Coffman Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a record review, observation, and interviews, it was determined that the facility failed to provide an assistive device for eating to a Resident. This was evident in one of four dining observations during the survey.The findings include:On 7/15/25, at 8:14 AM, a review of a report provided by the dietary manager for Residents who require special utensils during meals was completed. The review showed that Resident #40 required “a [NAME] anti-spill cup, a yellow-lipped plate, and small built-up utensils [special fork and spoon with built-up handles to aid people with a weakened grip]” for every meal. However, during dinner observation on 7/17/25, at 5:35 PM, Resident #40 was eating dinner in his/her room and did not have his/her weighted utensils. Staff #6, a geriatric nurse aid, was present and stated that she had given Resident #40 regular utensils because the weighted utensils had not been received from the dietary staff. In an interview on 7/17/25 at 6:05 PM, Staff #17, a dietary aid, confirmed 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 complaint, review of the facility policies and a closed medical record, as well as staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury. This was evident for 1 (Resident #6) of 6 residents reviewed during a complaint survey. The findings include: A review of complaint MD00183144 on 03/22/24 revealed an allegation that Resident #6 had fallen and was not assessed or treated for 6 hours. A review of the facility Change in a Resident's Condition or Status policy on 03/22/24, revealed that: 1) The nurse will notify the resident's attending physician or the physician on-call when there has been an accident or incident involving the resident. Under #4 of the policy: Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. A review of Resident #6's closed medical record on 03/22/24 at 11 AM…

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, interview and review of relevant documentation, it was determined that the facility failed 1) to ensure that clean dishes were stored in a manner to prevent contamination; 2) maintain a cleaning schedule for the ice machine 3) ensure bulk food items were labeled and dated and 4) failed to ensure the temperature of the nourishment refrigerator was monitored. These practices have the potential to affect all the residents in the facility. The findings include: 1) On 4/14/22 at 9:44 AM surveyor observed a tray of coffee cups sitting open side down on a tray. Per surveyor request, when the certified dietary manager (CDM #8) picked up two of the cups, water was noted to be present inside the cup. The CDM removed the tray from the clean area and indicated they should have been dried on the drying rack prior to being put in the clean area. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganism can grow. 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 observation and staff interview, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to store insulin pens and glucometers in a way that reduced the risk of bloodborne pathogen exposure, 2) failing to have a process in place to screen and educate visitors regarding infection control procedures for visiting, 3) failing to review and update Infection Prevention and Control policies and procedures on an annual basis. 4) failing to follow hand hygiene procedures during medication administration, 5) failing to properly store resident care equipment, and 6) failing to ensure daily COVID symptom assessments were being completed. This was evident during the annual survey and had the potential to affect all residents, staff, and visitors. This was also evident during an observation of 1 of 2 certified medication aides administering medications for 1 (#39) of 3 residents, and for 2 (#9, #19) out…

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 records and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 1 (#291) of 3 residents reviewed for Beneficiary Protection Notification. The findings include: The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 4/20/22 at 2:28 PM, a review of the SNF Beneficiary Protection Notification Review worksheet completed by the facility indicated Resident #291 was discharged from the facility on 1/18/22 with benefit days remaining and a SNFABN form was not provided to the…

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

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure their residents were free of abuse. This was evident during the annual survey and has the potential to affect all residents. The findings include: A review of the facility's Resident Abuse and Neglect policy, dated 5/2/18 with the last revision on 9/20/21, revealed that the facility had failed to establish a procedure for 1) staff to identify the types of abuse, 2) screening of all new employees to prohibit abuse, 3) notification of the State Agency with appropriate timeframes, 4) protecting the resident from the alleged perpetrator until an investigation can be completed, 5) conducting an investigation of alleged abuse, and 6) education of staff at least annually. In addition, the abuse policy failed to address how to identify, report, and investigate an injury of unknown origin. During a review of the concerns with the Assistant Director of Nursing (ADON) #13 on 4/22/22 at 11:38 AM, she reported that the facility needed to review and…

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

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to establish when to report suspicion of a crime and mandated time frames to report those suspicions. This was evident during the annual survey and has the potential to affect all residents. The findings include: On 4/21/22 at 1:00 PM, a review of the facility's Resident Abuse and Neglect Policy, dated 5/2/18 and revised 9/20/21, revealed that the facility failed to include in the policy to report to local law enforcement any suspicions of a crime and include the required timeframes of such reports. While reviewing the concerns with the Assistant Director of Nursing (ADON) #13 on 4/22/22 at 11:38 AM, she reported she had been aware that the facility's policies and procedures needed to be reviewed and updated. On 4/26/22 at 9:18 AM, the Administrator was made aware of the concern with the Resident Abuse and Neglect policy.

