Piedmont Hills Center for Nursing and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to provide a resident with an alternate preference during the lunch meal for 1 of 4 residents (Resident #12) reviewed for food preferences. The findings included: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included stage 3 pressure ulcer and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact and was independent with eating. Resident #12 was documented as being on a therapeutic diet. Resident #12 was interviewed on 12/2/24 at 10:32am. The resident discussed not liking the food at the facility. She explained she would often ask for an alternate meal or a sandwich and would not receive any alternate or sandwich. Resident #12 stated that is why I keep food in my room and pointed to a shelf that had canned food. The lunch meal was observed with Resident #12 on 12/2/24 at 12:15pm. Nursing Assistant (NA) #3 was observed to provide…

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 staff, Pharmacist and Nurse Practitioner (NP) interviews, the facility failed to send expired or discontinued narcotic medications back to the pharmacy for 2 of 4 medication carts. Findings included: 1. On 7/10/24 at 11:45 am, the medication cart on 2 North was reviewed with Medication Aide (MA) #2. The following were discovered during the review: a. Eighteen lorazepam 0.5 mg tablets in a pill card labeled with the order to administer one tablet by mouth twice a day for anxiety or restlessness to Resident #7. Thirty lorazepam 0.5 mg tablets were in a second pill card labeled with the same order to administer one tablet by mouth twice a day for anxiety or restlessness to Resident #7. Resident's EMR was reviewed with MA #2. The medical records revealed Resident #7 died on 6/14/24. MA #2 stated the two pill cards should have been sent back to the pharmacy by the nurse on 6/14/24. b. Twenty oxycodone-acetaminophen 5-325 mg tablets in a pill card labeled with the order to administer one tablet every four hours as needed to Resident #8. The pill…

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

Based on observation, record review, and staff interviews, the facility failed to submit a 24-hour and 5-day report to the State Agency when the facility became aware of an allegation of misappropriation of property by a staff member on 7/5/24 for 1 of 3 residents reviewed for misappropriation of resident property (Resident #2). Findings included: A review of the facility's undated Abuse, Neglect and Exploitation policy defined Alleged Violation as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Under Reporting/Response, the policy stated A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. law enforcement when applicable) within…

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 failed to ensure the sanitizing solution (chlorine) was maintained at the required concentration of 50 ppm (parts per million) during the final rinse cycle according to manufacturer's instructions in the low temperature dish machine. And failed to ensure the ceiling in the kitchen, meal delivery carts, and venting units were clean, free from debris, and/or in good working condition; and pots and pans stacked for use were clean and dry on the storage rack. The facility also failed to ensure the personal food items stored in the nourishment refrigerator/freezer in 1 of 2 residents' nourishment rooms (the first-floor nourishment room) were labeled and dated. These practices had the potential to affect food served to all residents. Findings included: 1. During the initial tour of the kitchen on 11/27/23 at 10:15 a.m., the operation of the low temperature dishwasher of the soiled breakfast dishes by dietary staff #1 and dietary staff #2 was observed. The sanitizing solution (chlorine) for the low temperature…

