Achieve Rehab And Nursing Facility

Based on observation, record review, and interview during the recertification and abbreviated (NY 00322762) surveys conducted 10/16/24 to 10/23/24, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, and nursing, needs for 1 of 3 residents (Resident #84) reviewed for hospitalizations, 2 of 2 residents (Residents #122 and #72) reviewed for urinary tract infections, 2 of 3 resident (Residents #179 and #98) reviewed for respiratory care, and 1 of 6 residents (Residents #281) reviewed for accidents. Specifically, 1.) Resident #84 did not have a care plan in place to address cardiac issues, 2.) Resident #122 did not have a plan of care in place to address urinary tract infection or cystitis (inflammation/infection of the bladder), and 3.) Resident #179 did not have a care plan in place to address respiratory care and the use of oxygen. The findings are: The facility policy, Care Plan revised 7/2020, documented that each resident will…

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 interview conducted during the Recertification and Abbreviated Surveys (NY 00326169, NY 00341314, and NY 00322762) from 10/16/24 to 10/23/24, the facility failed to ensure the residents' environment remained as free of accidents hazards as possible for 3 (Residents #280, #281 and #92) of 6 residents reviewed for accidents. Specifically, 1. Resident #280 was assessed at high risk for falls, care plan interventions were not in place and Resident #280 had an unwitnessed fall and required hospitalization for two lacerations to the face and a subdural hematoma (brain bleed). The facility did not thoroughly investigate to determine if interventions were adequate, and if the plan of care was followed. 2. Resident #281 was eating dinner, became unresponsive, required cardiopulmonary resuscitation and was sent to the Emergency Department. The facility did not investigate the incident to determine if the resident received the correct food consistency, had adequate supervision, or…

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 interviews during the recertification and abbreviated (351312) surveys from 10/16/24 to 10/23/24, the facility did not ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months. Specifically, performance appraisals were not documented every 12 months for 4 of 5 Certified Nurse Aides (Certified Nurse Aides #1, #2, #3, #4) records reviewed. The findings are: There was no documented evidence that an annual performance review was completed for Certified Nurse Aide #1 who was hired 8/22/2018, Certified Nurse Aide #2 who was hired 7/20/2023, Certified Nurse Aide #3 who was hired 9/16/2020 and Certified Nurse Aide #4 who was hired 6/22/2023. On 10/17/24 at 4:08 PM during an interview with the Director of Human Resources, the surveyor requested to view the annual performance reviews for Certified Nurse Aides #1, #2, #3, #4, and #5. The Director of Human Resources stated they could not locate the annual performance reviews for Certified Nurse Aides #1, #2, #3, and #4. They stated the process for the annual performance…

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 and interview conducted during the recertification survey from 10/16/24 to 10/23/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice. Specifically, there was food stored in the walk-in refrigerator and dry storage room that was undated and past the expiration date. Finding include: The revised-on October 2019 facility policy titled Food Storage: Cold documented the Dining Services Director/Cook ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. The revised-on October 2019 facility policy titled Food Storage - Dry Goods documented the Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate. During an initial tour of the kitchen on 10/16/24 at 9:39 AM, conducted with the Regional Director of Operations, the following were observed in the walk-in…

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 interviews during the recertification and abbreviated (NY00351312) surveys from 10/16/24 to 10/23/24, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, 1) the facility did not properly implement transmission-based precautions for 3 of 3 residents reviewed for infection control precautions (Residents #84, #117, #120) and 2) the facility did not ensure that an infection surveillance plan was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks for 3 of 5 residents reviewed for infection control (Residents #122, #72, #120). The findings are: The facility policy, Infection Prevention and Control, Surveillance Program pp 125-127 documented the purpose of the Surveillance Program is to conduct surveillance of resident and employee infections to guide prevention activities and the Infection Preventionist conducts surveillance of infections among residents and employees…

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, interviews and record reviews conducted during the recertification and abbreviated (NY00351312) surveys from 10/16/24 to 10/23/24 the facility did not maintain an effective pest control program so that the facility was free of pests. Specifically, Resident #70's room had glue traps for insects and rodents, with gnats and cockroaches observed inside the trap. Findings include: The facility policy and procedure titled Pest Control with a revised date of May 2008 documented the facility maintained an on-going pest control program to ensure that the building was kept free of insects and rodents. During observation on 10/16/24 at 10:38 AM, Resident #70's room had insect and rodent traps on the cabinet next to the resident's bed, and on the sink counter, with many gnats and a cockroach stuck inside the trap. During an interview on 10/16/24 at 12:05 PM, Resident #70 stated that in their room they had flies and roaches on a regular basis and that was why there were traps. The resident stated they had lived at the facility for over 3 years and the pest problem 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during recertification and abbreviated (NY 00351312) surveys from 10/16/24 to 10/23/24, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for 1 (Resident #14) of 1 resident reviewed for personal funds. Specifically, the facility did not ensure residents had access to their personal funds on weekends. The findings are: Review of an undated facility policy and procedure titled Resident Personal Needs Account Policy documented that residents have the right to manage their own personal funds. The facility assists with holding, safeguarding, managing, and accounting for their personal funds. The personal needs account will be accessible daily including weekends and holidays as residents see fit. Resident banking is typically conducted through the front desk from 7 am to 9:30pm, 7 days a week. Review of the facility policy…

