River Bend Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the staff, resident and the Nurse Practitioner (NP), the facility failed to request a refill from the pharmacy prior to the last dose being administered resulting in a resident missing 3 doses of the scheduled medication for 1 of 9 residents reviewed for unnecessary medications (Resident #16). Findings included: Resident #16 was admitted to the facility on [DATE] with diagnosis that included hypertensive heart disease without heart failure. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. A physician order dated 04/20/24 revealed Resident #16 was to receive prazosin hydrochloride (medication used to lower blood pressure) 5 milligrams (mg) at bedtime for blood pressure related to hypertensive heart disease without heart failure. A physician order dated 04/21/24 revealed Resident #16 was to receive amlodipine (medication used to lower blood pressure) 5 mg once a day at 9:00 AM for arterial hypertension related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to assess the risks of entrapment and complete bed rail assessments and failed to obtain informed consent prior to the installation for 2 of 3 residents reviewed for bed rails (Resident #4 and Resident #76). Findings Included: 1. Resident #4 was admitted to the facility 01/21/25 with diagnoses including dementia and Parkinson's disease (a brain disorder that can cause uncontrollable movements). A review of Resident #4's electronic medical records revealed no bed rail assessments had been completed since admission to the facility on [DATE]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was rarely or never understood, and her cognition was severely impaired. The MDS indicated Resident #4's range of motion was impaired on both sides of the upper and lower extremities, and she was dependent on staff assistance to roll left and right. The MDS revealed Resident #4's ability to move…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide ongoing, consistent, effective means of communication for a resident (Resident #69) to be able to communicate. Resident #69's primary language was Spanish, and she did not speak English. This deficient practice occurred for 1 of 1 resident reviewed for medically related social services. Findings included: Resident #69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. A care plan dated 1/12/25 read: Resident #69 has a communication problem related to language barrier; resident speaks Spanish language. The care plan goal was for her to be able to make basic needs known. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the staff and the Nurse Practitioner (NP), the facility failed to have effective systems in place for acquiring a scheduled opioid pain medication when nursing staff failed to request a prescription from the medical provider to avoid a gap in medication administration when refilling a controlled medication, and failed to utilize pharmaceutical resources in Pyxis (an automated dispensing machine that provided secure medication storage) which resulted in Resident #139 missing 3 days of a scheduled pain medication. This deficient practice occurred for 1 of 8 residents reviewed for pharmacy services (Resident #139). The findings included: Resident #139 was admitted to the facility on [DATE] with diagnoses including osteoporosis. She expired in the facility on [DATE]. The physician's order dated [DATE] revealed Resident #139 had an order to receive 1 tablet of tramadol (an opioid pain medication used to treat moderate to severe pain) 50 milligrams (mg) by mouth once daily 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 record review and interviews with the staff and the Nurse Practitioner (NP), the facility failed to prevent a significant medication error when nursing staff failed to administer tramadol (opioid pain medication) to Resident #139 for three consecutive days. This deficient practice occurred for 1 of 9 residents reviewed for significant medication errors (Resident #139). The findings included: Resident #139 was admitted to the facility on [DATE] with diagnoses including osteoporosis. She expired in the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #139 with severely impaired cognition. She had adequate vision and hearing with clear speech. The MDS indicated Resident #139 received both scheduled and as needed pain medications including opioid during the 7-day review period. The care plan for pain initiated on [DATE] revealed Resident #139 was at risk of pain. The goals were to remain free of interruptions in normal activities due to pain through the review date.…

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, observations, interviews with the Speech Therapist and staff, the facility failed to provide fluids of a nectar thick consistency as ordered by the physician for 1 of 8 residents reviewed for nutrition (Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE] and his current diagnoses included dementia and dysphagia (difficulty swallowing). The care plan last revised on 04/21/25 identified Resident #20 nutritional status was at risk related to advanced age, dementia, and dysphagia. Interventions included assist with meal setup, eating, and drinking as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20's cognition was severely impaired. The MDS assessment indicated Resident #20 had upper extremity impairment on one side, needed partial to moderate assistance with eating, received a mechanically altered diet, and had no signs or symptoms of a swallowing disorder. A review of the active diet order dated 04/24/25 revealed…

