Pineville Rehabilitation and Living Center

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification surveys conducted on 10/8/21 and 7/29/22, and the complaint investigation survey conducted on 4/3/23. This was for repeat deficiencies in the areas of baseline care plan, activities of daily living care provided for dependent residents, and nutrition/hydration status maintenance that were originally cited on 7/29/22 during the recertification survey, and subsequently recited during the current recertification survey completed on 1/25/24. Develop/implement comprehensive care plan was originally cited on the complaint survey on 4/3/23 and was also subsequently recited during the recertification survey on 1/25/24. Food procurement and storage was originally cited on 10/8/21 during the recertification survey, and subsequently recited during the recertification survey on 7/29/22, the complaint survey on 4/3/23 and the recertification survey 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 a written discharge notification to the Resident's Responsible Party (RP) for 1 of 1 resident (#335) reviewed for discharge. The findings included: Resident #335 was admitted to the facility on [DATE] and discharged to the hospital on 8/14/23 with diagnoses including dementia and bipolar. A discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #335's was cognitively intact. His functional abilities were not documented on the MDS. A review of the hospital Discharge summary dated [DATE] indicated Resident #335 was not taking suboxone medication (treats narcotic dependence) and suboxone was not listed on his medication list when he was discharged to the facility on 8/11/23. A review of an admission speech therapy encounter note dated 8/11/23 revealed Resident #335 scored 3 out of 15 on the cognitive screening tool whereas he was unable to remain focused on task during the cognitive assessment. The note further revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a baseline care plan within the required timeframe for a new admission for 1 of 3 residents (Resident # 288). The findings included: Resident #288 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with lewy bodies and Parkinson's disease. The admission Minimum Data Set (MDS) dated [DATE] was still in progress and had not been completed. A review of Resident #288's medical record showed that the baseline care plan was started on 1/12/24 and had only one section completed, which was general information section. The general information section was completed on 1/16/24. Resident #288's functional status, health conditions, dietary, therapy and social services were not completed. On 1/25/24 at 9:56 AM, a phone interview conducted with Nurse #3 who initiated the baseline care plan on 1/12/24 revealed that she didn't know why only one section was completed. Nurse #3 stated that she generally would fill…

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 assess and address weight loss for 1 of 3 residents reviewed for nutrition (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses inclusive of peripheral vascular disease, dementia, and anemia. A physician's order dated 1/4/24 indicated Resident #1 had an active order for regular diet, pureed texture, regular (thin) consistency for dysphagia. A physician's order (10/10/23) indicated health shakes two times a day for history of protein-calorie malnutrition one 4 oz serving with breakfast and dinner meal trays was discontinued on 1/3/24, when Resident #1 returned from a hospitalization. A physician's order dated 1/10/24 indicated weekly weights. Per the medical record, no weights were documented during the week of 1/10/24 and the next weight was documented on 1/19/24. A review of Resident #1's weights revealed the following: 9/4/23 218 pounds 9/11/23 216 pounds 9/29/23 206.6 pounds 10/9/23 210…

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 reviews, resident and staff interviews, the facility failed to provide shaving assistance (Resident #71, Resident #2), nail care (Residents #2, #14, and #30), and skin care (Resident #2) for 4 of 10 residents reviewed for activities of daily living for dependent residents. The findings included: 1. Resident #71 was admitted to the facility on [DATE] with diagnoses which included acute dislocation of the shoulder related to fall, and muscle weakness. Review of Resident #71's admission Minimum Data Set (MDS) assessment revealed it was in progress but not completed. The initial nursing assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation. Resident #71 required extensive assistance of 2 staff with bed mobility, transfers, dressing, and bathing, required extensive assistance of 1 staff member with personal hygiene, and was independent with eating once set up. Review of Resident #71's baseline care plan dated 07/21/22 revealed there…

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 reviews, resident and staff interviews, the facility failed to provide nailcare for toenails for 4 of 10 residents reviewed for foot care (Residents #14, #71, #2 and #64). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses of diabetes and peripheral neuropathy. Review of Resident #14's physician order dated 12/9/20 revealed a referral for podiatrist. The order further stated toenail debridement for Diabetes. Review of Resident #14's medical record revealed a podiatry note dated 11/22/21 for follow-up foot care with general notes that read onychomycosis (fungal infection) to bilateral # 1-5. The note described the toenails as brittle, elongated and thick. Recommendations included debridement every 61 days to minimize pain, pressure and infection of risk. Review of podiatry note dated 4/19/22 documented resident was not seen due to being out of the building A quarterly Minimum Data Set, dated [DATE] assessed Resident #14 was cognitively intact…

