Clinton Rehabilitation and Nursing Center

Based on interviews and record reviews conducted during the Recertification Survey on 5/24/2021, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements related to F656; Development and Implementation of Comprehensive Care Plans, and F686; Treatment and Services to prevent/heal Pressure Ulcers. Specifically, the facility did not ensure that the approved Plan of Correction (POC) for F Tag 656 Development and Implementation of Comprehensive Care Plans, and F Tag 686 Treatment and services to prevent/heal Pressure Ulcers cited during the Recertification Survey completed on 2/28/2019 were implemented. This is evidenced by: The facility document titled Quality Assurance Performance Improvement Program (QAPI) dated January 2018 documented, The QAPI program is to utilize an on-going, data driven, pro-active approach to advance the quality of life and quality of care for all…

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 during a recertification survey, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection for 2 (Unit A & C) of 2 units. Specifically, the facility did not ensure that contaminated items were not placed back into the clean multi-resident treatment cart that is used to provide treaments to residents' on both the A and C Units and did not ensure staff removed their gloves and perform hand hygiene between caring for the residents' and their environment. This is evidenced by: The Center for Disease Control (CDC) guidance titled Hand Hygiene Guidance, documented clinical indications for hand hygiene in healthcare settings are: Immediately before touching a patient, when hands are visibly soiled, after touching a patient or the patient's immediate environment, and immediately after glove removal. Finding #1 The facility did not ensure, a Registered Nurse (RN) on the A Unit did not place a contaminated wound spray bottle in a…

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 Provider Non-coverage (NOMNC), form CMS-10123. This was evident for 2 (Resident #16 and #34) of 3 sampled residents reviewed for Beneficiary Protection Notification. The findings are: 1) Review of the medical records for Resident #16 on 05/27/2021, included documentation that the resident last received rehabilitative services on 01/08/2021 and was provided the NOMNC to inform the resident of their right to an expedited review of a service termination on 01/07/2021, one day prior to the termination of services. 2) Review of the medical records for Resident #34 on 05/27/2021 included that the resident last received rehabilitative services on 02/08/2021 and 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 record review and interviews during a recertification survey the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for one (Resident #52) of 2 residents reviewed for abuse. Specifically, for Resident #52, the facility did not ensure the resident's allegation that a staff member was swearing and shouting at them and swearing and shouting at other residents was thoroughly investigated. This is evidenced by: A Policy and Procedure (P&P) titled, Resident Abuse Reporting last reviewed 11/15/2017 documented it is critical that if abuse, including mental abuse, exploitation, mistreatment, misappropriation of property or neglect, is suspected or observed it must be reported immediately to a Supervisor or any member of the management team, including the Social Worker, Director of Nursing, or the Administrator and an investigation must begin immediately. Resident #52: The resident was re-admitted to the facility with the diagnoses of chronic obstructive pulmonary 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 observation, record review and interview during the recertification survey the facility did not ensure, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #12) of 2 residents reviewed. Specifically, for Resident #12, who has cognitive impairment, the facility did not ensure the resident was consistently provided ongoing and appropriate activities based on the resident's abilities. This was evidenced by: A request was made to the Administrator on 5/28/2021 for the facility Policy & Procedure titled Activities. The requested policy and procedure was not provided. Resident #12 Resident #12 was admitted to the facility with the diagnoses of dementia and myoclonus (a sudden muscle spasm, the movement is involuntary and can't be stopped or controlled. It may involve one muscle or a group of muscles.) and Hypertension. The Minimum Data Set (MDS-an assessment tool) dated 3/5/2021 documented the…

