore on the buttocks while in the facility. On 9/18/23 Resident #39's medical record was reviewed and revealed a 6/12/23 at 4:51 PM wound assessment that documented a Stage III pressure ulcer was discovered and it documented, present on admission. The pressure ulcer was 1.7 cm (centimeters) in length, 1.5 cm in width and 0.5 cm in depth. The note was documented by the Assistant Director of Nursing (ADON). On 6/19/23 at 3:37 PM the ADON documented the pressure ulcer was larger and the wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, observation of resident rooms and equipment, and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 1 of 3 nursing units observed. The findings include: On 9/18/23 at 11:59 AM a review of complaint MD00194719 for Resident #40 was reviewed and alleged the facility did not have safe equipment for transfers and the facility was dirty and in disrepair. The complainant alleged Resident #40, who was admitted for rehabilitation following hip surgery, was placed in a room without grab bars on both sides of the toilet and that the bathroom sink was in deplorable condition. On 9/18/23 at 3:54 PM a tour was taken of the facility. The following observations were made: In room [ROOM NUMBER], the room Resident #40 was in, there was a small chip on the front side of the sink in the bathroom. There were 3 grab bars in which 1 grab bar appeared newly…

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 reported incidents, record review and interview with facility staff, it was determined that the facility failed to provide the residents with an environment that was free of misappropriation of property. This was evident for 1 (#29) of 48 residents reviewed during a complaint survey. The findings include: On 9/15/23 at 9:31 AM a review of facility reported incident MD00186992 and MD00187053 revealed Resident #29's spouse reported to staff on 12/21/22 that Resident #29 was missing a small red tablet that was brought into the facility on Thanksgiving Day in 2022 by the spouse and the resident's daughter. It was documented that staff called the daughter who confirmed she brought the tablet in on Thanksgiving Day from the community home where Resident #29 had resided, and there were games downloaded on the tablet. The facility's investigation documented that Resident #29 was interviewed and had last seen the tablet 2 days prior on the dresser, plugged into the charger. A staff interview that was included in the investigative packet provided to the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse and neglect. This was evident for 3 (#34, #23, #1) of 48 residents reviewed during a complaint survey. The findings include: 1) On 9/19/23 at 8:49 PM a review of facility reported incident MD00193218 revealed the family member of Resident #34 alleged that Resident #34 stated that another resident grabbed the resident's left arm and tried to pull the resident into the shower room. Review of the facility's investigation revealed the family member reported the incident to staff on Sunday, 6/4/23. Further review of the facility's investigation revealed 2 geriatric nursing assistants (GNAS) and 1 Licensed Practical Nurse (LPN) were interviewed about the alleged incident. Review of the 6/2/23 and 6/3/23 actual worked nursing scheduled revealed there was 1 other LPN and 4 other GNAs that worked during that time that were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, it was determined the facility staff failed to accurately revise a resident's care plan for wandering (Resident #7). This was evident for 1 of 5 residents reviewed during a complaint survey. The findings include: Review of Resident #7's medical record on 9/19/23 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation with the plan for the Resident to return home. Further review of the Resident's record revealed a care plan entitled: Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) and has a wanderguard on. The care plan had a last revision date of 8/24/23. A Wanderguard is used when a resident is at risk of wandering, a monitoring device such as a Wanderguard bracelet may be used to help ensure safety. Observation of Resident #7 on 9/19/23 at 9:00 AM revealed the Resident does not have a wanderguard in place. During interview of the Resident at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to perform activities of daily living for a dependent resident (Resident #12). This was evident for 1 of 3 residents reviewed during a complaint survey. The findings include: Observation of Resident #12 on 9/21/23 at 12:00 PM revealed the Resident to be unshaven. During interview of the Resident at that time, the Resident was asked if he/she wanted to be shaved and showered. The Resident stated sure. Review of Resident #12's medical record on 9/21/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Review of the Resident #12's MDS (Minimum Date Set) Assessment conducted on 8/25/23 revealed the facility staff coded the Resident in Section G0120 Bathing as total dependence. Further review of the Resident's medical record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to follow the hospital discharge summary and obtain blood work when ordered and apply an ice pack as ordered to a resident's surgical site. This was evident for 2 (#39, #45) of 48 residents reviewed during a complaint survey. The findings include: 1) On 9/18/23 at 10:30 AM a review of Resident #39's medical record revealed a 6/7/23 at 11:25 AM nursing note that documented the emergency room was called to give report on Resident #39. The Nurse Practitioner wanted the resident sent out to the hospital to receive a blood transfusion. Review of the hospital Discharge summary dated [DATE] documented, Problem 1: hemoglobin 6.5 and patient found to be light brown heme-positive (blood positive) stool. The summary continued, admitting diagnosis to hospital on 6/7/23 was hypokalemia, anemia, and GI bleed. The summary documented Resident #39 had chronic anemia. According to the National Institute of Health (NIH) anemia is a condition…