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, staff, and Nurse Practitioner interview the facility to have a medication error rate of less than 5% as evidenced by 4 medication administration errors out of 26 opportunities which gave the facility a medication error rate of 15.38%. This affected 1 of 5 residents observed during medication administration (Resident #83). The findings included: Review of physician orders dated July 2022 revealed the following orders: Humulin 70/30 (insulin) 45 units subcutaneously (sq) one time a day before breakfast, Aspirin 81 milligrams (mg) by mouth every day for coronary artery disease, Heparin Sodium (blood thinner) 5000 units sq every 8 hours, and Calcium Carbonate/Vitamin D3 600/400 mg by mouth everyday as a supplement. An observation of Nurse #5 preparing Resident #83's medication was made on 07/27/22 at 9:17 AM. Nurse #5 was observed to draw up Humulin 70/30 45 units of insulin into a syringe. Nurse #5 then began placing Resident #83's pills into a medicine cup that included: Aspirin 325 mg. Nurse #5 stated that she did not have the Heparin 5000 units…

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 interview the facility failed to store controlled substances in a permanently affixed compartment of the refrigerator for 2 of 2 medication rooms (East and [NAME] wing) and failed to remove expired medication from 1 of 1 central supply room. The findings included: 1a. An observation of the East wing medication room was made on [DATE] at 9:47 AM along with Nurse #5. The refrigerator was not locked and contained a metal lock box that was locked but was lying on a shelf in the refrigerator. The metal lock box was not permanently affixed and was removeable. Nurse #5 was interviewed on [DATE] at 9:48 AM who confirmed that the metal lock box was the controlled substance back up and she did not know the combination to open the metal box she would have to get it from another staff member. Nurse #5 was not aware of who was responsible for the metal lock box that contained controlled substances. The Director of Nursing (DON) was interviewed on [DATE] at 11:38 AM. The DON…

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 reviews, resident and staff interviews, and a test tray, the facility failed to serve food that was appetizing in appearance and temperature for 3 of 4 residents (Resident #64, Resident #71, and Resident #12) reviewed with food concerns. The findings included: Review of the resident council minutes revealed on 12/28/21 the residents in attendance stated they would like better quality of food. On 03/24/22 the residents stated, the food isn't warm when delivered to the rooms. On 05/26/22 the residents discussed likes and dislikes about the food with the Dietary Manager, but no details were provided in the minutes. Upon initial interviews with Resident #64, Resident #71 and Resident #12, the residents complained about the food being cold and not being appetizing in appearance. The resident's used descriptions such as awful, cold, tastes horrible, not fit to eat. The test tray was plated and left the kitchen on the last trays to be served to residents. The last trays arrived on the hall…

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 interview the facility failed to implement the Center for Disease Control and Prevention (CDC) guidelines for use of personal protective equipment (PPE) when 1 of 2 nurses (Nurse #5) failed to discard her mask and eye protection after entering and exiting a Covid positive patients room (Resident #16) and then entering a non-COVID positive patients room, Nurse #5 also failed to disinfect a glucometer (used to check a resident's blood glucose level) after use per the manufacture's recommendations which resulted in the potential for cross contamination for 1 of 6 residents observed during medication administration (Resident #83). In addition, 1 of 2 nurse aides (NA #2) failed to perform hand hygiene after providing incontinent care and before touching clean bedding and assisting with wound care for 1 of 6 residents (Resident #71) reviewed for pressure ulcers. The findings included: The Centers for Disease Control and Prevention (CDC) guideline entitled, Interim…

