Independence Care Center for Nursing and Rehabilit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint #NY00331841) from 03/26/2024 through 04/02/2020, the facility failed to ensure that the resident and/or the resident's representative was immediately informed of an accident which results in injury and had the potential for requiring physician intervention. This was evident for 1 (Resident #253) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration on the forehead. There was no documented evidence that the resident's representative was notified of the change in resident's condition. The findings are: The facility policy and procedure titled Change in Resident Condition or Status which was last revised in November 2023, documented that the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental…

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 Survey (NY00331841) from 03/26/2024 through 04/02/2024, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 1 (Resident #253) of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration to the forehead that was not reported to the New York State Department of Health. There was no witness on how Resident #253 sustained the discoloration and the source of injury could not be explained by the resident. The findings are: The facility policy and procedure titled Abuse & Neglect, with a last revised date of 03/18/2024 documented that all alleged or suspected incidents of abuse and or neglect will be investigated, and injuries of unknown origin will be investigated to rule out abuse,…

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 conducted during the Recertification and Complaint Survey (NY00318593) from 03/26/2024 through 04/02/2024, the facility did not ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #99) of 35 total sampled residents. Specifically, on 03/29/2024, Resident #99's right and left lower extremities were observed with severe edema, dry, and thick scaly skin. There was no documented evidence that the skin condition was evaluated and being treated. The findings are: The facility's policy and procedure titled Quality of Care dated 11/2023 documented each resident shall be cared for in a manner that promotes and enhances their quality of life, dignity, respect, and individuality. Resident #99 was admitted to the facility with diagnoses of Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Lower Extremity, Cellulitis of Right/Left Lower Limbs, and Localized Edema. 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 and interview conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that infection prevention and control program practices were maintained. Specifically, 1) the Licensed Practical Nurse (LPN) failed to practice hand hygiene between glove changes during wound care, and 2)oxygen tubing was observed touching the floor on multiple occasions. This was evident for 1 of 7 residents investigated for Pressure Ulcer/Injury and 1 of 3 residents reviewed for Respiratory care out of a sample of 38 residents. (Resident #4 and Resident #107) The finding is: 1.The facility's policy titled Pressure Ulcer Prevention Management and Treatment Program, reviewed on 10/27/21, documented Standard precautions utilizing barrier protection: #2- use clean disposable gloves for removing soiled dressing and place in plastic bag, #3-Remove soiled gloves and wash hands. Resident #4 was admitted to the facility with diagnoses that include Respiratory Failure, right basal…

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 F578 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record review completed during a recertification survey 02/23 - 03/02/2022, the facility did not ensure that advance directives were provided. Specifically, there was no evidence that staff assessed a resident's desire regarding advance directives. This was evident for one resident (Resident #420). The findings are: The facility's policy and procedure entitled Advance Directives, last reviewed 10/2021, stated that Social Work shall provide information concerning resident's rights to make decisions regarding medical care or treatment as soon as possible upon admission. The information will be reviewed with each resident, or with their health care proxy in lieu of capacity, and a copy provided to them. Resident #420 was admitted to facility 02/07/2022. The resident was noted to be alert and fully oriented. However, the resident's admission MDS had not yet been locked and posted so that a BIMS score was not available. A Resident is…

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 survey from 2/23/2022 to 3/2/2022, the facility did not ensure that residents' assessments were accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment (1). inaccurately documented that a resident had a diagnosis of Benign Prostate Hypertrophy (BPH), and (2). that a resident had an Indwelling catheter. This was evident for 1 of 3 residents reviewed for Respiratory Care and 1 of 1 resident reviewed for Urinary Catheter out of a sample 38 residents. (Resident #270 and Resident #4) The findings are: The facility policy and procedure titled, MDS Assessment Coordinator, reviewed 10/27/21, documented that each individual who completes a portion of the assessment (MDS), must certify the accuracy of that portion of the assessment by a) dating and signing the assessment (MDS): and b) identifying each section completed 1). Resident # 270 was admitted with diagnoses that included Asthma and Respiratory Failure. Benign Prostrate Hypertrophy…

