Charlestown Community Inc

Based on medical record review and interviews it was determined that the facility failed to implement physician instructions for behaviors health needs. This was evident for 1 (Residents #51) out of 5 residents reviewed for unnecessary medications. The findings include: On 9/16/25 at 10:35 AM, the surveyor reviewed Resident #51's medical record. The review revealed that Resident #51 has a Minimum Data Set (MDS) assessment with an Assessment Reference date of 7/28/25 that indicated Resident #51 had a change of condition. In the special treatments section Hospice care was not indicated. On further review a note written by Physician #29 on 8/6/25 stated Resident #51 was recently discharged from hospice. It also stated that Resident #51's mood disorder, that was due to a medical condition, would be treated with Seroquel and Sertraline along with mental health follow up. On 9/16/25 at 12:17 PM, the surveyor interviewed Clinical Nurse Specialist Staff #21. During the interview Staff #21 stated that she had stopped seeing Resident #51 when he/she became a hospice resident. The surveyor…

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

Based on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 2 of 2 residents (#117 and #1) reviewed. The findings include: 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. The MDS is to be completed 14 days after the assessment reference date. Review of Resident #117's medical record on 7/5/23 9 at 12:30 PM revealed the following: 1. A quarterly MDS with an ARD (assessment reference date) 5/16/23, has not been completed as of 6/6/23. 2. A quarterly MDS with an ARD (assessment reference date) 2/16/23, was completed on 4/7/23. 3. 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.

3) On 06/28/2023 at 9:02 AM, an abnormal appearing nickel-sized area was observed by surveyor on Resident #199's left temple area, close to the ear. The Resident was immediately interviewed, and when asked about it, the Resident said that he/she did not know what it was and that it sometimes itched. On 06/29/2023 at 1:30 PM, Resident #199's medical records were reviewed. An order was created on 06/14/2023. The order read: weekly skin assessment on Fridays 7 AM-3 PM. Complete skin assessment using the skin sheet and document findings on wound portal and in progress notes. No assessment that included the area on the left temple could be found in the progress notes written by nursing staff, physicians, or other disciplines. No skin assessment could be found in the wound portal. On 06/30/2023 at 10:00 AM, an interview was conducted with staff #3, a Nurse Practitioner (NP). When asked about the area in question, the NP said that she did not know but would look it up. When no notes could be found she said, I'll go take a look. After Resident #199's skin was assessed, the NP stated, It…

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

Based on review of medical records and staff interviews, it was determined that the facility staff failed to: 1) report recommendations to the attending physician and 2) failed to have a process in place that ensured a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed timely. This was evident for 3 residents (#84, #39, #53) of 5 residents reviewed for medication regimen review. The findings include: 1) Review of Resident #84's medical record on 06/30/23 8:00 AM, revealed two medication regimen reviews (MRR) for January 2023 and April 2023, that had not been acknowledged nor signed off by the attending physician. Both MRR's advised review of the resident's Fluoxetine dosage for a gradual dose reduction (GDR). Fluoxetine is a psychotropic medication to treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and panic disorder. The physician did not review the identified recommendations from the Pharmacist. During an interview with Staff #3 on 6/30/23 9:45 AM, it was revealed by Staff #3 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 review of medical records, facility policies and interviews it was determined that the facility failed to document the provision of the education and the consent, or refusal, of the pneumonia vaccine. This was found to be evident for 5 (Resident #32, Resident #34, Resident #35, Resident #61, Resident # 69) out 5 residents reviewed for immunizations. The findings include: On 7/13/23 8 AM surveyor requested the pneumonia vaccine education and consents for Resident #32, Resident #34, Resident #35, Resident #61, and Resident #69. On 7/13/23 10 AM the ADON stated the paperwork is at Iron Mountain and we probably will not be able to retrieve it anytime soon. During review of the electronic health record, on 7/13/23 10:45 AM, a document titled Vaccine Survey Report revealed the pneumonia vaccine administration dates for, Resident #34, Resident #61, and Resident #69, The administration date listed for Resident #34 as 2/26/2016, Resident #61 as 9/20/2019 and Resident #69 as 3/4/2017. Further review of the electronic health record in a section labeled E-Clinical, (where physicians…

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 that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby on 6/27/2023 through 6/28/2023 revealed no evidence of the State inspection results in an open and readily accessible area for residents, staff, and visitors to review. A tour of the facility did not reveal any signs posted telling residents where the state survey results are located. On 6/28/2023 at 09:57 AM an interview with the Assistant Nursing Home Administrator confirmed the facility staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed.

