Manchester Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible by failing to properly secure the resident's wheelchair to all of the locking mechanisms used to hold the resident's wheelchair in place during transport to another facility (Resident #1). This failure resulted in the wheelchair to fall/flip over backwards during a turn with the resident still in his/her wheelchair. The resident sustained a small gash in the back of his/her head which required first aid to stop the bleeding. The census was 53. The Administrator was notified on [DATE], of the past non-compliance. On [DATE], the facility initiated an investigation, interviewed staff, completed an evaluation of the van with no concerns, and provided video education to the driver related to review of all straps and proper securement of residents for transportation. The deficiency was corrected on [DATE]. Review of the facility's Vehicle and Driver Safety Program, showed:…

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 interview and record review, the facility failed to ensure professional standards of practice were met, when the facility admitted a resident without physician's orders and failed to provide prescribed medications that evening. The resident was sent to a different hospital, 14 hours later, without physician's orders (Resident #1). The facility did not have a policy for obtaining physician orders at the time of admission. The sample was 3. The census was 49. Review of the resident's hospital discharge summary and discharge instructions, received via email from the facility Administrator on 9/18/24 at 5:11 P.M., with a printed time and date stamp of 8/21/24 at 2:03 P.M. central daylight time (CDT), showed: -Diagnoses of Alzheimer's dementia, high blood pressure, diabetes type 2, coronary artery disease (CAD) with left anterior descending (LAD) artery stent placement (treatment for a condition that occurs when there is a blockage in the LAD artery, which can lead to a heart attack), hypothyroidism (thyroid…

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 record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADLs, personal care) received showers in accordance with their needs and preferences (Residents #4, #5, #7, #11 and #2). The sample was 11. The census was 44. Review of the facility's Skin Monitoring: Comprehensive Shower Review Sheet, showed: -Perform a visual assessment of a resident's skin while giving them a shower; -Report any abnormal looking skin (as described below) to the charge nurse immediately; -Forward any problems to the Director of Nursing (DON) for review; -Use the form to show exact location and description of the abnormality, using the body chart: -Describe and graph all abnormalities by number; -A space designated for residents' name and date; -A numerical listing from 1 to 14 for examples of visual assessment; -Space designated for certified nurse aide (CNA) signature and date shower provided; -Space designated to show if resident needed…