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

Based on observation, record review and interviews during the recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #52) of 2 residents reviewed for pressure ulcers. Specifically, for Resident #52, the facility did not ensure the resident received weekly pressure ulcer evaluations for over a six week time period, did not ensure wound care was provided per professional standards of practice and did not ensure a Comprehensive Care Plan (CCP) was developed to prevent pressure ulcers and promote wound healing. This is evidenced by: Resident #52: Resident #52 was re-admitted to the facility with diagnoses of chronic obstructive pulmonary disease, peripheral vascular disease and type 2 diabetes. The Minimum Data Set (MDS- an assessment tool) dated 4/19/2021, documented the resident was admitted from the hospital with one stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis) on the right buttock, one stage 2 pressure ulcer on 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 observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (Residents #52) of one (1) resident reviewed. Specifically, for Resident #52, the facility did not a ensure Resident #52 was provided with a physician ordered positive airway pressure device at bedtime to treat sleep apnea and did not ensure Resident #52 received oxygen via nasal canula per MD orders. This is evidenced by: Resident #52: This resident was re-admitted to the facility with diagnoses of obstructive sleep apnea, chronic obstructive pulmonary disease, chronic heart failure, and heart disease. The Minimum Data Set (MDS-an assessment tool) dated 4/19/2021, documented the resident required oxygen therapy. Finding #1 The facility did not a ensure Resident #52 was provided with a physician ordered positive airway pressure device at bedtime to treat sleep apnea. The physician'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.

Based on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on dementia management and resident abuse prevention. Specifically, the facility did not ensure staff were provided with training on dementia management and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, the behaviors may be perceived as challenging to staff and could increase the risk for resident abuse and neglect. This was evidenced by: The Policy & Procedure (P&P) titled Dementia Residents & the Use of Antipsychotic Medications dated 10/2017 documented that residents with a dementia diagnosis or who exhibit behavioral symptoms will have an interdisciplinary team approach which follows a care process that will enable the development of a plan of care to limit the distress of the behaviors through the use of individualized approaches and treatment. The P&P…

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 during a recertification survey the facility did not ensure mechanisms for documenting and communicating the resident's choices regarding Advance Directives was made to the interdisciplinary team and to staff responsible for the resident's care and did not ensure comprehensive care plans were developed to address advance directives for eleven (11) (Residents #'s 27, 73, 175, 176, 26, 44, 45, 62, 29, 42, and #43) of eleven (11) residents reviewed. Specifically, for Resident #'s 175 and 44, the facility did not ensure the residents' wishes were communicated to the residents' direct care staff and physician after the residents completed a MOLST form that changed their code status from a full code to a Do Not Resuscitate (DNR). Additionally, the facility did not ensure that Advanced Directive Care Plans were developed for Resident #'s 27, 73, 175, 176, 26, 44, 45, 62, 29, 42, and #43. This is evidenced by: Policy and Procedure for Advanced Directives revised on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 8 (Residents #9, 14, 26, 30, 55, 63, and 47) of 23 residents reviewed. Specifically, for Residents #9 and 47 the psychotropic drug use care plans were not resident specific, and for Residents #'s 26, 45, and #63 there was no care plan to address the use of an anticoagulant, for Resident #30, the care plan intervention to monitor for edema and notify the physician was not implemented, for Resident #'s 14 and 55, the physician was not notified of weight loss per care plan instructions. This was evidenced by: Resident #47: The resident was admitted to the facility on [DATE] with diagnosis including major depressive disorder, dementia. And cerebrovascular disease The Minimum Data Set sated 1/11/19,…

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, the facility did not ensure menus meet the nutritional needs of residents in accordance with established national guidelines, are updated periodically, and are reviewed and revised by the facilities dietitian for nutritional adequacy. Specifically, the facility did not ensure the resident's diet orders were in accordance with the diet manual, did not ensure the menu was updated periodically, and did not ensure the dietitian reviewed the menus for nutrition adequacy. This is evidenced by: Finding #1 The facility did not ensure the resident's diet orders were in accordance with the diet manual. The Policy and Procedure (P&P) titled Nutritional Review last updated 4/2009 documented each patient's diet care plan will follow the specific recommendations as defined in the facility's diet manual, and all dietary plans for the residents will follow the recommendations and restrictions as outlined by the facility's diet manual. The liberalized geriatric diet handbook, last approved 1/2019, documented the recommended…

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 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. Food packages shall be in good condition and shall protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants; food temperature thermometers shall be calibrated; and floors and ceilings are to be kept clean. Specifically, cans of food were dented, food temperature thermometers were not in calibration, and ceiling vents and floors were not clean. This is evidenced as follows. The main kitchen was inspected on 02/24/2019 at 12:22 PM. One #10 can of fruit cocktail, found in the common stock, had two V-shaped dents in the hermetic seal. One of 3 in-use thermometers were found out of calibration when checked by the standard ice-bath method as follows: 35 degrees Fahrenheit (F). The kitchen ceiling vent grates and the floor in the Nourishment Station were not clean. The Cook/Manager and cook #1 stated in an interview conducted 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.