Based on medical record review and interview with staff it was determined that the facility failed to ensure that staff identified injuries of unknown origin and reported them to the state survey and certification agency. This was found to be evident for 2 ( #22, #16) of 31 residents reviewed during the survey.The findings include: 1) A record review for Resident #22 on 4/21/22 at 8:33 AM, revealed an annual Minimum Data Set (MDS) with the assessment reference date of 11/22/21. Review of section C revealed Resident #22 had a Brief Interview of Mental Status score of 3 out of 15, indicating that Resident #22 had severe cognitive impairment. Review of section G revealed Resident #22 was totally dependent and required extensive assistance from staff for bed mobility and transfers to a chair. Further review of the medical record revealed a progress note that was entered on 3/21/22, by Licensed Practical Nurse (LPN) #20 that read Resident #22 had a purple bruise on right eyebrow area, no complaints when it was touched, Resident #22 was not sure how it had happened. LPN #20 also…

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

Based on medical record review and interview, it was determined that the facility 1) failed to include the required statement of the resident's appeal rights and contact information in the written notice of transfer, 2) failed to notify the resident/representative of the reason for the transfer, and 3) failed to notify the resident representative in writing of a transfer/discharge. This was evident for 1 (#30) of 1 resident reviewed for hospitalization. The findings include: On 4/26/22 at 10:00 AM, a review of Resident #30's medical record revealed the resident was transferred to an acute care facility on 4/7/22. On 4/26/22 at 1:35 PM, review of a Notice of Intent to Discharge form, dated 4/7/22 was initialed by Resident #30, and documented the resident was being discharged /transferred from the facility to an acute care facility. 1) The Notice of Intent to Discharge form indicated the resident had a right to appeal the discharge/transfer to the appropriate State Long-Term Care Agency and included phone numbers, fax number and mailing address. However, the written notice 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 record review and staff interview, it was determined that the facility failed to have a process in place to ensure that a Preadmission Screening and Resident Review level II (PASARR II) referral was completed for a resident who was newly diagnosed with a mental illness while living in the nursing home. This was evident for 1 (#25) of 14 residents reviewed during annual survey. The findings include: According to the State Operations Manual, a PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has MD, ID or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs. The Level II evaluation report must be used by the facility when conducting assessments of the resident, developing the care plan, and when transitions of care occur. Incorporating the Level II information in these processes promotes comprehensive assessment and provision of care for residents with MD or ID. On 4/20/22…

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 failed to develop a care plan to address a resident's needs related to activities. This was found to be evident for 1 (#9) of 3 residents reviewed for activities. 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. Review of Resident #9's medical record revealed that the resident was admitted to the facility in January 2022. The resident was dependent on staff for assistance with activities of daily living such as dressing, bathing and eating. The resident had unclear speech and was rarely understood. The resident was observed in bed, but no television or other activity was observed on 4/14/22 at 11:39 AM, 4/15/22 at 10:22 AM, 4/20/22 at 9:59 AM, 4/21/22 at 9:39 AM and 4/25/22 at 1:15 PM. Further observations of the resident throughout the survey failed to reveal the provision of activity services. On 4/26/22, review of the Activity admission Assessment, completed by the Activity…