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 record review, the facility failed to ensure a medication error rate of less than 5%. Out of 42 opportunities, 4 errors occurred, resulting in an 9.52% error rate (Residents #4 and #5). The census was 44. Review of the facility's Medication policy dated 10/24/22, showed: Procedure: Nursing Staff will keep in mind the seven rights of medication when administering medication: -The right medication; -The right amount; -The right resident; -The right time; -The right route; -Right indication; -Right outcome; -Additional considerations include: The Rule of 3. The Licensed Nurse administering medications will perform three checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR): -Compare the Licensed Practitioner's prescription/order with the MAR (first check); -Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check); -Compare the pharmacy label and MAR (third check); Documentation: -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, interview and record review, the facility failed to maintain complete and accurately documented clinical records regarding pressure ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction) for one of 11 sampled residents (Resident #2). The census was 44. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/24, showed the following: -admission date 4/7/24; -Cognitively intact; -Able to make self-understood; -Rejection of care 1-3 days per week; -Dependent on staff for transfers, locomotion, personal hygiene and bathing; -admitted with one Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister on his/her coccyx (tailbone)); -admitted with one Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts 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 and record review, the facility failed to follow their abuse policy by not thoroughly investigating an allegation of a resident being hit in the head by a male nurse. The facility failed to interview the resident and the resident's sibling who reported the allegation to the facility's Marketing Director while he/she was visiting the resident in the hospital (Resident #1). The sample was three. The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. 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, interview and record review, the facility failed to report an allegation of resident abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for one of three sampled residents (Resident #1). The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two residents who expired and had money in their accounts (Residents #301 and #302). The sample size was 15. The census was 43. Review of Resident #301's medical record, showed: -discharged on [DATE] and expired on [DATE]; -On [DATE], an ending balance of $4554.33; -No documentation of TPL completed. Review of Resident #302's medical record, showed: -discharged to the hospital on [DATE]; -On [DATE], an ending balance of $4194.75; -No documentation of TPL completed. During an interview on [DATE] at 11:59 A.M., the Business Office Manager (BOM) confirmed Resident #302 expired in September after he/she was sent to the hospital. The accounts for Resident #301 and #302 were locked so she could not access their money. TPL letters were not sent and should have been sent 30 days after the residents expired.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of four residents (Residents #198, #11, #13 and #24). The sample was 15. The census was 43. Review of the facility's Care Plan policy, revised 6/2020, showed: -Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs; -Procedure: The Facility will develop a person-centered baseline care plan for each resident within 48 hours of admission. The baseline care plan will include at least the following information: Initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A comprehensive person-centered care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. In the event that 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, interview and record review the facility failed to ensure services provided met professional standards of practice when one nurse prepared medications in a cup and handed the cup to another nurse to administer for three residents (Residents #33, #36 and #7). Staff also failed to complete post fall documentation for one resident (Resident #145). The sample was 15. The census was 43. Review of the facility's Medication Administration Policy, dated 10/24/22, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; -Documentation: The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment; -Initials may be used, provided that the signature of the person administering 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, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to provide adequate organized activities in the evenings and on the weekends. The resident council representatives reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program, including one on one activities (Residents #24, #37, #28 and #20). The sample size was 15. The census was 43. Review of the facility's Activities Program Policy, dated 6/20, and showed: -Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning; -The facility provides an Activity Program designed to meet 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 and record review, the facility failed to staff the facility with a Registered Nurse (RN) at least eight hours a day, seven days a week. The census was 43. Review of the facility's schedules, dated 10/29/23 through 11/29/23, showed on the following days no RN was scheduled on 10/29, 10/30, 11/3, 11/5, 11/6, 11/10, 11/17, 11/18, 11/19, 11/24, 11/25, 11/26 and 11/27. Review of the timecard sheets, showed: 10/29: no RN hours; 10/30: less than 8 hours of RN coverage documented; 11/3: less than 8 hours of RN coverage documented; 11/5 through 11/6: no RN hours; 11/10: less than 8 hours of RN coverage documented; 11/17: less than 8 hours of RN coverage documented; 11/18 through 11/20: no RN hours; 11/24: less than 8 hours of RN coverage documented; 11/25 through 11/27: no RN hours. During an interview on 12/1/23 at 10:00 A.M., the Staffing Coordinator said the facility is usually staffed with 2 nurses, either one RN and one Licensed Practical Nurse (LPN) or two LPNs. The Staffing Coordinator was aware the facility needed an RN on duty at least 8 hours daily, seven days 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 observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified four medication/treatment carts and one medication room. There was one medication cart for each of three halls and one medication cart used only by nurses. Three of the four carts and one medication room were checked for medication storage, and issues were found in the medication room and in the nurse medication cart. Staff failed to keep the medication room door locked at all times, separate the medications and food storage in the medication room refrigerators, date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution, and to place two locks on the substance controlled medication storage. Furthermore, the facility failed to discard an expired vial of insulin found in the nurse medication cart. The census was 43. Review of the facility's Storage of Medications Policy, revised 11/2020, showed: -Policy Statement: 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, interview and record review, the facility failed to ensure all residents were afforded the right to a dignified existence, self-determination, and communication with persons and services inside the facility. One of 15 residents sampled during the survey period was observed calling out loudly for assistance or attention while staff walked by the resident's room. The census was 47. Review of Resident #37's medical record, showed his/her diagnoses included anoxic brain damage (damage to the brain caused by a temporary lack of oxygen), pulmonary embolism (a blood clot in the lungs affecting a patient's ability to breathe), gastrostomy (a surgical opening into the abdomen for the introduction of nutrition), and Type 2 Diabetes. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has little to no participation in activities due to limited physical mobility. Interventions included: Establishing and recording the resident's prior level of 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 interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #34 and #246). The sample size was 13. The census was 43. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice 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 interview and record review, the facility failed to follow their own Grievance and Complaints Policy when staff failed to follow up and document one resident's (Resident #145) grievance for an allegation of missing items. The sample was 15. The census was 43. Review of the facility's Grievances and Complaints Policy, dated 10/24/22, showed: -Purpose: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints; - Any resident, representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property, etc., without fear of threat or reprisal in any form; - Grievances and/or complaints may be submitted orally or in writing and can be made anonymously through the compliance hotline; -Designation of Grievance Official: The Facility will identify a Grievance Official who is responsible for: -Overseeing the grievance process; -Receiving and tracking…