Based on observation, medical record review and interview, it was determined the facility staff failed to ensure that Resident #24 received assistance with the hearing devices to maintain hearing abilities and the ability to achieve the greatest independence with performing Activities of Daily Living to Resident (#24). This was evident for 1 of 3 residents selected for review during the 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. Medical record review for Resident #24 revealed on 3/16/22, the physician orders: please change hearing aids batteries on Mondays and Thursdays every week. Observation of Resident #24 on 6/27/23 at 1:08 PM, and 6/29/23 at 12:26 PM, revealed the resident was out of bed in the wheelchair in the dining room, however, the facility staff failed to place the hearing aide. Interview with the resident's Power of Attorney on 6/27/23 at 12:30 PM, revealed that Resident #24 on multiple…

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 interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 66 (#17) residents reviewed during the survey process. The findings include: In an interview with Resident #17 on 06/28/23 at 11:58 AM, revealed that Resident #17 stated, I only get showers once a week and I'm used to taking a shower daily. The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of Resident #17's most recent MDS completed on 2/13/23, revealed that s/he is total dependent for bathing requiring extensive assistance for all Activities of Daily Living (ADL). The Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating adequate cognitive ability. Further 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 observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the use of bedrails. This was evident of 1 of 2 Residents (Resident #60) reviewed for bedrails during an annual survey. The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits information along with a signed consent obtained before the use of bedrails. On 6/27/23 at 11:41 AM, the surveyor observed Resident #60 with 1/4th bed rails up on both sides of the bed. On 7/05/23 at 11:26 AM, the surveyor reviewed Resident #60's medical records. The review revealed that resident #60 was admitted 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 observations, interviews and record reviews, the facility staff failed to follow the facility's infection control policy. This was evident for 2 (# 10 and # 8) out of 2 observations for infection control. The findings include: On 7/10/23 at 11:30 AM, the surveyors observed Licensed Practical Nurse (LPN) # 10 use the glucometer on Resident #25. Following use the glucometer was cleaned with alcohol wipes by LPN # 10. During an interview conducted on 7/10/23 at 11:35 AM, LPN # 10 showed the surveyors a container of alcohol wipe packets. The LPN stated she used the alcohol wipes to clean the community glucometer. On 7/10/23 at 11:45 AM, the surveyors reviewed the facility's policy titled, Equipment: Cleaning, Disinfection, and Decontamination Standard Operation Procedure which stated to use Chlorox Germicidal Wipe or an equivalent germicidal solution appropriate for blood borne pathogens. During an interview conducted on 7/10/23 at 1:50 PM, the Assistant Director of Nursing (ADON) confirmed that the use of…

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

Based on resident interview and observation, it was determined that the facility staff failed to ensure that a shower chair was safe for use. This was evident for 1 (#46) of 66 residents reviewed during the recertification survey. The findings include: On 06/28/2023 at 10:04 AM, an interview with Resident # 46 revealed that the resident, who has trouble walking and muscle weakness, reported that he/she felt unsafe using his/her shower chair. The resident described the chair as wobbly. On 06/29/2023 at 11:00 AM, a subsequent observation and demonstration revealed that the legs of the chair appeared unstable when moved. On 06/29/2023 at 11:16 AM this finding was demonstrated to the Director of Nursing who removed the chair and replaced it.

