Fuquay-Varina Health and Rehabilitation Center

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 25 of 61 days reviewed for sufficient staffing. Findings included: Review of the daily assignment schedules from April 01, 2024, to May 28, 2024, revealed the facility failed to provide 8 hours of Registered Nurse (RN) coverage on the following dates: 04/01/24, 04/03/24, 04/05/24, 04/06/24, 04/07/24, 04/13/24, 04/20/24, 04/21/24, 04/22/24, 04/26/24, 04/27/24, 04/30/24, 05/04/24, 05/06/24, 05/09/24, 05/10/24, 05/11/24, 05/14/24, 05/18/24, 05/19/24, 05/20/24, 05/21/24, 05/24/24, 05/25/24, and 05/28/24. An interview was conducted with the facility Scheduler on 12/04/2024 at 9:30 AM. During the interview the Scheduler reported she was not aware that she needed to schedule an RN for at least 8 consecutive hours every day. The Scheduler explained that there had been a large amount of staff turnover, including RNs, since the facility changed ownership in June-July 2024. She further explained the facility had been using staffing…

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 interviews with Resident Council members and staff and review of Resident Council minutes, the facility failed to resolve concerns voiced by the Resident Council members for 1 of 6 months reviewed (July 2024). The findings included: Resident Council Meeting minutes from January 2024, February 2024, March 2024, July 2024, August 2024, and September 2024 were reviewed. A review of Resident Council minutes dated 7/9/24 indicated residents voiced concerns regarding not being able to get out of bed or get showers on their scheduled shower days due to staffing. Two administrative responses to the Resident Council form were reviewed dated 7/9/24. One stated the residents were being told they could not get out of bed due to staffing. There was no resolution listed. A second form revealed residents were concerned about not being able to get showers on their scheduled shower days due to staffing. There was no resolution listed. Review of Resident Council minutes dated 8/13/24 revealed there were no administrative resolutions from the July 2024 meeting. An interview was conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 2 of 21 residents reviewed for advance directive (Residents #14 and Resident #17). The findings included: a. Resident #14 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, dysphagia, and end stage renal disease. There was no documentation in Resident #14's medical record for education regarding the formulation of an advanced directive and/or an opportunity to formulate an advance directive was offered. An interview was conducted with the Director of Social Services on 12/04/2024 at 3:51 PM. She revealed that during care plan meetings or as needed, code status was discussed. However, the conversation never went further into detail to include advance directive. During an interview with the Admissions Director on 12/05/24 at 8:22 AM, she revealed that prior to the change of ownership in June 2024,…

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 protect residents' right to be free from misappropriation of resident property for 2 of 21 residents reviewed for misappropriation of resident property (Resident #152 and Resident # 97). Findings included: a. Resident #152 was admitted to the facility on [DATE] with diagnoses that included hypertension, respiratory failure and fracture of facial bone. The resident was discharged from the facility on 11/01/2024. An admission Minimum Date Set (MDS) dated [DATE] revealed that Resident #152 was cognitively intact. A review of the initial facility report dated 10/28/24 at 11:45 AM documented that a resident (Resident #152) reported that his air pods (wireless Bluetooth earbuds designed by apple) had been removed from his room. The resident reported he left the facility at approximately 4:30 PM on Friday 10/25/2024 and returned at 12:00 AM on 10/26/2024. Resident #152 reported he left the air pods charging on his bedside table. The air pods were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review the facility failed to develop a comprehensive care plan to include application of splints or multi podus boots for 1 of 32 residents (Resident #56) reviewed for comprehensive care planning. Findings included: Resident #56 was admitted into the facility on 4/16/2019 with a re-entry on 6/24/2024. A review of Resident #56's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #56 was severely cognitively impaired. A review of Resident #56's physician orders indicated on 7/1/2024 an order for bilateral multi podus boots up to four hours daily and on 10/8/24 an order for apply left hand splint when sitting up in wheelchair daily, remove when going back to bed. Resident #56's was to wear bilateral elbow extension splints daily, applied with afternoon care once back in bed and removed at PM care for effective contracture management. A review of Resident #56's comprehensive care plan revised on 10/22/2024 did not have a care plan related 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, observations, and staff interviews, the facility failed to apply left hand splint, elbow extender splints and multi podus boots as ordered for 1 of 3 sampled residents with limited range of motion/contractures (Resident #56). The findings included: Resident #56 was admitted into the facility on 4/16/19 and readmitted on [DATE]. A review of Resident #56's quarterly Minimum Data Set (MDS) dated [DATE] indicated that he was severely cognitively impaired. A review of Resident #56's physician orders indicated on 7/1/2024 an order for bilateral multi podus boots (an orthotic to treat and prevent ankle and foot contractures) up to four hours daily and on 10/8/24 an order to apply left hand splint when sitting up in wheelchair daily, remove when going back to bed. Resident #56's was to wear bilateral elbow extension splints daily (an orthotic to help increase elbow extension in patients with non-fixed contractures), applied with afternoon care once back in bed and removed at PM care for effective…