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 record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene for two residents observed with long, dirty fingernails and food/beverages on clothing (Residents #24 and #246). The sample size was 15. The census was 43. Review of the facility's Activities of Daily Living (ADL), Supporting, policy, revised March, 2018, showed: -Policy Statement; -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Policy Interpretation and Implementation; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADLs are…

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, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, two errors occurred resulting in a 7.69% error rate (Residents #16). The census was 43. Review of the facility's Medication Administration Policy, dated 10/24/22, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Medications will not be left at the bedside. Review of mybrevo.com, showed: -Breo Ellipta, Breo is a prescription medicine used long term to treat: Chronic Obstructive Pulmonary Disease (COPD, chronic lung disease) and asthma: -Patient instructions: Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water; -Warning and Precautions: Candida albicans (yeast) infection of the mouth and pharynx (throat) may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. Review of Resident #16's quarterly Minimum Data…

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 interview and record review, the facility failed to ensure a resident was free from significant medication errors when the facility failed to administer ordered medications for two days after admission for one resident (Resident #198). The sample size was 15. The census was 43. Review of the facility's Medication Administration policy, revised October 24, 2022, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: -Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law; -No medication will be used for any resident other than the resident for whom it was prescribed; -Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; -Holding Medications: Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the Medication…

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 and record review, the facility failed to ensure five of five randomly selected Certified Nurses Assistants (CNAs), employed for one year or longer, received the required annual 12 hour in-services. The census was 60. Review of the CNA individual in-service records, showed the following: -CNA G, date of hire 8/30/11, with total number of hours zero; -CNA H, date of hire 11/18/16, with total number of hours zero; -CNA I, date of hire 6/27/18, with total number of hours zero; -CNA J, date of hire 10/16/12, with total number of hours zero; -CNA K, date of hire 1/7/19, with total number of hours zero. During an interview on 2/21/20 at 7:40 A.M. and 8:20 A.M., the administrator said it was the prior Director of Nurses (DON) responsibility to track and ensure CNAs received their 12 hours of continued educational in-service training. As of two weeks ago, it was the unit manager's responsibility, but the unit manager walked out, and now it is the current DON's responsibility. The administrator verified the facility did not have a system in place for tracking and ensuring…

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 interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated at least annually. The census was 60. Review of the Facility Assessment, showed the following: -Facility assessment dated [DATE]; -No further review and/or update of the Facility Assessment annually as required. During an interview on 2/21/20 at 7:40 A.M., the administrator verified the Facility Assessment had not reviewed and/or updated annually since 11/13/17. The administrator said he is responsible for ensuring the Facility Assessment is reviewed and updated annually.

Based on interview and record review, the facility failed to ensure residents' code status forms were updated annually, ensure code status forms were legible and ensure the code status forms matched the code status listed on the physician's order sheets for four of 15 sampled residents (Resident #3, #7, #105 and #24). The census was 60. 1. Review of Resident #3's medical record, showed the following: -An admission face sheet, showed an admission date of 10/22/18; -A signed code status form, dated 2/15/19, for do not resuscitate (DNR, no life prolonging methods are performed); -A physician's order sheet (POS), dated 1/29/20 through 2/28/20, showed an undated order for full code status (all lifesaving methods are performed). Further review of the resident's medical record, showed no other updated code status forms regarding DNR and/or full code status. 2. Review of Resident #7's medical record, showed the following: -An admission face sheet, showed an admission date of 6/28/10; -A signed code status form, dated 8/31/18, for a DNR code status; -No updated code status form found since…

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 record review, the facility failed to ensure all physician's orders were followed and care met professional standards of quality, by not providing bone stimulation therapy, blood sugar checks, obtaining monthly, admission, or weights recommended by the registered dietician (RD), administering oxygen, monitoring a fluid restriction, reporting x-ray results in a timely manner, obtaining orders for hospice care and not documenting a resident's death for 14 (Resident #24, #18, #307, #3, #40, #45, #32, #27, #26, #7, #154, #28, #44 and #106) of 15 sampled residents, one expanded (#104) sampled resident and one closed (#54) record. The census was 60. 1. Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/19, showed the following: -No cognitive impairment; -Extensive assistance required for bed mobility, dressing, toilet use and personal hygiene; -Lower extremity impairment on both sides;…