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 who evaluate care plans failed to revise the interdisciplinary care plans to reveal accurate approaches. This was evident for 1 (#30) of 1 resident reviewed for pressure ulcers. 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. Review of Resident #30's medical record revealed that Resident #30 received treatment for a pressure ulcer on his/her left heel. Review of Resident #30's care plans revealed a care plan with the start date 3/11/22, Resident has potential for skin injury R/T (related to) fragile skin, that included the approaches 1) Benadryl capsule; 25 mg; amt: 1, oral. Special instructions: 1 TID (3 times a day) PRN (as needed) for c/o (complaint) itching d/t (due to) rash and 2) Nystatin-triamcinolone cream; amt: small amount; topical. Special instructions: apply small amount to bilateral feet BID. Both care plan approaches had the start date 3/11/22. 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 review of observation, interviews, and review of medical records and activity staff documentation, it was determined that the facility failed to ensure that each resident received an ongoing program to support their choice of activities. This was found to be evident for 2 (#9, #16) of 3 residents reviewed for activities during the survey. The findings include: 1) Review of Resident #9's medical record revealed that the resident was admitted to the facility in Januray 2022. The resident was dependent on staff for assistance with activities of daily living such as dressing, bathing and eating. The resident had unclear speech and was rarely understood. The resident was observed in bed, but no television or other activity was observed on 4/14/22 at 11:39 AM, 4/15/22 at 10:22 AM, 4/20/22 at 9:59 AM, 4/21/22 at 9:39 AM and 4/25/22 at 1:15 PM. Further observations of the resident throughout the survey failed to reveal the provision of activity services. On 4/26/22, review of the Activity admission 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 and interview, it was determined that the facility failed to ensure that staff completed the controlled drug count at the change of shift as evidenced by documentation by nursing staff that the count had been completed prior to the end of the shift. This was found to be evident for 1 out of 3 controlled substance log books reviewed. The findings include: Review of the facility's Controlled Medications policy, updated 8/19/2015, revealed the following: Narcotics are counted at the end of each shift by the off-going and on-coming staff and both sign for correctness of the count. On 4/20/22 at 10:10 AM, review of the Shift Count signature sheet for the narcotics kept on the nurse's treatment cart revealed the nurse who was currently responsible for the cart (nurse #4) had already signed her name in the space designated for Going Off Duty. On 4/20/22 at 10:15 AM, nurse #4 confirmed that narcotics are kept in a lock box on the treatment cart and that she is responsible for their administration. When asked about the process for the count, nurse #4 reported:…

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, medical record review and staff interview, it was determined that the facility staff failed to ensure a medication error rate of less than 5 percent for 1 (#18) of 3 residents observed with 28 medication administration opportunities resulting in an error rate of 6.9 % by 1 of 2 certified nursing assistants. The findings include: EC (enteric coated) initials following the name of medication means a substance has been applied to the drug to protect the stomach from the drug, protect the drug from stomach acid, or release of the drug past the stomach. Crushing EC medication may result in the drug being released too early, being destroyed by stomach acid, or irritating the stomach lining. ER (extended release) initials that follow the name of the medication means the medication will be released in the blood stream over an extended period. Breaking or crushing the pill form of the medication may cause too much of the medication to be released at one time which could cause serious side effects. EC and ER medications should not be crushed. 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 observation and staff interview, it was determined that the facility failed to store medications in a locked container and limit access to those medications as evidenced by a medicine cart left unlocked and unsupervised with topical medications and the keys to the cart in a cup sitting on top of the cart. This was evident for 1 of 3 medicine carts observed during the survey. The findings include: An observation on 4/20/22 at 9:16 AM, revealed a medication cart in 200 hallway that was unlocked and unattended. On the top of the cart was an unlabeled medicine cup with a dab of white cream in it, a second unlabeled medicine cup with a clear liquid in it, and a green colored packet of OcuSoft (a treatment for eyelids). Also, under the computer was a plan white paper cup. Licensed Practical Nurse (LPN) #4 returned to the cart at 9:21 AM. There were 4 residents sitting in wheelchairs in the hallway and 1 of the residents was mobile in his/her wheelchair going up and down the hallway and passing the unattended cart. An interview was conducted with LPN #4 on 4/20/22 at 9:21 AM, when…