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, resident and staff interviews, the facility failed to ensure Resident #64 was scheduled for a neurology appointment for 1 of 1 resident reviewed for medical appointments (Resident # 64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hypothyroidism and failure to thrive. Resident #64's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #64 on 12/2/24 at 12:21 PM. She reported she had a referral to a neurologist and an appointment was never made. Resident #64 stated she questioned her diagnosis of Parkinson's disease and wanted a neurology appointment to confirm the diagnoses. Record review revealed a referral was made to neurology on 3/1/24 by the facility scheduler. A letter written to the facility by the Referral Coordinator at the local neurology office addressed to the Scheduler at the facility dated 3/26/24 read…

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

Based on observation and staff interviews, the facility failed to dispose/discard expired medications in 1 of 3 medication carts (Rehab Medication Cart) observed. The findings included: During an observation of the Rehab Medication Cart on 12/04/24 at 9:34 A.M., one bottle of aspirin 325 milligrams (mg) tablets with an expiration date of 09/2024 and one bottle of Allergy Relief tablets with an expiration date of 04/2024 were observed in the top drawer of the cart. During an interview with Certified Medication Aide (CMA) #1 on 12/04/24 at 9:36 A.M., CMA #1 confirmed she had been working the Rehab Medication Cart that day. She stated it was the responsibility of the nurses to check the medication carts for expired medications. During an interview with Nurse #8 on 12/04/24 at 9:45 A.M., Nurse #8 stated it was his responsibility to check the Rehab Med Cart for expired medications. When asked if he was sole person responsible for checking the medication carts for expired medications, Nurse #8 clarified and stated that it was the responsibility of all nurses to check their 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to have a complete and accurate medication and administration record for 2 of 5 residents reviewed for medical record accuracy (Resident #250 and Resident #350). Findings included: 1. Resident #250 was admitted to the facility 07/19/24. Review of Resident #250's Emergency Department (ED) Note revealed she was sent to the hospital on [DATE] for evaluation and transferred to the hospital. Review of Resident #250's medical record revealed there was no entry to indicate the resident was transferred to the hospital on [DATE] or the resident's condition at the time of transfer. The only documentation in the medical record was a nurse blood pressure vital sign 120/70 dated 08/09/24 at 10:04 AM written by Nurse #2 regarding Resident #150's hospital transfer. An interview was conducted on 12/04/24 at 1:45 PM with Nurse #2 revealed she was working as a floor nurse on the 700-hall on 08/08/24 and 08/09/24. Nurse #2 said Resident #250 told her that she had…

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, facility staff failed to implement infection control policy and procedures when Physical Therapist Assistant (PTA #1) and Physical Therapist (PT #2) did not don Protective Equipment (PPE) for Enhanced Barrier Precautions (EPB) to include a gown when providing high-contact resident care activities for Resident #251 who had indwelling upper chest dialysis catheter. The deficient practice was identified for 2 of 2 staff members observed for infection control practices (PTA #1 and PT #2). The findings included: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated 03/26/24 read in part: EBPs require use of gown and gloves by staff during high-contact patient care activities as defined below: Transferring. During an observation on 12/02/24 at 10:35 AM an EBP sign was posted by Resident #251's room door that read in part: Enhanced Barrier precautions, and providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens,…