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 record review, the facility failed to ensure residents received a minimum of two showers and failed to ensure the fingernails of two residents were kept trimmed. Of the 15 residents sampled, problems were found with four (Residents #27, #32, #45 and #28). The census was 60. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal care; -Diagnoses included heart disease and Alzheimer's disease. Review of the care plan, dated 8/2/13 and last updated on 12/12/19, showed the following: -Problem: Resident requires total care with all activities of daily living (ADLs) due to dementia. All needs must be anticipated by staff; -Goal: Resident will have all ADL needs anticipated by staff and be clean/dry and appropriately dressed; -Interventions: Extensive assistance with bed mobility, facility 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 interview and record review, the facility failed to ensure residents that qualified for restorative therapy services received those services as ordered for three of 15 sampled residents (Residents #3, #32 and #45). The census was 60. 1. Review of Resident #3's medical record, showed the following: -An admission face sheet showed an admission date of 10/22/18; -Diagnoses included history of falls and osteoarthritis (chronic degeneration of the joint cartilage). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Intact cognition; -Required supervision with bed mobility and transfers; -Required extensive assistance from staff with toilet use, hygiene and bathing; -No limited range of motion affecting upper/lower extremities; -No restorative therapy (RT) services received. Review of the resident's physician's order sheet (POS), dated 1/29/20 through 2/28/20, showed an undated order for RT, two…

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 record review, the facility failed to adequately assess a resident's falls and follow their policy for fall management for one resident (Resident #44). The resident's fall resulted in an injury which required hospitalization. The facility also failed to protect three residents (Resident #18, #45 and #154) out of four observations from potential harm by not following their training guidelines or the manufacturer's recommendation for a Hoyer lift (mechanical device used to transfer a resident from one surface to another) transfer. In addition, the facility failed to protect residents from potential harm by not securing dangerous chemicals and razors on the secured unit, which had the potential to affect all ambulatory residents on that unit. The sample size was 15. The expanded sample size was nine. The census was 60. Review of the facility's undated Fall Risk Assessment and Prevention Policy and Procedure, included the following: -It is the policy of this facility to assess…

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 record review, the facility failed to ensure one resident with a history of urinary tract infections (UTIs), received appropriate treatment and services for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Additionally, the facility failed to obtain orders for the use, care and changing of catheters for three residents. The facility identified three residents as having a urinary catheter. All three were chosen, one for the initial sample (Resident #28) of 15 and two (Residents #42 and #255) for the expanded sample. Problems were found with all three. The census was 60. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/19, showed the following: -No cognitive impairment; -Total dependence on staff for transfers and dressing; -Extensive assistance of staff required for bed mobility, toileting, personal hygiene and bathing; -At risk 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 observation and interview, the facility failed to post and ensure the daily nurse staffing information contained the required information by not including the name of the facility, daily census and number of actual or total hours for each licensed and non-licensed nursing staff that were directly responsible for resident care for four of five days of observation. The census was 60. Observation on 2/19/20 at 1:10 P.M., 3:00 P.M. and 6:00 P.M., showed the facility's nurse staffing information posted on the board next to the employees' time clock in the main dining room, included the date and number of licensed and non-licensed nursing staff for each shift, but did not contain the name of the facility, daily census and actual/total hours worked for each nursing staff. Observation on 2/20/20 at 7:00 A.M. and 9:45 A.M., 2/21/20 at 6:00 A.M., 7:30 A.M. and 12:00 P.M. and 2/24/20 at 6:40 A.M., showed no daily nurse staffing information posted in the entrance of the lobby, main dining room, nurse's stations and/or outside of the Director of Nurses (DON) office. During an interview…

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 and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three narcotic books reviewed. The census was 60. Review of the facility's controlled substance policy, revised 1/2017, showed the following: -The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the oncoming licensed nurse and the off- going licensed nurse. Both nurses will sign on the narcotic sign in and out sheet that the count was completed. 1. Review of the west nurse's cart on 2/20/20 at 8:50 A.M., showed a controlled substances shift change count sheet dated, February 2020, which contained the following information: -18 of 40 shifts with only one nurse signature for the shift change count; -Four of 40 shifts with no count of narcotics. 2. Review of the west certified medication technician's (CMT) cart on 2/20/20 at 8:50 A.M., showed a controlled substances shift…