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 conducted during the recertification survey from 10/16/2024 to 10/23/2024 the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for 1 (Resident #179) of 3 residents reviewed for Medication Administration. Specifically, Resident #179 was found with physician ordered Ipratropium-Albuterol inhaler, Sodium Chloride nasal solution and Flonase allergy relief nasal spray in their room on their bedside table. The findings include: The facility policy titled Storage of Medications dated 11/2020 documented the facility is responsible for storing drugs and biologicals in a safe, secure, and orderly manner. Resident #179 was admitted to the facility with diagnoses including Asthma, Obstructive Sleep Apnea, and Anxiety. The 9/19/2024 Physician Order documented Fluticasone Propionate nasal suspension 50 microgram/actuation, 2 spray two times a day in both nostril. Sodium Chloride nasal solution 0.65% four times a day in both nostrils 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 and interview during the Recertification Survey from 10/16/24 to 10/23/24, the facility did not ensure that food on trays was held at palatable temperatures for 1 of 2 residents (Resident #70) reviewed for Food. Specifically, for Resident #70 food was not served at palatable temperatures. The findings are: Resident #70 was admitted with diagnoses including but not limited to non-Alzheimer's dementia, malnutrition, ataxia. The current Physician Order documented regular texture, regular thin consistency, please provide moist ground meats, except when on a sandwich (turkey sandwich, hamburger). The 8/30/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #70 had intact cognition, and needed set-up and clean-up assistance with eating. During an interview on 10/16/24 at 12:05 PM, Resident #70 stated they did not like the food, the food was cold. The surveyor observed stored closed food packages in the resident's room. The resident's son was present and stated they just went shopping to buy the resident food. On 10/21/24 at 1:01…

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 conducted during the recertification and abbreviated surveys (NY 00326169) from 10/16/24 to 10/23/24, the facility did not ensure that the Minimum Data Set assessments accurately reflected the residents' status at the time of the assessments for 1 (Resident #280) of 35 sampled residents. Specifically, the Minimum Data Set assessment inaccurately documented that Resident #280 who had a care plan for bed and chair alarms, was assessed to have no alarms. The findings are: Resident #280 was admitted with diagnoses including but not limited to a displaced intertrochanteric fracture of the right femur, history of falling, and muscle weakness. The 8/2/23 At Risk For Falls Due To An Adjustment To A New Environment Care Plan documented interventions including placing alarms to both the bed and the chair. The 8/5/23 admission Minimum Data Set documented Resident #280 had intact cognition and had no bed or chair alarms. During an interview on 10/22/24 at 3:28 PM, the Minimum Data Set Coordinator stated that when they are doing the Minimum Data Set, they…

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 a recertification survey and abbreviated survey (NY 00322762), the facility did not ensure staff were provided with education on activities that constitute abuse, neglect, exploitation, dementia management and misappropriation of resident property for 1 of 6 staff members reviewed (Certified Nurse Aide #13) for education. Specifically, the facility was unable to provide documented evidence Certified Nurse Aide #13 received any education. Findings include: The 3/08 Policy titled Abuse Prevention Reporting and Investigating documented all employees receive education related to abuse, neglect and misappropriation of resident property, involuntary seclusion, and abandonment. The 9/1/23 Investigation Summary completed by former Director of Nursing #12 documented Resident #92 sustained a wrist fracture. The evidence including statements and an x-ray determined that there was reasonable cause that neglect had occurred and it was a direct care plan violation by Certified Nurse Aide #13. Certified Nurse Aide #13 was immediately removed from 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 Based on record review and interviews conducted during an abbreviated survey (NY00316474), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for one of three residents (Resident #1) reviewed for accidents. Specifically, Resident #1 who had a diagnosis of dementia history of wandering and elopement exited the facility through the front door on 05/11/2023 independently undetected by staff. Resident #1 was care planned to have wander guard, but the resident had no wander guard on. Resident #1 obtained access as the receptionist was letting a visitor out the front door. Resident #1 wandered out the front door of the facility and walked along side fence and was observed by Recreation Aide (RA#1) who escorted them back into the building unharmed. The findings are: The Facility Policy on Wandering/Elopement Residents dated 2/1/2017 was reviewed. The policy documented that the residents care plan will be modified to indicate…