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 a complaint, a closed medical record, and staff interviews, it was determined that the facility staff failed to timely obtain pain medication and failed to perform pain assessments for a newly admitted resident after having surgery. This was evident for 1 (#40) of 48 residents reviewed during a complaint survey. The findings include: On 9/18/23 at 11:59 AM a review of complaint MD00194719 revealed an allegation that pain medication was not available for Resident #40 upon admission to the facility and that the resident was not assessed for pain while in the facility. On 9/18/23 at 11:59 AM a review of Resident #40's medical record revealed a 7/13/23 at 2:05 PM nursing note that documented Resident #40 was admitted to the facility from an acute care facility where Resident #40 underwent surgery for a fractured right hip with trochanter repair following a fall. The note documented that Resident #40 received Percocet for pain per the hospital. Review of the 7/13/23 hospital discharge summary documented that Resident #40 was to have Oxycodone-acetaminophen (Endocet)…

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 complaint MD00194719, medical record review, and interviews, it was determined the facility failed to ensure that pain medications were available to a resident upon admission to the facility. This was evident for 1 (#40) of 6 residents reviewed for a complaint during a complaint survey. The findings include: 1) A review of complaint MD00194719 on 9/18/23 at 11:59 AM revealed an allegation that Resident #40's pain medications were not given timely and were not available upon admission. On 9/18/23 at 11:59 AM a review of Resident #40's medical record revealed a 7/13/23 at 2:05 PM nursing note that documented Resident #40 was admitted to the facility from an acute care facility where Resident #40 underwent surgery for a fractured right hip with trochanter repair following a fall. The note documented that Resident #40 received Percocet for pain per the hospital. Review of the 7/13/23 hospital discharge summary documented that Resident #40 was to have Oxycodone-acetaminophen (Endocet) 5-325 mg. 1 tablet by mouth every 4 to 6 hrs. prn (when necessary) for moderate pain…