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, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor intervention the committee put in place following a focus infection control survey conducted on 2/05/21. This was evident for seven deficiencies that were cited in the areas of Environment (homelike), Activities of daily living for dependent Resident, Comprehensive Resident Centered Care Plan (discharged planning process)Bowel/Bladder incontinence ,Resident Allergies, Preferences and Substitutes and Food Procurement, Store/Prepare/Serve-Sanitary and on the current recertification and complaint survey conducted on 12/04/23. The facility's Quality Assessment and Assurance (QAA) Committee also failed to maintain implemented procedures and monitor intervention the committee put in place following an annual recertification and complaint survey conducted on 12/13/21. This was evident for six deficiencies that was cited in the areas of Environment (homelike), Resident Assessment (Accuracy of 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 record review and staff interviews, the facility failed to ensure they had provided mandatory training that outlined and informed all their staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program. Findings included: During an interview with the Staff Development Coordinator (SDC) on 11/30/23 at 10:35 AM the SDC stated she had been working in her role at the facility for 2 months and had not completed any QAPI in-servicing for the staff as a part of the mandatory yearly facility training. The SDC stated she was also unable to locate any staff QAPI training completed by the previous SDC. During an interview with the facility administrator on 12/1/23 at 9:48 AM she stated the key facility staff was meeting monthly, but she was not aware of the regulation that stated all facility staff should be trained yearly on the facility QAPI program and the current goals they are working towards.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to honor resident requests for two showers per week for 1 of 2 sampled residents reviewed for self-determination (Resident #101) Findings included: Resident #101 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was cognitively intact, with no behaviors or rejection of care and required moderate assistance with showers. The facility's shower schedule revealed Resident #101 was scheduled for a shower on Monday and Thursday on the evening shift (3:00pm to 11:00pm). Resident #101's medical record did not reveal any refusal of showers that were documented in the progress notes. The facility shower documentation from 10/01/23 through 11/30/23 revealed that Resident #101 had one shower documented on 10/02/23,10.08.23,10.12.23,10/14/23,10/16/23,10/20/23,11/01/23,11/02/23,11/07/23, and 11/30/23. The documentation revealed that Resident #101 was provided a bed bath instead 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, resident, and staff interviews the facility failed to investigate and resolve grievances for Residents #12, #419, #267 and maintain evidence demonstrating the result of the grievances for Residents #80, #29, #68. This was for 6 of 17 residents reviewed for grievances. The findings included: An interview was conducted on 11/30/23 12:30 PM with Social Worker #1. She revealed that when she was made aware of a grievance, she would initiate the grievance form and give it to the appropriate department head to investigate. She further revealed that she had pending grievances that had not been investigated for Residents #12, #419 and #267. The Social Worker indicated that the lack of follow-up on these grievances was due to frequent turnover in the social work department. 1a.Resident #12 was admitted on [DATE]. A review of Resident #12's grievance dated 1/31/23 was conducted and revealed no documented investigation or follow up noted on the grievance form. An interview was conducted with 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 and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 6 of 6 residents reviewed for MDS accuracy. (Resident #99, Resident #11, Resident 102, Resident #518, Resident #80 and Resident #51). Findings included: 1a. Resident #99 was admitted to the facility on [DATE]. Review of physician order initiated on 4/20/23 revealed Resident #99 had an order for Risperidone (antipsychotic) 1milligram(mg) tablet, give one tablet by mouth one time a day for schizophrenia. Review of physician order initiated on 7/11/23 revealed Resident #99 had an order for Sertraline HCL (antidepressant) 25mg tablet, give one table by mouth one time a day for depression. Review of the Medication Administration Record (MAR) revealed Resident #99 received Risperidone (antipsychotic) 1mg tablet, every day starting 7/1/23 through 7/31/23. Review of the MAR revealed Resident #99 received Sertraline HCL (antidepressant) 25mg tablet, every day starting 7/12/23 through 7/24/23. A 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 observation, record review, resident and staff interviews, the facility failed to provide oral hygiene to a resident (Resident #69) dependent on staff for activities of daily living (ADL). This occurred for 1 of 10 residents reviewed for ADL. Resident #69 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and a history of a cerebral infarction. A review of the quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #69 was cognitively intact, had adequate vision and hearing, required extensive assistance of one staff member with personal hygiene, and did not refuse care. A review of the care plan dated 9/20/2023 included a focused area that Resident #69 had an ADL self-care performance deficit related to a history of decreased mobility. The interventions identified the Resident required 1 to 2 person staff assistance with personal hygiene and oral care. An observation of Resident #69 was conducted on 11/27/2023 at 10:25 a.m. and the Resident had only two teeth on…

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

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 22 out of 120 days reviewed for staffing. The failure to have RN coverage for the facility had a high likelihood of impacting every resident in the facility. The findings included: Review of the PBJ Staffing Data Report CASPER Report 1705D/FY Quarter 3 2023 (April 1 - June 30) compared to the Staff Schedule/Assignment Sheets, and RN timecard reports revealed that there was no RN coverage for eight consecutive hours for 4/2/23, 4/9/23, 5/6/23, 5/7/23, 5/13/23, 5/14/23, 5/15/23, 5/20/23, 6/3/23, 6/4/23, 6/10/23, 6/11/23, 6/18/23. Further review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets, and RN timecard reports revealed there was no RN coverage for eight consecutive hours for 11/4/23, 11/5/23, 11/6/23, 11/7/23, 11/9/23, 11/20/23, 11/11/23, 11/15/23, 11/18/23. An interview was conducted on 11/30/23 at 10:08 AM with the facility scheduler. She stated she had been in her position for 2 months. She 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, staff interviews, Consultant Pharmacist, and the Medical Director (MD), the Pharmacy Consultant failed to identify drug irregularities for the use of a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior). This was for 1 of 8 residents reviewed for unnecessary medications (Resident #106). The findings included: Resident #106 was admitted to the facility on [DATE] with diagnoses that included Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #106's active orders revealed a physician order dated 07/16/23 for 0.5 milligrams (mg) risperidone (an antipsychotic medication) to be given as one tablet by mouth and scheduled to be administered twice daily for sleep. Review of quarterly Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #106 ' s cognition was severely impaired, and he had no behaviors. The consultant pharmacist's Medication Regimen Reviews (MRR)…

