Atlee Hill Health And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined that the facility failed to provide residents/representatives with a copy of their baseline care plan, which included a summary of the Resident's medication. This was evident for 2 (#14, #83) of 43 residents reviewed during the recertification survey.The findings include:A baseline care plan is a document that outlines initial instructions for providing care to a resident in a long-term care facility, typically developed within 48 hours of admission. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) In an interview on 8/19/2025, at 8:49 AM, Resident #14's representative stated that he had not received a copy of the Resident's baseline care plan, including a list of his/her medications. A record review on 8/21/2025, at 10:52 AM, showed that Resident #14 was admitted to the facility on…

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

Based on record reviews and interviews, it was determined that the facility failed to provide evidence to support a diagnosis of schizoaffective disorder. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medications.The findings include:According to facility medical records, Resident #2 has a medical history of major depression, dementia, bipolar disorder, and schizoaffective disorder, bipolar type.Schizophrenia is a severe and persistent mental disorder that affects how a person thinks, feels, and behaves. It can cause abnormal interpretations of reality and disruptions in a person's thought processes, perceptions, emotional responses, and social interactions.A Minimum Data Set (MDS) is a standardized assessment tool used to evaluate the health status of residents in long-term care facilities. The information helps facilities create care plans based on the residents' needs. MDS assessments are required for all residents.On 8/27/25 at 1:45 PM, the surveyor reviewed Resident #2's MDS assessments.On 12/19/24, Section I (Active Diagnoses) Psychiatric/Mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined that the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADL) was provided with showers. This was evident for 1 (#48) of 3 Residents reviewed for ADLs. The findings include:In an interview with Resident #48 on 8/19/2025 at 3:11 PM, s/he indicated that s/he would like to get more showers than were offered as of the time of the interview.A record review showed that Resident #48 had been in the facility since June 2025. A continued review included an MDS assessment dated [DATE], for Resident #48, which recorded that the resident required staff assistance with showering.The Minimum Data Set (MDS) is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions.A subsequent record review on 8/25/25, at 3:14 PM, of the GNA (Geriatric Nurse Aid) shower documentation from July 2025 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 medical record review and interviews, it was determined that the facility failed to ensure that care was provided in accordance with professional standards and physician orders. This was evident for 3 (#75, #76, and #79) of 5 residents reviewed in relation to complaint investigations.The findings include:1) Resident #79 was admitted to [NAME] Hill Nursing and Rehab Center following a hospitalization for dyspnea (shortness of breath or difficulty breathing). Their medical history included Congestive Heart Failure (weakened heart muscle that makes pumping blood difficult for the heart), Atrial Fibrillation (irregular and sometimes rapid heart rate), and hypertension (high blood pressure). On 8/21/2025, the surveyor reviewed a Facility Reported Incident (FRI) #337732 and a correlating complaint #337733 that were reported to the Office of Healthcare Quality (OHCQ) regarding a medication error involving Resident #79. The FRI document submitted to OHCQ by the facility’s Nursing Home Administrator (NHA),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide necessary treatment and services to promote the healing of pressure ulcers. This was evident for 1 (#14) out of 3 residents reviewed for pressure ulcers during the survey.The findings include:A review of Resident #14's medical record on 8/19/2025 at 9:08 AM revealed the Resident was admitted to the facility in August 2025 with a noted open wound to the sacral area with no measurements.A continued review included a skin/wound note dated 8/11/25 that showed that the Resident was assessed to have a right buttock/sacrum stage 3 pressure sore ( A pressure sore or injury is a localized area of skin damage that develops over a bony prominence or other hard surface due to prolonged pressure, shear, or friction). According to the note, Resident #14 reported that the wound was an existing wound upon admission.Further review of Resident #14's admission MDS, dated [DATE], noted that the Resident had a stage 3 pressure ulcer, which…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident received their medication according to the attending physician's order. This was evident for one out of 5 complaints reviewed during the survey.The findings include:A review of complaint #337738 contained an allegation that staff failed to assess and give medication to Resident #75 when s/he complained of chest pain.A continued review showed that the Resident's medical history included chest pain secondary to unstable angina and had an attending provider's order to have Nitroglycerin Tablet Sublingual 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for Chest Pain x 3 doses.Further review included a nurse's note dated 10/19/24 that stated Reported from previous shift that Resident [complained] of chest pain through the night. She was given prn Zofran. The review failed to show that Resident #75 was given Nitroglycerin when s/he complained of chest pain.In an interview on 8/28/2025 at 3:57 PM, Staff #10, Registered nurse (RN), reported that she had gotten a report…

