Point Lookout Nursing & Rehab

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 treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) provided cares to three residents (Residents #1, #2, and #3) in an unrespectful and undignified manner when the CNA rushed residents, raised his/her voice at residents, and spoke in a disrespectful tone of voice when answering the residents' call lights. The facility census was 89. Review of the facility policy Resident Rights, undated, showed each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #1's face sheet (document with admission information) showed the following: -admission date of 12/01/23; -Diagnoses included dementia (brain damaged by injury or disease which involves progressive impairments in memory, thinking, and behavior which negatively impacts a person's ability to…

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

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when food items were not dated or labeled after opening, or were left open and exposed to absorb ice crystals and odors and when staff failed to keep the kitchen free of an accumulation of grime and debris. This had the potential to affect all residents who ate food from the kitchen. The facility census was 83. Record review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 3/4/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Food shall be stored in a safe manner (no open containers, without covers, spillage from one food item onto another, etc.) to prevent cross-contamination -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)…

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 a clean and homelike environment when staff failed to replace/fix ceiling tiles damaged by a water leak for one resident (Resident #10), failed to repair damage on two residents' (Residents #8 and #72) bedroom walls, and failed to change ceiling tiles that were stained from water leaks in the resident hallways and dining rooms. The facility census was 83. The facility did not have a specific policy pertaining to the repair of walls or ceiling tiles. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admission date of 03/04/22; -Diagnoses included type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument,…

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 give written information to the resident and/or resident's representative regarding the facility's bed hold policy for five residents (Residents #8, #12, #17, #69, and #83) who were transferred out to the hospital. The facility census was 83. Record review of the facility's Bed Hold Guidelines (undated), showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on a weekend or holiday; -If the resident or 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 observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Residents #8 and #79), who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene, including showers and nail care, out of a sample size of 23. The facility census was 83. Record review showed the facility did not have a policy available for showers. Record review of the facility provided undated policy, title Nails, Care of (Fingers and Toes), showed the following information: -Purpose to provide cleanliness, comfort, and prevent spread of infection; -The nursing assistant may perform nail care on the residents who are not at risk for complications of infection; -The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease; -Staff should prepare equipment; -Staff should soak the resident hands for five minutes in a basin of warm water; -Scrub nails gently with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician's orders for bed rail use for two residents (Resident #46 and #69); failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for two resident's (Resident # 23 and Resident #46); failed to obtain informed consent prior to the use side rails for two resident's (Resident #23 and Resident #46); failed to address the use bed rails in residents' care plans for two residents (Residents #12 and #46); failed to conduct an initial safety gap check for five residents (Residents #12, #23, #36, #46, and #69); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 83. Record review of the (undated) facility policy, titled Bed Rail Policy, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed; -They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter,…

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 interview, the facility failed to to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while completing medication administration for 7 residents (Residents #10, #23, #35, #51, #55, #66, and #69). The facility census was 83. 1. Record review of the facility policy, titled Medication Administration, dated 2/7/13, showed the following information: -Medications are given to benefit a resident's health as ordered by the physician; -Staff should bring the cart to the resident room; -Knock on the door before entering the room; -Introduce yourself, call resident by name, and check picture ID in the medication book; -Wash hands; -Read the label three times before administering the medication; -Administer medication; -Remain in the room while the resident takes the medication; -Return the medication cart to designated location when medication pass is completed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #10). The facility had a census of 83. The facility did not have a shower policy. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 Diabetes Mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/2023, showed the following: -Cognitively intact; -Independent with transfers; -Required physical help with part of bathing activity. Record review of the resident's current care plan, last revised 03/15/2023, showed the following:…