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 secure medicated treatment supplies left in an unattended treatment cart for 1 of 2 treatment carts (the upper-level treatment cart). In addition, the facility failed to secure resident medications left in an unattended medication cart for 1 of 2 medication carts (second floor- east side medication cart). The findings included: 1. During hall tour observation on 11/27/23 12:05 PM, the treatment cart #1 on the upper level beside the nurse's station was observed to be unlocked during a continuous observation from 12:05 PM to 12:17 PM. The cart lock button was not pushed in indicating the drawers, which contained the supplies in the cart, were in an unlocked position. On 11/27/23 at 12:17 PM, residents were observed ambulating around the upper-level nurse's station near the unlocked cart without any staff members present. Observation of Treatment Cart #1 with the unit manager on 11/27/23 at 12:20 PM revealed the top drawer to contain topical ointments. The second drawer contained medicated dressings and bandages. Both…

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, resident and staff interviews the facility failed to follow a Dental provider's recommendations to assist a resident in obtaining dentures. This occurred for 1 of 2 residents (Resident #46) reviewed for dental services. The findings included: Resident #46 was admitted to the facility 9/14/2018 with diagnoses that included left hemiparesis, dysphagia, and edentulous. A review of Resident #46's orders revealed a regular texture diet. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact and had no rejection of care. The MDS documented the resident had no complaints or difficulty with swallowing, no coughing or choking during meals, and had not experienced weight loss. A review of the care plan revised 10/24/2023 included a focused area that was initiated 12/28/2018, that read; Resident #46 has an oral/dental health problem related to missing his teeth. The interventions included coordinating arrangements for dental care 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, observations, resident, and staff interviews the facility failed to maintain a resident's dignity by not providing toileting assistance to a resident continent of bowel and bladder (Resident #518). Resident was instructed to use the bathroom in an incontinent brief and she indicated this did not feel-good wearing briefs and did not like it because she was able to tell when she needed to be toileted . This occurred for 1 of 13 residents reviewed for dignity. Findings included. Resident #518 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #518 was cognitively intact with no behaviors or rejection of care and frequently incontinent to both bowel and bladder. On 11/29/23 at 5:13am, an observation of incontinence care was made with Resident #518 and NA #3. Resident #518 was noted to be wearing a brief that was soaking wet. After providing incontinence care, NA #3 was observed reapplying a new brief on Resident #518. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and resident interviews the facility failed to ensure advanced directive information was correct throughout the medical record for 1 of 2 residents (Resident #71) reviewed for advanced directives. Findings included: Resident #71 was admitted to the facility on [DATE]. Resident #71's electronic medical record revealed an active physician's order dated 10/07/2021 that read Full Code. A review of the Social Service Progress Note dated 03/17/2023 revealed a care plan meeting was held with Resident #71 and the Interdisciplinary Care Team. Resident #71's code status was changed to Do Not Resuscitate (DNR) per her request. A review of the code status chart for the 200-hall revealed Resident #71 had a signed Medical Orders for Scope of Treatment (MOST) form dated 03/17/2023 signed by the resident and the Nurse Practitioner that read DNR. Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively intact. Resident #71's care plan dated…

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, staff interviews, and the Medical Director interview, the facility staff failed to notify medical provider of resident's complaint of right shoulder pain, and genitalia area for 1 of 1 resident reviewed. (Resident #518). Findings included: Resident #518 was admitted to the facility on [DATE] with diagnosis that included chronic pain syndrome, disorder of thyroid, adult failure to thrive, bipolar disorder, constipation, anorexia, hypothyroidism, chronic pain syndrome, and spondylosis. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #518 was cognitively intact. Record review of Resident #518 Nurse Practitioner (NP) progress note dated 11/20/23 indicated Resident #518 was not sleeping well due to pain. Review of Medical Director's progress note for Resident #518 dated 11/22/23 indicated that resident has pain and numbness in bilateral arms and legs. Review of physical therapy treatment encounter note for Resident #518 dated 11/22/23 indicated…