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

Based on medical record review, observation and interview it was determined that the facility failed to maintain a medication error rate of less than 5%. This was found to be evident for one (Resident #37) out of the four residents observed for mediation administration as evidenced by two errors out of 25 opportunities for error.The findings include: On 8/20/25 at 8:37 AM surveyor observed the Certified Medication Aide (CMA #6) prepare and administer the medications for Resident #37. The CMA prepared a total of six medications: Carbidopa/Levodopa; metformin; a multivitamin; omeprazole; Sertraline; and liothyronine. Prior to administering the medications the CMA confirmed six medications were going to be administered to the resident. The CMA reported that she had administered the resident's synthroid earlier in the day. After the observation, surveyor reviewed the resident's current medication orders which revealed that in addition to the six medications administered, there were orders for two additional medications scheduled to be given at 9:00 AM: Meclizine for vertigo (dizziness);…

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, observations, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated their preferences. This deficient practice has the potential to affect all residents. The findings include:A review of complaint #337742 revealed an allegation that the meals delivered to the residents did not match what was stated on the menu.While observing the breakfast tray line on 8/26/2025, at 7:39 AM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #46. The listed food items on the meal ticket to be served to Resident #46 were: 3 oz biscuit with sausage gravy, 6 oz Cheerios, 6 oz orange Juice, 8 oz 2% milk, one bottle of water, pepper, and two packets of sugar.However, continued observation failed to show that Resident #46's tray contained the portion sizes listed on the meal ticket for the resident's Cheerios and orange juice. Staff #23, the Dietary Director, was present and asked about the portion size for the Cheerios and orange juice. Staff #23…

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

Based on record review and interviews, it was determined that the facility failed to provide evidence of educating, offering, and/or providing the pneumonia vaccine to residents. This was evident for one (Resident #9) out of five residents reviewed during the infection control task.The findings include:On 8/26/2025 at 11:08 AM, the surveyor conducted a record review of resident immunization records. The surveyor was unable to find evidence that Resident #9 had been offered, educated about, or received the pneumonia vaccine.On 8/26/2025 at 11:14 AM, the surveyor spoke with the Director of Nursing (DON) and requested evidence that Resident #9 had been educated and either received or declined the pneumonia vaccine.On 8/26/2025 at 12:12 PM, the surveyor again spoke with the DON, who stated they were unable to provide evidence that Resident #9 had received, or was educated about and declined, the pneumonia vaccine. The DON verbalized understanding that offering and educating is a regulatory requirement and stated it must have been missed because offering and educating is part of 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 observation and interview with staff, it was determined that the facility failed to store food and equipment in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: On 12/11/2023 at 8:10A.M., during the initial tour of the kitchen, Surveyors inspected a small walk-in refrigerator/freezer. Surveyors observed a 2lb (pound) bag of green sweet peas opened and undated, a 2lb bag of broccoli florets opened, undated, and wrapped in plastic wrap, and potato wedges opened, undated, and wrapped in plastic wrap. During the continued tour of the kitchen, Surveyors inspected the main walk-in refrigerator. Surveyors observed the shelves of the refrigerator which contained a 5lb bag of mozzarella cheese opened and undated, a 5lb bag of grated parmesan cheese opened and undated, provolone cheese slices opened and undated, feta cheese opened and undated, and an 8lb carton of macaroni salad opened and undated, a bag of fresh parsley opened and…

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

Based on observation and interviews with staff, it was determined that the facility failed to properly contain and cover waste in dumpsters. This was evident for 2 of 3 dumpsters in the outdoor garbage storage area observed during the annual survey. The findings include: During a tour of the facility's outdoor garbage storage area on 12/18/2023 at 8:44 A.M., the Surveyors and Dietary Manager (DM, Staff #21) observed a dumpster with an open lid filled to the top with trash bags and 11 trash bags on the ground surrounding the dumpster. During an interview conducted on 12/18/2023 at 8:50 A.M., Staff #21 confirmed that the expectation for trash disposal was that all trash should be contained inside the dumpster to avoid potential attraction of pests. Staff #21 informed the Surveyors that one dumpster is for cardboard and two dumpsters are for trash. During an interview with Environmental Services Director, Staff #29 on 12/12/2023 at 10:11 A.M., Surveyors were informed that a third dumpster was ordered for trash.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined the facility staff failed to develop and implement a baseline care plan to provide resident centered care for each newly admitted resident, based on the resident's minimum healthcare information. This was evident for 4 (#52, 118, #46, and #64) of 41 residents reviewed during the recertification 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. 1) Resident #52's medical record was reviewed on [DATE] at 10:43 AM. The record revealed Resident #52 was admitted on [DATE] with diagnoses which included but were not limited to Dementia, and Cognitive communication deficit. The residents Brief Interview of Mental Status (BIMS) score was 3/15 indicating severe cognitive impairment. A Baseline Plan of Care was developed [DATE] 18:53 (6:54 PM) and electronically signed by Staff #2 the Assistant Director of Nursing…