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 3 of 7 (#140, #142, #132) residents reviewed for hospitalization during the investigative portion of the survey. The finding includes: 1. A medical record review of both paper and electronic records for Resident #140 was completed on 1/3/19 at 2:22 PM revealed Resident #140 was hospitalized twice in December 2018 secondary to respiratory related concerns. Further review of the medical record failed to reveal any documentation that the resident or the responsible party had been provided with a written notification of the transfer or the rationale for the transfer. 2. Review of the medical record for Resident #142 on 1/4/19 at 12:16 PM revealed the resident was hospitalized in December 2018. Staff #30 was interviewed on 1/10/19 at 11:55 AM regarding what paperwork is sent 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 staff interview and review of medical record documentation, the facility failed to ensure that staff fully adhered to Resident Assessment Instrument (RAI) process. In a pattern, this concern was evident in 17 of 44 residents reviewed for RAI Minimum Data Set (MDS) concerns (Residents 1, 6, 7, 8, 9, 10, 12, 14, 18, 19, 20, 23, 26, 43, 49, 122, and 146). Specifically 1) facility staff failed to incorporate Care Area Assessment CAA findings into care planning; 2) facility staff opened care plans without goals, interventions and/or rationales; 3) facility staff signed off that CAAs were completed before the MDS screening had been done (the MDS screening must be finished before CAAs because the screening is what triggers the CAAs); 4) the MDS screening was not completed timely including completion of some screenings after residents had discharged and some after the next assessment was already completed; and 5) the facility employed an internal assessment system that relied on an internal 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 review of medical record documentation, the facility failed to adhere to the mandated schedule for conducting quarterly Resident Assessment Instrument (RAI) assessments. The failure to reassess residents at least every 92 days, as required, increased the risk for serious harm related to care planning and care delivery that was not predicated on a full and complete understanding of each resident's status and each resident's evolving needs which can change over time. This concern was evident for 14 of 44 (Residents #2, 7, 8, 13, 15, 20, 21, 25, 26, 27, 49, 56, 145 and 146) residents reviewed for survey-triggered concerns in MDS coding. The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident's needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that 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 staff interviews and review of medical record documentation, the facility failed to follow the prescribed Resident Assessment Instrument (RAI) process when assessments were not completed timely and were then not transmitted timely into the Federal Quality Improvement Evaluation System (QIES). This concern was evident for 13 of 44 residents reviewed (Residents #4, 5, 6, 8, 9, 11, 17, 23, 24, 25, 26, 27 and 32) for survey-triggered MDS coding concerns. The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident's needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and review of medical record documentation the facility failed to ensure sufficient coordination of the Resident Assessment Instrument (RAI)process when comprehensive assessments were not completed timely, quarterly assessments were not completed timely, discharge assessments were not completed timely, care area assessments were not completed timely, care planning staff did not have access to ensure CAA findings could be incorporated into care planning, and resultant care plans were missing, inaccurate, inconsistent and incomplete. The failure to ensure the staff followed the prescribed resident assessment process contributed to increased risk for serious resident harm when care planning did not reflect or support individualized needs of residents. The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident's…

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

Based on observation of an interaction between resident and staff, it was determined that the facility failed to maintain an environment that enhanced a resident's dignity and respect. and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life. This was evident in 1 observation of Resident #140. The findings include: 1. Surveyor activities on 1/2/19 at 1:20 PM included observation of residents and staff on the second floor of the north building that were situated in the common area in front of the nursing station. At 1:27 PM a resident pointed out something on the floor caught up in Resident #140's wheelchair wheel. Surveyor identified the item as dentures and notified the nursing staff that there was a set of dentures on the floor. Geriatric nursing assistant (GNA) Staff #7 donned a pair of gloves, picked up the dentures and went to the Resident #140's room to clean them. She returned and placed them in front of Resident #140. Resident #140 looked at the dentures and stated: I do not wear dentures. Staff #7 asked 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 record review, and resident and staff interviews, it was determined that the facility failed to afford a resident the opportunity to participate in his/her care planning process. This as evident for 1 out of 5 residents (Resident #117) reviewed for care planning. Findings include: During interview with Resident #117 on 01/04/19 at 2:10 PM, he/she reported not attending or being offered a care plan meeting since his/her admission in September 2018. The Resident stated he/she was unaware of the process to request one, however he/she had asked nursing about it on two separate occasions. Resident #117 was unaware of the plan for discharge. Review of Resident #117's progress and social work notes on 1/9/19 at 11:30 PM revealed no documentation of a care plan meeting with the Resident. During an interview with Staff #15 and Staff #22 on 01/10/19 at 09:20 AM regarding care plans and care plan meetings with short term/rehab residents, Staff #15 stated care plan meetings are done on admission, an as needed basis, if a significant change takes place or if the Resident or family…