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 F656 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record reviews completed during a recertification survey 02/23-03/02/2022, the facility did not develop a person-centered care plan for a resident consistent with that resident's medical needs. Specifically, a care plan was not developed to address the use of psychotropics, insulin, antihypertensives or anticoagulants. This was evident in 1 of 4 residents (Resident #140) reviewed for unnecessary medications in a sample of 35. The findings are: Resident #140 was admitted to the facility on [DATE]. The resident's MDS dated [DATE] stated that the resident had received insulin on 7/7 days, antipsychotics on 7/7 days, antianxiety medications on 7/7 days, antidepressants on 7/7 days and an anticoagulant on 7/7 days. Resident #120's medical orders for 01/07/2022 were reviewed and were noted to include: Amlodipine 10 mg once a day for Hypertension Metoprolol 25 mg once a day for Hypertension Buspirone 15 mg once a day for Depression…

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 survey 2/23/2022 to 3/2/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives participated in the development of a Comprehensive Care Plan (CCP). Specifically, residents were not afforded the opportunity to participate in the care plan meetings. This was evident for 2 of 2 residents reviewed for Care Plan out of a sample of 38 residents. (Resident #12 and #121) The findings are: The facility policy and procedure titled CCP (Comprehensive Care Plan) Participation - Assessment/Care Plans with effective date 10/27/2021 documented under Policy Interpretation and Implementation 1) The resident and his/her family, and/or the legal representative (sponsor), are invited to attend and participate in the resident's assessment and care planning conference; 3) A seven (7) day advance notice of the care planning conference is provided to the resident and interested family members. Such notice is made 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 interview and record review conducted during a Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, nursing staff did not administer pain medications as per physician's orders to a resident who complained of pain on several occasions prior to wound dressing change. This was evident for 1 of nine 9 residents reviewed for Pressure Ulcers out of 38 sampled residents. (Resident #150). The finding is: The facility policy titled Pain Assessment Procedure, last updated on 1/21/21 documented the following: The facility will utilize the interdisciplinary approach to assess each resident for acute and chronic pain and develop an effective program that will address those needs. The policy also documented that, every resident who experiences pain will 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 staff interviews and record review conducted during the Recertification survey conducted from 2/23/22 to 3/2/22, the facility did not ensure that competent care and services were provided to assure safety and maintain the highest practicable level of mental and physical wellbeing for a resident. Specifically, a Certified Nurse Aide (CNA) did not demonstrate competency and skills in providing care to a resident with pressure ulcers. The CNA cleaned the resident's pressure ulcers during Activities of Daily Living (ADL) care and did not address the resident's concerns regarding pain during care. This was evident for 1 of 9 residents reviewed for Pressure Ulcers out of 38 sampled residents. (Resident #150). The findings are: Resident #150 was admitted to the facility with diagnoses which included Diabetes, Stage 3 Pressure Ulcer, Pain to Left Arm, Pain to Left Lower Legs. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognitive status was intact, 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 interviews, observations and record reviews conducted during a Recertification survey from 2/23/22 to 3/2/22, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the medication room refrigerator on 1 of 5 units during the Medication Storage task. (4th floor) The findings are: The facility's policy and procedure entitled Storage of Medication last reviewed 10/2021, documented that the facility will not use discontinued, outdated, or deteriorated drugs or biologicals; all such drugs will be returned to the dispensing pharmacy or destroyed. On 02/28/22 at 12:13 PM, the refrigerator in medication room on the 4th floor was observed. The following medications and manufacturer's expiry dates were observed: - Timolol eye drops with an expiration date of 10/26/2021 - a Glucagon vial with an expiration date of 11/21/2021 - a Novolog vial with an expiration date of 11/21/2021 - a Novolog vial with an expiration date of 12/15/2021 - a Novolog vial with an expiration date of 12/25/2021 and, - a Novolog…

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 review conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, medications were not administered as ordered by the physician: 1). Acetaminophen 500mg was administered instead of instead of Acetaminophen 325mg as ordered and 2). Administration of Artificial tears was omitted leading to a medication error rate of 8%. This was evident for 2 of 25 medication observations conducted during the Medication Administration facility task. The findings are: 1.Resident #107 was admitted to the facility with diagnoses that included Generalized Osteoarthritis and Pressure Ulcers. The Physician order dated 08/30/20 and last renewed 02/01/22 documented Acetaminophen 325mg 1 tablet 2 times daily for diagnosis of Generalized Osteoarthritis. On 03/01/22 at 10:42 AM, during a medication administration observation conducted on Unit 5, Registered Nurse (RN) #5 was observed administering Acetaminophen 500mg 1 tablet by mouth to Resident #107,…