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

Based on observation, staff interview, and documentation review it was determined that facility staff failed to keep medication and treatment carts locked when unattended. This was evident on 1 of 4 nursing units observed during random observations made during a complaint survey. The findings include: On 9/18/23 at 4:30 PM observation was made on the dementia unit of a treatment cart and a medication cart sitting in the hallway near the shower room that was unlocked and unattended. The surveyor opened the top drawer of the treatment cart and observed prescription ointments. The surveyor then opened the top drawer of the medication cart and observed 2 insulin pens, a pair of scissors, eye drops, and other miscellaneous items. The remaining drawers were opened and contained resident medications. The surveyor stood at the carts for 4 minutes until Licensed Practical Nurse (LPN) #4 looked up and the surveyor asked her if she realized that she left the carts unlocked. She said, oh. LPN #4 sat at the nurse's station until the surveyor informed LPN #4 that there was a resident walking in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to notify the physician with the laboratory results of a CBC (complete blood count) that were outside of clinical reference ranges. This was evident for 1 (#39) of 6 residents reviewed for a complaint during a complaint survey. The findings include: On 9/18/23 at 10:30 AM a review of Resident #39's medical record revealed a hospital Discharge summary dated [DATE] that had discharge instructions for the facility to obtain a CBC (complete blood count) in 3 days which would have been on Monday, 6/12/23. Review of the medical record revealed the facility did not get the blood draw until 6/14/23. The result was a hemoglobin of 8.6 with a hematocrit of 26.8. Review of the lab orders in Resident #39's medical record documented that the Director of Nursing (DON) had created the order in the medical record on 6/10/23 and had put them in to be done on 6/14/23. Further review of the medical record failed to produce documentation 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 residents or resident's representatives were notified in writing of reason residents are being transferred out of the facility to an acute care hospital. This was found to be evident for 4 out of 4 residents records reviewed for hospitalization involving Resident's (R#72), (R#74), (R#284) and (R#287) reviewed during the investigative portion of the survey process. The finding includes: 1). On 06/01/22 at 9:30 AM closed medical record review involving R#72 revealed resident was transferred out of facility to acute care hospital for unplanned change in condition with transfer note written on 8/24/19 and 01/05/22 for further medical evaluation. Resident returned to the facility after each hospital course. 2). On 06/06/22 at 4:00 PM reviewed intake MD00151033 revealed a concern that resident #284 was transferred to acute care hospital for a change of physical condition on 01/26/20 from facility for medical evaluation after experiencing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interviews it was determined that the facility failed to revise and update care plan that addressed residents after change in condition (Resident #72, #284, #74, #6 and #48). This was evident 5 out of 31 residents reviewed during an annual survey. The finding includes: The 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. Medical record review revealed residents (R#72), (R#74) and (R#284) was admitted to the facility with diagnosis which included but not limited to chronic respiratory failure, cerebral infarction, dementia and other chronic health condition which requires ongoing medical monitoring and treatment. 1). On 06/01/22 at 9:30 AM closed medical record review involving R#72 revealed resident was transferred out of facility to acute care hospital for unplanned change in condition with transfer note written on 01/05/22 for further medical evaluation.…

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, the facility staff failed to ensure residents receive treatment and services in accordance with professional standards of practice (Resident #26, #48, #443, #22, #70, #9 and #389). This was evident for 7 out of 71 residents reviewed during an annual survey. The findings include: 1. The facility staff failed to order a medication for Resident #26. Review of Resident #26's medical record on 6/1/22 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include urinary tract infection. Further medical record review revealed the Resident was seen by a urologist on 2/23/22 and ordered for the Resident to continue Methamine 1 mg twice a day. A urologist is a medical doctor specializing in conditions that affect the urinary tract. Methamine is an antibiotic that eliminates bacteria that cause urinary tract infections. It usually is used on a long-term basis to treat chronic infections and to prevent recurrence of infections. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident review, and staff interview it was determined that the facility staff failed to ensure resident wishes for showers were honored (#6 and #52). This was evident for 2 out of 71 residents in the survey sample. The findings are: 1. Resident #6 was interviewed on 5/31/22 at 4:28 PM. The resident said that he/she has only received one shower since admission on [DATE]. The clinical record was reviewed on 6/2/22 at 1:22 PM. It was revealed that the resident received bed baths on: 5/9/22, 5/12/22, 5/15/22, 5/18/22, 5/22/23, 5/24/22, 5/26/22, 5/28/22, 5/31/22, 6/1/22, and 6/2/22. There was an absence of evidence that the resident received any showers. The Administrator was informed of the lack of showers on 6/6/22 at 12:30 PM. Evidence of showers was not provided prior to the exit conference. 2. This surveyor interviewed Resident #52 on 5/31/22 at 4:11 PM. The resident said he/she has not had a shower since admission on [DATE]. The resident's clinical record was reviewed and there…