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 and resident interviews, the facility failed to provide the resident council members with a response to grievances reported during the resident council meetings for 3 of 3 resident council grievances reviewed. Findings included: Review of Resident Council minutes dated 8/1/23 revealed resident council members expressed a concern that the council does not get resolutions to issues from resident council meetings. A resident council grievance dated 8/2/23 stated a concern about resolutions to issues from resident council written by the Activities Director. The form reflected it being solely addressed by the Activities Director. The staff response section stated the Activities Director would ensure follow-up with department heads. The form had an area designated for the date on which the resolution was approved by the Resident Council. There was no council approval date, and the area was blank. The implementation date was 8/9/23. Review of Resident Council minutes dated 9/5/23 revealed concerns about showers and timeliness of pain medications. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure advanced directive information was accurate throughout residents' electronic and paper medical records for 4 of 5 residents (Resident #42, Resident #52, Resident #57, and Resident #76) reviewed for advanced directives. Findings included: 1) Resident #42 was admitted to the facility on [DATE]. Resident #42's electronic medical record revealed an active physician's order dated [DATE] that read full code. This order was still active on [DATE]. Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired. Review of Resident #42's care conference notes showed a note dated [DATE] at 2:00 P.M. read in part (Guardian) is requesting a letter be written to change the resident code status from CPR (cardiopulmonary resuscitation) to DNR (Do Not Resuscitate) . Resident will remain a CPR CODE STATUS until the letter is received and approved by the guardian supervisor. Resident #42's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, staff, and Physician interviews, the facility failed to follow physician orders for pressure ulcer dressing changes, compete wound care as ordered, and set an alternating pressure mattress according to the resident's weight. This occurred for 3 of 3 residents (Resident #1, Resident #81, and Resident #32) reviewed for wound care. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included paraplegia, stage 4 pressure ulcer to right buttocks, stage 4 pressure ulcer to left buttocks, stage 4, pressure ulcer to left lower back. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and did not exhibit any behaviors. The MDS also documented Resident #1's pressure ulcers. Physician order dated 9-14-23 read clean stage 4 wound to right buttocks with wound cleanser, apply silver alginate, and cover with a foam dressing daily. Physician order dated 9-14-23 read clean stage 4 wound to…

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

Based on record review and staff interviews the facility failed to have 8 consecutive hours of Registered Nurse (RN) coverage for 7 of 120 days reviewed. Findings included: Review of punch in times (times recorded by digital timecards) for 4/8/23, 4/9/23, 5/6/23, 5/7/23, 5/20/23, 5/21/23, and 6/17/23 at the facility revealed there was no RN working during these days. During an interview on 10/13/23 at 11:33 AM the Scheduler stated she took the position of scheduler on June 3rd. She further stated she was not trained in the position, and she was unaware that there was a requirement for an RN to be on the schedule for 8 hours. She concluded she had heard the term 'RN coverage' but was told by the administrator not to use agency RN for coverage and did not know there needed to be 8 hours for coverage due to lack of training. During an interview on 10/13/23 at 11:39 AM the Director of Nursing stated she was aware of the regulation that facilities needed 8 hours of RN coverage per 24 hours. She concluded there was no monitoring in place to review for 8 hours RN coverage of the schedule…