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 staff it was determined the facility staff failed to develop plans of care that included measurable objectives and timeframes to meet the resident's needs and the services to be furnished to assist the resident to attain or maintain his/her highest practicable well-being. This was evident for 4 (#118, #46, #76 and #80) of 41 care plans reviewed during the annual survey. The finding include: Resident #118's medical record was reviewed on 12/19/23 at 1:06 PM. The resident was admitted on [DATE] with an indwelling urinary catheter. The Physician orders included orders written 12/8/23 for an indwelling catheter, to change the catheter bag every 28 days and PRN (as needed), and for Catheter site care. An order was written on 12/12/23 for: Bladder scan for lower abdominal pain or inability to void > (more than) 6 hours. If >350 ml (milliliters)and unable to void with encouragement replace foley and inform provider; and an order written 12/13/23 for: Replace foley…

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, record review and interviews with staff it was determined the facility staff: 1) failed to implement a system for management of resident care equipment, 2) failed to establish and implement consistent infection control measures, 3) staff did not practice hand hygiene and, 4) staff did not follow transmission-based precautions; to prevent transmission of infection. This was evident for 3 (#118, #46 and #119) of 6 residents, and 5 (GNA # 18, 19, 20, 30, & RN #11) out of 7 staff observed for infection control during an annual survey. The findings include: 1) On 12/11/23 at 9:47 A.M., the surveyor observed a plastic drawer stand containing Personal Protective Equipment (PPE) and a Contact Precautions sign posted in the hallway to the left of Resident #118's door. The sign was published by the Centers for Disease Control and Prevention (CDC) and indicated: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Additionally, the sign instructed: PROVIDERS 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 medical record review and interview with staff it was determined the facility staff failed to inform and provide written information to all residents concerning the right to formulate at the resident's option, an Advance Directive. This was evident for 2 (#54 and #46) of 5 residents reviewed for Advance Directives. The findings include: ADVANCE DIRECTIVES: A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care. Resident #54's medical record was reviewed on 12/11/23 at 10:38 AM. The review failed to reveal a copy of Resident #54's Advance Directive in their medical record, or evidence that the facility staff provided education to the resident and offered them an opportunity and assistance to formulate one or more Advance Directives. An admission checklist, found in Resident #54's paper record included a space to check off Advance Directive, however, the checklist was blank. Resident #46's medical record was reviewed on 12/13/23 at 8:39…

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 related to a complaint and interviews with the facility staff and family, it was determined that the facility failed to report an unobserved fall with injury to the Office of Health Care Quality (OHCQ). This was evident during the review of 1 of 3 (#80) falls reviewed. The findings include: 1. Review on 12/20/23 at 7:50 AM of the complaint #MD00180645 revealed concern related to Resident #80 and a fall occurring on 6/13/22. Resident #80 was found in his/her room with blood on their forehead, face, and clothing with a 'notable raised contusion to right forehead that was also bleeding,' according to the facility change in condition report. Resident #80 was sent to the hospital via 911. Per the electronic health record (EHR) reviewed on 12/20/23 at 9:00 AM, Resident #80 was diagnosed with vascular dementia with behavioral disturbances and cognitive communication deficit. On 12/20/23 at 9:47 AM the Nursing Home Administrator (NHA) was interviewed related to what is reported to the state. She stated she would look regarding this incident, however, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that the resident and/or the resident representative (RP) were provided with a notice of transfer in writing. This was evident for 3 (#80, #61 and #29) of 3 residents reviewed during an annual survey with complaints. The findings include: 1. Review of the medical record for Resident #80 on 12/20/23 at 7:50 AM revealed an emergent hospital transfer on 6/13/22. The corresponding progress notes documented notification to the RP, however, the progress notes document the incident occurred at 12:00 PM and the notification did not occur until after 6PM. Additionally, there was no documentation that any written communication was provided to the RP regarding the reason for the transfer. Interview with Staff LPN #11 on 12/20/23 at 10:26 AM revealed that upon transfer they send a transfer form with the resident however, this is not documented anywhere in the notes. Interview with Resident #80's RP on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to notify the resident or the resident representative in writing of bed hold policy in writing. This was found to be evident for 2 (Resident #61 and Resident #29) of 3 residents reviewed for hospitalizations during the investigative portion of the annual survey. The findings include: 1) On 12/18/2023 at 8:15 AM the surveyor conducted a review of Resident #61's medical record. The record revealed the resident was admitted to the facility in 11/08/2023 with diagnoses including Nephritic Syndrome with Focal and Segmental Glomerular Lesions, Gastro Esophageal Reflux Disease, Acute Gastritis, Chronic Atrial Fibrillation, Chronic Kidney Disease and Essential Hypertension. Further review into the medical record revealed Resident #61 was transferred to the hospital on [DATE] due to bleeding and the bed hold policy was not found. On 12/18/2023 at 11:26 AM an interview with Registered Nurse, Staff #8, was conducted. Staff #8 was asked what…