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 resident and staff interview, it was determined that the facility failed to serve meals and beverages at an appetizing temperature as evidenced by resident complaints that the food and coffee were served cold when they eat in their rooms. This was evident for 2 (#31 and #10) of 14 residents screened for dining concerns. The findings include: During the initial screening process on 4/14/22 at 9:15 AM, an interview with Resident #31 revealed that the food was being served cold and the coffee was lukewarm. An observation on 4/14/22 at 12:15 PM, of the lunch trays being served on the 300 unit revealed that the food was brought to the unit in an unheated cart, on regular dinner plates with cellophane wrapped over them. An interview with Resident #10 on 4/15/22 at 11:21 AM, revealed that Resident #10 was being served cold food when eating in his/her room and that the coffee was not warm enough. On 4/21/22 at 12:30 PM, a second observation of lunch trays being delivered to the 300 unit revealed the trays were in an unheated cart, on regular dinner…

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

Based on medical record review and interview, it was determined that the facility failed to develop effective plans of correction (PoC) to correct previously cited deficiencies. This has the potential to affect all residents. The findings include: Review of the plan of correction for the last annual survey, conducted in December 2018, revealed that the facility had been cited under F 609 due to failure to report injuries of unknown origin to the state agency as required. This deficient practice was identified again during this survey. Cross reference to F 609. The previous POC included education. It did not include a review or revision of the abuse policy or procedures. It failed to address the entire regulation, focusing only on the specific example provided to support the deficient practice. The QA component indicated that the QA nurse would review all skin injury reports for injury of unknwon origin for appropriate reporting monthly for 3 months with results to QAPI for review and recommendations. Additionally, the facility was cited under F 609 in November 2020 due to failure 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 and staff interview, it was determined the facility failed to provide housekeeping and maintenance services necessary to keep the resident's environment clean and in good repair. This was evident on 3 of 3 hallways. The findings include: The following environmental concerns were observed during the survey: In room [ROOM NUMBER], there was a shared bathroom. The left flange was loose on the hand rail on the wall to the left of the toilet. The interior door frames of the door which led into room [ROOM NUMBER] had scrape marks with paint missing. The door guard to the left door frame of the interior bathroom door was peeling. In room [ROOM NUMBER]B, the middle of the exterior bathroom door had an area of finish that was missing, which exposed the wood. In room [ROOM NUMBER], the bedroom side of the bathroom door had a deep gash, approximately 7 inches long, 2 inches high and 2 inches deep. The grab bar to the left of the bathroom door was loose and there was spackling around the flange 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.

3) On 12/7/18, a review of Resident #4's medical record revealed that, on 11/14/18 at 11:00 PM, in a progress note, the nurse documented that the resident was on an antibiotic for a MRSA (methicillin resistant staphylococcus aureus) infection in a scalp wound. Review of Resident #4's November 2018 MAR documented that, from 11/14/18 to 11/24/18, Resident #4 took the antibiotic medication, Bactrim DS twice a day for a MRSA infection. Review of Resident #4's quarterly MDS assessment, with an ARD of 11/19/18, Section I, diagnosis, revealed the MDS assessment failed to capture the wound infection diagnosis. Continued review of Resident #4's November 2018 MAR revealed documentation that the resident received the medication Lovastatin 20 mg, by mouth every day for hyperlipidemia (high cholesterol). Review of Resident #4's quarterly MDS assessment with an ARD of 11/19/18, revealed Section I, diagnosis, 13300. Hyperlipidemia was left blank; the MDS failed to capture the hyperlipidemia diagnosis. The MDS Coordinator confirmed the inaccuracies on 12/6/18 at 2:30 PM. 4) On 12/718, 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 6) On 12/4/18 at 11:14 AM, observation of Resident #4 revealed the resident was using oxygen. On 12/6/18, review of Resident #4's December 2018 Respiratory Administration History record revealed a 4/4/15 physician's order for Oxygen via nasal cannula, may titrate to keep SPO2 (saturation of peripheral oxygen) above 90%, check SP02 every shift while in use every shift which was documented as being administered every shift from 12/1/18 through 12/6/18, days. Review of Resident #4's quarterly assessment dated [DATE], documented diagnoses that included dependence on supplemental oxygen. Review of Resident #4's care plans failed to reveal that a comprehensive care plan had been developed to address Resident #4's respiratory status and use of oxygen. On 12/7/18 at 12:59 PM, the Director of Nurses was made aware of these findings. 7) On 12/10/18, a review of Resident #35's December 2018 Medication Administration Record (MAR) revealed a 3/7/18 physician order for Acetaminophen (pain medication) 650 mg (milligrams) 3…

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.