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 implement an effective pest control program to control the presence of flies and gnats in the hallway and resident rooms. This was evident in 1 of 1 resident care hall and 5 of 46 resident rooms (Rooms 16, 29, 30, 51 and 52). The findings included: An observation on 07/25/22 at 3:22 PM revealed a fly in the hallway outside room [ROOM NUMBER] that landed on a computer and was swatted away. An observation on 07/25/22 at 3:40 PM revealed a fly outside room [ROOM NUMBER] in the hallway flying around. An observation on 07/25/22 at 4:08 PM revealed a fly outside of room [ROOM NUMBER] that kept landing on a computer and was swatted away several times. An observation on 07/25/22 at 4:11 PM revealed a fly on the table outside room [ROOM NUMBER] and 42. An observation on 07/26/22 at :19 AM revealed a fly in the hallway at the nurses station and was swatted away during an interview with Nurse #2. An observation and 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 reviews, resident and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when 1 of 1 staff member (Nurse #3) spoke to the resident in a perceived disrespectful manner and failed to promote the resident's dignity and privacy by not providing a cover for his urinary catheter for 1 of 1 resident (Resident # 64) reviewed for dignity and respect. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses which included neurogenic bladder and urinary retention. Review of Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. The MDS also revealed Resident #64 had an indwelling urinary catheter. 1.a. Observation of and interview with Resident #64 on 07/25/22 at 12:01 PM revealed him lying in bed on an air mattress. Resident #64 stated there had been an incident earlier in the morning of the power going off. Resident #64 stated when the power went off his air…

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 observations the facility failed to implement a care plan intervention for 1 of 3 residents (Resident #34) reviewed for call lights. The findings included: Resident #34 was originally admitted to the facility on [DATE] with diagnoses which included aphasia, contracture to right hand and knee, muscle weakness, anxiety, and depression. Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was not cognitively intact and required extensive assistance with one person assist for most activities of daily living (ADL). Review of Resident #34's care plan dated 06/27/22 indicated Resident #34: -Had a communication problem. The goal for Resident #34 was to maintain current level of communication function. Interventions included to keep Resident #34's call light in reach. - Was at an increased risk of falls. The goal for Resident #34 was to be free of falls through the review date. Interventions included Resident #34 would have a working…

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 2. Resident #19 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #19 was cognitively intact and had no behaviors of rejection of care. A review of the shower schedule for room [ROOM NUMBER]-A revealed the shower days were scheduled for Tuesday and Friday first shift. A review of the shower notebook revealed there were no shower sheets for Resident #19 in the notebook. A review of Resident #19's medical record revealed there was no documentation of refusing his showers. A review of Resident #19's Activities of Daily Living documentation for 07/2022 revealed there were no showers documented in the Resident's medical record. An observation and interview were conducted with Resident #19 on 07/25/22 at 12:52 PM. The Resident was lying in bed and his hair appeared dry, not greasy, with his beard neatly trimmed and had no odors of incontinence or body odor. The Resident remarked how he had not had a shower in a while when asked about his showers. 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 and Nurse Practitioner interviews the facility failed to report an abnormally high white blood cell count to the provider when it was available and two days later the resident was admitted to the hospital with systemic inflammatory response syndrome (SIRS) and altered mental status for 1 of 1 resident reviewed for hospitalizations. The findings included: Resident #52 was readmitted to the facility on [DATE] with diagnoses that included diabetes, malignant neoplasm of breast, mixed irritable bowel and others. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #52 was cognitively intact and required extensive assistance with activities of daily living. Review of a physician order dated 07/12/22 read; complete blood count (CBC), comprehensive metabolic panel (CMP) and ammonia level. The blood work was not ordered STAT (immediately) but was collected on 07/15/22. Review of Resident #52's medical record revealed Resident #52 was diagnosed with a Urinary…

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 record and investigate a grievance for 1 of 7 residents (Resident #468) and failed to provide a written grievance summary for 1 of 7 residents (Resident #67) reviewed for grievances. Findings included: Review of the facility grievance policy, undated, indicated a policy statement which stated all grievances and complaints filed with the facility would be investigated and corrective actions would be taken to resolve the grievance(s). 1. Resident #468 was admitted on [DATE]. Review of Resident #468's Minimum Data Set (MDS) revealed a comprehensive admission assessment dated [DATE]. The resident was coded as cognitively intact. Resident #468 was discharged home on 5/6/22. Review of the facility grievances log from February 2022 through May 2022 revealed no recorded grievances for Resident #468. During a telephone interview with Resident #468 on 7/26/22 at 2:20PM, she stated it took nursing staff a while to respond to her call light for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of cognition for 1 of 1 resident reviewed for MDS accuracy (Resident #13). The findings included: Resident# 13 was readmitted to the facility on [DATE]. The diagnoses included right side hemiplegia following a stroke, aphasia and dysphasia. The quarterly MDS dated [DATE] revealed Resident# 13 was cognitively intact. A revised Care Plan dated 6/23/22 indicated Resident #13 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to stroke. The Care Plan further indicated Resident #13 was cognitively impaired. An interview with the Social Worker (SW) on 7/26/22 at 4:40 PM indicated she was responsible for conducting and entering the (Brief Interview for Mental Status) cognitive score into the Electronic Medical Record (EMR). She further indicated she conducted the cognitive interview for Resident #13 but could not provide an exact…