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

Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to document a reported fall with acute pain in a resident's medical record. This deficient practice occurred for 1 of 1 resident record reviewed for accuracy of documentation (Resident #69). Findings included: An interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated she had gone to the bathroom with two staff members and fell onto her right knee when she was being assisted off the toilet Saturday. Resident #69 reported she had pain in her right knee immediately but did not cry or scream out. Review of Resident #69's medical record revealed there was no documentation or assessment information from Saturday 6/7/25 about the reported fall. The last documented progress note in Resident #69's medical record was documented on 6/6/25. There was no additional documentation for Resident #69 until 6/8/25 at 1:30 PM. A telephone interview was conducted with the day shift (7:00 am to 7:00 pm)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews the facility failed to provide an influenza vaccine to 1 of 5 residents reviewed for immunizations (Resident #23). The findings included: Resident #23 was admitted to the facility on [DATE]. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #23 was cognitively intact. The MDS indicated Resident #23 had not received the influenza vaccine and indicated the reason as not offered. Review of Resident #23's medical record revealed she had not received an influenza vaccine since October 2023. An influenza vaccine informed consent form signed by Resident #23 was present in the medical record and indicated Resident #23 wanted to receive the influenza vaccine. The consent form was not dated. An interview was conducted on 6/13/25 at 11:50 AM with Resident #23. She stated the facility had offered her the flu vaccine and she remembered completing the consent form but that she had never received the flu vaccine. Resident #23 said someone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with the Responsible Party (RP), and staff, the facility failed to implement their abuse policy and procedures for reporting and protecting residents after a resident (Resident #2) reported a male Nurse Aide (NA) attacked and cursed at her. After the allegation of abuse was reported the male NA assigned to the unit remained at the facility for the rest of his shift with access to other residents. Additionally, the facility failed to report Resident #2 alleged sexual abuse to Adult Protective Services. The deficient practice occurred for 1 of 4 residents reviewed for abuse (Resident #2). Findings included: A review of the facility's Abuse, Neglect and Exploitation Policy dated 9/1/24 revealed it was the facility's policy to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. For Reporting/Response the facility's policy was to report all alleged violations to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with resident, staff, and the Nurse Practitioner (NP), the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 3 of 3 residents (Resident #29, Resident # 58, and Resident #113) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised on [DATE], revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. a. Resident #29 was admitted to the facility on [DATE] with diagnoses including acute respiratory distress. A review of the physician's order dated [DATE] revealed Resident #29 had an order to receive 0.25 milliliters (ml) of morphine sulfate oral solution with the strength of 20 milligrams (mg) per ml by mouth once every 4 hours as needed for pain related to acute respiratory distress. A review of the controlled substance count sheet for 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 record review, interviews with the Registered Dietitian (RD) and staff, the facility failed to implement the recommendation for a protein supplement and failed to administer the correct amount of a nutritional supplement as ordered by the physician for 2 of 3 residents reviewed for nutrition (Resident #25 and #51). Findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and severe protein calorie malnutrition. A nutrition/dietary note dated 10/27/23 revealed a recommendation was made to administer 30 milliliters (ml) of liquid protein twice a day related to severe calorie-protein malnutrition. Review of the current physician orders included an order for the administration of a liquid protein with directions to give 30 ml twice a day due to severe calorie-protein malnutrition with a start date 10/30/23. Review of the Medication Administration Record (MAR) from [DATE] through June 2024 revealed the physician's order dated 10/30/23 for liquid…

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 f. Resident #25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and severe protein-calorie malnutrition. Review of the medical records for Resident #25 revealed physician progress notes dated 01/11/24, 02/15/24, and 03/31/24 to indicate she was seen by the facility's Medical Doctor (MD). There was no other evidence in the medical records of Resident #25 of physician visits conducted by the MD. Review of the medical records for Resident #25 revealed she was seen by the NP on 10/5/23, 11/11/23, 12/13/23, 3/19/24, 4/4/24, and 5/24/24. The Director of Nursing was no longer employed and unable to be interviewed. The facility's MD was out of the country and unable to be interviewed. During an interview on 06/26/24 at 1:39 PM, the Regional Clinical Nurse Consultant revealed the MD kept track of his own schedule for when regulatory visits were due. She revealed when the MDS Coordinators noticed physician visits were not being completed, the Medical Records staff member conducted an…

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

Based on record review and staff interviews, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least 8 consecutive hours per day for 6 of 85 days reviewed (Dates 04/27/24, 04/28/24, 05/20/24, 05/21/24, 05/26/24, and 06/08/24). Findings included: Review of the daily nurse staffing sheets and associated time clock reports for the period 04/01/24 through 06/24/24 revealed the facility did not have the required RN coverage on the following dates: 04/27/24, 04/28/24, 05/20/24, 05/21/24, 05/26/24, and 06/08/24. During an interview on 06/27/24 at 3:53 PM, the Scheduling Coordinator revealed she took over handling the Skilled Nursing staff schedules on 03/18/24 and was usually able to ensure there was an RN scheduled daily anywhere from 8 to 12 hours. The Scheduling Coordinator stated the only time there wouldn't be the required RN coverage was when the RN scheduled called out of work. During an interview on 06/26/24 at 9:34 AM and a joint interview with the Administrator on 06/27/24 at 6:12 PM, the Regional Clinical Nurse Consultant acknowledged 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.