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

Based on resident and staff interview, it was determined the facility staff failed to have petty cash available to Resident #40. This was evident for 1 of 1 resident selected for review of Personal Funds and 1 of 71 resident selected for review during an annual survey. The findings include: Surveyor interview with Resident #40 on 6/1/22 at 3:00 PM revealed the resident stated that he/she wanted to order a pizza. The resident stated that he/she was notified that there was $10.00 in the petty cash in the facility for the resident to access. The resident stated that no pizza would cost $10.00 and forfeited the pizza. Interview with the Nursing Home Administrator (NHA) on 6/2/22 at 11:45 AM revealed that there is $500.00 in the facility for petty cash, separated by departments. $100.00 is up front and the other $400.00 is locked up. Further interview with the NHA and [NAME] President of Regulatory Compliance on 6/8/22 at 10:45 AM revealed access to petty cash is only available while there is staff in the facility from administration (NHA, Director of Nursing). Once the administrative…

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 council meeting, tour of the facility, and staff interviews it was determined that the facility staff failed to ensure residents are informed of the results to the state surveys as well as signage to inform the residents of the location of the state survey results. The findings are: This surveyor met with members of the resident council on 6/2/22 at 2:10 PM. The residents stated that they were unaware of where the state survey book was located. They also stated that they were unaware of any signage that would inform them of the location(s) of the state survey book. Tour of the facility on 6/2/22 at 4:29 PM revealed that none of the units had a survey book located in plain sight and in easy access. There were also no signs telling residents where the survey books are located. This surveyor toured the facility with the Administrator on 6/3/22 at 11:00 AM. Survey books were found behind each of the nursing stations. Being behind the nursing stations would require the residents ask the nursing staff to see the results.

Based on medical record review it was determined the facility staff failed to transmit a MDS assessment to the Centers of Medicare/Medicaid (CMS) within 14 days of completion for Resident #1. This was evident for 1 of 71 residents selected for review 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 problem. MDS information is transmitted electronically by nursing homes to the national MDS database at CMS. Medical record review on 6/1/22 at 3:30 PM revealed the facility staff completed a Minimum Data Set (MDS) for Resident #1 on 4/14/22; however, failed to transmit the MDS to CMS within the 14-day time frame. Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data 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 it was determined that the facility staff failed to initiate care plan for Resident #70 for communication. This was evident for 1 of 71 residents selected for review during the annual survey. 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 A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client's changes in condition and evaluation of goal…

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 administer medications to Resident #5 in accordance with the standard of nursing practice. This was evident for 1 of 3 residents selected for review during medication administration observation during the annual survey. The findings include: Medical record review for Resident #5 on 6/1/22 at 10:00 AM (for drug reconciliation) revealed the physician ordered the following medications for Resident #5: On 6/24/21 the physician ordered: MVI (Multi-vitamin) 1 tablet by mouth every day-(supplement), 6/24/21 Fish oil 1000 milligrams, 2 capsules a day (supplement), 6/26/21 Magnesium oxide 400 mgs by mouth 1 tablet, 1 time a day (supplement), 6/28/21 Vitamin D3, 5000 units 1 tablet, 1 time a day (vitamin supplement), 7/26/21 Tylenol 325 mgs, 2 tablets by mouth every 8 hours as needed for pain (pain medication) and, 7/28/21 Letrozole 2.5 mg 1 tablet, 1 time a day for breast cancer (estrogen blocker). Observation of medication pass on 6/1/22 at 8:18 AM revealed CMA (Certified Medicine Aide) #1 failed to…

