Sullivan County Adult Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated and extended survey (NY00376081), the facility did not ensure that all nursing staff were competent and trained in providing care to residents with various psychiatric/mood disorders as listed in the current facility assessment. Specifically, 1 (Resident #1) of 4 residents with psychiatric diagnoses do not have staff in the facility that are trained to provide appropriate behavioral health care. The facility was unable to provide documented evidence that they provided nursing staff education on behavioral health training other than for dementia. Resident #1 Minimum Data Set, dated [DATE] with diagnoses unspecified dementia, moderate with mood disturbance. non traumatic brain dysfunction, non-Alzheimer's dementia. No behaviors are noted. Resident #1 was evaluated and was found to be moderately cognitively impaired with a brief interview of mental status of 11. On PHQ2-9 a depression screening tool Resident #1 scored a 13, indicating elevated…

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

Based on observations and interviews conducted during the recertification survey from 9/22/24 to 9/27/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice, and essential equipment was not in safe operating condition. Specifically, 1. Food was stored in the walk-in freezers and refrigerators that was unlabeled, undated and without expiration dates. 2. Expired foods were stored in refrigerators and the dry storage room. 3. Freezers #6 and #7's insulation door seals were not attaching properly causing the formation of ice on the ceiling and walls inside the freezers. 4. Damaged tile flooring next to the dishwashing machine formed an uneven and wobbly surface. Finding include: The undated facility policy Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated. During an initial tour of the kitchen on 09/22/24 at 4:40 PM conducted with Head [NAME] the following were observed in the walk-in freezer #7: 1. A bag of frozen chicken breast, without original box,…

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 the Recertification and Abbreviated surveys (NY 00351488 and NY 00335211) from 9/22/24 to 9/27/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each floor, the facility did not provide adequate staffing to meet the needs of the residents. The findings are: The Facility assessment dated [DATE] documented Licensed Practical Nurses providing direct care and Nurses Aides were staffed based on the acuity of units or demands of unit as determined by the Clinical Administration on a fluid basis as the needs of the residents and census are ever changing. 1) The facility census on 9/22/2024 was 115 residents. On 9/27/2024, the Unit 1 census was 17 and Unit 2 census was 39. A review of actual Staffing Sheets from 9/1/2024 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.

Based on observation and interview conducted during the Recertification survey from 9/22/24 to 9/27/24, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, food was served out of temperature (chicken, pasta, vegetables, and milk). Findings include: The facility policy Food and Nutrition Services revised on 8/2023 and edited on 12/4/2023 documented, food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During an interview on 9/22/24 at 5:42 PM, Resident #27 stated the food was cold by the time they got their tray in their room. Resident #27 stated it took the Certified Nurse Aide a half-hour to bring the tray to them, after they finished serving the residents in the dining room. During an interview on 09/23/24 at 11:36 AM, Resident #94 stated that the food was cold by the time they brought it to them. During a Resident Counsel Group meeting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the residents had a right to make choices about aspects of his or her life in the facility that are significant to the resident for 1(Resident #110 ) of 1 residents reviewed for Choices. Specifically, Resident #110 was moved from their room(163) on 9/22/24 to another room(169) while the ceiling in their room was being repaired, and on 9/23/24 when the repair was completed, Resident #110 was not moved back into their room as per their preference until 9/26/24. The findings are: The facility policy titled Resident Room Changes dated 2/2016 and revised on 4/2024 documented that in recognition of the possible physical, mental, and psychological impact that a room change may produce, the facility makes every effort to lessen any negative effect that a room change may have on a resident, and the room change will be carried out in manner to maintain residents' rights…

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 conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the residents had a right to a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #34 and #110 ) of 5 residents reviewed for Environment. Specifically, the ceiling in room [ROOM NUMBER] on Unit 2 where Residents #34 and #110 resided, was observed with a large hole in the ceiling, a basin on the floor that was collecting water, with a bed pad underneath. The findings are: The undated facility policy titled Maintenance Work Order Policy documented that the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. On 09/22/24 at 06:21 PM, the ceiling in room [ROOM NUMBER] on unit 2 was observed with a big hole in the ceiling that was approximately 2.5 feet…