Based on record review and interview during the recertification survey, the facility did not ensure the policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility did not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. The policy for foods brought in by visitors was reviewed on 02/24/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene. The Dietetic Services Supervisor stated in an interview conducted on 02/24/2019 at 1:35 PM that written information is not given regarding safe food handling practices to families and visitors that bring food to residents; if visitors ask, some safe food handling practices are explained. 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 record review and interview during a recertification survey, the facility did not ensure that written notification was provided to the resident and the resident's representative of the resident's transfer or discharge and the reasons for the move for 5 (Resident #'s 14, 18, 55, 72, and #176) of 5 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and resident's representative were notified in writing when the residents were admitted to a hospital from the facility. This is evidenced by: Resident #18: The resident was admitted to the facility on [DATE] with diagnoses including dementia, diabetes and depression. The Minimum Data Set (MDS) dated [DATE], assessed the resident could sometimes understand, sometimes be understood, and had severely impaired cognitive skills. Progress Notes documented the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation that written…

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 and record review 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 met professional standards of quality care for 3 (Resident #'s 42, 44, and #45) of 7 residents reviewed for baseline care plans. Specifically, for Resident #'s 42, 44 and #45, the facility did not ensure a baseline care plan was developed within 48 hours of admission. This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, and insomnia. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, could understand others, and could make herself understood. During a record review on 2/26/19, there was no documentation that a baseline care plan was developed. Resident #44: The resident was admitted to the facility on [DATE], with the diagnoses 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.

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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #61) of 1 resident reviewed for pressure ulcers. Specifically, for Resident #61, the facility did not ensure that consistent, weekly pressure ulcer evaluations were provided to the resident over a two-month period. The findings were: Resident #61: The resident was admitted to the facility on [DATE] with diagnoses of lymphedema, non-Hodgkin lymphoma, and peripheral vascular disease. The Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognition, could understand others and could make herself understood. The Comprehensive Care Plan for Pressure Ulcers, last updated on 12/31/18, documented the resident had a stage 2 pressure ulcer on the left buttock. Weekly Wound Observation Tools for January and February 2019, documented evaluations were…

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, interviews, and record review during a recertification survey the facility did not ensure that a resident who entered the facility without limited range of motion (ROM) did not experience reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion was unavoidable; and §483.25(c)(2) A resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #62) of one resident reviewed for ROM. Specifically, for Resident #62, the facility did not ensure a blue hand roll was applied to the resident's left hand to help prevent contracture. This is evidenced by: Resident #62: The resident was admitted to the facility on [DATE], with the diagnoses of Parkinson's disease, frontotemporal dementia, and seizures. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely be…

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 the resident environment remained free of chemical hazards for 1 (Resident #55) of 1 resident reviewed for accident hazards. Specifically, the facility did not ensure the resident's bedside table was free from housekeeping chemicals. This is evidenced by: Resident #55: The resident was admitted to the facility on [DATE] with type 2 diabetes, constipation, and gastro-esophageal reflux (GERD). A diagnosis list documented recurrent depressive disorders (6/29/16), anxiety disorder (5/26/16), aphasia (5/26/16), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, could sometimes understand others and could usually make herself understood. A safety data sheet dated 3/4/2015 documented the chemical, Oxivir Tb (benzyl alcohol, potassium hydroxide, and dodecylbenzene sulfonic…

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 acceptable parameters of nutrition were maintained for 3 (Resident #'s 14, 43, and 55) of 6 residents reviewed for nutrition. Specifically, for Resident #'s 14 and 43, timely assessment and intervention did not occur when a resident experienced weight loss; for Resident #'s 14 and 55, the facility did not ensure that the physician was notified of weight loss as directed in the resident's care plan. This is evidenced by: The Policy and Procedure (P&P) titled Weighing Residents dated 2/2016 documented that the Dietetic Service Supervisor (DSS) was to review weights every Monday, document a progress note, and notify the Registered Nurse (RN) if a reweight or medical assessment was needed. Resident #14 The resident was admitted to the facility on [DATE] with dementia without behavioral disturbance, major depressive disorder, and diabetes. The Minimum Data Set (MDS) dated [DATE] documented the resident…