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, staff, and Physician interviews, the facility failed to have a medication error rate less than 5% as evidenced by 15 medication errors out of 33 opportunities, resulting in a medication error rate of 45.45% for 2 of 4 residents (Resident #14, and Resident #7) observed during the medication administration observation. Findings included: 1a. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included cerebral infarction and gastrostomy status. Observation of medication administration through a gastro tube occurred on 10-10-23 at 8:00am with Nurse #3. The nurse was observed checking the manufacturers instructions regarding if Resident #14's medication could be crushed. Nurse #3 contacted the Nurse Practitioner informing him some of Resident #14's medications were not allowed to be crushed (Duloxetine, and Memantine). The Nurse Practitioner instructed Nurse #3 to call the pharmacy. The nurse was observed and heard talking to the Pharmacist who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to discard expired medications for 1 of 2 medication storage rooms observed (station 1 medication room), failed to keep unattended medications in a locked medication cart for 1 of 5 medication carts observed (700-hall medication cart), and failed to keep unattended medications in a locked treatment cart for 2 of 3 treatment carts observed (station 1 treatment cart and station 2 treatment cart). Findings Included: 1. During observation of the station 1 medication room [ROOM NUMBER]/13/23 at 8:34 AM with the Director of Nursing, the station 1 medication room was observed to contain six bottles of simethicone 125 milligrams which had an expiration date of 9/2023, one bottle of simethicone 80 milligrams which had an expiration date of 8/2023, and one bottle of simethicone 80 milligrams which had an expiration date of 9/2023. During an interview on 10/13/23 at 8:34 AM the Director of Nursing stated the simethicone 125 milligrams, and 80 milligrams were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to 1) label/date opened food items stored in 1 of 1 one of one walk-in freezer and 2) label/date food items stored in 1 of 1 dry goods storage area. These practices had the potential to affect food served to all residents. Findings included: 1. Accompanied by the Dietary Manager, an initial tour of the kitchen was conducted on 10/9/23 at 10:59 A.M. Observations made of the walk-in freezer identified the following: - 1 opened clear plastic bag filled halfway with shrimp, no open date or use by date on the package - 1 opened clear plastic bag with 19 beef hot dogs, no open date or use by date on the package - 1 opened clear plastic bag fille halfway with chicken patties, no open date or use by date on the package - 1 large Styrofoam cup with a red straw sticking out of the plastic lid on top, the contents were frozen, no label or date on the cup An interview was conducted with the Dietary Manager during the tour of the walk-in freezer on 10/9/23 at…

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

Based on observation and staff interviews, the facility failed to maintain the area surrounding the dumpsters free of debris for 2 of 2 dumpsters observed. Findings included: During an observation of the dumpster area with the Dietary Manager and the Assistant Dietary Manager on 10/9/23 at 11:15 A.M., debris was found next to and behind the back of the right and left dumpsters. Debris included 11 disposable gloves, 4 plastic lids used on disposable Styrofoam cups/bowls, 1 plastic knife, 4 plastic spoons, 1 plastic bowl, 1-8ounce empty bottle of water, one baseboard, and three pieces of damp crumbly cardboard. An interview was conducted on 10/9/23 at 11:15 A.M. with the Dietary Manager. The Dietary Manager confirmed there were items laying around the dumpster and stated the area should be free from debris. During the interview, he stated he had been employed at the facility for approximately three weeks and had not cleaned the area around the dumpsters during his period of employment. The Dietary Manager further explained he was unsure who was responsible for maintaining the area…

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

Based on record review, observations, and interviews with resident, family, responsible party, physician, police dispatch, and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation survey of 6/11/2021, the revisit survey of 8/6/21, the complaint investigation survey of 9/20/2021, and the recertification and complaint investigation survey of 6/17/2022. This was for nineteen recited deficiencies on the current recertification and complaint investigation survey of 10/18/2023. The deficiencies included: Self Determination (F561), Request/Refuse/ /Discontinue Treatment/Formulate Advance Directive (F578), Grievances (F585), Reporting of Alleged Violations (F609), Accuracy of Assessments (F641), Baseline Care Plan (F655), Develop and Implement Comprehensive Care Plan (F656), Care Plan Timing and Revision (F657), Activities of Daily Living Care Provided for Dependent Residents (F677), Treatment and…