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 and complaint (NY00335402) survey from 9/22/2024 to 9/27/2024, the facility did not ensure that all alleged violations involving misappropriation of resident property were reported to the New York State Department of Health. This was evident for 1 (Resident #49) of 3 residents reviewed for abuse. Specifically, the facility did not report an allegation that Resident #49's gold necklace was removed by a staff member and never returned to the resident. The findings are: The facility policy titled Resident Abuse dated 6/2023 documented any report of abuse will be reported in keeping with the New York State Department of Health regulations. Resident #49 was diagnosed with Parkinson's disease and cerebral infarction. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #49 was moderately cognitively impaired. A facility Investigation initiated 2/20/2024 documented Resident #49 and their designated representative…

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 interview and record review and observation during the recertification survey from 9/22/24-9/27/24, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standard of practice for 1 of 2 residents (Resident #105) reviewed for Respiratory Care. Specifically, oxygen was applied to Resident #105 and did not have a physician order. Findings include: Resident #105 had diagnoses including dependence on renal dialysis, chronic systolic heart failure (heart can't pump blood efficiently) and atrial fibrillation. (an irregular, often rapid heart rate). The 8/24/24 Quarterly Minimum Data Set documented Resident #105 had intact cognition and did not document the resident was on oxygen therapy. The 4/24 Oxygen Administration Policy documented to verify there is a physician order for this procedure. Review the physician's orders for facility protocol for oxygen administration. A 9/11/24 nursing progress note documented at 4:00 AM, the resident complained of shortness of breath and their oxygen saturation on room air 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the Physician reviewed the resident's total program of care, including medications, and treatments, at each visit for 1(Resident #107 ) of 1 residents reviewed for Hospice. Specifically, Resident #107 was admitted to the facility on [DATE], on Hospice, had no Physicians order to receive Hospice services. The findings are: The undated facility policy titled Physician Responsibilities documented that when a new resident is admitted to the nursing home, the physician conducts a thorough evaluation. This includes reviewing the resident's medical history, assessing current health conditions, and documenting any necessary treatments or interventions. Resident #107 was admitted with diagnoses including but not limited to Alzheimer's disease, anxiety disorder, depression, and psychotic disorder. The 8/6/24 Quarterly Minimum Data Set documented Resident #107 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 record review and interviews during an abbreviated survey (NY00311382), the facility did not immediately notify the designated representative (DR) and/or Health Care Proxy (HCP) when there was a significant change in Residents medical/clinical status. This was evident for 1 of 3 residents (Resident #1) reviewed for notification. Specifically, Resident #1 tested positive for covid on 02/15/2023. The HCP was not informed until 02/22/2023 when the HCP was contacted by the facility regarding Resident #1's chest X-ray results. The findings are: The Facility Policy titled Resident Rights and Quality of Life dated 05/2009 documented that each resident will have the right to participate in planning care and treatment or changes in care and treatment. Residents adjudged incompetent or otherwise found to be incapacitated under the laws of the State of New York shall have such rights exercised by a DR who will act on their behalf in accordance with State law; and the facility shall except in a medical emergency, consult with the resident immediately if the resident is competent, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey conducted from 12/27/2022 -1/5/2023, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident population in accordance with resident needs identified in the facility assessment. Specifically, three of four resident care units reviewed for sufficient staff did not consistently have adequate staff to meet the needs of the residents as per the facility staffing minimum. In addition, during a Resident Counsel meeting held on 1/3/23, four residents (#38, 63, 37, and 75) verbalized that staffing was inadequate. The findings are: The facility Policy and Procedure entitled Staffing dated 10/2022 documented the facility provides staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during Recertification Survey, the facility did not ensure that care was provided in a manner to maintain dignity for 2 of 2 residents (#23 and #72) reviewed for dignity. Specifically, the urinary foley catheter tubing and drainage collection bag for Resident #23 and #72 were not covered with a privacy cover to prevent direct observation by other residents and their families. The findings are: The facility Policy and Procedure (P&P) titled Resident Rights/Dignity dated 10/2022 documented the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in recognition of a person-centered care approach. Resident #23 had diagnoses and conditions including Peripheral Vascular Disease, Neurogenic Bladder and Quadriplegia. The 9/26/22 Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) documented that Resident #23 had severely impaired cognition; was totally…