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

Based on observation and interview, it was determined the facility staff failed to provide Residents #59 and Resident #37 in a position conducive to eating. This was evident for 2 of 20 residents observed during tour of station during delivery of food trays on Station 1. The findings include: One of the most important steps in preparing to assist a resident at meal or snack time is assuring proper positioning, making it easier for the resident to eat as independently as possible. Residents require individual strategies for positioning, but this usually includes keeping the upper body securely in an upright position. Poor positioning leads to a higher risk for choking or aspirating food or liquid into the lungs. 1. The facility staff failed to provide Resident #59 in the most conducive position for eating. Observation of Resident #59 on 5/31/22 at 12:15 PM revealed the resident noted in bed eating lunch. It was also noted the resident was noted with an extreme lean to the left side and not fully in a high fowlers position ( high fowler's position, the resident is usually seated…

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 staff failed to provide restorative nursing services that would allow Resident #31 the ability to achieve the greatest independence with performing Activities of Daily Living. This was evident for 1 of 2 residents selected for ADL decline and 1 of 2 residents selected for review of Range of Motion and 1 of 71 residents selected for review during the annual survey process. The findings include: Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. It is the expectation the facility staff will provide all ADL services to residents as the resident can tolerate. 1 A. The facility staff failed to provide Resident #31 with Restorative Nursing (RNP) for Range of Motion (ROM) as ordered by Physical Therapy (PT) in collaboration with the physician. Medical record review for Resident #31 on 6/33/22 at 9:00 AM revealed on 3/8/21 the PT ordered: Restorative Nursing: Active range of motion exercise…

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 medical record review it was determined the facility staff failed to provide grooming and personal hygiene services (Resident #27). This is evident for 1 of 3 residents selected for review of ADL care and 1 of 71 residents selected for review during the annual survey process. The findings include: The activities of daily living (ADLs) are a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The basic ADL include the following categories: Ambulating: The extent of an individual's ability to move from one position to another and walk independently. Feeding: The ability of a person to feed oneself. Dressing: The ability to select appropriate clothes and to put the clothes on. Personal hygiene: The ability to bathe and groom oneself and maintain dental hygiene, nail, and hair care. Continence: The ability to control bladder and bowel function Toileting: The ability to get to and from the toilet, using it appropriately, and cleaning oneself. Surveyor observation of Resident #27…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #6). This is evident for 1 of 3 residents reviewed during a annual survey. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). The findings included: Review of Resident #6's medical record on 6/8/22 revealed the Resident was admitted to the facility 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 observations, it was determined the facility staff failed to provide fall mats next to the bed of Residents #22 and Resident #59. This was evident for 2 of 71 residents selected for review during the annual survey process. The findings include: Fall mats are made from high-impact foam and are designed to help prevent injury from potential falls and are usually placed next to the bed where most falls occur. 1. The facility staff failed to place fall mats next to the bed of Resident #22 as ordered by the physician. Medical record review for Resident #22 on 6/1/22 at 9:30 AM revealed on 4/16/21 the physician ordered: bilateral fall matt while in bed. Surveyor observation of the resident on 6/1/22 at 11:00 AM, 6/2/22 at 8:29 AM, 6/3/22 at 7:40 AM, revealed the resident in bed; however, the facility staff failed to apply the bilateral fall mats as ordered. 2. The facility staff failed to provide fall mats next to the bed of Resident #59 as ordered by the physician. Medical record review for Resident #59 on 5/31/22 at 10:45 AM revealed on 6/28/20 the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to obtain monthly weights as ordered, conduct an accurate readmission nutrition assessment and conduct all quarterly nutritional assessment by a licensed dietitian for a resident (Resident #41). This was evident for 1 out of 3 residents reviewed during the annual survey. The findings include: Review of Resident #41's medical record on 6/2/22 revealed the Resident was admitted to the facility on [DATE]. Review of the Resident's care plans revealed the Resident had a care plan entitled Resident has risk for weight loss due to inadequate meal intakes with a start date of 12/14/21. A. Further review of the medical record revealed a physician order on 9/1/21 for monthly weights, the first Monday of the month. Review of the Resident's weights in the medical record revealed the Resident had no monthly weight documented for November 2021 and no monthly weight documented 12/6/21 (the first Monday of the month). B. Further review of the Resident's…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain pre and post dialysis weights and vital signs for Resident (#27). This was evident for 1 of 1 resident selected for review of Hemodialysis and 1 of 71 selected for review during the annual survey process. The findings include: Medical record review for Resident #27 on 6/2/22 at 11:30 AM revealed on 10/9/18 the physician ordered: Hemodialysis, MWF. Healthy kidneys clean the blood and remove extra fluid in the form of urine. They also make substances that keep the body healthy. Dialysis replaces some of these functions when the kidneys no longer work. In hemodialysis, a dialysis machine and a special filter are used to clean the blood. Weights and vital signs are generally the numeric measures of life that typically include a patient's temperature, heart rate, respiratory rate, and blood pressure. The main reason why these signs need to be monitored is basically to establish a baseline before, during, and after a dialysis treatment. Review of the facility staff documentation revealed…