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

Based on medical record review and staff interview it was determined that facility staff failed to initiate and conduct a thorough investigation after a resident sustained an injury of unknown origin. This was evident for 1 of 1 residents (Resident #66) reviewed during survey investigation. The findings include: Resident #66 's medical record was reviewed on 1/9/19. Resident # 66 has a diagnosis of but not limited to Dementia. Continued medical record review revealed a Change in Condition Note dated 2/10/18 that read Per assigned GNA (Geriatric Nursing Assistant) she took Resident #66 to his/her room to put him/her in bed and then went to retrieve linen from the closet. When the GNA returned to the room the resident was lying across the bed with blood running down his/her left leg. An Incident Report was entered into Resident #66's medical record on 2/10/2018. The incident report classifies Resident #66's leg laceration as a self-inflicted injury. In the section marked Steps Taken to Prevent Recurrence (Actions) it is written: Bed checked for sharp edges, frame, possible banged on…

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

Based on medical record review and staff interview it was determined that facility staff failed to report a resident' injury of unknown origin to the State Agency immediately or within 2 hours of discovery. This was evident for 1 of 1 residents (Resident #66) residents reviewed during survey investigation. The findings include: Resident #66 's medical record was reviewed on 1/09/19 and revealed a Change in Condition Note dated 2/10/2018 that reads Per assigned GNA (Geriatric Nursing Assistant) she took Resident #66 to his/her room to put him/her in bed and then went to retrieve linen from the closet. When the GNA returned to the room the resident was lying across the bed with blood running down his/her left leg. An Incident Report was entered into Resident #66's medical record on 2/10/18. The incident report classifies Resident #66's leg laceration as a self-inflicted injury. In the section marked Steps Taken to Prevent Recurrence (Actions) it is written: Bed checked for sharp edges, frame, possible banged on the wheel chair legs no sharp edges noted. Continued record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to reassess a resident following a significant change in condition related to hospice services. This was evident for 1 of 53 residents (Resident #79) selected for review during the survey process. The findings include: The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. MDS assessments are completed upon admission, quarterly and for any significant change in condition. Categories of MDS are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other…

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 with facility staff, it was determined that the facility failed to 1) code the correct stage of a resident's pressure ulcer on the Minimum Data Set (MDS) correctly, 2) code correctly a resident's restraints use or functional status. This was evident in 2 of 28 residents reviewed (Resident #127 and #59). The findings include: The MDS is a tool that is a federally mandated process for clinical assessment required by nursing homes to complete on each resident. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. The facility staff develops plans of care based on the MDS assessment, past medical history, current clinical status as well as resident and family input. 1. Review of the medical record for Resident #127 on 1/3/19 at 10:15 AM revealed documentation of a worsening stage 2 pressure ulcer. Review on 1/8/19 at 7:56 AM of the wound portal documentation revealed admission…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to revise a care plan related to a resident's 1A) identified skin wounds, 1B) history of falls, 2) A residents activities of daily living status and 3) follow a resident care plan when transferring a resident. This was found to be evident for 2 of 5 residents reviewed for care plans and 1 in 5 facility self reports reviewed. (Residents #140, #82, and # 412). The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1A. During tour of the facility Resident #140 was observed sitting in the common area of Unit 2 in front of the nursing station on 1/2/19 at 1:33 PM. Resident #140 was noted with a large bruise on his/her left lower abdomen in various stages of healing and bilateral Geri sleeves were in place. During interview with Resident #140 on 1/3/19 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.

Based on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for resident. This was evident for 1 of 53 residents (Resident#59). selected for investigation during the survey process. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Review of Resident #59's medical record revealed a Functional Status care plan for grooming that stated the Resident was independent and needed setup…

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 residents and staff, it was determined that the facility failed to provide a resident with the identified assistance for activities of daily living (ADL) as identified in the resident's care plan. This was evident for 1 of 3 residents (Resident #2) reviewed for ADL's. The findings include: During interview with Resident #2 on 1/3/19 at 11:05 AM s/he revealed that s/he was supposed to be toileted with 2-3 staff because of his/her recent fall. Resident #2 further verbalized fear to the surveyor that staff were only transferring him/her with 1 person to the bathroom and making him/her do 'more' than s/he was able, and s/he was afraid of falling again and acquiring more fractures. The concern and reported fear was immediately reported to the facility Director of Nursing (DON). A review of Resident #2's medical record on 1/8/19 at 9:33 AM revealed the admission nursing assessment assessed the resident as being always continent and noted that s/he would need assistance throughout the day. Review of the ADL verification worksheet completed…

