Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase

Based on medical record review, interview of residents, family and facility staff, it was determined that the facility failed to: 1) review, and update residents care plans based on changes related to their individual plan of care; 2) update a resident's care plan to address his/her history of escalating wandering behaviors associated with the gradual dose reduction of Seroquel and 3) have care plan meetings involving members of the interdisciplinary team to include dietary and geriatric nursing assistant responsible for the resident. This was evident for 5 out of 23 residents (Resident #41, #44, #24, #23 and #55) reviewed during the investigative stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. 1A) Review of the medical record for Resident #41 on 7/9/19 at 12:37 PM revealed a fall on 3/14/19 with…

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

Based on review of posted staffing and interview with the Director of Nursing (DON) it was determined that the facility failed to identify a charge nurse other than the DON. The findings include: Review of the facility census on 7/12/19 from 6/1/19--7/11/19 revealed an average census of 68-75. The Administrator was interviewed on 7/12/19 at 2:00 PM regarding the findings that the average census was over 60 residents and the DON was listed as the charge nurse. The DON addressed the survey team at 2:30 PM on 7/12/19 and stated that although she is listed as the charge nurse, she does not perform bed side care duties. The regulatory concern that the DON is added into the staffing and identified as the charge nurse on both units of the facility for day shift from the review of 6/1-7/11/19 and not as the DON was again reviewed with the DON, the Administrator and the Executive Director at exit on 7/12/19.

Based on medical record review and interview it was determined that the facility failed to include the required statement of the resident's appeal rights and Ombudsman contact information in the written notice of transfer. This was found to be evident for 1 out of 2 residents (Resident #47) reviewed for hospitalization during the investigative stage of the survey. The findings include: On 7/11/19 review of Resident #47's medical record revealed the resident had been discharged to the hospital on 5/21/19. Further review of the medical record revealed a letter sent to the responsible family member regarding the Notice of Hospital Transfer. Review of this letter failed to reveal any documentation regarding the resident's appeal rights or the contact information for the Ombudsman. On 7/11/19 surveyor discussed the concern with the Director of Nursing and the administrator that the letter does not include the required information regarding appeal rights. The concern regarding the failure to include required information in the Notice of Hospital Transfer was again reviewed at time of exit…

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 Resident #1's Minimum Data Set assessment was not submitted regarding the resident's discharge. This was evident for 1 of 1 resident (Resident #1) reviewed for the resident assessments during the investigative stage of the survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). Review of Resident #1 medical records on 7/11/19 reveals that the resident had a discharge to the hospital on 2/25/19 and was not readmitted to the facility. Review of the resident's MDS assessment completed on 2/21/19 revealed no subsequent MDS assessments completed for 120 days. In interview with the MDS Coordinator #6 on 7/11/19 and review of the resident's medical records, MDS Coordinator #6 realized that the discharge assessment was never completed for Resident #1. The MDS Coordinator #6 verbalized that she will be sending a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview with the facility staff it was determined that the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failure to accurately assess behavior; 2) failure to assess the resident health condition-falls. This was evident for 2 out of 23 (R #6 and #32) records reviewed during the investigation stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) On 7/10/19 Resident #6 was observed wandering on the memory unit followed by Staff #13 who redirected the resident to the activity room on the memory unit. Medical record review on 7/11/19 revealed the resident was admitted to the facility in 2017 for long term…

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 with resident, staff and observation it was determined that the facility failed to provide activities to all residents equally that were admitted to the facility. The findings include: Resident #44 was interviewed on 7/9/19 at 10:26 AM. Resident #44 stated that s/he has been here for a few months and the activities they are offering are kind of boring. S/he further stated that s/he has the internet and his/her television to watch. Observations of the unit that Resident #44 resided on during the survey failed to reveal any activities occurring. This concern was brought to the attention of the Recreations Coordinator, Staff #3 on 7/10/19 at 11:08 AM. She stated that on the rehab side of the facility, where Resident #44 resides, there is music provided twice a month and all residents who are here for rehab are always invited and encouraged to join art classes that are provided on the other unit. She further stated that some residents are at the facility for rehab and not interested in the activities. Regarding the activities that occur on the long-term care unit,…