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

Based on observation and staff interview it was determined that the facility staff failed to ensure the medication carts are locked and secured. This was evident for 1 unit out of the 6 units in the facility. The findings are: This surveyor was at the nursing station for rooms in the 300's and 400's. While at the desk this surveyor observed an unlocked medication cart on 5/31/22 at 3:45 PM. The drawers were able to be opened. There was one resident in the hallway about 10 feet away, but the resident did not react to the drawers being opened. Another resident went past the unlocked medication cart in their wheelchair. Staff RN #11 was made aware at 4:03 PM and he locked the cart. The Director of Nursing was made aware on 6/1/22 at 2:12 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to obtain dental services for a resident (Resident #68). This was evident for 1 out of 20 residents reviewed for dental services during an annual survey. The findings include: Observation of Resident #68 on 5/31/22 at 1:45 PM revealed the Resident to have no upper teeth and 10 lower teeth that were broken with obvious decay. During interview with the Resident at that time, the Resident stated he/she would like to have his/her lower teeth pulled and to be evaluated for dentures. At that time the Resident denied any pain. Review of the Resident's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital. On 3/21/22 the facility staff conducted an annual MDS (Minimum Data Set) assessment and coded the Resident in Section L0200 Dental as Obvious or likely cavity or broken natural teeth. Further review of Resident #68's medical record revealed on 10/2/21 the Resident was seen by the dentist. At…

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 2. The facility staff failed to maintain the medical record for Resident #27 in the most accurate form. Medical record review for Resident #27 on 6/1/22 at 11:30 AM revealed on 1/28/19 the physician ordered: Wanderguard placed regarding resident being transferred off of closed-unit. Wanderguard to be checked by nursing every shift for patency of said wanderguard. Continue with plan of care and monitoring. Further record review revealed the physical ordered: Inspect Wanderguard every shift to make sure it is in good working condition, If not, replace immediatley, every shift. 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. Review of the MDS completed by the facility staff on 9/14/21, 12/4/21, 2/14/22 and documented Section E- 0900- Wandering- Prescence 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, medical record review and staff interviews; It was determined that the facility staff failed to maintain a sanitary environment to prevent the development and transmission of infection in 1. storing and transporting of linen and 2. in the administration of medication (Resident #5). This was evident in 1 out of 2 clean linen carts observations and 1 out of 3 residents during medication administration during the annual survey. The findings include: 1. On 6/1/22 at 8:35 AM during facility tour observed on station-6 the observation nursing unit observed unattended uncovered linen cart standing between residents' rooms [ROOM NUMBERS]. Surveyor was able to count all the clean linen on linen cart which included: On the 1st shelve of linen cart 1-television remote, 1-8fl.oz bottle of smooth and cool cleaner shampoo and body wash, 4-hospital gowns, 3-bed pads, 8-bath towels, 2-flat sheets, 8-fitted sheets, and 20-pillow cases. After surveyor completed counting the clean linen on the linen cart…