4) Resident #24's medical record was reviewed on 12/10/18 at 12:58 PM. The resident had a physician's order for Amitriptyline 10 mg (milligrams) at bedtime for insomnia, which was decreased on 8/25/18, from 25 mg at bedtime. The resident had a plan of care for insomnia, which included the intervention 'Administer medications: Amitriptyline 25 mg every night at bedtime'. The Evaluation note, dated 9/18/18, indicated Care Plan reviewed and current. The plan of care was not updated to reflect the dosage change of the resident's Amitriptyline, nor did the plan evaluate the resident's progress or lack of progress toward reaching his/her goal. Staff #1 was made aware of these findings on 12/10/18 at approximately 2:30 PM. 3) Review of the written care plans for Resident #14 on 12/10/18 revealed a plan for activities with a stated goal Resident will express satisfaction with daily routine and leisure activities. There were three written evaluations for the activities plan of care, with the last evaluation dated 11/27/2018. All three evaluations indicated that a care conference was held for…

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 surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior annual quality indicator survey. The findings include: On 12/10/18 at 3:15 PM, the surveyor reviewed the results of the facility's last quality indicator survey dated 8/16/17. The corrective actions implemented by the facility after the last annual survey failed to effectively correct deficiencies related to failing to maintain a safe, clean, comfortable homelike environment, failing to ensure the accuracy of assessments and failing to develop/implement comprehensive care plans. These failures resulted in a continuation of the deficient practices as identified during the current recertification survey. Cross reference F 584, F 641 and F 656. On 12/10/18 at 3:36 PM, the Quality Assessment and Improvement program was reviewed with staff #17. Deficient practices cited during the last…

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 surveyor observation, it was determined that the facility staff failed to treat each resident with respect and dignity by failing to accommodate the dining needs of all residents seated together at a meal in a timely manner. This was evident for 2 (#6 and #7) of 4 residents seated together during breakfast service. The findings include: On 12/4/18 at 8:15 AM, the surveyor observed 4 residents sitting at a table in the dining room. One resident at the table had already begun eating his/her breakfast while getting occasional prompts from staff. Staff #18 began feeding Resident #2 his/her breakfast at 8:18 AM. Resident's #6 was sitting reclined approximately 2 feet away from the table dozing. An open plastic container of fruit loops, a carton of milk and 2 full beverage cups were on the table beside Resident #6. At 8:19 AM, staff placed a plate containing a poached egg and bread, and a cup of yogurt on the table with the other food near Resident #6. At 8:29AM Staff #19 began feeding Resident #6. Resident #6 was not provided with the assistance he/she required to eat breakfast…

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

Based on record review and interview with facility staff, it was determined that the facility failed to notify the physician and resident's representative timely of a residents injury. This was evident for 1 (#6) of 18 residents reviewed during the investigative phase of the survey. The findings include: Resident #6's record was reviewed on 12/7/18 at 9:53 AM. The record revealed an event report, dated 9/25/18 12:05 AM, which indicated that the resident had a scratch type area with swelling on forehead. The report indicated that, neither the physician, nor the resident's representative/family were notified of this injury. An event report, dated 9/26/18 12:00 AM, 24 hours later, documented a reddish purple bruise to right inner aspect and underneath side of right eye. It also indicated may be result of injury to head yesterday. The report indicated that the physician and the resident's family were notified of this injury on 9/26/18 at 3:15 PM. This was 39 hours after the injury on 9/25/18. During an interview on 12/7/18 at 12:10 PM Staff #1 confirmed that 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 staff interview, it was determined the facility failed to document what preparation and orientation was given to a resident to ensure an orderly transfer to an acute care facility. This was evident for 1 (#37) of 1 resident reviewed for hospitalization. The findings include: Review of the medical record for Resident #37 on 12/10/18 revealed that, on 12/6/18, the resident complained of shortness of breath and was sent to an acute care facility. There was no documentation in the medical record that the resident was prepared and oriented about the transfer. Interview of the Assistant Director of Nursing (ADON) on 12/10/18 at 11:15 AM confirmed that the documentation was not there. The ADON stated, I am sure they are doing it. It is just not documented.