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: 1) maintain observation of a cognitively impaired resident who was later found outside of the facility unsupervised and 2) conduct a timely re-assessment of the resident's risk for wandering or elopement after he/she was found to have exited the facility unattended. This was evident for 1 of 20 residents (Resident #24) reviewed during survey investigation. The findings include: 1) Facility staff failed to maintain observation of a cognitively impaired resident who was later found outside of the facility unsupervised. Facility Reported Incident (FRI) MD00140702 was reviewed on 7/9/2019. The FRI stated that on 5/23/2019 facility staff took Resident #24 to a church activity. When the activity was complete staff began to transport residents back to their rooms. During this process Resident #24 was found outside of the facility by a member of the community. Resident #24's medical record was reviewed on 7/9/2019 and revealed that the resident has a diagnosis of Dementia. Continued record…

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

Based on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass by 2 nurses and 4 residents with 30 medication opportunities. The findings include: 1) Observation of medication pass completed by Staff #8 at 8:12 AM on 7/12/19 with Resident #47 revealed an order for vitamin B-12. The medication pass was observed and Staff #8 was observed to crush the medication and administer the medication to the resident. A review of the order after the administration revealed that the medication was to be administered sublingually. Staff #8 was interviewed on 7/12/19 at 11:15 AM and confirmed that the medication was crushed. Observation of the bottle of vitamin B-12 revealed it stated that it was quick dissolve tablet formula. She stated that she would put in a request for a medication change as moving forward she did not feel the resident would be able to take the medication in the prescribed dissolvable tablet…

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 tour and observation it was determined that the facility failed to maintain a secure store room. This was evident during a random tour of the facility. The findings include: During tour of the facility with the Administrator on 7/11/19 at 1:07 PM the Administrator opened the door to the clean utility room and stated that it is always open. Observation within the store room revealed oxygen tanks, multiple containers with catheters used for intravenous access and a sharps box that was over filled. The concern that the room was not secure, and residents would have access as they would pass the room on the way to the dining room or rehab gym was reviewed. A lock was placed on the door immediately.

Based on medical record review and staff interview it was determined that facility staff failed to document a resident's wandering behaviors in the medical record. This was evident for 1 of 23 residents (Resident #24) reviewed during survey investigation. The findings include: Resident #24's medical record was reviewed on 7/9/2019 and revealed a Nursing Note entered into the medical record on 7/10/2019 at 9:47 AM that read: Elopement risk assessment completed. Resident identified as a potential risk for elopement. Order obtained for application of Wanderguard. A Wanderguard is a tracking wrist or ankle band that is used to prevent persons at risk from leaving a facility unless they are accompanied. Further medical record review revealed no wandering behaviors documented for the resident since 5/23/2019. The Director of Nursing (DON) was interviewed on 7/10/2019 at 11:15 AM. The DON stated that it is expected that nursing staff would document Resident #23's wandering behaviors. She stated that staff frequently fail to document wandering behaviors for Resident #23 as they have come 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 staff interview it was determined that the facility failed to provide proper ventilation for residents. This was true for 1 of 2 bathing spas (Chop Tank) that were in the facility. Findings include: An observation was conducted on 7/11/19 at 2:45 PM on the Chop Tank unit. Observation of the residents shower spa revealed standing water on shower walls, no air flow from the ceiling vents or by windows that opened to the outside. Paper was held up to the ceiling vent by Staff (#4) that did not adhere to the vent. Interview with the GNA, Staff#5 on 7/11/19 at 3:11 PM revealed that it does get humid and uncomfortable when showering several residents in a row in the room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility staff failed to enhance and promote resident dignity by failing to 1. knock prior to entering resident's rooms, 2. engaging residents in casual conversation, and addressing resident's requests for assistance (#43), and 3). obtaining permission from resident before providing care (#233). This was evident for 2 of 91 residents reviewed during the survey, however exampled #1 has the potential to affect all residents. The findings include: 1. While making observations of the various units in the facility on 2/15/18 at 12:22 PM, Staff #1, a Geriatric Nurse Assistant (GNA) went into room [ROOM NUMBER] and did not knock prior to entering the resident's room. Within minutes, Staff #2, a GNA came out of another resident room and entered room [ROOM NUMBER] and did not knock prior to entering the resident's room. In an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 2/15/18 at 1:30 PM, they were…