Based on observation, staff interviews, and record reviews, the facility failed to secure an opened bottle of Silvadene cream for 1 of 1 Resident (Resident # 30) review for medication storage, failed to removed expired over-the-counter (OTC) medications in accordance with the manufacturer's expiration date for 1 of 2 medication storage rooms and 1 of 4 medication carts (Upper medication storage room and Upper C halls medication cart), failed to remove expired insulin as specified by the manufacturer's guidelines for 1 of 4 medication carts (Upper C halls), and failed to store insulins and eye drops in the temperature specified by the manufacturer's guidelines in 3 of 4 medication carts during medication storage checks (Upper C halls, Lower C halls, and Lower D halls). The findings included: a. During a joint observation conducted with Nurse #2 on 06/23/24 at 9:51 AM, an opened bottle of Silvadene cream 1% containing approximately 10 grams was left unattended on the top of the bedside table in Resident #30's room. An interview was conducted with Resident #30 on 06/23/24 at 9:58 AM.…

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

Based on observations, record review, and interviews with staff the facility failed to follow their infection control policy and procedures to implement Enhanced Barrier Precaution (EBP) precautions for residents with indwelling medical devices during high-contact care activities of a central line, feeding tube, tracheostomy, and urinary catheter (Resident #25, #51, #18, and #2) and failed to follow their hand hygiene policy and procedure after removing gloves, after handling items potentially contaminated with body fluids, and when moving from a contaminated body site to a clean body site during incontinence care (Resident#36). These failures occurred for 5 of 5 residents reviewed for infection control. Findings included: Review of the facility's enhanced barrier precautions (EBP) policy and procedures with no revision date read in part, It was the facility's policy to implement barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP referred to an infection control intervention designed to reduce the transmission of MDRO that employed…

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, family and staff interviews, the facility failed to invite residents and/or their Resident Representative (RR) to participate and provide input in care planning for 1 of 2 sampled residents (Resident #30). This practice had the potential to affect other residents. Findings included: Resident #30 admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. Review of Resident #30's electronic medical record revealed an admission MDS assessment was completed on 12/05/23 and quarterly MDS assessments were completed on 03/04/24 and 06/04/24. Further review revealed no evidence that she or her RR were invited to attend a care plan meeting to discuss and provide input regarding…

