Cooperstown Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure the desired staffing levels for Licensed Practical Nurses (LPNs), as documented in the Facility Assessment, were met 9 of 9 calendar days from 2/27/2022 to 3/7/2022 and Certified Nursing Assistants (CNAs), as documented in the Facility Assessment, were met for 9 out of 9 calendar days from 2/27/2022 to 3/7/2022. This is evidenced by: The Facility assessment dated [DATE]; rev. 03/1/2022 documented Staffing Plan; See Attached. On 3/7/2022 at 2:40 PM, the Administrator provided an undated document and stated the document was the current Facility Assessment Staffing Plan. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure a nourishing bedtime snack was provided when there was a greater than 14-hour time span between the evening meal and breakfast. This was evidenced by: A review of the document titled, Mealtimes undated, documented the meal times were approximate to when the trays/meals would arrive in the designated dining areas: Breakfast: Cart Country Meadows (CM) Left #1: 7:40 AM Cart CM Right #2: 7:48 AM Cart [NAME] (WB) Left #3: 7:56 AM Cart WB Right #4: 8:04 AM Cart Mountain Ridge (MR) Left #9: 8:12 AM Cart MR Right #10: 8:20 AM Cart Rolling…

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, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, the automatic dishwashing machine (dish machine) was not operating within the manufacturer's specifications, the concentration of chemical sanitizing rinse (QAC) utilized in the three-compartment sink was less than that required by the manufacturer, and equipment and serving areas (9 of 9 kitchenettes) required cleaning or equipment repairs. This is evidenced as follows: The kitchen and unit kitchenettes were inspected on 02/28/2022 at 11:16 AM. During the inspection of the kitchen, the concentration of QAC used in the sanitizing rinse sink of the 3-compartment sink was found to be 150 ppm when measured at 73 degrees Fahrenheit (F); the manufacturer's label…

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 interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure medical records on each resident were complete and accurately documented for 6 (Residents #s 36,42,57,104,113, and 512) of 33 residents reviewed. Specifically, for Resident #36 the facility did not ensure documentation of the resident's condition or follow-up upon return from the emergency room, for Resident #42 the facility did not ensure documentation for the resident's transfer out of bed (oob) was accurately reflected when the resident did not get oob; for Resident #57, the facility did not ensure documentation reflected the resident's ongoing reports of diarrhea or the need for an antidiarrheal being administered on four out of eight days in March 2022, for Resident #104, the facility did not ensure the administration of narcotic pain medication that was administered on an as needed basis (PRN) to the resident who reported pain level of 7 out of 10 was consistently documented, for Resident #113, the facility did not ensure Certified Nurse Aides…

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 interviews during a recertification survey dated 2/28/2022 through 3/8/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases, infections and COVID-19. Specifically, for 1 (Serenity Place) of 5 units, the facility did not ensure contact and droplet precautions were maintained when Resident #55, who tested positive for COVID-19, was not socially distanced from residents who did not test positive for COVID-19 and for Resident #42, the facility did not ensure infection control practices were maintained during the disposal of soiled linen following incontinence care. Finding #1: Resident #55 was admitted to the facility with diagnoses of dementia, hypertensive heart disease, and mild intermittent asthma. The Minimum Data Set (MDS-an assessment tool) dated 10/9/21, documented the resident had severely impaired cognition, could usually understand others and could make self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility did not maintain an adequate pest control program as evidenced by multiple sightings of rodent droppings. This is evidenced as follows: During observations on 02/28/2022 at 11:16 AM, rodent droppings were found in the cabinets below the tray line counters in the Oak Creek and [NAME] Creek kitchenette on the [NAME] pod, the Gardenia Court kitchenette on the Country Meadows pod, the [NAME] Glen kitchenette on the Rolling Hills pod, and the Serenity Place pod main kitchenette. Record review of the facility pest-control sighting logs (dated from April 2021 through February 2022) on 02/28/2022 documented staff last reported rodent activity on the [NAME] pod in May 2021 but not at any other time since. Staff did not report evidence of rodent activity on the Country Meadows pod,…

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 medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Non-coverage, Form CMS-10123-NOMNIC (NOMNIC). This was evident for two (2) out of three (3) sampled residents reviewed for Beneficiary Protection Notification (residents #363 and #63). This is evidenced as follows: During the medical record review for Resident #363 on 03/02/2022, it was revealed that the resident #363 last received covered services on 11/13/2021 and was provided the NOMNC to inform the resident of their right to an expedited review of a service termination on 11/12/2021, one day prior to the termination of services. During the medical record review for Resident #63 on 03/02/2022, it was revealed that the Resident #363 last received covered…

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 during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not provide needed care or services resulting in an actual or potential decline in one or more residents' physical, mental, and/or psychosocial well-being for 1 (Resident #113) of 2 residents reviewed for bowel and bladder. Specifically, for Resident #113, who received daily medications to treat constipation, the facility did not ensure the daily medications to treat constipation were effective, did not ensure their standard of practice for Bowel Management was followed and did not ensure that the medication administration record's alert tab for a resident not having a BM (bowel movement) for 3 days was utilized when the resident did not have a bowel movement for a 12 day period from 12/25/2021 through 1/5/2022. This was evidenced by: The Policy & Procedure (P&P) titled Bowel Management dated 5/2019, documented the Certified Nurse Aide (CNA) was to document the resident's bowel…