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 conducted during the Recertification Survey conducted from 12/27/22 to 1/05/2023, the facility did not ensure that a resident's representative was made aware of the facility's bed hold policy before and upon transfer to a hospital for 1 of 3 residents reviewed for Closed Record Review. Specifically, Resident #62 was transferred to the hospital on [DATE] for an evaluation and the facility did not give advance notice of the bed hold policy to the resident/resident's representative prior to the transfer. The findings are: Resident #62 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Diabetes Mellitus Type II and Bullous pemphigoid. The 9/19/22 admission MDS (Minimum Data Set - a resident assessment tool) documented a BIMS (Brief Interview for Mental Status) score of 14, which indicated intact cognition. The 12/20/22 Transfer to the Hospital Summary documented the resident was transferred to the hospital and admitted for Acute Kidney Injury,…

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, interview, and record review conducted during the Recertification Survey conducted from 12/27/2022 -1/5/2023, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #63) reviewed for ADL's. Specifically, Resident # 63 did not consistently receive twice a week showers as per the CNA (Certified Nursing Assistant) Accountability and the unit shower schedule. The findings are: The facility Policy and Procedure (P&P) titled Activities of Daily Living (ADL) un dated documented a program of activities of daily living (ADL) is provided to prevent disability and return to a maximum level of independence. The policy further documented the resident self-image should be maintained. In addition, the resident will be offered shower/bed bath based on resident preference and schedule. Assistance will ne provided based on plan of care. Resident #63 was admitted with diagnoses which included Major Depressive Disorder, Disorder of…

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

Based on observations, record review, and staff interviews during the Recertification Survey, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a splint device was not provided to the resident as per physician order. This was evident in 1 of 1 resident (Resident #66) reviewed for ROM care and services. The findings Are: The facility policy and procedure titled Splint, Braces, Casts and Immobilizers (assistive devices) undated documented the following: the facility will access each splint, brace, cast and immobilizer to ensure proper placement fitting, minimal pressure and proper placement and cleaning. Nursing and rehab will collaborate as necessary for resident safety and comfort. Resident #66 was admitted with diagnoses which included Peripheral Vascular Disease, Non-Alzheimer's Dementia and Anxiety. The 11/27/22 Quarterly Minimum Data Set (MDS) documented that the resident had severely impaired cognition,…

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 interview and record review during the Recertification Survey conducted between 12/27/2022-1/5/2023, the facility failed to employ qualified staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. Specifically, the Diet technician was a full-time employee at the facility, but did not have a certification and the Registered Dietician was remotely employed 8 hours per week and did not report to the facility. The Findings include: The undated facility policy and procedure titled Nutritional assessment documented the Dietician in conjunction with the nursing staff and healthcare professionals will complete a nutritional assessment for each resident upon admission and as indicated by change in condition that places the resident at risk for impaired nutrition. During an interview conducted with the diet technician (DT) on 01/04/23 at 03:36 PM, they stated they are a diet tech with an associate degree. The DT stated they are supervised by the Registered Dietician. The DT stated they completed the nutrition assessments. DT…

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 conducted from 1/27/2022-1/4/2023 the facility did not ensure that each resident received, and was provided food that accommodated resident allergies, intolerances, and preferences, for one Resident (#95) of three residents reviewed for nutrition. Specifically, the facility did not ensure Resident #95 who was allergic to pineapple was not given pineapple on their meal tray. The Findings are: The undated and revised 10/2017 Policy and Procedure titled Food and Nutrition Policy documented each resident was provided with a nourishing palatable well-balanced diet that meets their daily nutritional and special dietary needs taking into consideration the preferences of each resident. The resident was admitted with diagnoses including but not limited to Dysphagia, Dementia and Parkinson. The 10/26/22 Quarterly Minimum Data Set (MDS) documented the resident had severe cognitive impairment and required setup and supervision for meals 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 observations and interviews conducted during the Recertification Survey from 12/27/22-1/05/23, the facility did not ensure that food was prepared and served in accordance with professional standards for food safety. This was evident during the Kitchen Task observation. Specifically, the cook and 2 food service technicians were observed in the kitchen with their face masks pulled down off their noses and mouths, the cook, who is bearded, was observed without a beard cover, and the Maintenance Assistant was observed in the kitchen without a hair net. The findings are: The undated facility policy titled, Hair Restraint documented that the food service employees are required to have all their hair covered and don a hairnet when preparing and serving food. On 12/27/22 at 09:46 AM during the initial kitchen tour, a bearded cook was observed without a beard cover and had their mask pulled down below their nose and mouth, a food service technician was observed without a hair net and the Food Service Director (FSD) was observed not wearing a face mask. On 12/28/22 at 09:13 AM during…