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 interview and record review, the facility failed to ensure the attending physician documented timely in the resident's medical record that any irregularities identified during the monthly medication regimen review (MRR) had been reviewed and what, if any, action had been taken to address it, and failed to have all MRRs documented, for 10 of 15 sampled residents(Residents #27, #32, #40, #45, #3, #7, #28, #24, #34 and #18). The census was 60. 1. Review of Resident #27's medical record, showed the following: -admitted to the facility on [DATE]; -Diagnoses included heart disease and Alzheimer's disease; -Pharmacy MRR completed on 1/7/20, with noted irregularities; -No documentation in the record if the physician reviewed the identified irregularities and if action had been taken. 2. Review of Resident #32's medical record, showed the following: -admitted to the facility on [DATE]; -Diagnoses included heart failure and Alzheimer's disease; -Pharmacy MRRs completed on 12/4/19 and 1/7/20, with noted…

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, the facility failed to keep the floors in the kitchen free from food crumbs, debris, and stains and sufficiently air dry dishes before use during three of three days of observation. The census was 60. 1. Observations of the kitchen on 2/19/20 at 10:57 A.M. and 3:55 P.M., 2/20/20 at 12:55 P.M., and 2/21/20 at 7:05 A.M. and 12:00 P.M., showed the following: - The floor tiles and grout throughout the kitchen noticeably dirty with food crumbs, dirt and debris; -Cracked tile under the drying rack parallel to the dish machine with a build up of crumbs and debris; -The perimeter of the grease trap with gaps between the tiles and the lid, with a build up that measured 1 inch to 3 inches, with a thick build up of crumbs and debris. During an interview on 2/21/20 at approximately 1:15 P.M., the dietary manager (DM) said she was aware of the status of the floors. They did not currently have a schedule to deep clean the floors. 2. Observations of the kitchen, showed the following: -On 2/19/20 at 10:57 A.M., three stacks of 12 ounce (oz) glasses, with five…

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 interview and record review, the facility failed to provide information for 10 of 15 sampled residents (Resident #27, #32, #34, #40, #45, #3, #7, #106, #18 and #307) to show they received a yearly Tuberculin Skin Test (TST) to determine the presence of Tuberculosis (TB) or a yearly screening based on signs and symptoms of the disease. Furthermore, the facility failed to provide a second step TST to new employees as per their policy. The census was 60. Review of the facility's Infection Prevention and Control Manual TB Control Plan, dated 2019, showed the following: -Residents in long term care facilities have been identified as a high-risk group for re-activation of latent TB infection, acquisition of TB infection and potential spread of TB within the facility. This facility has a comprehensive TB screening program that is administered by the Infection Control Nurse at the direction of the Quality Assurance Committee; -Policy: I. Tuberculin Skin Test (TST, also known as PPD): -1. For all new admissions,…