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 and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS), CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) at least two days before the end of Medicare part A services to two of three residents (Residents #48 and 105) reviewed for SNF Beneficiary Protection Notification Review. Findings included: 1a. Resident #48 was admitted to the facility under part A Medicare services on 9/21/23. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was discussed by telephone with Resident #48's responsible party on 11/21/23. The notice indicated that Medicare coverage for skilled services was to end 10/27/23 and the resident would remain in the facility. A review of the medical record revealed a CMS-10055 SNF ABN (ABN) was not provided to the resident or responsible party until 11/21/23. 2b. Resident #105 was admitted to the facility under part A Medicare services on 8/1/23. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage…

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 interviews with resident and staff, the facility failed to maintain a dresser drawer in good repair for 1 of 2 residents reviewed for a safe comfortable, homelike environment (Resident #98). The findings included: Resident #98 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set on 10/26/23 revealed Resident #98 was cognitively impaired and required extensive assistance with dressing. During an observation and interview on 11/27/23 at 12:45 PM, Resident #98 was seen sitting on her wheelchair beside a dresser which did not have the front face of the first two drawers and had visible exposed broken wood with rough edges. Resident #98 indicated the dresser had been broken for a long time and she was not able to use it for her belongings. During a follow up observation of Resident #98's room on 11/29/23 at 7:46 AM the dresser drawer was observed to be in the same condition of disrepair. During an interview on 11/29/23 at 7:52 AM, Nurse Aide (NA) #8…

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 prevent misappropriation of property when an unknown person used a resident's bank card information and made an unauthorized purchase. This occurred for 1 of 7 residents (Resident #267) reviewed for abuse. The findings included: Resident #267 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #267 was cognitively intact. An interview was conducted on 11/30/2023 at 12:30 p.m. with the Social Worker (SW) and she revealed she had started working at the facility in late October 2023. She added when she started, the residents had several concerns and grievances that needed to be addressed. The SW added she received a grievance from Resident #267 on 11/27/2023 around midday. Resident #267 had reported that someone had made a fraudulent charge to her bank card, in the amount of $192.00, and the bank reported to the Resident the charge was made at the facility location. 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, resident and staff interviews, the facility failed to implement their abuse policy for immediately notifying the Administrator of allegations when they 1) failed to notify the Administrator of an allegation of abuse (Resident #116) and 2) failed to notify the Administrator of misappropriation of resident property (Resident #267). This deficient practice occurred for 2 of 7 residents reviewed for abuse. Findings included: A review of the Review of the facility policy titled: Abuse, Neglect and Exploitation dated February 2023 Revision read as follows: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later…

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 certify the accuracy of pain interview responses relative to the resident's condition for 1 of 1 resident reviewed for pain. (Resident #518) Findings included: Resident #518 was admitted to the facility on [DATE]. Record review of Resident #518's Nurse Practitioner (NP) progress note dated 11/20/23 indicated Resident #518 was not sleeping well due to pain. Review of occupational therapy treatment encounter notes for Resident #518 dated 11/20/23 indicated Resident reported 10/10 global pain affecting function. Review of Medical Director's progress note for Resident #518 dated 11/22/23 indicated Resident has pain and numbness in bilateral arms and legs. Review of physical therapy treatment encounter note for Resident #518 dated 11/22/23 indicated Resident reported pain all over body and limiting resident's ability to scoot. Review of occupational therapy treatment encounter notes for Resident #518 dated 11/22/23 indicated Resident reporting…

