Sapphire Nursing At Wappingers

Based on observation, record review and interview conducted during the recertification survey from 4/8/2024-4/17/2024, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, 1) undated and unlabeled food were in the freezer; 2) the dishwasher was not reaching the appropriate temperature; 3) staff were storing personal food in the refrigerator used for the residents' meals; 4) the exhaust wall fan was covered with dust and grease debris; 5) staff were not wearing beard cover while serving the residents their meals; and 6) tuna fish in a stainless steel container and lettuce were on the same shelf in the refrigerator. The findings include: The facility policy entitled Food Receiving And Storage Issued 6/26/2018 stated food services, or other designed staff, will always maintain clean food storage areas. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables 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, record review and interview conducted during a recertification survey from 4/8/24-4/17/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (#22, #8, #14, #56, and #18) reviewed for infection control. Specifically, 1) staff did not change gloves after touching a resident and/or assistive device and before handing out Resident #8's food tray and staff were observed using the same hand while feeding Resident #22 and Resident #8; 2) staff did not wear a gown during a dressing change for Resident #14 on Enhanced Barrier Precautions; 3) staff did not wear a gown during a treatment for Resident #56 on Enhanced Barrier Precautions and 4) there was no documentation that oxygen tubing was changed weekly and as needed for Resident #18. The findings are: The facility policy for Infection Prevention and Control Program dated 3/21/24 documented the program was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents had the right to a dignified existence for 8 of 8 residents reviewed for dining (Residents #54, #40, #39, #19, #25, #49, #56 and #28). Specifically, 1)clothing protectors were applied to Resident # 54, #40, #39, #19, #25, and #49 without first obtaining the residents permission; and 2) staff were observed standing over Resident #56 and #28 while feeding the residents their lunch. Findings include: The facility policy titled Resident Rights dated 2/27/18 documented all residents will be treated with kindness, respect, and dignity. The facility policy titled Preparing Resident for Meal dated 8/30/18 documented to inquire if the resident would like to wear a clothing protector in order to prevent spills of food items from staining clothes. 1. Resident #54 had diagnoses of atrial fibrillation, cerebrovascular accident, and dysphagia (difficulty swallowing). The Minimum Data Set…

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 from 4/08/24 to 4/17/24, it was determined for 1 of 1 resident (Resident # 11) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation that a thorough investigation was completed or that there was timely resolution after Resident #11's report of missing clothing. The findings are: The facility Policy and Procedure titled Investigation of Grievance/concerns reviewed 11/20/23 documented that the facility would complete a prompt, thorough investigation of all grievances. Resident #11 was admitted with diagnoses of chronic obstructive pulmonary disease, bipolar disorder, and atrial fibrillation. The Quarterly Minimum Data Set (MDS an assessment tool) dated 3/5/2024 documented the resident was cognitively intact and had continuous behaviors. The social work progress note dated 3/27/2024 documented they would look into the resident's missing clothes. There was no documented evidence that a grievance…

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 staff interviews and record review during the recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that required documentation was sent to the receiving provider at the time of a hospital transfer for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, there was no documented evidence that a transfer summary was completed/sent when Resident #54 was transferred to the hospital. The findings are: Policy and Procedure dated 11/1/2017 titled Admission/Discharge/Transfer documented: when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Resident #54 was admitted with diagnoses which include history of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that 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 record review and interview during a recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that they provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s) for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, Resident #54 and/or their representatives were not provided written notice of the bed hold upon discharge to the hospital. The findings are: The Policy and Procedure dated 11/12/2019 and titled Bed Hold documented: The facility will notify the designated representative and / or the resident of the facility's bed reservation policies, in writing, at the time of admission and at the time of transfer. Resident #54 had Diagnosis's of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that the resident be sent to the hospital. The nursing progress note…

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 a recertification 4/8/24-4/17/24, the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living for 1 of 3 residents reviewed for activities of daily living (Resident #52). Specifically, Resident #52 was not toileted timely after calling for assistance. The findings are: Resident #52 was admitted on with diagnoses including Type II Diabetes Mellitus, and Major Depressive Disorder. The Annual Minimum Data Set (a resident assessment and screening tool) dated 1/14/24 documented the resident was cognitively intact and required moderate staff assistance for walking and toilet use and was always continent of bowel and occasionally incontinent of urine. The care plan for Activities of Daily Living initiated on 1/7/24 had interventions that included toilet every 2-4 hours and as needed. The care plan for incontinent care dated 1/7/24 documented the resident would be free from skin breaks, free from psycho social complications including withdrawal, embarrassment,…