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, staff interviews and record review during a Recertification Survey and Abbreviated Survey (#272489 and #290316) conducted from 9/19/22 to 9/27/22, the facility did not ensure that residents received a safe and/or appropriate discharge. This was evident for 2 out of 2 residents reviewed (Resident #228 and #226) for discharge. Specifically, 1. the facility did not ensure Resident #228 had a safe discharge plan prior to being discharged to the community and 2. the facility did not complete the Patient Review Instrument (PRI) for Resident #226 in a timely manner for transfer to another facility. The findings are: The Facility Policy and Procedure titled, Discharge Plan and Summary, dated 11/2021 documented when notified of resident's request for discharge, Social Service Staff will notify CCP Coordinator to set up a discharge meeting to include the Attending Physician, appropriate staff, the resident and/or family, pertinent information regarding the reasons for the request, prospective…

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 conducted during a Recertification Survey conducted between 9/19/22-9/27/22, the facility did not ensure that the Comprehensive Care Plan was revised for 2 of 2 residents (Resident #98 and Resident #121) Specifically, 1. The Contracture Care Plan for Resident #98 was not revised to reflect the physician prescribed use of bilateral hand rolls and bilateral knee splints and 2. The Advanced Directive Care Plan for Resident #121 was not revised to reflect the change from Full Code to Do not Resuscitate, Do Not Intubate and Comfort Measures Only. The findings are: The Policy and Procedure titled Care Plan Policy dated 8/2/21 documented Comprehensive Care Plans are reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Resident #98 had diagnosis including but not limited to Non-Pressure Chronic Ulcer of Left Ankle with Spastic Quadriplegic Cerebral Palsy and Contracture of Muscle-Multiple…

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, interview and record review conducted during the Recertification Survey conducted 9/19/22- 9/27/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two of two residents (Resident #55 and #98) reviewed for Quality of Care. Specifically, 1. Resident #55 did not receive twice a week Unna boot changes to treat venous stasis of the lower extremity as ordered by the physician. Additionally, 2. (Resident #98) the use of hand rolls and knee splints were not consistently utilized as per physician orders. The findings are: Review of the Policy and Procedure (P&P) titled Treatment of Venous Stasis Ulcers revised 8/2021 documented to treat the healing of venous stasis ulcers through the application of even pressure on affected extremities, without causing trauma or further skin breakdown. The policy further documented the application of the Unna boot must be done according to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review conducted during a Recertification Survey from 9/19/22 to 9/27/22, the facility did not ensure that care and treatment were provided to ensure prevention of pressure ulcers for 1 of 4 residents (Resident#98) reviewed for Pressure Ulcers. Specifically, for Resident #98, heel lift boots wre not applied as per physicians orders. The Findings Are: Resident #98 had diagnosis including but not limited to Non-Pressure Chronic Ulcer of Left Ankle with Spastic Quadriplegic Cerebral Palsy and Contracture of Muscle-Multiple Sites. Review of the Annual Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition, no behaviors noted total assistance of one-two staff for bed mobility, transfer, eating and toileting, and was at risk for development of pressure ulcers but had no pressure ulcers. Review of the Quarterly MDS dated [DATE] documenetd severe cognitive impairment, no behaviors noted, total assistance of one-two staff for bed mobility, transfers,…

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, interview, and record review during the Standard survey completed 9/27/22, the facility did not ensure they maintained an effective pest control program to ensure the facility was free of pests. Specifically, there were multiple observations of gnats flying around the hallway and resident rooms on unit 2 East. The findings are: Review of the Policy and Procedure (P&P) titled Pest Control dated 11/2021 documented all possible measures are taken, within reason, to maintain as pest-free a facility as possible. Additional treatments by the pest control company are obtained as needed. The P&P further documented housekeeping or maintenance will conduct weekly inspections for evidence of pests, document problems found during inspection and the remedial actions taken. In addition, staff should report insect or pest sightings to the environmental services supervisor immediately. Review of the Pest Tech Book on 9/26/22 at 1:44 PM for unit 2 East documented no evidence of gnats being reported by…