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 and staff interviews, the facility failed to protect the private health information for 2 of 2 sampled residents (Resident #1 and Resident #53) by leaving confidential medical information unattended and exposed in an area accessible to the public. The findings included: Resident #1 was admitted to the facility on [DATE]. a. A continuous observation was made on 06/25/24 from 9:31 AM through 9:36 AM of an unattended medication cart in the hallway of Lower C halls between room C09 and C11. Nurse #1 left the medication cart with the Medication Administration Record (MAR) of Resident #1 visible on the medication cart's computer screen when she was away administering medication. The screen showed the name and the picture of Resident #1. The surveyor could easily access information related to her current medications and other private health information. The unattended computer was accessible by anyone passing by the medication cart. During an interview with Nurse #1 on 06/25/24 at 9:39 AM, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to identify and implement effective interventions to prevent resident-to-resident physical abuse when a severely cognitively impaired resident (Resident #23) with a known history of aggression hit another severely cognitively impaired resident (Resident #11) in the face for 1 of 5 residents reviewed for abuse. As a result of the incident, Resident #11 sustained a small cut measuring 0.2 centimeters (cm) by 0.1 cm to the left eyebrow and bruising to the left top of hand measuring 3.5 cm by 3 cm. Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, diabetes, vascular dementia, psychotic disturbance, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #11 with severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to implement their abuse policy and procedures in the areas of reporting and investigation by not submitting an Initial Allegation Report within 2 hours to the State Regulatory Agency and not initiating an investigation when an allegation of abuse was reported to the Administrator. This deficient practice affected 1 of 5 residents reviewed for abuse (Resident #31). Findings included: The facility's undated policy titled, Abuse, Neglect and Exploitation, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop individualized, comprehensive care plans that included areas of focus for nutritional risk and indwelling catheter for 2 of 5 residents reviewed for nutrition and urinary catheters (Resident #2 and Resident #22). Findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included urinary retention and dementia. A physician's diet order for Resident #2 dated 03/29/24 read in part, regular diet with pureed texture and regular/thin liquids. A physician's order for Resident #2 dated 03/29/24 read in part, suprapubic catheter (flexible tube that enters the body through a small incision in the abdomen that helps drain urine from the bladder) one time a day. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. He was dependent on staff assistance for all self-care tasks, including eating. He had an indwelling catheter and received a mechanically altered diet.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with the Nurse Practitioner (NP) and staff the facility failed to obtain a physician's order for the administration of heparin (an anticoagulant medication) used by Nurse #1 to flush the peripherally inserted central catheter for 1 of 5 residents reviewed for unnecessary medications (Resident #25). Findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and pulmonary embolism. The care plan last reviewed 3/22/24 included Resident #25 was at risk for complications related to anticoagulant therapy for the use of apixaban with the goal to have no adverse reactions to the medication. Interventions included administer as ordered by the physician and monitor for side effects signs of bleeding and bruising. Review of Resident #25's current physician orders included the administration of apixaban (an anticoagulant medication) give 5 milligrams (mg) twice a day for atrial fibrillation started on 10/05/23 and 4.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with resident, staff, and the Nurse Practitioner (NP), the facility failed to pull controlled medications from the medication cart and returned them to the pharmacy after the resident was deceased . As a result, controlled medications of a deceased resident remained in the medication cart were targeted and diverted for 1 of 1 resident reviewed for pharmacy services (Resident #113). The findings included: Resident #113 was admitted to the facility on [DATE] with diagnoses including thrombocytopenia. He passed away in the facility on [DATE]. A review of the physician's order dated [DATE] revealed Resident #113 had an order to receive 5 mg of oxycodone by mouth once every 12 hours for moderate to severe pain. This order was discontinued on [DATE]. A review of the MARs for [DATE] revealed Resident #113 had received oxycodone 5 mg once on [DATE]. The admission MDS dated [DATE] coded Resident #113 with an intact cognition. A review of the controlled substance count sheet 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to include documentation in the medical record of refusal or acceptance of the influenza and pneumonia vaccinations for 1 of 5 residents (Resident #20) reviewed for immunizations. The findings included: Resident #20 was admitted to the facility on [DATE] with the quarterly minimum data set (MDS) dated [DATE] revealing she was cognitively intact. The MDS indicated Resident #20 did not receive the flu vaccination because Resident #20 received it from an outside location with no date noted. It was further documented that the pneumonia vaccination was not offered to Resident #20 and her pneumonia vaccination was not up to date. Record review of Resident #20's immunizations and consents revealed no available documentation regarding receiving, offering, refusing, or education for the flu or pneumonia vaccinations. An interview on 6/26/24 at 1:30 PM with Resident #20 revealed that she usually refused the flu shot every year but thought that she had agreed…

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, interviews with the Registered Dietitian, Nurse Practitioner, Medical Doctor, and staff, the facility failed to obtain weekly weights as ordered by the physician and failed to implement the recommendation for a nutritional supplement to promote weight stability and failed to implement interventions when weight loss was identified for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, and cerebral vascular accident (blocked or reduced blood flow to the brain) with hemiplegia (severe or complete loss of strength or movement) affecting the left nondominated side. Review of the current physician's orders for medication and nutritional supplements included mirtazapine 7.5 milligrams give 1 tablet at bedtime related to symptoms and signs concerning food and fluid intake; 2.0 fortified nutrition shake give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete and submit an Initial Allegation Report within 2 hours to the State Regulatory Agency for 2 of 3 residents reviewed for abuse (Resident #2 and Resident #3). Findings included: Resident #2 was admitted to the facility 01/17/24. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #3 was admitted to the facility 08/23/22. The quarterly MDS assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. The Administrator completed an Initial Allegation Report to the State Regulatory Agency on 03/10/24. The report designated the type of allegation as Resident Abuse and stated the facility became aware of the allegation on 03/09/24 at 5:15 PM. Allegation details revealed Resident #2 was found in Resident #3's room and had grabbed Resident #3's arm. The residents were separated, and Resident #2 was assisted to her room. Resident #2 received increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse for 2 of 3 residents reviewed for abuse (Resident #2 and Resident #3). Findings included: The facility's undated Abuse, Neglect and Exploitation policy read in part as follows: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; providing complete and thorough documentation of the investigation. Resident #2 was admitted to the facility 01/17/24. The admission Minimum Data Set (MDS) assessment…