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

Based upon resident interviews, record review and staff interviews it was determined that facility staff failed to consider or act upon Resident Council's grievances regarding food and staff interactions with residents. The findings include; On 02/15/18 at 1:27 PM a meeting with the facility's Resident Council was conducted. Members stated that they had expressed concerns in recent council meetings regarding staff chatting amongst themselves around them, ignoring/declining residents' requests for assistance, failing to knock on doors before entering Residents' room, and providing care for residents without notification or obtaining permission. However, review of the January's Resident Council meeting revealed no acknowledgement of any of these concerns. Interview with the Administrator following the meeting revealed that s/he was not aware of concerns from the Resident Council meeting regarding staff interaction with residents. Administrator stated that it was expected that any grievances, recommendations and concerns expressed during Resident Council would be documented in 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 3. A care plan meeting was conducted with the interdisciplinary team on 1/22/18 for Resident #78 and on 2/9/18 for Resident #137. In an interview with the Director of Nursing (DON) on 2/16/18 at 3:00 PM s/he stated that the family/and or resident was provided input, however, a copy of the careplan meeting was not given to the resident and/or family representative. Based on review of the medical record and interview with staff it was determined that the facility failed 1. to have a system in place to provide a summary of the interim plan of care to the resident or responsible party. This was found to be evident for 5 of 5 residents (#133, #75, #78, #137, and #29) reviewed for care planning in the investigative portion of the survey process. The findings include: 1. On 2/16/18 review of Resident #133's medical record revealed that the resident was admitted on [DATE] for rehabilitation and with diagnosis that included muscle weakness, chronic kidney disease, muscle weakness and high blood pressure and dementia.…

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, observations and interviews with facility staff it was determined the facility failed to 1. develop a care plan for a resident with a footrest and attached foot buddy as an immobilizer, 2. develop a care plan for a resident with a falls history, and 3. develop a care plan for precautions and monitoring for residents on blood thinner medications. This was evident for 4 of 30 residents (#37, #78, #13 and #82) residents reviewed during this survey. residents reviewed for accidents during the survey process. The findings include: 1. Failed to develop a care plan for a resident who used a footrest with attached foot buddy as an immobilizer. On 2/14/18 at 1:45 PM, Resident #37 was observed sitting in a wheelchair in the bedroom with his/her feet in a footrest with buddy attachment. The strap was observed across the front of the resident's legs restricting movement. The Director of Nursing was made aware of the improper placement of the footrest on the resident. An interview was conducted with Staff #11 on 2/15/18 at 12:30 PM and s/he was asked to…

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

Based on medical record review and interview with staff it was determined that the facility staff failed to 1. update a care plan to reflect the presence of and current treatment of a pressure ulcer, and 2. implement a care plan to address concerns identified during a nurse assessment of a resident. This was found to be evident for 2 out of 8 residents (Resident #45 and #33) reviewed for care planning revision. The findings include: 1. On 2/15/18 Resident #45's medical records were reviewed. This review revealed that on 12/30/17 a geriatric nursing assistant (GNA) reported to the nurse that the resident had an open area in the middle of her/his back, Further review of the note revealed that the nurse cleaned it with normal saline solution and covered it with a dressing. According to the annual minimum data set completed on 1/10/18, the resident had a stage 1 or greater pressure ulcer. On 2/15/18 review of the care plan revealed a plan initiated 10/17/17 for Resident is at risk for skin breakdown secondary to the following risk factor Braden Assessment score (preferred tool…