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 staff interviews conducted during a Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure controlled drugs were stored appropriately in locked compartments. Specifically, controlled drugs were observed stored on the medication cart outside of the locked compartments for storage of controlled drugs. This was observed on 1 of 5 units during the Medication Storage Task. (Unit 5) The findings are: The facility policy titled Controlled Substances reviewed October 2021 documented controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. On 02/28/22 at 2:40 PM, an observation was conducted of the medication cart on Unit 5. The medication cart was observed parked next to the nurse's station as medications were not being administered at that time. Three blister packs containing controlled drugs were observed in the 4th drawer next to the locked…

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 the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. The findings are: The facility Policy titled, Deposit of Resident Funds documents, Resident personal funds held and managed by the facility will be safeguarded. On 07/15/19 at 03:15 PM an interview was conducted with Medicaid Coordinator (MC). Medicaid Coordinator who stated she is not aware of Surety bonds and believes the administrator is aware. On 07/16/19 at 12:32 PM an interview was conducted with the facility Administrator. The facility Administrator stated, The resident funds are supposed to have some type of backing so if God forbid something happens the funds are insured. The Administrator went on to state, the residents have individual accounts in the Amalgamated Bank and they are Federal Deposit Insurance Company (FDIC) insured because they are individual accounts. The Administrator further stated he is not aware of the protection of above and beyond FDIC insured requirements and stated he 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 observations, interview, and record reviews during the recertification survey, the facility did not ensure sufficient nursing staff to provide nursing and related services as determined by resident assessments considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The findings are: A Facility Policy and procedure related to Staffing and dated 7/16/19 documents that Certified Nursing Assistants (CNA) are scheduled to work on each unit as follows: Unit Day Evening Night 2nd 5 4 3 3rd 4 3 2 4th 4 3 2 5th 5 4 3 6th 4 3 2 The Facility Assessment Tool dated 11/19/18 documents that each floor has the capacity for 40 residents for a total of 200 residents. The average census is 192 with 10 certified ventilator beds on the 2nd floor. On average, there are 18 residents who are ventilator dependent in the facility, 22 residents who require suctioning, and 22 who require tracheotomy care. There are also between 192-198 residents that require some form of assistance with Activities of Daily Living (ADL). 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 observations, record review and staff interviews, the facility did not ensure that cold foods were stored at a temperature of 41 degrees F and below. Specifically, the facility did not ensure that it maintained proper temperatures of Potentially Hazardous Foods (PHF) to prevent food borne illness. After three observations the temperatures of sandwiches on 7/9, 7/15/ and 7/16 which were taken at various times, did not reach the required temperature of 41 degrees F or below. These sandwiches consisted of tuna, ham and cheese, baloney and cheese and turkey and cheese sandwiches. This was evident during the initial and follow-up visits for the Kitchen Task part of the survey. The facility policy and procedure titled Nutrition Service Policy and Procedures Section 7 Review Date 5/17/17 documented: The Dietary Department [NAME] or Supervisor will take all hot and cold food and beverage item temperatures three times per day. The temperatures will be monitored for accuracies within the acceptable safe temperature zone for each item. Procedure documents the following: (1) The [NAME]…