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 the facility did not ensure that resident representatives were notified in writing of transfers from the facility to the hospital. This was evident for 5 of 5 residents reviewed for hospitalization. (Residents # 73, 19, 105, 120 and 23). The findings are: Resident #73 was transferred to the hospital on 3/11/19 with a diagnosis of hyperkalemia (elevated potassium level). The resident returned to the facility on 3/13/19. Resident #19 was transferred to the hospital on [DATE] with a diagnosis of pneumonia. The resident returned to the facility on [DATE]. Resident #105 was transferred to the hospital on [DATE] with a diagnosis of pneumonia. The resident returned to the facility on [DATE]. Resident #23 was transferred to the hospital on 2/15/19 with a diagnosis of flu and cellulitis of the right thigh. The resident returned to the facility on 2/20/19. Resident #120 was transferred to the hospital on 3/17/19 related to ongoing lethargy, poor appetite and elevated body 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that 1) a care plan with measurable objectives, time frames, and appropriate interventions was initiated for 1 resident reviewed for positioning and mobility (Resident #72) and 2) interventions for the care of an indwelling catheter were included in the plan of care for 1 of 4 residents (Resident #72) reviewed for hospitalization. The findings are: 1. Resident #72 was admitted with diagnoses including neurogenic bladder and paraplegia. Review of the minimum data set (MDS- a resident assessment tool) dated 8/3/18 the resident was cognitively intact, received extensive assist for bed mobility and had impairment of both lower extremities. Review of the MDS dated [DATE] indicated the resident was cognitively intact, received extensive assist for bed mobility, transfers, toileting, and had functional limitation of both lower extremities. Review of the comprehensive care plan dated 9/11/18…

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 the facility did not ensure that a care plan that addressed care needs related to infections had been reviewed and revised to include a recent hospitalization for pneumonia. This was evident for 1 of 4 residents reviewed for hospitalization (Resident #19). The findings are: Resident #19 was admitted to the facility on [DATE]. Current diagnoses as identified on the annual minimum data set (MDS- a resident assessment tool) dated 6/28/18 include; obstructive neuropathy, Alzheimer's disease and anxiety. Review of the admission/discharge/transfer information in the EMR (Electronic Medical Record) indicated the resident was transferred to the hospital on [DATE] and returned on 12/31/18. Review of the nursing progress notes indicated the following: 12/27/18: shallow breathing and intermittent periods of apnea, lethargic, transferred to emergency department for evaluation. 12/27/18: called hospital. Resident diagnosed with bilateral pneumonia. 12/31/19: readmitted to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident (Resident #120) reviewed for hospitalization was provided the necessary care to promptly address ongoing poor fluid intake to prevent dehydration. Specifically, the resident's fluid intake and output were significantly low for approximately five weeks (2/9/19 to 3/14/19) with no timely measures in place to prevent dehydration and/or electrolyte imbalance. The findings are: Resident #120, an 84 year female, was admitted to the facility on [DATE] with the diagnoses of Cystitis (infection of the bladder), Urinary Tract Infection and Dementia. The resident's advanced directives reflected in a Medical Orders for Life Sustaining Treatments (MOLST) form document dated 2/6/19 indicated that a trial of intravenous fluid was allowed and the decision on tube feeding was deferred. A dietary assessment dated [DATE] revealed that the resident's estimated daily fluid requirement was 1770 cc.…

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 conducted during the recertification survey the facility did not ensure that treatments and services to prevent further decrease in range of motion and/or contractures was provided for 1 resident (Resident #72) reviewed for position/mobility. Specifically, passive range of motion was not being performed for a resident with impaired mobility. The findings are: Resident #72 was admitted with diagnoses including; hypertension and paraplegia. Review of the 8/3/18 Minimum data set (MDS; a resident assessment tool) indicated he was cognitively intact, received extensive assist for bed mobility and had impairment of both lower extremities. Review of the 2/3/19 MDS indicated the resident was cognitively intact, received extensive assist for bed mobility, transfers, toileting needs and had functional limitation of both lower extremities. Review of the comprehensive care plan dated 9/11/18 revealed an intervention to provide daily PROM (passive range of motion) to all extremities during cares. An observation on 3/22/19 at 2:07 PM 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.

Based on record review and interview the facility did not ensure that the consultant pharmacist's recommendations were acted upon by the resident's primary care physician. This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #100). The findings are: Resident #100 was admitted with diagnoses including; Atrial Fibrillation, Hypertension and Thyroid Disorder. Review of the March 2019 physician's orders included the following medications; Tylenol 650 mg every 12 hours for chronic pain Tylenol 650 mg every 6 hours for chronic pain due to trauma Hydroxyzine 25mg three times daily for Anxiety Lasix 20mg twice daily for Hypertension Losartan 25mg daily for Hypertension Mirtazapine 7.5 mg at bed time for Depression Paroxetine 40 mg daily for Depression Synthroid 50mg daily -Malignant Neoplasm of Thyroid Gland Warfarin 3 mg in the evening for Atrial Fibrillation. The Consultant Pharmacist Monthly Medication Regimen Review (MRR) indicated the following: 5/30/18 - order labs: Lipid panel (tests for cholesterol level and other blood lipids) and HGBA1C (to test 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.