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

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for each step in the MRR process. This is evidenced by: The Policy for Medication Regimen Review with an effective date of 11/28/16 documented: 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 2. Facility should inform the Consultant Pharmacist of any physical and/or mental conditions of the resident which are likely to affect his/her medication therapy outcome. 3. The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director.…

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, interviews and record review during a recertification survey, the facility did not ensure the medication regime for one (1) resident (Resident #9) of five (5) reviewed for unnecessary medications was free from unnecessary medications. Specifically, for Resident #9, the facilty did not ensure that an as needed (PRN) anti-anxiety medication was adequately monitored for effectiveness, did not ensure the medication was administered for the physician ordered indication, did not ensure pharmacological interventions were utilized prior to administering the PRN anti-anxiety medication, and did not ensure documentation included the reason the medication was administered. Additionally, the facility did not ensure the resident's Psychotropic Care Plan included non-pharmacological interventions. This was evidenced by: Resident #9: The resident was admitted on [DATE], with diagnoses of major depressive disorder with anxiety, history of transient ischemic attacks (TIA), cerebral infarction (CVA), 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 interviews during the recertification survey, the facility did not ensure referral for dental services 1 (Resident #14) of 2 resident with loose-fitting dentures. Specifically, the facility did not ensure dental services were provided to a resident within 3 days for loose-fitting dentures. this is evidenced by: The Comprehensive Care Plan (CCP) titled Dental, last revised 10/16/17, documented interventions to monitor/document/report as needed for loose dentures, and mouth inspections at least weekly with changes reported to the nurse. Record review of the last 3 months did not include dental consults. A progress note dated 2/2/19, documented the resident became angry when teeth removed, though her dentures were not fitting or staying in place properly. During an interview on 2/24/19 at 1:54 PM, a resident representative stated since the resident lost weight, her dentures do not fit well and she does not wear them. During an interview on 2/28/19 at 9:04 AM, Certified Nursing Assistant (CNA) #1 stated she does not put the residents dentures 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 record review and interviews during the re-certification survey, the facility did not ensure food and nutrition staff had appropriate qualifications. Specifically, the facility did not ensure the food service director (FSD) designated to serve as the director of food and nutrition services received frequent scheduled consultations from the dietitian. This is evidenced by: The facility did not provide documentation of frequently scheduled consultations from the qualified dietitian to the FSD. During an interview on 2/25/19 at 2:39 PM, Food Service Supervisor #5 (FSS) stated she has been in her current position since 1999. She stated the consulting dietitian works 1-2 times a week in the evening, and they do not have regularly scheduled meetings at this time. During a telephone interview on 2/27/19 at 12:45 PM, the Registered Dietitian stated she does not have regularly scheduled meetings with FSS. 10NYCRR415.14(a)(1)(2)

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the dumpster was not closed or in good condition. This is evidenced as follows. The dumpster was inspected on 02/24/2019 at 12:22 PM. The top covers to the dumpster were open, four ¼-inch holes were found in the front side of the dumpster, and the front covers do not seat to the dumpster frame. Refuse was found inside the dumpster., The Cook/Manager stated in an interview conducted on 02/24/2019 at 1:07 PM, that she doesn ' t know who left the dumpster open, but all employees know to keep the dumpster closed; and the facility will call the dumpster vendor to replace the dumpster with one that does not have holes and covers that seat. 10 NYCRR 415.14(h)

Based on record review and interview the facility did not provide a complete Facility Assessment that documented a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies during the recertification survey. Specifically, the facility did not ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This is evidenced by: On 02/27/19, the facility assessment was reviewed for Sufficient and Competent Nurse Staffing and did not include an evaluation of the staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. During an interview on 02/28/19 at 09:50 AM, the Administrator stated the facility assessment provided to the survey team was the complete facility assessment. She stated the facility assessment did not address staffing levels or the number of staff needed in the facility. On 02/28/19 at 10:45 AM,…

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.