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 during the recertification survey conducted from 2/28/2022 to 3/8/2022, the facility did not ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 (Resident #113) of 7 residents reviewed for nutrition. Specifically, for Resident #113, the facility did not weigh and re-weigh the resident in accordance with professional standards and did not evaluate the need to develop and implement nutritional interventions when the resident had a significant weight loss of 81.2 lbs. in a 2-month period from 12/14/2021 to 2/13/2022. This was evidenced by: Resident #113 was admitted with diagnoses of Parkinson's disease, metabolic encephalopathy, and diabetes. The Minimum Data Set (MDS- an assessment tool) dated 12/14/2021, documented the resident had moderately impaired…

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 interviews during the recertification survey dated 2/28/2022 through 3/8/2022 the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #66) of 1 resident reviewed for dialysis. Specifically, for Resident #66, who receives dialysis, the facility did not ensure the comprehensive care plan (CCP) included interventions to provide direction for facility staff regarding the care of and monitoring for complications required for a resident receiving dialysis and did not ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This was evidenced by: The Policy and Procedure (P&P) titled Dialysis Management dated 5/2019 documented, residents receiving hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. The nurse will obtain orders for monitoring of site, and interventions as…

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 interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure the policy developed for the monthly medication regimen review (MRR) included time frames for the different steps in the process. This is evidenced by: The Policy and Procedure (P&P) titled Medication Regimen Reviews (MRR) dated 3/20, did not document time frames when the facility staff would complete the steps in the MRR process. During an interview on 3/8/22 at 1:11 PM, the Director of Nursing stated there should be time frames for each step of the process and the policy would be fixed to address that. 10NYCRR415.18 (c)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey and an abbreviated survey (Case #NY00288001) dated 2/28/2022 through 3/8/2022, the facility did not ensure residents were free from significant medication errors for 1 (Resident #89) of 6 residents reviewed. Specifically, the facility did not ensure Resident #89 received antiparkinsonian medication as prescribed by the physician. This is evidenced by: The Facility Policy titled, Medication-Reconciliation last revised on 1/2020, documented the Corporation (named) will accurately reconcile medications of newly admitted residents to contribute to the creation of an accurate master medication list. Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient's current medications (including name, dosage, frequency, and route) and comparing the incoming admission, transfer and/or discharge medication orders to that list. Resident #89 Resident #89 was admitted with diagnoses of Parkinson's disease,…

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 interviews during the recertification survey and an abbreviated survey (Case #NY00262847) dated 2/28/2022 through 3/8/2022, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #366) of 1 resident reviewed for laboratory services. Specifically, for Resident #366, the facility did not ensure a physician ordered urinalysis (UA- a test of the urine used to detect and manage a wide range of disorders, such as urinary tract infections) and Culture and Sensitivity (C&S- a laboratory test to detect and identify bacteria and yeast in the urine, which may be causing a urinary tract infection) dated 8/11/20 was obtained for over 7 days. This was evidenced by: Resident #366: Resident #366 was admitted to the facility with the diagnoses of heart failure, benign prostatic hyperplasia (condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and atrial fibrillation. The Minimum Data Set (MDS - an assessment tool) dated 7/24/20 documented the resident had…

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

Based on observation, record review, and interviews during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure resident menus were followed. Specifically, the facility did not ensure a an alternative entree was consistently provided and did not consistently provide the menu as written on the resident's meal ticket. This is evidenced by: The facility's lunch menu for Week #1 on Wednesday menu documented; sliced pork, mashed sweet potatoes and green peas. The alternate lunch menu documented; hot turkey sandwich and wax beans. The facility's lunch menu for Week #1 on Thursday documented; Fish, garden rice and seasoned spinach. An alternate menu item was an egg salad sandwich and green beans. During an observation on 3/2/22 (Wednesday) at 12:54 PM, Resident #42's meal tray on their bedside table included ground meat, cauliflower, and a mashed orange colored food item on a plate. A printed meal ticket on the meal tray with Resident #42's name documented; sliced pork loin and diced carrots. During an observation on 3/3/22 at 12:47 PM, Resident #42 was…

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 interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure foods brought to residents by family and other visitors was stored and handled safely, and the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the policy does not include a procedure to ensure all residents have the necessary assistance in accessing and consuming food brought to them by visitors, and outdated food brought to residents was not discarded. This is evidenced as follows: Review of the facility policy on 03/04/2022 for food brought in by visitors, documented that the policy requires staff to label with the resident name and date received on all foods brought to residents. The policy did not include a procedure to assist residents that are unable on their own to access and consume food brought to them by visitors. During an interview on 03/04/2022 at 3:21 PM, the Director of Nursing stated the policy will be updated to include a procedure to assist residents in accessing…