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, record review and observation, it was determined that the facility failed to ensure residents care plans were reviewed and revised as required. This was evident for 2 (Resident #20 and #29) of 41 residents reviewed for careplans during the annual survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident ' s functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. During an interview conducted on 12/13/23 at 7:54 AM, Resident #20 reported that he/she fell out of bed while trying to reposition him/herself in bed; Resident #20 stated that 911 was called and he/she went to the hospital for evaluation and x-rays. On 12/15/2023 at 8:02 AM, review of Resident #20's medical records revealed a treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview it was determined the facility staff failed to ensure the resident's environment was as free of accident hazards as possible. This was evident for 1 (#52) of 5 residents reviewed for Accidents. The findings include: On 12/11/23 at 12:33 PM Resident #52 was observed lying in bed with their lunch in front of them on their overbed table. At 12:49 PM the resident was observed standing at their bedside dressed in a disposable brief and a shirt, pushing their overbed table from the bedside toward the doorway. No fall mats were observed in the room. Staff went into the room to assist the resident after surveyor intervention. A review of Resident #52's medical record on 2/11/23 at 1:42 PM revealed a physician order written 9/15/23 for: Fall mats when in bed, place on each side of bed. Another review of the resident's record on 12/13/23 at 10:43 AM revealed a Fall Risk Evaluation dated 9/14/23 which indicated Resident #52 was disoriented x 3, had 1-2 falls 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 Based on observation, review of the medical record and interview with staff it was determined the facility staff failed to provide appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for 1 (#118) of 2 residents reviewed for Urinary Catheter. The findings include: An intermittent (straight) catheter is inserted through the urethra into the bladder to empty it, then removed. An indwelling urinary catheter is inserted in the same way as an intermittent catheter, but the catheter is left in place. The catheter is held in the bladder by a water-filled balloon, which prevents it falling out. These types of catheters are often known as Foley catheters. On 12/12/23 at 10:14 AM Resident #118 was observed lying in bed with a urinary catheter bag hanging on the side of their bed frame. Review of Resident #118's medical record on 12/19/23 at 1:06 PM revealed Resident #118 was admitted to the facility on [DATE]. The review revealed a current physician…

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 and resident representatives, it was determined that the facility failed to have a process in place to implement and determine the competency of staff after a new protocol is put in place. This was evident related to a complaint regarding the implementation of care for a 'PleurX' catheter. A PleurX catheter is a small flexible tube that is surgically placed in the peritoneal space of your abdomen, used to remove excess peritoneal fluid (ascites). The findings include: Interview on 12/19/23 at 11:19 AM with the complainant for #MD00180645 revealed concerns with the way the drain that was in their family members (Resident #80) PleurX catheter was drained. They stated that they were asked to do it as and even stepped in as staff did not seem to know what they were doing. A review of Resident #80's medical record on 12/20/23 at 12:00 PM revealed a hospitalization on 12/18/22 related to respiratory distress. During the hospitalization Resident #80 was diagnosed with ascites (fluid collection in the abdomen). The decision…