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 that the residents received care in a safe, clean, comfortable and homelike environment. Specifically, the facility did not ensure that a safe, functional, sanitary, and comfortable environment is provided for residents, staff and the public. This was evidenced by multiple observations of the overall facility including facility common areas, and nursing stations and staff work areas. The facility policy and procedure titled Maintenance Policy and Procedure Manual Subject: Maintenance Repair request program, Maintenance Repairs Communication and Records: Effective 12/23/2017 documents: The Maintenance Department is responsible for establishing and maintaining work orders and requests, inspections of building, maintenance schedules. Maintenance work orders shall be completed to establish a priority of Maintenance service. Policy interpretation and Implementation:(1) In order to establish a priority of maintenance service, work orders must be filled out 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 reviews and Interviews the facility did not ensure that residents, or their representatives were invited to Care Plan meeting. Specifically, the facility held Annual Care Conferences for 4 residents and did not invite either the residents or their family members/next of kin to the meeting. The findings are: 1) Resident #178 is a [AGE] year old admitted to facility on 3/10/2015. Diagnosis includes Heart Failure, Hypertension, Diabetes Mellitus, , Hyperlipidemia, Non-Alzheimer's Dementia, Bipolar Disorder. Minimum Data Set (MDS) 30 day Schedule assessment dated [DATE] documented resident is Cognitively Intact. Review of Social Services progress note dated 3/11/2019 documented Quarterly review -remains alert and oriented, verbally disruptive at times and is very demanding, attention seeker. Advance directives will be reviewed with her no less than quarterly. No documentation resident was invited to meeting. No documentation resident attended the meeting. No documentation resident refused to attend…

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 and interviews conducted during the recertification survey, the facility did not ensure that infection control guidelines were followed to prevent the spread and development of communicable diseases and infections. Specifically,1) Residents were observed receiving Oxygen by nasal cannula with the oxygen tubing running from the nasal cannula along the floor and resting on the floor to the connection on the oxygen concentrator. Multiple residents receiving oxygen through a ventilator were observed to have oxygen tubing laying on the ground. This included, but was not limited to 2 (two) residents (Resident #1, Resident # 6). 2) Multiple Gastrostomy Tube (GT) poles for hanging tube feeding were observed to be dirty. The findings are: The facility policy titled, Oxygen Therapy protocol via nasal Cannula Respiratory Care/Nursing dated 9/2005 and reviewed 4/19 documents, Infection control 2) Oxygen tubing must be maintained off the floor, oxygen tube must be replaced with a new one without delay.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during recertification survey, the facility did not ensure that residents and/or families were informed and provided with written information concerning the right to formulate an advance directive. Specifically, the facility did not document that advance directives were explained to or discussed with family members and a resident's representative. This was evident for 1 of 1 resident reviewed for Advance Directives (Resident #142). The finding is : The facility policy and procedure on advance directives, reviewed 10/2018, documented, Social Work shall provide information concerning resident's rights to make decisions regarding medical care or treatment as soon as possible upon admission. The information will be reviewed with each resident, or with their health care proxy in lieu of capacity, and a copy provided to them. Social Worker will discuss advanced directives with the resident or health care proxy, designated representative, guardian 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the resident's Level II status was not captured on resident's Minimum Data Set (MDS) 3.0. This was evident for 1 of 63 sampled residents. The findings is: Resident #142 was admitted to the facility on [DATE] with diagnosis that included: Schizoaffective Disorder, Schizophrenia, Hypertension, Diabetes Mellitus, Non- Alzheimer's Dementia. Pre admission Screen and Record Review (PASRR form (a form to identify recommendations of inpatient psychiatric care for people needing more care than nursing homes provide) dated 10/3/18 documented that the resident has a serious mental illness. Level II referral was made. ASCEND (Maximus Company) Level II evaluation was completed 10/3/18 and recommended resident is appropriate for any Nursing Facility setting. Services to include written person-centered plan of care, ongoing psychiatric consults…

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 the recertification survey, the facility did not ensure that drugs and biological's were stored in accordance with Federal and State regulations. Specifically, 1) A multidose vial of Tuberculin Purified protein Derivative (PPD) Tubersol was not labeled with a date of opening by the nursing staff, thus there is no indication as to when it should have been discarded. 2) Twelve multidose vials of Influenza vaccine were found to be outdated in the medication refrigerator located in the nursing supervisors office. The finding is: The facility policy titled, Opened Multidose Vials undated documents, Procedure - 1) The nurse who opens the vial must write the date on the label. 2) When the three (3) month time frame has elapsed, the vial must be disposed of according to the Drug Destruction Policy. Exceptions- 1) Opened vials of PPD test solution must be replaced after 30 days due to oxidation possible degradation of the solution. 2) Influenza vaccine- may stay…

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.