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

Based on observation, record review and staff interview it was determined that the facility failed to follow a physician order for Resident #117 which stated staff were to maintain Resident's surgical boot to left foot at all times except bathing. This was evidence for 1 of 11 residents reviewed. Findings include: Record review on 01/09/19 at 1:30 PM revealed a physician order for Resident #117 dated 12/5/18 for 'left lower extremity (left leg) to be elevated as often as possible and for CAM (controlled ankle movement) boot to be in place on left leg at all times - may remove for bathing and dressing changes. Resident observation on 01/09/18 at 9:00 AM revealed Resident #117 without CAM boot on left leg. Boot was on the Resident's dresser across the room. Surveyor asked Resident #117 how often and when it was usually placed on his/her leg and Resident stated staff take it off every night and it stays off while he/she sleeps and it is usually placed back on in the morning. The resident also stated that sometimes the staff does not put it back on until after breakfast. During an…

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

Based on medical record review and interview, the facility staff failed to perform and/or document weekly skin assessments for a resident with pressure ulcers (Resident #79). This was evident for 1 out of 53 residents selected for review during the survey process. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). Review of Resident #79's medical record revealed the Resident developed a Stage II pressure ulcer to the sacrum on 12/3/18. Further review of the medical record revealed the pressure ulcer was reassessed and measured by the facility staff on 12/4/18. Review of the weekly skin…

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 administrative record review and interviews with facility staff it was determined the facility failed to 1) keep residents safe and free of accidents and hazards while providing care 2) failed to maintain a unit free of potential accident hazards. This was found to be evident during the tour of unit 2 on the north side and a review of 2 residents (Residents #88 and #412) reviewed for falls and 3) failed to ensure Resident #8 remained as free of accident hazards as possible when it failed to conduct the required quarterly assessment to evaluate the resident's needs after four documented falls had already occurred in the prior 92 days (assessment window). The failure to follow the prescribed RAI process, timely assess the resident, and reevaluate care planning that had been ineffective during the assessment period, left Resident #8 at increased risk for additional falls and for fall related injuries. The findings include: 1. Review of Resident #88's medical record on 1/3/19 and a note dated 8/11/18 revealed at approximately 7:30 AM a GNA, Staff # 19 reported to the nurse 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 facility staff it was determined that the facility failed to 1) correctly document the placement of a residents wander guard, 2) document weekly in the wound portal the status of a residents wound and 3) failed to follow a physician order for daily nursing skin assessments. This was evident during the review of 3 of 28 resident records (Residents #82, #127 and #95). The findings include: 1. Observation of Resident #82 on 1/3/19 at 7:40 AM revealed a resident in a wheelchair with a splint noted on the right wrist and tray table attached to the wheelchair on the right side that the residents right arm rested on. A review on 1/3/19 of Resident #82's medical record revealed an order on 6/3/15, last verified by the physician on 12/28/18, for a wander guard (application designed to prevent persons at risk from leaving a facility unless they are accompanied) to the residents left ankle and for staff to check the placement, function and battery every shift. A review of Resident #82's care plans on 1/9/19 at 11:50 AM revealed that there 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility staff failed to develop and implement a care plan to manage hospice services for a resident. This was evident for 1 of 53 residents (Resident #79) selected for review during the survey process. The findings include: Review of Resident #79's medical record revealed the Resident was admitted to the facility on [DATE]. Further medical record review revealed the Resident had a change of condition and was admitted to hospice services on 11/26/18. Interview with the Director of Nursing on 1/10/19 at 1:39 PM revealed the facility staff maintain a binder on the nursing unit for every Resident with their current care plans. Review of Resident #79's care plan binder on 1/10/19 revealed there was no care plan for hospice services. Further review of the Resident's electronic medical record also revealed there was no care plan for hospice services. Interview with the Director of Nursing on 1/11/19 at 7:40 AM confirmed the facility and hospice…

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 staff interviews, review of other pertinent documentation and survey findings, it was determined the facility staff failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address identified quality deficiencies. This was found to be evident during the facility's annual Medicare/Medicaid survey. The findings include: The facility's previous annual survey conducted on 9/5/17 found the facility with deficiencies cited for care plan development that were not resident specific. During this year's annual survey that was conducted on 1/2/19 thru 1/11/19, it was again found that care plans were not resident specific. Review of the facility's Quality Assurance Program (QAP) with the Director of Nursing (DON) and Administrator on 1/11/19 at 12:57 PM revealed that repeat deficiencies were identified with care plans not being resident specific, and that the facility's plan to address the identified concerns were not corrected. The DON stated that the facility's Holistic Assessment Process came out in March 2018. 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.