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 the facility's Controlled Drug Count Verification sheets and interview with staff it was determined that the facility failed to ensure that an account of all controlled drugs were completed and accurate. This was found to be evident for 1 out of the 2 narcotic lock boxes located in the nursing medication cart. The findings include: During an observation of the Controlled Drug Count verification conducted on 12/19/2023 at 7:48 AM, the surveyors observed License Practical Nurse (LPN) #12 read off the Controlled Drug Count form for Resident #114's Brivact 100 mg count and stated the remaining count was 7. Registered Nurse (RN) #11 reviewed the actual medication blister pack and stated there are 6 remaining tablets not 7. LPN # 12 reviewed the blister pack and confirmed the count was off and that there were 6 remaining tablets not 7 as recorded on the Controlled Drug Count verification form. LPN #12 stated that RN # 15 had administered the medication on the evening shift on 12/18/2023. The surveyors observed LPN #12 write in pencil on the next blank line of the form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to 1) have a system in place to ensure that the attending physician documented and signed in the medical record to show they have reviewed an irregularity or recommendation identified by the pharmacist, what, if any action was taken, and his or her rationale of why the recommendation had been rejected in the resident's medical record and 2) have a policy/procedure for the monthly medication regimen review time frames for the different steps the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident, and integrate pharmacy consultant recommendations into the medical record as required. This was evident for 2 (#29 and #46) of 5 residents investigated for Unnecessary Meds during the annual survey. The findings include: A Medication Regimen Review (MRR) is when a consultant pharmacist completes a comprehensive review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review it was determined the facility failed to ensure adequate indication for use, identify resident specific behaviors, implement non-pharmacological behavioral interventions, and monitor for clinically significant side effects and responses, for use of an antipsychotic medication. This was evident for 1 (#118) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds and Med Regimen Review. The findings include: Review of Resident #118's medical record on 12/18/23 at 1:24 PM revealed the resident was admitted to the facility from the hospital on [DATE]. His/her diagnoses included but was not limited to Unspecified Dementia, severe, with other behavioral disturbance; Depression; and Anxiety Disorder. The resident did not have a diagnosis of schizophrenia or psychosis. Physicians medication orders written on 12/8/23 included: Memantine HCl (hydrochloride) (a medication used to treat dementia) 5 mg (milligrams) 1 tablet by mouth twice daily for dementia; Sertraline HCl, (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, interview and observations completed during medication pass, the calculated medication error rate during the annual survey for medication pass was determined to be 7.4%. The findings include: 1.) A medication observation was completed on 12/19/23 at 8:01 AM with certified medication aide (CMA) staff # 10. The medication pass began at Resident #18's room. According to staff #10 and the electronic medication administration record (EMAR) 5 medications were due for administration. This included multivitamin, Colace, vitamin D, brillinta-a blood thinner and MiraLAX. Staff #10 reported that Resident #18 did not take the MiraLAX, that s/he was educated prior and will refuse it. The surveyor asked if the staff and physicians were aware, and she said 'yes.' This surveyor proceeded to watch staff #10 enter Resident #18's room after knocking. She then slightly raised the bed from its flat position and requested Resident #18 to take the medication which s/he did, swallowing them whole. We exited the room and staff #10 proceeded to sign off the 5 medications that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medications in designated carts on the nursing unit. This was found to be evident for 2 out of 2 medication carts observed during a tour of the facility. The findings include: During a tour of the west and east wings conducted on 12/15/2023 at 7:01 AM, this surveyor observed the medication cart located on the east wing unlocked. This surveyor was able to open each drawer of the cart and observe medications that were labeled with the resident's name and room number as well as house medications. License Practical Nurse (LPN) # 12 assigned to the medication cart was observed exiting resident room [ROOM NUMBER]. During an interview conducted on 12/15/2023 at 7:02 A.M., LPN #12 stated that she was aware that her medication cart should have been locked and the facility's expectation is to always lock cart when away from the cart. During the continued tour, this surveyor observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) received the required Dementia training. This was found to be evident for 5 (GNA # 10, 23, 26, 27, & 28) out of 5 GNA training records reviewed during the annual survey. The findings include: On 12/21/2023 at 07:30 A.M. a review of the Geriatric Nursing Assistants #10, 23, 26, 27, & 28 training records did not reveal an education course for dementia. During an interview conducted on 12/21/2023 at 11:03 A.M. the Administrator provided a current list of the annual education courses required for all nursing staff. The list revealed that a dementia course is not offered to the staff. The Administrator stated she would contact the education provider to confirm that a dementia educational course is not under another category of courses that are required. On 12/21/2023 at approximately 11:00 A.M. the Administrator stated after reviewing the required nursing courses with the education…

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 the medical record, it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time. This was evident for 6 of 34 (Resident #16, #44, #22, #5, #38 and #12) residents reviewed during the survey process. 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. 1) Review of Resident #16's medical record on 4/15/19 at 2:55 PM revealed an annual MDS (minimum data set) with an assessment reference date (ARD) of 10/25/18 and a quarterly MDS with an ARD dated 1/25/19. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. The Quarterly MDS reflected that Resident #16 experienced a decline in his/her ability to transfer and in toilet use. A…

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

Based on 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 4/19/19 at 4:31 PM, the surveyor reviewed the results of the facility's last quality indicator survey, dated 11/13/17, and a complaint survey dated 6/15/18. The corrective actions implemented by the facility after the annual and complaint surveys failed to effectively correct deficiencies related to failure to provide notification of changes, quality of care related to documentation of pressure ulcer/skin breakdown, activities and pharmacy reviews addressed by the physician. These failures resulted in a continuation of the deficient practices as identified during the current recertification survey. Cross reference F 580, F 684, F 756, and F 679. On 4/19/19 at 5:38 PM, the Quality Assessment and Improvement program was reviewed…

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

Based on observation, medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for: 1) 1 of 1 (Resident #12) resident reviewed for communication/sensory deficit and 2) 1 of 5 (Resident #16) residents reviewed for unnecessary medications. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) A review of Resident #12's 2/19/19 Quarterly MDS Assessment on 4/15/19 at 9:20 AM, revealed that Section B0300 Hearing Aid, was marked as yes, for hearing aid or other hearing appliance used. An interview conducted on 4/15/19 at 8:35 AM with Resident #12, revealed that the resident was hard of hearing. The surveyor had to ask a question multiple times. The resident turned his/her head so the surveyor could speak in the right ear. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, it was determined that the facility 1) failed to develop a base line care plan within 48 hours of a resident's admission, and 2) failed to provide a resident and/or a resident's representative with a summary of the baseline care plan that included a summary of the resident's medications. This was evident for 1 of 5 (Resident #247) residents reviewed for hospitalization. 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. On 4/15/19 at 10:23 AM, Resident #247 was observed to have a cast on his/her right leg. During an interview, Resident #247 stated he/she was at the facility for rehab because he/she recently had surgery on his/her right ankle. When asked, Resident #247 indicated he/she had not received a copy of his/her baseline care plan along with a copy of the resident's medications. Review of Resident #247's medical…