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 interviews during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP), that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs for 6 (Resident #s 22, 29, 61, 85, 99, and #152) of 32 residents reviewed for comprehensive care plans. Specifically, the facility did not ensure that CCP's were developed to address Resident #22's contractures and range of motion (ROM) needs for the right upper extremity; Resident #29's respiratory issues that required treatment with nebulized medication and elevated ammonia levels that required medication to treat; Resident #85's internal defibrillator and episodes of syncope requiring hospitalization; Resident #99's contractures and ROM requirements; Resident #152's self administration of medication and did not ensure Resident #61's Pressure Ulcer care plan included individualized interventions to promote wound healing. This is evidenced by: The Policy and…

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

Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections determined for 2 (Resident #'s 100 and 137) of 3 residents reviewed for dressing changes. Specifically, for Resident #100, the facility did not ensure that the outside of the multi-use bottles of ¼ inch iodoform packing strip and wound cleanser were clean, that gloves were changed when contaminated and that handwashing was performed between glove changes during a dressing change to the left hip; for Resident #137, the facility did not ensure gloves were changed when contaminated and handwashing performed between glove changes, that scissors were cleaned prior to use and sterile packages were opened correctly during a dressing change to the pressure ulcers of the 3rd and 4th toes on the left foot. This is evidenced by: Resident #100: The resident was admitted to the facility with diagnoses of unspecified open wound of left hip,…

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 during the recertification survey, the facility did not ensure that an accurate assessment was done by a qualified professional for 2 (Resident #'s 22 and 29) of 32 residents reviewed for accuracy of assessments. Specifically, the facility did not ensure section G of the Minimum Data Set (MDS -an assessment tool) accurately represented the functional status of Resident #22's right upper extremity (UE) for the time period of 6/23/16-10/10/19 and did not accurately represent the functional status of Resident 29's left foot and left hand. This was evidenced by: The facility policy and procedure MDS dated 5/2017 documented to follow the guidelines of the most current State-specified Resident Assessment Instrument (RAI) manual correctly and effectively according to Centers for Medicare and Medicaid Services (CMS). The RAI consists of three basic components: The MDS, the Care Area Assessment process, and the RAI Utilization Guidelines. The utilization of the three…

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 interview during a recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 3 (Resident #'s 73, 75, and #82) of 13 residents reviewed for baseline care plans. Specifically, for Resident #'s 73, 75, and #82, the facility did not ensure the baseline care plans included minimum healthcare information related to Social Services. This is evidenced by: The policy and procedure titled Care Plans- Baseline, last revised 2/2019, documented the interdisciplinary team would review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: (A) Initial goals based on admission orders; (B) Physician orders; (C) Dietary orders; (D) Therapy services; (E) Social services; (F) PASARR recommendation, if applicable.…

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 during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (Resident #82) of two residents reviewed for Activities of Daily Living. Specifically, for Resident #82, the facility did not ensure the resident, who was unable to carry out activities of daily living, received her weekly shower to maintain good personal hygiene. This is evidenced by: The Policy and Procedure titled ADL- Bath (Shower) last revised 7/2019, documented it was the policy of the facility to shower resident, to cleanse and refresh the resident, observe the skin, and to provide increased circulation. Resident #82: The resident was admitted to the facility with the diagnoses of dementia, major depressive disorder, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 10/23/19 documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #'s 96 and 152) of two residents reviewed for accidents. Specifically, the facility did not ensure that Resident #'s 96 and 152 were assessed for their ability to self-medicate prior to leaving medications in their rooms for them to self-administer resulting in Resident #152 missing 7 doses of Dulera HFA (a multidose inhaler used to control symptoms of obstructed airflow in the lungs). This is evidenced by: A Medication Self-Administration policy last reviewed 5/2019, documented that criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Staff and the practitioner would assess each resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for one (Resident #152) of two reviewed for respiratory care. Specifically: the facility did not ensure that the residents Oxygen (O2) tank did not run dry resulting in the resident not receiving O2 therapy as prescribed. This is evidenced by: Resident #152: The resident was admitted with diagnoses of COPD (chronic obstructive pulmonary disease, recurrent pneumonia and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 9/19/19, assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others and received oxygen therapy while a resident. A facility…

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 interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 (Resident #35) of 1 residents reviewed for dialysis care. Specifically, for Resident #35, the facility did not ensure there was consistent communication with the dialysis treatment facility and that there was an ongoing assessment of the resident's condition and monitoring for complications following dialysis treatments. Resident #35: The resident was admitted to the facility with diagnoses including end stage renal disease, dependence on renal dialysis, and atrial fibrillation. The Minimum Data Set (MDS- an assessment tool) dated 9/19/19, documented the resident was cognitively intact. A Physician's Order initiated on 10/2/19, documented; Upon return from dialysis, obtain vital signs, evaluate resident for mental status, pain, access site condition, review communication sheet to include post-dialysis weight (report if change of +/- 5 pounds), and document…

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.