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 Nurse Practitioner interview the facility failed to check a blood glucose level before breakfast as ordered by the provider for 1 of 5 residents observed during medication administration (Resident #83). The Findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included diabetes. No Minimum Data Set (MDS) information was available for Resident #83. Review of Resident #83's admission assessment dated [DATE] indicated he was alert and oriented. Review of a physician order dated 07/15/22 read: Accucheck (fingerstick glucose) before meals. An observation was made on 07/27/22 at 9:29 AM, Nurse #5 entered Resident #83's room to check his blood glucose level. When she entered the room there was no breakfast tray in the room and Resident #83 and his family member stated that breakfast had already been delivered and the tray collected. Nurse #5 proceeded to explain to Resident #83 and his family member that she had gotten a late start…

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, staff, and Wound Nurse Practitioner interviews the facility failed to implement interventions to promote healing of unstageable pressure ulcers for 1 of 6 residents reviewed with pressure ulcers (Resident #83). The finding included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right femur. Review of nursing admission assessment dated [DATE] indicated that Resident #83 was alert and oriented. Review of a baseline care plan dated 07/15/22 indicated that Resident #83 had a history of skin issues, but no current skin issues were noted. Review of admission nursing assessment dated [DATE] indicated that Resident #83 had unstageable pressure ulcers to his right and left heel. The right heel measured: 7.0 centimeters (cm) x 5.0 cm and the left heel measured 7.5 cm x 5.0 cm. No Minimum Data Set (MDS) information was available for Resident #83. Review of a physician order dated 07/16/22 read: paint bilateral…

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, Registered Dietitian and Nurse Practitioner interviews the facility failed to assess interventions for significant weight loss and have systems in place to identify further weight loss for 1 of 1 resident reviewed for weight loss (Resident #41). The findings included: Resident #41 was readmitted to the facility on [DATE] with diagnoses of infection following a procedure, gangrene, and peritonitis. A review of weights revealed Resident #41's readmission weight on 3/4/2022 was 152.8 lbs and on 7/14/2022 her weight was 132.2 lbs, for a total of 20.6 lb weight loss or 13.16% weight loss in a 4-month period. Review of the care plan dated 3/21/22 revealed Resident #41 was at nutritional risk related to poor appetite and intake, weight loss, increased nutritional needs for wound healing, interventions included: provide and serve supplements as ordered, monitor/record/report to medical provider signs and symptoms of malnutrition, and significant weight loss of 3 pounds in 1 week, > 5%…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident, staff and Nurse Practitioner interviews the facility failed to have a physician order for the use of oxygen for 1 of 1 resident reviewed with oxygen (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #12 was cognitively intact and required extensive assistance with activities of daily living. The MDS further revealed that Resident #12 required oxygen during the assessment reference period. Review of the Resident #12's physician orders revealed no active order for oxygen use. An observation and interview were conducted with Resident #12 on 07/25/22 at 12:20 PM. Resident #12 was resting in bed and was observed to have a nasal cannula in his nose that was connected to concentrator that was set to deliver 2 liters of oxygen. Resident #12 stated he had been on oxygen for a while…

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 interview the facility failed to maintain a complete and accurate medical record by failing to document the completion of wound care (Resident #42) for 1 of 6 residents reviewed for pressure ulcers. The findings included: Review of Resident #42's physician orders revealed a treatment order dated 6/18/2022. This order read: Sacral wound treatment orders: cleanse wound with wound cleaner, next apply acetic moistened gauze 4 x 4's to entire wound bed, then apply gauze over the soaked gauze, then cover with abdominal pads to entire area every day shift. Review of Treatment Administration Record for July 2022 revealed no documentation of treatment completion for 10 of the 29 days reviewed. The dates of missed documentation were 7/4, 7/5/,7/7, 7/9, 7/13, 7/16, 7/17, 7/21, 7/23, and 7/25/2022. On 7/29/2022 at 11:13AM an interview was conducted with Nurse #8. She stated she was familiar with Resident #42 and had provided his wound treatments. Nurse #8 revealed she was Resident #42's assigned Nurse on July 21st and July 23rd and provided his wound treatments…

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.