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 resident/staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan. This was evident for 1) 1 of 1 (Resident #36) resident reviewed for Infections (not UTI or Respiratory); 2) 1 of 1 (Resident #44) residents reviewed for Hospice; 3) 1 of 2 (Resident #22) residents reviewed for dementia care; 4) 1 of 1 (Resident #27)residents reviewed for Constipation and for 5) 1of 2 (Resident #35) residents reviewed for accidents. 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. 1) Review of Resident #36's medical record on 4/16/19 at 12:02 PM, revealed an admission assessment dated [DATE] at 11:02 PM, that documented broken and carious (meaning permanently damaged) teeth and mouth pain was marked yes. The assessment was completed by Licensed Practical Nurse (LPN) #16. However, review of the…

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

Based on interview with staff and review of the medical record, it was determined the facility staff failed to provide care to assist residents in maintaining their highest possible level well-being by 1) failing to follow infection control standards of practice. This was evident for 1(#36) resident observed during an initial tour of the facility, 2) failing to provide dental services for a resident who had dental issues and pain, 3) failing to monitor the skin condition for a resident at risk for skin breakdown, weekly, as per the physicians orders. This was evident for 1 (#44) of 1 resident reviewed for Hospice and End of Life, 4) failed to assess residents for weekly skin assessments and document per the physician order for 2 (#37 and #36) of 3 residents assessed for weekly skin assessments. The findings include: 1) During the initial tour of the 2nd floor unit on 4/15/19 at 10:00 AM, staff #9 in Resident #36's room was observed wearing an isolation gown that was untied and exposed the staff's back and shoulders. Staff #9 was observed moving between bed A and B. Bed A'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 review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months this was evident for 4 out of 4 personnel files reviewed. Additionally, the facility failed to conduct at least 12 hours of in-service education for 3 of 4 personnel files reviewed. The findings include: On 4/17/19, a review of 4 GNA employee personnel files with the Human Resource (HR) coordinator (staff #7) revealed the following; Staff #21, hired on 3/4/2010 received a performance evaluation dated 3/9/17. Staff #21's last annual training was date 4/11/18. The HR coordinator indicated that annual training is to be completed annually during the month of the employee's hire date. Staff #22, hired on 9/18/09, did not reveal any performance evaluation and the last yearly education was dated 9/6/17. Staff #23, hired 1/14/11, revealed the last performance evaluation was reviewed in 2016. The last yearly education was documented for 3/29/18. Staff #24, hired on 8/22/14,…

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

Based on observations, medical record review and staff interview, it was determined that the facility failed to assess a resident's blood pressure as prescribed prior to the administration of an oral antihypertensive medication. This was identified for 1 (#29) of 6 residents observed for medication administration. The findings include. On 4/19/19 at 8:31 AM, observation of medication administration to resident #29 by staff #18, on 4/19/19 at 8:45 AM, revealed that the resident was administered the medication Atenolol for high blood pressure. Upon exiting the room, staff #18 was asked; is there any parameters for holding the medication for high blood pressure? Staff #18 responded no. Review of the electronic medication administration record revealed that there were parameters for holding the blood pressure medication. Review of the physician's orders revealed that the medication Atenolol tablet 50 mg by mouth was prescribed on 1/24/18, with instructions to hold the medication for blood pressure less than 110/60 and/or pulse less than 60. Review of the medication administration…

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

Review of the medication administration records for residents #14, #29, #38, and #46 for reconciliation of medications administered on 4/19/19 revealed that medications prescribed for each resident for 6 AM and/or 7 AM administration were not signed off as given. The director of nursing was notified of the concern that night shift did not sign off medications as given by 10 AM on 4/19/19, with report that she would follow-up. Resident #38 was interviewed at 11:26 AM on 4/19/19. The resident acknowledged receiving the medications as he/she would know as he/she did not experience pain. Resident #38 is prescribed to receive a pain medication at 6 AM. Residents #14, #29, and #46 were each interviewed but unable to accurately remember if night shift had administered medications. Follow up from the Director of nursing later on 4/19/19 revealed that she was able to contact the night shift nurse with explanation that the 6 AM and 7 AM were administered but there was a glitch in the electronic medical record that had prevented documentation. Based on medical record review and staff…

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, staff and resident interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to properly put on and remove personal protective equipment (PPE), to ensure roommate's area was not contaminated, follow isolation precautions, to properly decontaminate a resident's room following isolation, and have accessible information for Housekeeping staff guiding them on what products to use to decontaminate isolation rooms. This was evident for 1 (#36) out of 1 resident reviewed for Infection (not UTI or Respiratory). The findings include: During the initial tour of the 2nd floor unit, on 4/15/19 at 10:00 AM, staff #9 was observed in Resident #36's room wearing an isolation gown that was untied which exposed staff #9's back and shoulders. Staff #9 was observed moving between bed A and B. Bed A's over-the-bed table had to be moved to get into the bathroom and was being moved with gloved hands. Staff #9 left the room without sanitizing the area…

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, it was determined that the facility staff failed to treat each resident in a dignified manner by failing to knock on a resident's door to request permission before entering. This was evident for 1 of 9 (Resident #46) residents reviewed on Short Hall 1. The findings include: On 4/14/19 at 10:54 AM, an interview was conducted with Resident #46 in the resident's room with the resident's door closed. On 4/14/19 at 10:54 AM, Staff #2 was observed entering Resident #46's room without knocking on the door. The Director of Nurses was made aware of the above findings on 4/17/19 at 4:00 PM.