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 and staff interviews the facility failed to develop a resident specific care plan for 1) discharge planning and this occurred for 1 of 5 residents (Resident # 568) reviewed for discharge planning and 2) urinary catheter status and this occurred for 1 of 2 residents (Resident #106) reviewed for urinary catheter care. The findings included: 1)Resident #568 was admitted to the facility on [DATE] with diagnoses that included severe burns to 10-19% of the body surface. A review of the electronic medical record revealed Resident #568 was her own legal representative. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #568 had not been willing to participate in the mental assessment and had verbal behaviors of yelling out 1 to 3 days during the lookback period. The assessment did not assess the Resident preference to return to the community. A review of the care plan dated 11/2/2023 did not include the discharge preferences of the Resident. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Responsible Party, and staff interviews the facility failed to have a discharge planning process in place for a resident with a discharge goal of transferring to an alternate facility for 1 of 1 sampled resident for discharge planning (Resident #98). Findings Included: Resident #98 was admitted to the facility on [DATE] with a diagnosis that included altered mental status. A review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #98 was cognitively impaired. A telephone interview was conducted with the Responsible Party on 11/28/23 at 10:03 PM. She indicated that she made a request on 11/1/23 for assistance with transferring the resident to another skilled nursing facility and still had not received a response. An interview was conducted on 11/29/23 at 10:30 AM with the Admissions/Concierge Director and she revealed that she was notified on 11/1/23 via email by Resident #98's Responsible Party of the request for discharge planning assistance to another skilled nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and the Medical Director interview, the facility failed to provide a diagnosis for the use of risperidone (a psychotropic medication which is any drug that affects brain activities associated with mental processes and behavior). This was for 1 of 8 residents (Resident #106) reviewed for unnecessary medications. The findings included: Resident #106 was admitted to the facility on [DATE] with diagnoses that included Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of quarterly Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #106 ' s cognition was severely impaired, and he had no behaviors. Resident #106's active care plan, last reviewed on 11/10/23, revealed a focus that read resident used psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) related to diagnosis (no diagnosis listed). Date Initiated: 08/01/2023. The interventions included…

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, staff and resident interviews the facility failed to honor food preferences for 1 of 7 residents reviewed for preferences (Resident #71). Findings included: Resident #71 was admitted to the facility on [DATE]. Review of the dietary progress note dated 10/13/2022 indicated Resident #71 requested a diabetic diet with yogurt at every meal. Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively intact. Review of the care plan dated 10/03/2023 revealed Resident #71 had a potential nutritional problem. The interventions included determining Resident #71's food preferences, providing them at mealtime and providing a controlled carbohydrate diet per Resident #71's request. During an interview on 11/27/2023 at 10:13 A.M Resident #71 stated she was not receiving yogurt with her meals. Resident #71 indicated she requested yogurt with every meal due to wanting more protein and it was listed on her meal tickets. During an observation 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 ensure the residents' medical record included pneumococcal immunization status to include to inform, offer, and provide education on the pneumococcal immunization. This occurred for 3 of 5 residents (Resident #54, #71, and #80) reviewed for pneumococcal immunization status. The findings included: A review of the facility policy titled; Pneumococcal Vaccine revised January 2023 read: upon admission nursing staff will document in the Immunization Record the resident's history of immunization with the pneumococcal vaccine. 1)Resident #54 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE], for Resident #54, was reviewed for the immunization section. The pneumococcal vaccine question had documentation that read: the vaccine was not up to date and had not been offered. A review of Resident #54's medical record revealed there was no documentation to indicate whether the Resident received or refused 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 record review, observation and staff interviews the facility failed to provide a privacy curtain for 1 of 1 rooms (room [ROOM NUMBER]) reviewed for privacy. The findings included: Resident #80 was admitted to the facility on [DATE]. Her most recent annual Minimum Data Set, dated [DATE] revealed that she was severely cognitively impaired. On 11/27/23 at 9:37 AM, an observation of Resident #80's room revealed half of the metal track on the ceiling was noticed to be missing and there was no privacy curtain hung. During an interview on 11/27/23 at 11:30 AM with Nurse Aide (NA) #6, assigned to Resident #80, she stated that she thought the curtain was removed a couple days ago because it was dirty but she was not sure. She stated that she will use the roommate's curtain to shield Resident #80 from view or she will shut the room door if the roommate is out of the room. During an interview on 11/27/23 at 12:10 PM with the unit manager, he stated that another resident wandered into Resident #80's room and pulled…

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 complete the mandatory twelve hours of annual in-servicing for 1 of 4 nursing assistants (NA) #1 reviewed for competent nursing staff. The findings included: NA #1 date of hire was 7/21/21. Review of NA #1's educational record did not include 12 hours of the annual mandatory in-servicing for 2022 or 2023. The Staff Development Coordinator was interviewed on 11/30/23 at 9:30 AM. She stated she was new to her role and had been with the facility for 2 months. She stated that the facility did not use an online in-servicing program and was currently still paper-based. She was unable to explain how NA #1's training requirements were missed and added that she was in the process of reviewing all staff members' training files. The Regional Nurse Consultant provided documentation on 12/1/23 at 11:42 AM of NA #1's completed dementia and annual mandatory in-servicing totaling 2.25 hours on 11/22/23. She stated that she was also unable to find the training record for NA #1. She stated that she was aware that all nurse aides must…

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.