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 give written transfer notice to the resident and/or resident's representative for two residents (Residents #17 and #69) who were transferred out to the hospital. The facility census was 83. Record review of the facility provided copy of the form letter being sent to a resident's responsible party, titled Emergency Transfer Notice, showed the following information: -The letter is to serve as your emergency notice of transfer from the facility due to the need for urgent medical care which cannot be met by the facility; -More information on the discharge process can be received from State Long Term Ombudsman and address and phone number listed; -The name and address of facility transferred to; -Phone number of the facility and administrator signature. Record review showed the facility did not provide a policy regarding emergency transfer notice to residents or resident representatives. 1. Record review of Resident #17's face sheet showed the following…

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 notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #70) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 83. Record review showed the facility did not provide a policy regarding PASARR requirements. 1. Record review of Resident #70's Level 1 Nursing Facility Pre-admission Screening for Mental…

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 revise the comprehensive care plan for three residents (Residents #24, #36, and #39) of 18 sampled residents to reflect the residents' current care needs. The facility census was 83. Record review of the facility policy, titled Care Plan Comprehensive, with no date, showed the following: -An individualized care plan team with input from the resident, family, and/or legal representative will develop and maintain comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -A well-developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels; -Managing risk factors to the extent possible or indicating the limits of such interventions; -Addressing ways to preserve and build upon residents strengths; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -When a significant…

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 develop and implement an effective system to ensure a resident's choice of code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was readily accessible to staff and documented consistently throughout the medical record for one resident (Resident #10). The facility census was 83. Record review of the (undated) facility policy titled, Advance Directive, showed the following: -The facility will respect advance directives in accordance with state law. -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. -Upon admission of a resident, the social services designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives. -Information…

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 program of meaningful activities based on residents' interests and abilities when the staff did not provide activities as scheduled and did not track attendance of activities to evaluate if activities needs were being met for two residents (Residents #10 and #13). The facility had a census of 83. Record review of the facility policy titled, Activity/Recreational Therapy Manual, last reviewed on 03/12, showed the following: -The purpose is for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. -To enhance the quality of the residents daily life; -The Activity Director will develop a monthly activity calendar based on the residents' needs and interests. -Group activities will be scheduled at times when the maximum number of residents can participate in a specific…

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 restorative nursing services to maintain or improve residents' functional status as directed by therapy for two residents (Resident's #39 and #13) out of 23 sampled residents. The facility census was 83. Record review of the (undated) facility policy titled, Criteria for Restorative Nursing Assistant (RNA) program, a section of the Restorative Nursing Manual, showed the following information: -Referral to the RNA program may be made by nursing, Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and physician, as well as through the Minimum Data Set (MDS- a federally mandated assessment completed by staff) process, Certified Nurses Aide (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, or ST, the referral to the RNA is made; -The nurse or therapist initiating the referral transfers the assessment information to the Restorative Nursing Treatment Plan; -An appropriate inservice or instruction…

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 obtain physician orders to discontinue the use and care of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #36), failed to remove the catheter from the care plan and Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), and failed to document accurately when they charted the changing of catheter as completed when the resident no longer had a catheter. A sample of 23 residents was selected for review in a facility with a census of 83. Record review of the facility undated policy, titled Physicians Orders showed the following: -The following information is provided to assist staff in recording physicians' orders: -Foley catheter orders should include: -Why it is needed; -Specify the size (example, #18 French Foley catheter to straight drain) and the frequency to change; -Catheter care specifics what is to be used or according to facility procedure.…

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, facility staff failed to post required nurse staffing total hours and failed to include the resident census in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. The facility census was 83. Record review showed the facility did not provide a policy regarding posting staffing hours. 1. Observation on 3/12/23 at 5:00 P.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/12/23, 3/13/23, and 3/14/23 with names of staff scheduled. 2. Observation on 3/13/23 at 9:54 A.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/12/23, 3/13/23, and 3/14/23 with names of staff scheduled. 3. Observation on 3/14/23 at 2:00 P.M.,…