Based on observation, medical record review, and family and staff interview, it was determined the facility failed to render care in accordance with the resident's care plan and failed to apply an ordered treatment. This was evident for 1 (#7) of 2 residents reviewed for positioning/mobility. The findings include: Review of Resident #7's medical record, on 12/4/18, documented that the resident had frequent skin tears. Review of the care plan section of the medical record revealed a care plan, Resident at risk for skin injury d/t (due to) fragile skin. The interventions on the care plan included Geri sleeves to bilateral arms for skin protection. Review of Resident #7's December 2018 physician's orders stated, geri sleeves to bilateral arms for skin protection. This was initially ordered on 1/26/15. Another order patient is to wear edema glove to left hand before rising out of bed in AM and off when in bed in evening was noted with an order date of 9/28/18. Observation was made, on 12/4/18 at 1:04 PM, of the resident sitting in a wheelchair in his/her room. The resident's daughter…

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, family interview, medical record review and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (#7) of 2 residents reviewed for mobility. The findings include: Observation was made, on 12/4/18 at 9:12 AM, of Resident #7. Resident #7's hands were closed in a fist like position. The resident did not have on a brace or splint device. The resident's daughter stated that the resident wore a brace at night. The daughter stated that the right hand was contracted and the left hand appeared to be getting worse. Review of Resident #7's medical record on 12/4/18, documented that the resident wore a resting hand splint from 9 PM to 5 AM daily on the left hand. On 12/10/18 at 9:08 AM, the Occupational Therapist (OT) was asked if the resident had a contracture in his/her hands. The OT stated, in August 2018 we picked him/her up for a left-hand contracture, but I could range him/her out quite…

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 record review, it was determined that the facility staff 1) failed to ensure the maintenance of bedrails, 2) failed to ensure that resident bed rail assessments were kept in the resident's medical record, 3) failed to ensure that resident's bed rail assessment information included attempts at using alternatives to bed rails, including how the alternatives did not meet the resident's medical or safety need or were inappropriate and 4) failed to reveal ongoing assessment to assure that the bed rail is used to meet the resident's needs. This was evident for 1 (#16) of 1 residents reviewed for accidents. The findings include: On 12/4/18 at 8:55 AM, Resident #16 was observed lying in bed. Observation of the resident's bed revealed that there was a metal half bed rail attached to each side of the resident's bed and both bed rails were loose, putting the resident at risk for entrapment. On 12/4/18 at 3:09 PM, the Director of Nurses (DON) accompanied the surveyor to the resident's room and confirmed that the side rails on Resident #16's bed 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 on medical record review and staff interview it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure a medication had a clear dosage regimen. This was evident for 1 (#35) of 7 residents reviewed for unnecessary medication. The findings include: On 12/7/18, review of Resident #35's December 2018 MAR (medication administration record) revealed a 3/7/18 physician's order for Acetaminophen 650 mg by mouth as needed for pain or temperature greater than 100. The order failed to indicate the time between doses or how often the resident could take the medication. On 12/10/18 at 2:53 PM, the Director of Nurses confirmed the findings.

Based on observation and medical record review, it was determined the facility failed to keep accurate medical records as evidenced by professional nursing staff signing off that a treatment was performed when it was observed not to be done. This was evident for 1 (#7) of 2 residents reviewed for mobility. The findings include: Review of Resident #7's December 2018 physician's orders stated, geri sleeves to bilateral arms for skin protection and patient is to wear edema glove to left hand before rising out of bed in AM and off when in bed in evening. Observation was made on 12/4/18 at 1:04 PM, of the resident sitting in a wheelchair in his/her room. The resident's daughter was present at the time. The resident was not wearing geri-sleeves. The daughter confirmed that she had not seen the geri-sleeves on Resident #7 in a while and stated that the resident was supposed to wear an edema glove but had not seen the glove. The resident was not wearing an edema glove. A second observation was made on 12/6/18 at 1:20 PM. The resident was not wearing geri-sleeves or the edema glove. 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.