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 interviews and record review during a Recertification Survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Nursing Staff documented on two occasions in medical record assistive devices were applied to prevent further decrease in range of motion when they were not being provided. This was evident for 1 of 1 resident (Resident #66) reviewed for Positioning and Mobility. The finding is: The facility policy and procedure titled Splint, Braces, Casts and Immobilizers (assistive devices) undated documented the following: the facility will access each splint, brace, cast and immobilizer to ensure proper placement fitting, minimal pressure and proper placement and cleaning. Nursing and rehab will collaborate as necessary for resident safety and comfort. Resident #66 was admitted to the facility with diagnoses which include Peripheral Vascular Disease, Non-Alzheimer's Dementia and Anxiety. The 11/27/2022 Quarterly Minimum…

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 a Recertification Survey from 12/27/2022-1/4/2023 the facility did not ensure that an infection prevention and control program was established and maintained to prevent the transmission of a Multi Drug Resistant Organism for 1 of 1 (#47) resident reviewed for Infection Control. Specifically PTA #1 ( Physical Therapist Aide) did not use appropriate Personal Protective Equipment (PPE) when providing services for Resident # 47, who had a Multi Drug resistant Organism and was on contact precautions. The findings are: Review of policy and procedure titled Infection Control dated 4/05 and revised 7/22 documented Transmission based precaution will be used in addition to standard precaution for residents with suspected infection and pathogens that can be transmitted by droplet or contact routes. Appropriate PPE (gloves, gowns, masks goggle etc.) will be available outside of the resident room as necessary, in an over the door isolation station or in the drawer bin directly outside the resident room. Resident # 47 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observations, interview and record review conducted during the recertification survey, the facility did not ensure that information regarding resident Advance Directive (a legal document in which a person specifies what actions should be taken if they are no longer able to make decisions for themselves because of illness or incapacity) was consistently and accurately documented for 1 (Resident #6) of 2 residents reviewed for Advance Directives. Specifically, the residents' physician's orders, certified nurse's aide care guide, and the hard copy medical record all documented the resident's Advance Directive status as Do Not Resuscitate (DNR; a legal order in respect of the wishes of a patient in case their heart were to stop or they were to stop breathing) and the resident's Comprehensive Care Plan (CCP) and the Social Services unit resident's list documented the resident's Advance Directives status as a full code (full code status means that all possible measures are taken to revive a person 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, interview, and record review conducted during the recertification survey, the facility did not ensure that an allegation of staff to resident abuse was fully investigated. Specifically, the facility did not conduct a full investigation regarding an allegation of staff to resident abuse made by the resident's family member. This was evident for one resident (Resident # 60) reviewed for abuse. The findings are: Resident # 60 has diagnoses and conditions including Hypertension, Chronic Obstructive Pulmonary Disease and Chronic Atrial Fibrillation. According to the 7/11/19 Quarterly Minimum Data Set( MDS; an assessment tool), the resident had severely impaired cognition and required extensive assistance with Activities of Daily Living (ADLS). During a family interview on 8/26/19 at 12:18 PM, the son of Resident # 60 stated that approximately six months ago on the evening shift a Certified Nursing Assistant (CNA # 9) had his mother in her bathroom and the resident was screaming. He stated that when a nurse knocked on the bathroom door, he saw CNA # 9 reach up 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 observation, interview, and record review conducted during a recertification survey, the facility did not ensure that an allegation of staff to resident abuse was fully investigated. Specifically, the facility did not conduct a full investigation, including but not limited to resident assessment and staff interviews, regarding an allegation of staff to resident abuse made by the resident's family member, to determine if abuse occurred or if the incident should have been reported to the State. This was evident for one resident (Resident # 60). In addition, the facility did not ensure that an allegation of resident to resident abuse was fully investigated for 2 of 2 residents (#39 and #58). The findings are: 1. Resident # 60 has diagnoses and conditions including Hypertension, Chronic Obstructive Pulmonary Disease and Chronic Atrial Fibrillation. According to the 7/11/19 Quarterly Minimum Data Set( MDS; a resident assessment tool) the resident had severely impaired cognition, and required extensive…

