Piney Grove Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews, the facility failed to provide the resident's preference of showers for 3 of 3 residents reviewed for choices (Resident #17, Resident #189 and Resident #64). The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. Resident #17's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance with showering and bathing. The assessment also revealed Resident #17 had no rejection of care behaviors and according to the assessment, it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the middle hall revealed Resident #17 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00PM). The documentation of showers in the electronic medical record for Resident #17 for 08/13/24 through…

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, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 6 of 10 months reviewed (January 2024, March 2024, April 2024, June 2024, July 2024, and August 2024). Findings included: Review of the Resident Council Minutes for the period 09/25/23 through 09/20/24 revealed the following: a. The Resident Council meeting minutes dated 01/31/24 revealed under New Business there were noted resident concerns about not receiving showers, staff turning off call lights and not providing care, ice not being passed daily, and better customer service. b. The minutes from the Resident Council meeting held on 02/16/24 were not available for review. c. The Resident Council meeting minutes dated 03/22/24 revealed the section for old business noted resident concerns with showers not being given or in a timely manner, staff turning off call lights and not answering them, and better customer service. There was no indication of the…

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

Based on record review and staff interviews, the facility failed to notify the Regional Ombudsman when residents discharged or transferred from the facility for 6 of 6 months (April 2024, May 2024, June 2024, July 2024, August 2024, and September 2024). Findings included: Review of the facility's Admission/Discharge report for the period 04/01/24 to 09/30/24 revealed there were 149 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) revealed since starting her employment in October 2023, she had not sent notifications to the Regional Ombudsman when residents discharged or transferred from the facility and wasn't aware that she needed to do so. During an interview on 10/09/24 at 10:16 AM, the Administrator revealed he had spoken with the SW and she had not been contacting the Regional Ombudsman to notify them of any resident discharges or transfers. The Administrator stated both he and the SW had no excuse as to why notifications were not sent to the Regional…

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, family and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for residents who wished to discharge to the community for 3 of 4 sampled residents (Residents #82, #13 and #137). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition with a discharge goal to return to the community. The MDS noted an active discharge plan was in place for Resident #82. The Social Service admission assessment dated [DATE] noted Resident #82's discharge goal was to return to the community. 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.

Based on record reviews and staff interviews, the facility failed to maintain accurate Treatment Administration Records (TAR) for 1 of 4 residents reviewed for pressure ulcers (Resident #238). The findings include: a. Review of Resident #238's medical record revealed a physician order dated 02/17/2024 to cleanse sacral pressure ulcer with wound cleanser and pat dry then apply non-adhesive pad then cover with foam dressing every day and as needed. Review of Resident #238's 02/2024 TAR revealed there was no documentation on 02/27/2024 to indicate the treatment was completed as ordered. An interview was conducted with former Wound Nurse #1 on 10/09/2024 at 7:01 AM who was assigned to perform pressure ulcer treatments on 02/27/2024. Wound Nurse #1 explained that she remembered Resident #238 and when she performed the Resident's admission skin assessment on 02/16/2024 the Resident had a stage II pressure ulcer on her sacrum. Wound Nurse #1 reported she worked Monday through Friday, but she was also responsible to take call which meant if she was called into work during the week after her…

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 reviews, and resident and staff interviews, the facility failed to implement infection control policies and procedures when the Wound Nurse did not follow the procedure for dressing change for a wound (Resident #25). In addition, Nurse Aide (NA) #11 failed to remove soiled gloves and perform hand hygiene after incontinence care and before she touched the resident, bed linens and the bed control (Resident #25), the Wound Nurse did not follow enhanced barrier precautions (EPB) while applying stabilizing devices to indwelling catheters for two residents (Resident #60 and Resident #63), Nurse #9, failed to follow enhanced barrier precautions while administering intravenous antibiotics into a central venous catheter (Resident #139) and NA #1 did not follow EPB when providing catheter care (Resident #63). The deficient practice occurred for 4 of 5 staff observed for infection control practices (Wound Nurse, Nurse Aide (NA) #11, Nurse #9, and NA #1). The findings included: 1. Review of the facility's policy and procedure on clean dressings last revised 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 interviews with resident, staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to notify the NP and MD that a resident was completely out of her narcotic pain medication resulting in her missing 14 consecutive doses for 4 ½ days for 1 of 3 residents reviewed for notification (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. The physician's order dated 10/25/23 revealed Resident #17 had an order to receive one tablet of oxycodone-Acetaminophen oral tablet 5-325 milligrams (mg) (oxycodone with acetaminophen) or Percocet (a type of opioid analgesic consisted of oxycodone/acetaminophen that acted on the central nervous system to relieve pain) by mouth three times a day for pain. The medication was scheduled to be given at 8:00 AM, 2:00 PM and 8:00 PM. The Medication Administration Record (MAR) for August 2024 revealed Resident #17 had not received her…

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, residents and staff interviews, the facility failed to invite residents to participate and provide input in care planning for 2 of 3 sampled residents (Residents #82 and #13). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition. Review of Resident #82's electronic medical record revealed no evidence he was invited to attend a care plan meeting to discuss and provide input regarding his plan of care following the completion of the admission MDS assessment dated [DATE]. Review of the facility's Care Plan Meeting Schedules for the period August 2024 - October 2024 revealed a care plan meeting with Resident #82 was not listed on the schedules. During an interview 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 observations, record review, and resident, family member, and staff interviews, the facility failed to clean and trim nails on both hands of a dependent resident and failed to shave chin hairs on a dependent resident for 1 of 3 dependent residents reviewed for activities of daily living (Resident #43). The findings included: Resident #43 was readmitted on [DATE]. Her diagnoses included diabetes mellitus type II, osteoporosis, and dementia. Resident #43's Care Area Assessment for activities of daily living (ADL) dated 07/14/24 revealed she needed assistance from staff with all activities of daily living due to her diagnoses of dementia, hemiplegia following a stroke affecting her left non-dominant side and osteoporosis. Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired but was able to make her needs known. The assessment also revealed Resident #43 required substantial to maximal assistance with showering and bathing 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 observations, record review, resident and staff interviews the facility failed to apply compression wraps daily per the physician's order for 1 of 1 resident (Resident #57) reviewed for edema (swelling). Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included lymphedema (chronic condition that causes swelling, most often in the arms or legs, due to a buildup of lymph fluid). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. She required substantial/maximum staff assistance with lower body dressing and received application of nonsurgical dressings other than to feet. It was further noted that Resident #57 had not rejected care during the MDS assessment reference period. An active physician's order dated 08/23/24 for Resident #57 read in part, apply compression garments (wraps) in the morning daily for 8 to 12 hours. Remove at night and elevate legs. Every shift for lymphedema of bilateral lower extremities.…

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 secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 3 residents reviewed for urinary catheter (Resident #63). The finding include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (enlarged prostate which can cause urinary obstruction). The admission Minimum Data Set assessment dated [DATE] revealed Resident #63's cognition was moderately impaired and had an indwelling urinary catheter. Review of Resident #63's care plan revised 07/10/24 that addressed the use of an indwelling urinary catheter related to benign prostatic hyperplasia. The goal that he would be free of urinary tract infections would be attained by utilizing interventions that include following catheter care policies and procedures and abiding by enhanced barrier precautions. Review of Resident #63's physician order dated 08/20/24 indicated indwelling urinary catheter…

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.