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

Based on observation, medical record review, resident and staff interviews it was determined that the facility staff failed to put a system into place to ensure that delegation of duties regarding medication administration are properly conducted for residents. The findings include: Delegation is the process for a Registered Nurse (RN) to transfer authority / responsibility to direct another person to perform nursing tasks and activities not normally allowed to do. The RN retains responsibility for the delegation through supervision/monitoring, follow up of tasks/activities delegated; provide direct observation of residents, evaluate the nursing care provided and follow-up as needed. A certified medication aide (CMA) is a certified nursing assistant (CNA) that has completed additional classroom training to be certified to dispense medications to residents while working under the supervision of a Registered Nurse Observation of medication administration passes performed by CMA (Staff #16) was conducted on 2/13/18 at 8:00 AM on the Peach Blossom unit. Medication administration error…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to 1. keep a resident safe from accidents and hazards (#78), 2. identify hazard risks (foot rests, uncovered foot rests and jagged/splintered handrails). This was evident for 2 of 30 residents (#78 and #17) reviewed during the facility's annual survey. The findings include: 1. Resident #78 was admitted to the facility with the following but not limited to diagnosis: Displaced Intertrochanteric fracture of left femur. Review of a progress note dated 2/1/18 at 2:52 PM, indicated that Resident #78 had an unwitnessed fall from wheelchair to floor, and sustained a laceration to the back of the head (right side) and a skin tear to top of the left hand. According to the progress note, physical therapy left Resident #78 with Staff #13. The progress note further indicated that after Staff #13 assisted the resident with lunch, s/he walked out of the resident room for a few minutes to grab linens to give the resident a shower, and upon return to the room, found Resident #78 lying on 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 medication administration observation it was determined the facility staff failed to ensure a medication error rate of less than 5 percent (7.89%) for 5 Residents (Resident #59, #79, #70, #139 and #137) reviewed during medication pass on the Peach Blossom Unit. The findings include: 1. Observation of medication administration passes performed by CMA (Staff #16) was conducted on 02/13/18 at 8:00 AM on the Peach Blossom unit. Surveyor observed CMA (Staff #16) administered to Resident #59 a small cup that contained 4 pills. The resident examined the cup, passed it back, and asked if the pills could be mixed in applesauce the way they were used to getting them. The CMA retrieved the pills, dissolved them with the applesauce, and re-administered the medications. Surveyor asked CMA #16 if there was a way to know how the resident's take their medications. The CMA replied that they rely upon a cheat sheet which was received from one of the nurses the day before. It would indicate if a resident's preferred or needed to take their medications with applesauce. However 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 interviews and review of dietary temperature logs it was determined that the facility staff failed to ensure meals were palatable. This failure had the potential to affect all residents receiving meals from the facility's kitchen. The findings include: On 2/14/18 Resident #65 was interviewed. During the interview the resident reported that the food is not always hot. In addition, the resident's family member also reported that the food is not always hot. It was further reported that the resident enjoys scrambled eggs but cold eggs are not appetizing. Review of the Resident Council concerns forms revealed that in August 2017 there was a concern about the food being lukewarm and sometimes cold. The October 2017 concern revealed that the food temperature was somewhat better but still cold. Further review of the January 2018 council concern reveal that the breakfast is always cold. During an interview with the food service director, he acknowledged that the food was sometimes cold but it was due to how they were transporting food in the hallways. He also revealed that he was…