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

Based on record review and staff interviews the facility failed to ensure Nurse Aides (NA) received at least 12 hours of in-service training in one year. This was for 5 of 5 NA in-service training records reviewed (NA #12, NA #10, NA #4, NA #5). Findings included: Education records from 6/1/2022 to 10/16/2023 provided by the facility's Regional Nurse Consultant reported the following training completed by each nurse aide. The number of hours of in-service training were not provided: * NA #12: Understanding Bloodborne Pathogens on 5/4/2023 and Let's Talk About COIVID Vaccination on 7/20/2023. * NA #10: Let's Talk About COVID Vaccination on 7/20/2023 * NA #13: Basics of Hand Hygiene, Effective Communication and Fire Safety: The Basics on 4/25/2023 and Let's Talk About COVID Vaccination on 7/20/2023. * NA #4: Weights, Weight: Measuring with a Wheelchair and Height Measurements on 7/9/2023 and Let's Talk About COVID Vaccination on 7/20/2023 * NA #5: Let's Talk About COVID Vaccination on 7/20/2023, On 10/16/2023 at 8:21 a.m. in a phone interview with NA #12, she stated she started…

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 provide required dementia management training for 7 of 8 nursing staff (Nursing Assistant (NA) #12, NA #10, NA #13, NA #4, NA #5, Nurse #4 and Nurse #5) reviewed for education requirements. Findings included: Education records from 6/1/2022 to 10/16/2023 provided by the facility's Regional Nurse Consultant were reviewed for the following nursing staff: * NA #12: There was no dementia management training recorded on the education records. * NA #10: There was no dementia management training recorded on the education records. * NA #13: There was no dementia management training recorded on the education records. * NA #4: There was no dementia management training recorded on the education records. * NA #5: There was no dementia management training recorded on the education records. * Nurse #4: There was no dementia management training recorded on the education records. * Nurse #5: There was no dementia management training recorded on the education records. On 10/16/2023 at 8:21 a.m. in a phone interview with NA #12, 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, resident interview and staff interviews, the facility failed to honor a resident's choice related to showers for 1 of 9 dependent residents reviewed for choices (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE], and diagnoses included congestive heart failure. The admission Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact and considered choosing a sponge bath or shower very important. The quarterly MDS assessment dated [DATE] indicated Resident #29 required physical assistance of one person with bathing, bed mobility and transfers. Resident #29's care plan dated 5/8/2023 indicated Resident #29 required assistance with grooming, bathing, mobility and transfers due to congestive heart failure, reduced mobility, and muscle weakness. Based on the facility's shower schedule, Resident #29 was scheduled showers on Mondays and Thursdays. There were no shower sheets for Resident #29 in the facility's shower book. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, interview with a Resident Representative and record reviews, the facility failed to develop a baseline care plan within 48 hours of a resident's admission and failed to provide a written summary of the baseline care plan to the Resident or Resident Representative for 4 of 28 sampled residents (Residents #29, #77, #388 and #89). Findings included: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included, in part, diabetes and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29's medical record was reviewed and revealed no evidence a baseline care plan had been completed after the resident's admission. During an interview with Resident #29 on 10/10/23 at 2:08 PM, she said she could not remember if the facility offered her a written summary of the baseline care plan. On 10/10/23 at 9:38 AM an interview was conducted with MDS Nurse #1. She explained 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 observations, record review and staff interviews the facility failed to develop a comprehensive care plan which addressed wandering behavior and the use of a wander/elopement alarm for 1 of 33 residents (Resident #71) whose comprehensive care plans were reviewed. Findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses including dementia, generalized muscle weakness and unsteadiness on feet. A review of an Elopement Risk Tool for Resident #71 dated 7/15/23 completed by the Director of Nursing (DON) revealed Resident #71 was found to be at risk for elopement. It further revealed her wandering behavior affected her safety and well-being. A review of the physician's orders for Resident #71 revealed an order dated 7/15/23 for a wander guard (a type of elopement alarm) to be placed to her right ankle. A nursing progress note dated 7/27/23 at 7:58 AM written by Nurse #2 revealed in part Resident #71 was reported missing around 9:00 PM to 11:00 PM (7/26/23). All open doors were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure an interdisciplinary team reviewed and revised a resident's comprehensive care plan and failed to ensure the resident's representative was involved in care planning after a quarterly Minimum Data Set (MDS) assessment for 1 of 33 residents (Resident #71) whose care plans were reviewed. Findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses including dementia, generalized muscle weakness and unsteadiness on feet. A review of a progress note for Resident #71 dated 5/4/23 2:11 PM written by the Social Worker (SW) revealed the SW mailed an invitation to Resident #71's care conference to Resident #71's representative. A review of Resident #71's care plan revealed the following focus areas and their last reviewed dates: discharge, 5/27/23; activity, 8/23/23; falls, 11/14/22; respiratory, 11/14/22; pain, 11/14/22; nutrition, 11/12/22; communication, 11/14/22; cognition, 11/14/22; advanced directives, 11/14/22; 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and family interviews the facility failed to change a resident's soiled brief due to meal trays being passed on the halls for 1 of 8 resident reviewed for activities of daily living care (Resident #53). Findings included: Resident #53 was admitted to the facility on [DATE]. Review of Resident #53's most recent Minimum Data Set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He had no moods or behaviors. He was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. He had an indwelling urinary catheter and was always incontinent of bowel. His active diagnoses included anemia, coronary artery disease, heart failure, hypertension, peripheral vascular disease, obstructive uropathy, and diabetes mellitus. Review of Resident #53's care plan dated 9/28/23 revealed he was care planned to require assistance for eating, mobility, transfers, dressing, grooming, toileting and bathing 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 observation, record review, and staff interview the facility failed to assess the resident's left upper arm shunt site upon returning to the facility after dialysis for 1 of 1 resident reviewed for dialysis. (Resident #390). The findings included: Resident #390 was admitted to the facility on [DATE], and diagnoses included end stage renal disease. Resident #390 was discharged from the facility on 8/21/2023 and was re-admitted to the facility on [DATE]. Physician's orders dated 8/25/2023 included dialysis on Tuesday, Thursday, and Saturday at a local dialysis center. There were no other orders for Resident #390 related to dialysis care. The 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #390 was cognitively intact. The MDS reflected Resident #390 had received dialysis while not residing in the facility and had not received dialysis while a resident in the facility for the 5-day look back period. The care plan dated 9/5/2023 stated Resident #390 had end stage renal disease and required…