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, interview and record review, the facility failed to ensure one resident remained free from restraints, conduct a restraint assessment and obtain a physician's order for the use of a restraint (Resident #45). The facility identified no residents with restraints. The sample size was 15. The census was 60. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/20, showed the following: -No cognitive impairment; -Dependent on staff for all mobility and personal care; -Diagnoses included cerebral palsy (CP-a group of disorders that affect a person's ability to move and maintain balance and posture), quadriplegia (paralysis from the neck down),contractures and gastrostomy tube (G/T-a small rubber tube inserted through the abdomen in to the stomach to administer nutrition and hydration). Observations on 2/19/20 at 10:53 A.M., 2/20/20 at 11:38 A.M. and 1:19 P.M., 2/21/20 at 11:26 A.M. and 2/24/20 at 12:18 P.M., showed the resident sat in his/her wheelchair in the common room. 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 interview and record review, the facility failed to ensure care plans were updated to reflect the residents' current needs by not including services and care provided by hospice providers, in collaboration with the facility, for three residents (Residents #106, #54 and #34). The facility identified seven residents who received hospice care. Three were chosen for the sample of 15, and problems were found with all three of them. The census was 60. 1. Review of Resident #106's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admission date [DATE]; -Intact cognition; -Diagnoses included anemia (decrease in the number of red blood cells) and respiratory failure; -Required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Condition or chronic disease of life expectancy of less than six months; -Received hospice care. Review of the resident's hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide residents individualized activities, designed to meet the residents' interests and support the physical, mental, and psychological well-being of each resident for two of 15 sampled residents (Residents #307 and #32). The census was 60. 1. Review of Resident #307's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/11/20, showed the following: -admitted [DATE]; -Activity preferences: Listening to music, going outside in good weather and doing favorite activities; -Brief interview for mental status (BIMS) score 10 out of 15; cognition moderately impaired. Review of the resident's medial record, showed the following: -Diagnoses included clostridium difficile (c-diff, bacteria that can cause swelling and irritation of the large intestine or colon) and recurrent major depressive disorder; -No activity assessment completed. Review of resident's care plan, in use during 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, interview and record review, the facility failed to ensure one resident with a wound (Resident #154) of 15 sampled residents, received the appropriate treatment and care, by not treating the wound for multiple days, following a readmission to the facility and after a new order was received from the wound care provider. The census was 60. Review of Resident #154's face sheet, showed the following: -Initial admission to facility on 1/27/20; -readmitted on [DATE]; -Diagnoses included heart failure, chronic kidney disease, obesity, high blood pressure, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and cellulitis (skin infection). Review of the resident's treatment administration record (TAR), showed weekly skin assessments on Tuesdays, left blank on 2/4/20 and 2/18/20, with no documentation on the back of the TAR. Review of the resident's hospital discharge orders, dated 2/14/20, showed the following wound care instructions, left lateral leg, cleanse…

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 record review, the facility failed to ensure residents received appropriate assessment and necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for two of 15 sampled residents (Resident #154 and #28). The census was 60. 1. Review of Resident #154's face sheet, showed the following: -Initial admission to facility on 1/27/20; -readmitted on [DATE]; -Diagnoses included heart failure, chronic kidney disease, obesity, high blood pressure, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and cellulitis (skin infection). Review of the resident's treatment administration record (TAR), showed weekly skin assessments on Tuesdays, left blank on 2/4/20 and 2/18/20, with no documentation on the back of the TAR. Review of the resident's hospital discharge orders, dated 2/14/20, showed the following wound care instructions, left heel,…

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 and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for one of five residents reviewed for unnecessary psychotropic medications (Resident #18). The sample was 15. The census was 60. Review of Resident #18 medical record, showed the following: -Diagnoses included dementia and anxiety; -Cognitively intact. Review of the resident's physician order sheets (POS), dated 1/29/20 through 2/28/20, showed the following: -An order, dated 12/2/19, for alprazolam (Xanax, used to treat anxiety) 0.25 milligrams (mg), take twice daily as needed; -No end date noted for the PRN order. Review a pharmacy medication regimen review, to determine if resident had been using the PRN alprazolam dated 1/6/20, showed, If resident has not used it within the past 14 days, please clarify. During an interview with the Director of Nurses and corporate nurse on 2/25/20 at 9:00 A.M., they said PRN anti-anxiety medication orders should be renewed (ordered for a limited time). The doctor and the nurse should re-evaluate usage…

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, interview and record review, the facility failed to ensure two random sampled residents (Resident #31 and #12) and one sampled resident (#307) remained free from significant medication errors regarding insulin not administered as ordered. The sample was 15. The census was 60. 1. Review of Resident #31's medical record, showed the following: -An admission date of 2/28/19; -Diagnoses included diabetes. Review of the resident's physicians order sheet (POS), dated 1/29/20 through 2/28/20, showed the following: -An order dated 2/28/19, to administer Novolog (fast acting) insulin, 18 units subcutaneous (SQ, beneath the skin) three times daily (TID) (scheduled administration time 7:30 A.M., 11:30 A.M. and 4:30 P.M.); -An order dated 2/28/19, to administer Lantus (long acting) insulin 55 units SQ every morning (scheduled administration time 7:30 A.M.) Review of the resident's nurses medication administration record (MAR), dated 1/29/20 through 2/28/20, showed the following: -An order dated 2/28/19, to administer Novolog 18 units SQ TID (scheduled administration time…

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.