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 residents or their representatives were given timely written notification of the transfer and the reasons in a language and manner they understood. This was evident for 2 of 2 residents (#107 and #6) reviewed for hospitalization. The findings are: 1. Resident #107 has the following diagnoses and conditions: Non-Alzheimer's Dementia, Diabetes Mellitus and Asthma. The Minimum Data Set (MDS-a resident assessment and screening tool) dated 7/13/19 indicated the resident had severe cognitive impairment. Review of the nursing progress notes for 8/24/19 revealed the resident experienced a change in condition. The Physician was notified and ordered the resident be sent to the hospital. Record review indicated the resident family member was notified by phone only. Interview with the Social Worker on 9/4/19 at 11:16 AM revealed the facility does not send out written notification of transfer/discharge to the family and does not notify the Ombudsman's Office. Resident #6…

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 survey, the facility did not ensure that interventions were implemented according to the plan of care. This was evident for 2 of 3 residents reviewed for implementation of the care plan. Specifically, 1. there was no documented evidence that a urinalysis (U/A) and culture and sensitivity (C/S) were obtained for a resident with symptoms of urinary tract infection ( UTI ) (Resident #102) 2. there was no documented evidence that a dialysis site was assessed for signs of infection. (Resident #108). The findings are: 1. Resident #102 was admitted with diagnoses including Hypertension, Parkinson Disease and Encephalopathy. The 7/26/19 admission Minimum Data Set (MDS; a resident assessment tool) documented resident #102 had a Brief Interview of Mental Status (BIMS) score of 5, received extensive assist for toilet needs, and was always incontinent of bowel and bladder. Review of the care plan revealed planned interventions for UTI related to a history of Vancomycin Resistant Enterococci (VRE) dated 7/9/19. It…

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 conducted during the recertification survey, the facility did not ensure that care and treatment was provided for a resident with a history of urinary tract infection (UTI). This was evident for 1 of 3 residents reviewed for urinary tract infection. (Resident #102). The findings are: 1. Resident #102 was admitted to the facility on [DATE] with diagnoses including Hypertension, Parkinson's Disease, and Encephalopathy. The 7/26/19 admission Minimum Data Set (MDS; a resident assessment tool) revealed resident #102 had a Brief Interview of Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment, received extensive assist for toilet needs, and was always incontinent of bowel and bladder. Review of the care plan for UTI related to history of Vancomycin Resistant Enterococci (VRE) dated 7/9/19 included monitor for signs and symptoms (s/s) of infection and obtain a urine culture and sensitivity if ordered. The 8/22/19 Physician Notification Form indicated 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 interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (Resident #108) reviewed for dialysis that 1.there was ongoing communication between the dialysis center and the facility regarding the resident's response to dialysis treatment and 2. that nurses were assessing the dialysis site for signs and symptoms (s/s) of infection, bleeding, and the presence of bruit and thrill. The findings are: Resident #108 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Hypertension and Atrial Fibrillation. According to the physician's current orders, the resident is scheduled to be provided dialysis services three days weekly. The resident's plan of care dated 12/12/18 did not reflect how the facility would communicate with the dialysis center. Additionally, the plan of care did not include the frequency for monitoring the access area for redness/pain, and did not include assessment for s/s of infection, bleeding, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 6 residents reviewed for unnecessary medications (#26) that the monthly medication regimen reviews (MMR) were consistently conducted by the consultant pharmacist. The finding is: Resident #26 was admitted to the facility on [DATE] with diagnoses including Non Alzheimer Dementia, Anxiety, and Depression. The 3/31/19 Annual MDS (Minimum data Set: an assessment tool), revealed the resident had severe cognitive impairment. The MDS further revealed the resident was prescribed an antipsychotic (Abilify), antidepressants (Trazadone and Celexa), an anticoagulant (Coumadin) and a diuretic (Lasix). Review of the record revealed the MMR reviews for the last 6 months were only completed on 2/28/19, 3/28/19 and 8/14/19. An interview was conducted on 8/30/19 at 1:30PM with the Assistant Director of Nursing. She stated that after checking the medical record, she could only find MMR reviews for 3 of the last 6…

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.