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

Based on staff interviews, record reviews, and review of the facility's abuse policies and procedures the facility failed to develop an abuse policy that included procedures related to screening, training, prevention, identification, investigation, protection, and coordination with QAPI to address allegations of abuse. The findings included: The facility's Abuse Policy titled Elder/Dependent Adult Abuse Assessment and Reporting, dated July 2011 revealed all alleged violations involving mistreatment, neglect, abuse, including injuries of unknown origin, will be reported immediately to the Department Supervisor who will forward the complaint to the Administrator. It is the policy of the facility to report any suspected cases of elder abuse or dependent adult abuse. Employees subject to the reporting requirements include any employees who provides direct resident care and any other employee whose duties require him/her to regularly work directly with elders or dependent adults. The policy failed to include written procedures for screening potential employees, training of new and…

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

Based on observations and staff interviews the facility failed to date opened food, remove expired food available for use, and indicate the expiration date of thawed milkshakes for 1 of 1 walk-in cooler; failed to date and cover food item in 1 of 1 walk-in freezer; failed to label and date food and beverage items, indicate the expiration date of thawed milkshakes, and remove expired food available for use in 2 of 2 nourishment rooms (upper and lower floor nourishment rooms). This practice had the potential to affect food served to residents. Findings included: 1. An initial tour of the walk-in cooler on 09/11/23 at 9:42 AM revealed the following: a. 5 thawed chocolate milkshakes sitting on a cart and 8 thawed milkshakes and 2 boxes of thawed milkshakes each containing 50 milkshakes sitting on a shelf. The manufacturer instructions stamped on each carton of milkshake indicated the product was good for 14 days after thawed. None of the milkshakes had a date indicating when they were placed in the cooler to thaw or when they expired. b. an opened 5-pound container of pimento cheese…

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

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 03/25/22. This was for three repeat deficiencies originally cited in the areas of accuracy of assessments, food procurement - store/prepare/serve, and infection control that were subsequently recited on the current recertification and complaint investigation survey of 09/15/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F641: Based on record review and staff interviews the facility failed to accurately code a Minimum Data Set (MDS) assessment in the area of antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications (Resident #36). During the recertification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a resident was treated with dignity and respect when Nurse Aide (NA) #2 was observed speaking to a resident in a disrespectful manner for 1 of 1 resident reviewed for dignity (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE], transitioned to Hospice care on [DATE] and expired on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had intact cognition and required extensive assistance with activities of daily living. During an interview on [DATE] at 1:46 PM, Nurse Aide (NA) #1 stated she assisted NA #2 provide incontinence care for Resident #60 on [DATE] around shift change. Resident #60 was total care and required 2 person-assist. Resident #60 had taken his clothes off, threw his diaper on the floor and had soiled himself. While providing care, NA #2 was yelling at Resident #60 and told him, he was stupid, he shouldn't be acting this way, he knew better and there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) prior to discharge from Medicare Part A skilled services to 2 of 3 residents reviewed for beneficiary notification review (Residents #9 and #21). The Findings Included: 1. Resident #9 was admitted to the facility on [DATE]. Review of the medical record revealed a Notice of Medicare Non-Coverage (NOMNC) was discussed with Resident #9's Responsible Party (RP) on 08/23/23 which indicated Resident #9's Medicare Part A coverage for skilled services would end on 08/25/23. Resident #9 remained in the facility. Review of Resident #9's medical record revealed no evidence a SNF-ABN was also provided to Resident #9's RP. During an interview on 09/12/23 at 5:14 PM, the Social Worker explained he used to issue a SNF-ABN in conjunction with a NOMNC when a resident's Medicare Part A services ended but was instructed by the previous corporate representative that he only needed 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 observations and staff interviews, the facility failed to ensure 2 of 2 facility contractors followed the Special Droplet Contact Precautions signage posted on the doors of residents' rooms by not donning and doffing Personal Protective Equipment (PPE) while entering and exiting 2 of 6 resident rooms on transmission-based precautions (TBP) for COVID-19. The findings included: The Special Droplet Contact Precautions (SDCP) signage, with a revised date of 02/09/22, noted staff should follow the instructions listed on the signage before entering the resident's room which included: all healthcare personnel must: 1) clean hands before entering and when leaving the room, 2) wear a gown when entering room and remove before leaving, 3) wear N95 or higher level respirator before entering the room and remove after exiting, 4) wear protective eyewear (face shield or goggles), and 5) wear gloves when entering room and remove before leaving. A continuous observation on 09/12/23 from 9:50 AM to 10:00 AM of the lower C hall revealed Contractor #1 and Contractor #2 entered room C13 wearing…

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.