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 were free of significant medication errors when staff checked one resident's (Resident #23) blood glucose level and administered a sliding scale dose of insulin 40 minutes after the resident ate his/her meal. Staff also failed to prime the insulin pen and hold the insulin dose for six to 10 seconds at the site of administration as recommended by the manufacturer to ensure the resident received the full and correct dose of insulin. The facility census was 83. Record review of the (undated) facility policy, titled Diabetic Infection Control, showed the following: -Insulin injection pens are for single resident use; -The policy did not address timing of blood glucose checks or priming insulin pens before injection or holding insulin pens after injection. Record review of the website Medscape (medical reference website for healthcare professionals) showed the following information: -Typical times to check blood glucose levels…

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 restorative nursing services to maintain or improve residents' functional status as directed by therapy for four residents (Resident #31, Resident #42, Resident #48, and Resident #75) out of 21 sampled residents. The facility census was 103. Record review of the facility's policy titled, The Restorative Nursing (RNA) Program, dated May 2006, showed the following information: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -The RNA program is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; -It is the purpose of this facility to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -It is…

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 interview the facility failed to update the care plan for one resident (Resident #58) when the resident returned from the hospital with a peripherally inserted central catheter (PICC) intravenous (IV) line for infusion of antibiotics due to an osteomyelitis (a bone infection) and cellulitis (an infection of the tissue), out of a selected sample of 21 residents. The facility's census was 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-entered from the hospital on 4/24/19; -Moderate cognitive impairment; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Functional limitation in range of motion to bilateral lower extremities; -Used a wheelchair for mobility; -Suprapubic catheter (a urinary catheter that is surgically placed through the abdominal wall…

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, observation, and interview the facility failed to identify, assess, and monitor one resident's (Resident #53) pressure ulcer and failed to follow appropriate infection control measures when cleaning one resident's (Resident #40) multiple pressure ulcers and failed to measure on resident's (Resident #40) pressure ulcers, according to professional standards, in a selected sample of 21 resident's. The facility's census was 103. Record review of the facility's pressure ulcer policy, dated March 2015, included the following information: -Purpose: To prevent and treat further breakdown of pressure ulcers; -Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; -Observe skin. Any persistent reddened area that remains after pressure is relieved is considered a high-risk area for pressure ulcer to begin; -Change…

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 evaluate one resident with a history of falls (Resident #21) in a timely manner for the need of an assistive device when requested by the resident. The facility failed to assess and document one resident's (Resident #53) reported incident involving a mechanical lift. A sample of 21 residents was selected for review in a facility with a census of 103. Record review of the facility's policy titled Fall Precaution and Management and Guidelines, (undated) showed the following: -Objective to identify residents at significant risk of falls and provide for additional precautions to reduced or manage risk; -A resident will be placed on the fall precaution program when any of the following conditions exist: a. Fall risk assessment score on John Hopkins Fall Risk Assessment Tool if 6 or greater, or as identified by the specific fall risk tool used; b. The resident is identified through use of the care area assessment (CAA) as requiring care…

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 obtain an agreement with a dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) provider, failed to obtain a physician's order for dialysis before the resident received dialysis, and failed to consistently send and complete a dialysis communication form for one resident (Resident #253) in a selected sample of 21 residents. The facility's census was 103. 1. Record review of the facility's Dialysis, Care of a Resident Receiving policy, dated March 2012, showed the following sections: -Care of the AV (arteriovenous) shunt/fistula/grafts (abnormal connection or passageway between an artery and a vein); -Care of a subclavian (major arteries of the upper thorax, below the collarbone) or femoral vein (a large vein in the thigh) catheter; -Checking the thrill sensation (the sensation like a vibration, caused by blood flowing through the fistula; the thrill indicates 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, record review, and interview, the facility failed to ensure the record was accurate and complete when staff did not document a change of condition for one resident (Resident #58) when the resident's condition declined and facility staff sent the resident to the hospital where the resident was diagnosed with osteomyelitis (a bone infection) and cellulitis (an infection of the tissue) out of a selected sample of 21 residents were selected for review in a facility with a census of 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-admitted to the facility from the hospital on 4/24/19; -Moderate cognitive impairment; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Functional limitation in range of motion to bilateral lower extremities; -Wheelchair for mobility;…

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.