Based on review of the medical record and interview with facility staff it was determined that the facility staff failed to notify the Physician and Resident Representative when the resident experienced a significant weight loss. This was evident for: 1) 1 of 1 (Resident #5) resident's reviewed for Nutrition and 2) the facility failed to document and assess a resident's wound, located over pressure points in a manner that ensured the resident's attending physician remained informed as the wound progressed in size and severity. This was evident for 1 of 1 (Resident #37) resident reviewed for pressure ulcers. The findings include: 1) Review of Resident #5's medical record on 4/15/19 revealed that the resident had a significant weight loss of 10.83 % from 208.6 pounds on 7/11/18 to 186 pounds on 1/7/19. A Quarterly Nutrition Assessment note dated 1/25/19 documented the resident's weight loss and indicated that his/her weight was moderately above the resident's maximum iwr (ideal weight range). The nutrition assessment note also included will suggest Remeron for appetite and will…

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

Based on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident for 1 (#1) of 2 residents reviewed for activities. The findings include: On 4/18/19 at 2:00 PM, Resident #1's 2019 activity calendar, (which documented the resident's 1 to 1 visits and attendance in activities) was reviewed and the Musical Encounters Observation Documentation forms for 2019 were reviewed and indicated Resident #1 refused group activities every day. Review of Resident #1's January 2019 calendar revealed that the facility staff provided the resident with 1 to 1 visits on 1/17/19, 1/23/19 and 1/31/19, which was 3 activity staff visits in 31 days. On 1/20/19, activity staff documented the resident was asleep. February's activity calendar documented the activity staff provided Resident #1 with 1 to 1 visits on 2/3/19 and 2/20/19, which was 2 activity staff visits in 28 days and there was documentation…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident receiving oxygen therapy had orders that did not conflict and that were being followed. This was evident for 1 (Resident #5) of 1 resident reviewed for respiratory care. The findings include: During an observation that took place on 4/14/19 at 10:30 AM, it was noted that Resident #5 was receiving oxygen via nasal cannula at a rate of 3 Liters per minute (L/min). A nasal cannula is a device that delivers oxygen directly to a person's nares via flexible plastic tube. Resident #5's medical record was reviewed on 4/14/19 at 10:40 AM. During the review, two orders for oxygen were found. Both had the same start date. The first order directed staff to monitor oxygen saturation values and apply 2 L/min of oxygen to keep the saturations above 92%. The second order for oxygen directed staff to administer oxygen at 2 L/min at all times. Review of the Treatment Administration Record (TAR) for March and April, 2019, revealed that both orders had been initialed by nursing…

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, the facility staff failed to document a review of the care, the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen. The finding was evident for 1 (#37) of 1 resident reviewed for physician visits. The findings include: Review of Resident #37's medical record revealed physician progress notes that failed to document the progression of the wounds on the sacrum and the left hip for the period of 4/15/19 - 4/19/19. The sacral wound had started as dermatitis and the wound on the left hip as a skin tear, (and both were classified as such) on the Wound Evaluation Flow Sheet between 7/18/18 to 4/12/19. Observation of the wound care being provided by the Assistant Director of Nursing (ADON), on 4/18/19 at 12:15 PM, revealed the sacral wound measured 5 cm x 4 cm x 0.5cm. The ADON described the wound as follows: wound bed with 100% granulation, wound edges attached,…

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 the medical record and interview with facility staff, it was determined the facility staff failed to ensure irregularities reported to the attending physician by the pharmacist were acted upon for 2 (#22 and #16) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds, and Med Regimen Review and for 1 (#35) of 2 residents reviewed for accidents. The findings include: Resident #22's medical record was reviewed on 4/17/19 at 4:06 PM. The monthly drug regimen review sheet indicated that the pharmacist made a referral to the physician on 4/9/19, however, the actual referral was not in the record. During an interview on 4/17/19 at 4:29 PM, Staff #5 and #6 were unable to find the referral. At 5:06 pm, Staff #5 provided the surveyor a copy of referral signed on that date (4/17/19). Staff #5 indicated that the physician was in earlier, signed the form and left it in the Social Workers office. The referral indicated the resident had fallen 3/25/19, that the medications listed on the referral may potentially affect coordination, and requested that the physician…