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

Based on medical record review and interview with the facility staff, it was determined that the facility failed to document timely notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare. This was evident in 3 of 3 (#77, #48 and #23), residents reviewed regarding liability notices. The findings include: Notification to residents regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. In addition, the (advance beneficiary notice) ABN gives you information to make an informed choice about if to get items or services, understanding that you may have to accept responsibility for payment. 1. On 2/21/18 Resident #77's Beneficiary Protection and Notification task was conducted. It revealed that the facility was not able to locate the ABN forms. During an interview with Social Worker (SW- Staff #9) she revealed that she…

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 residents or resident representatives were notified in writing that they were being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 2 of 2 resident's (#68 and #77) reviewed for hospitalization during the survey. The finding includes: 1. On 2/22/18 Resident #68's medical records were reviewed. This review revealed a nurse's note written on 1/18/18 which indicated that the resident had an unwitnessed fall in the bathroom which resulted in a laceration with uncontrolled bleeding. Further review of the medical records revealed that the physician saw the resident and ordered the resident be sent out to the hospital. Review of the nurse's note written on 1/18/18 revealed that the resident's responsible party (RP) was called to give an update on the resident's status. Further review of the medical records failed to reveal any documentation that written…

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 residents or resident responsible party (RP) were given written notification of the facility bed hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 2 of 2 residents (#68 and #77) reviewed for hospitalization during this survey. The finding includes: 1. On 2/22/18 Resident #68's medical records were reviewed. This review revealed a nurse's note written on 1/18/18 which revealed that the resident was being transferred to the emergency room for evaluation. Review of the nurse's note written on 2/22/18 revealed that the resident's RP was called and made aware of the transfer to the hospital. Review of the medical record failed to reveal any documentation that the resident or the responsible party had been provided written notification of the bed hold policy, During an interview with the Director of Nursing (DON) and the Administrator on 2/22/18 the surveyor requested documentation 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 medical record review and staff interview it was determined that the facility staff failed to provide an accurate assessment of Resident #17's transfer status. This was true in 1 (Resident #17) of 30 residents reviewed during survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 02/15/18 at 7:00 PM, Resident #17's medical records were reviewed. This review revealed that the resident had an annual MDS assessment on 09/02/17. A review of the assessment that was completed on 09/02/17 Section G Functional Status under sub-section for; Bed Mobility and Transfers revealed that the resident was coded as extensive assistance, which meant that the Resident was involved in the activity, and staff provide weight bearing support. Further review of the MDS revealed that the resident was coded as requiring 2 persons 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, interview with facility staff it was determined that the facility failed to obtain an Occupational Therapy evaluation prior to giving the resident a walker and to assess the resident for elopement risk prior to placing a wander guard. This was true for 1 out of 30 (Resident #133) residents reviewed during the investigative stage of the survey. The findings include: On 2/16/18 Resident #133 medical records was reviewed. This review revealed that the resident was admitted to the facility in December 2017 for rehabilitation and with diagnosis that included atrial fibrillation (irregular heart beat) difficulty in walking and dementia. Review of the initial fall assessment revealed that the resident scored a 22, a score 10 or higher represents a high risk for fall. Further review of the resident assessment revealed a referral for fall precaution management, physical therapy (PT) and to continue current plan of care. Review of the nursing admission note revealed that the resident got up without calling for assistance and that the resident appeared weak 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 observations it was determined the facility staff failed to adhere to infection control practices and policies when providing care to the residents. This was evident during the facility's annual medicare/medicaid survey. The findings include: An observation was made on 2/15/18 at 12:22 PM of Staff #1, a GNA coming out of room [ROOM NUMBER] and going into room [ROOM NUMBER]. Upon entering the resident room, Staff #1 removed a yellow caution sign that was on the floor, and proceeded to assist the resident in the room. The staff did not wash or sanitize his/her hands. Another staff, #2, a GNA was observed on 2/15/18 at 12:26 PM coming out of room [ROOM NUMBER] and then entered room [ROOM NUMBER] to assist staff #1 with the resident. Staff #2 did not wash or sanitize his/her hands. The Nursing Home Administrator was made aware on 2/15/18 at 12:50 PM.