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 ensure a resident attended a medical appointment for 1 of 1 sampled resident reviewed for medically related social services (Resident #88). The findings included: Resident #88 was admitted on [DATE] with diagnoses that included reduced mobility and gait abnormality. Review of Resident #88's hospital Discharge summary dated [DATE] revealed an orthopedic appointment scheduled 6/19/23. Resident #88's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors or refusals of care. There was no evidence in the medical record that Resident #88 attended her 6/19/23 outpatient orthopedic appointment scheduled for 6/19/23 as noted on the hospital discharge summary. The medical record indicated Resident #88 was discharged from the facility on 6/23/23. The resident was unavailable for interview. A phone interview was conducted on 10/11/23 at 11:26 AM with Resident #88's responsible party who stated…

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 Medical Director, and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included muscle spasms and convulsions. Resident #17 had a physician's order dated 5/8/23 for Lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for muscle spasms or convulsions. The order for the Lorazepam PRN was entered into the Electronic Medical Record (EMR) by Nurse #9 and did not have a stop date. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact and received one day of an antianxiety medication during the assessment period. The August 2023, September 2023, and October 2023 Medication Administration Records (MARs) revealed Resident #17 had received as needed dosages…

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 implement their infection control policy when Nurse Aide (NA) #9 did not perform hand hygiene during meal delivery and set up which required NA #9 to reposition the resident's personal belongings for 1 of 2 NAs observed passing meal trays. This had the potential to result in cross-contamination of microorganisms between residents. Findings included: A review of the facility's policy titled; Hand Hygiene last revised 7/2021 revealed in part the following: IV. Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid the transfer of microorganisms to other residents, personnel, equipment, and the environment. V. Procedure: 7. Staff will perform hand hygiene according to CDC…

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.