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, observation and interview it was determined the facility staff failed to provide Resident #113 with the preferred flavor of dietary supplement. This was evident for 1 of 41 residents selected for review during the annual survey process. The findings include: Review of the Resident 113's meal ticket on 9/19/18 at 8:00 AM revealed Resident #113 was to have vanilla or strawberry ensure. Ensure is a source of complete, balanced nutrition for supplemental use with or between meals. It may benefit residents who have malnutrition, are at nutritional risk, are experiencing involuntary weight loss, or on modified diets. Observation of the resident's breakfast tray at that time revealed the facility staff failed to provide Resident #113 with vanilla or strawberry ensure; however, provided Resident #113 with milk chocolate ensure. Interview with Resident #113 at that time also revealed he/she did not like chocolate ensure and failed to ice or cool the Ensure. Interview with the Director of Nursing on 9/19/18 at 1:00 PM confirmed the facility staff failed to provide…

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 resident interview, staff interview, and observation it was determined that the facility staff failed to ensure furniture was maintained in a clean fashion. The findings include: An observation of room [ROOM NUMBER] on [DATE] at 10:32 AM revealed that a maroon recliner situated next to the A bed had multiple white stains on the seat and foot rest. The recliner was observed again on [DATE] at 9:20 AM to still be in the room. The resident in the B bed was interviewed. The resident said the roommate had expired about three weeks ago and the roommate's family had donated it to the facility. According to the resident maintenance was supposed to move it but had not as of this date. The Environmental Services Director was interviewed on [DATE] at 1:29 PM. He stated that donated furniture is normally removed immediately, stored, and cleaned. He told two members of the maintenance department within fifteen minutes of this interview to move the recliner.

Based on medical record review and interviews, it was determined the facility staff failed to administer pain medication as ordered by the physician and failed to evaluate the effectiveness of that pain medication in a timely manner for Resident #376. This was evident for 1 of 41 residents reviewed during the survey process and 1 of 7 residents reviewed during a complaint survey (MD 00127697). The findings include: Pain has been identified as the fifth vital sign. Assessment of a resident's experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams' ability to achieve pain management. Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the resident's experience of pain. Measuring pain enables the nurse to assess the amount of pain the resident is experiencing. Resident's self-reporting (expression) of their pain is regarded as the gold standard of pain assessment…

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 failed to obtain a medication error rate below 5%. Based on observation of medication pass, it was determined the medication error rate was 5.88%. This was evident for 1 of 3 residents observed and 2 out of 34 opportunities (Resident #116). The findings include: 1. The facility staff failed to administer medication to Resident #116 as ordered by the physician. Medical record review for Resident #116 revealed on 11/19/16 the physician ordered: Vitamin D 5000 IU (international unit) every day. Having enough vitamin D is important for several reasons, including maintaining healthy bones and teeth; it may also protect against a range of conditions such as cancer, type 1 diabetes, and multiple sclerosis. Vitamin D is essential for strong bones, because it helps the body use calcium from the diet. Observation of medication pass on 9/19/18 at 8:30 AM revealed facility nurse #3 staff failed to administer the Vitamin D as ordered by the physician. 2. The facility staff failed to administer…

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

Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition on the lower level of the facility. The findings include: 9/19/2018 at 8:58AM, during the tour of the lower level of the facility with the Maintenance Director the following observation was made: The tour of the lower Unit level revealed Power strips in the patient's rooms. Six of the patient's rooms had Haier portable air conditioners connected to a powder strip. The manual for the Haier portable air conditioner revealed safety precautions that read do not use an adapter or an extension cord and a warning that read Following theses basic precautions will reduce the risk of fire, electrical shock, injury or death when using your air conditioners. The Surveyor informed the Office of Health Care on 9/19/2018, and a Life Safety inspector was sent out to tour the Facility on 9/20/2018. At that time the power cords were removed, and the Haier portable air conditioners were connected to the electrical supply as…

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