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

Based on medical record review, It was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication by 1) failing to ensure that a psychotropic medication prescribed to be administered as needed was limited to 14 days and 2) failing to provide ongoing evaluation for the risks, benefits and continued need for psychotropic medications. This was evident for 2 (#46 and #22) of 5 residents reviewed for unnecessary medications. The findings include: 1) On 4/16/19 at 11:17 AM, Resident #46's medical record was reviewed. Review of Resident #46's April 2019 MAR (medication administration record) revealed an order with a start date of 4/16/19 for Ambien (Zolpidem) (hypnotic medication) 5 mg. by mouth every 24 hours as needed at bedtime for a sleep aid. The order did not have a stop date. Review of the medical record failed to reveal documentation by the prescribing practitioner as to the duration of the PRN (as needed) order or a rationale for extending the PRN order beyond 14 days. On 4/17/19 at 4:00 PM, the Director…

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 the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#29, #38) of 6 residents observed with 2 errors out of 26 medication administration opportunities which resulted in an error rate of 7.69 by 2 certified medicine aides out of 4 total staff observed. The findings include: On 4/19/19 at 8:20 AM, certified medication assistant (staff #19) was observed for administration of medications to resident #38. The resident received 5 medications by mouth and was offered Advair Diskus. Advair is inhaled through the mouth. Upon exiting resident #38's room, staff #19 stated that he/she did not have to rinse the resident's mouth. Upon surveyor intervention, it was noted to staff #19 of a label on the Advair Diskus packaging with instructions to rinse mouth after inhalation of this medication. The manufacture of Advair Diskus instructs the following as written in the insert of the packaging; Rinse your mouth with water without swallowing after using…

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 and interview with facility staff, it was determined that the facility staff 1) failed to ensure that inhalation medication and prescribed topical creams were secured in a locked storage area accessible to authorized personnel only, in 1 of 9 room observations on Short Hall 1 and 2) failed to ensure that a respiratory inhaler was labeled to reflect when it was opened in 1 of 2 medication carts observed out of 4 medication carts in the facility. The findings include: 1) On 4/14/19 at 9:52 AM, observation was made of Resident #38 in his/her room, sitting up in his/her bed. At that time, an Advair (fluticasone propionate and salmeterol) Inhaler and a tube of Clotrimazole & Betamethasone cream 1 % (topical combination used to treat fungus infections) which had Resident #38's name on a pharmacy label was observed on the resident's bed side table. On 4/14/19 at 11:30 AM, Staff #1 confirmed the findings and removed the Advair inhaler & prescribed topical cream from the resident's bedside table. 2) The surveyor observed the medication cart for rooms 208 - 219…

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, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a complaint of broken teeth and mouth pain. This was evident for 1 (#36) out of 3 residents reviewed for Dental services. The finding include: On 4/15/19 at 10:33 AM, during an interview with Resident #36, the surveyor observed that the resident had broken teeth. During an interview with the resident, on 4/15/19 at 10:33 AM, it was reported that he/she has 9 broken teeth which required extraction per the family dentist. Resident also reported that he/she had some mouth pain while eating and drinking. Resident stated that he/she and a family member discussed this with facility staff at the time of admission and nothing had been done up to this point. A medical record review, on 4/16/19 at 12:02 PM, revealed an admission Assessment completed on 3/28/19 at 11:02 PM, and signed by nursing staff #16 that documented broken and carious (meaning permanently damaged) teeth and mouth pain were marked yes.…

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, it was determined that the facility failed to ensure that food was stored in a sanitary way. This was evident for 1 of 2 kitchen observations performed during the survey. The findings include: During an observation that took place, on 4/18/19 at 9:40 AM, in the presence of the Certified Dietary Manager (CDM), a tray of exposed meat patties was found in the freezer without any labeling or covering of any kind. The CDM stated that the patties came from a box that was kept nearby in the freezer and that the patties would be cooked the same day for lunch. The uncovered patties were not protected from spalsh and other contamination, and were not labeled. The director of nursing was made aware of these concerns on 4/19/19 prior to survey exit.

Based on record review and staff interview, the facility failed to 1) document in the medical record that the Flu and Pneumonia vaccine was offered and administered to 1 (resident #36) of 5 residents and 2) failed to document that the Pneumonia vaccine was administered for 1 (#26) of 5 residents surveyed for immunizations. The findings include: 1. On 4/19/19 at 10:40 AM, a review of Resident #36's medical chart failed to reveal evidence that the Flu or PNA (Pneumonia) vaccine were offered or administered. The consent form for the Flu/Pneumonia vaccine was left blank. During an interview with the Director of Nursing on 4/19/19 at 11:27 AM, she supplied documentation that Resident #36 received the Flu shot, but failed to produce documentation that the pneumonia vaccine was administered. The documentation for the Flu vaccine was kept in her office and was not in the medical record. 2. On 4/19/19 at 10:48 AM, a review of Resident #26's medical record, revealed a signed consent form, dated 8/3/18, to accept the Flu and Pneumonia vaccine. The Flu vaccine was administered on 10/5/18.…

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.