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 conducted 4/8/2024-4/17/2024, the facility did not ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 1 resident (Resident #50) reviewed for activities. Specifically, Resident #50 did not have an admission activity assessment completed to assess for and provide meaningful activities. Findings include: A review of the policy and procedure titled Activities dated 2/4/2019 documented the activities programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Resident #50 was admitted with diagnoses including diabetes, end stage renal disease, and anxiety disorder. The activities care plan dated 12/7/2023 documented the resident was on contact isolation for clostridium difficile (C. diff, bacterial infection of bowel) and required in room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that pain management was consistently provided for 2 of 2 residents reviewed for pain (Resident #56 and #43). Specifically, 1) Resident #56 did not receive Lidocaine patches as ordered and was not provided monitoring of their pain level to determine the need for an alternate treatment; and 2) Resident #43's pain level was not monitored. The findings are: A review of the policy and procedure titled Pain dated 5/25/2018, documented the staff will reassess the individuals pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain. 1) Resident #56 was admitted with diagnoses including quadriplegia after fall with a neck fracture, neurogenic bladder, and subluxation (partial dislocation) of the shoulder. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and 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 conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure that they consistently posted the daily nurse staffing information (daily resident census, total number/ actual hours worked by licensed nurses and certified nurse aides, and specific units) to be readily accessible to residents and visitors. Specifically, the daily nursing staff information was posted in the lobby area of the building on the other side of a coded door that the residents were unable to unlock unless accompanied by staff. Furthermore, the daily nursing staff information was not updated to reflect any staffing changes throughout the day and the specific units were not reflected on the posting. The findings are: On 04/09/24 at 9:20 AM, upon entering the lobby of the building the daily nurse staffing information was posted and not easily accessible to residents due to needing a code to unlock the door that led to the lobby area. Additionally, the specific units were not reflected on the posting. On 04/11/24 at 5:08 PM, 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 record review and interview conducted during the recertification survey from 4/08/24 to 4/17/24, the facility did not ensure that the Facility Assessment was reviewed, accurate and updated as necessary. Specifically, the education, training, and competencies required for the certified nurse aides on the Facility Assessment were out of their scope of practice. The findings are: The Facility Profile dated 2/21/24 and last reviewed with the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 3/20/24 documented the certified nurse aides had training and competencies in glucometers, medication administration, gastronomy tube placement, ventilation/tracheostomy, aseptic dressings, electrocardiograms, and Pleural catheters. During an interview on 04/12/24 at 12:15 PM, the Administrator stated the Facility Assessment was accurate and it was reviewed recently with the Quality Assurance Agency/Quality Assurance and Performance Improvement committee. During an interview on 04/12/24 at 12:20 PM, the Director of Nursing stated that the Facility Assessment…

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 a recertification survey from 4/8/2024-4/17/2024, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility was unable to provide a February or March 2024 infection/antibiotic tracking report. The findings are: There was no documented evidence for an infection and antibiotic tracking report for February and March 2024. During an interview on 4/15/24 at 12:00 PM the Infection Control Practitioner stated the facility was a little behind in reviewing, the tracking and antibiotic stewardship. They stated the last one reviewed was in January 2024. During an interview on 4/15/24 at 12:16 PM the Administrator stated that the infection control nurse was responsible for the antibiotic stewardship. The Administrator stated they were unaware that the facility was behind in infection control tracking and antibiotic stewardship. 10 NYCRR 415.19 (a)(1,3)

Based on observation and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that residents were provided a safe, sanitary, and comfortable home-like environment. Specifically, 1. there was a strong urine odor in Resident #33 and 36's shared room and 2. the window curtain in Resident #25's room was hanging off the rod. The findings including: The facility policy entitled: Cleaning and Disinfecting Rooms Revised 11/12/2019. The facility policy stated environment surfaces will be disinfected on a regular basis, three times per week and when surfaces are visibly soiled. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. Conduct monthly spot checks to ensure that all curtains and window treatments are cleaned and orderly. During an interview on 4/8/24 at 10:35 AM, Resident #33 stated everything was broken in the facility. At that time there was a strong urine odor inside the room. During an observation on 4/9/24 at 12:47 PM, and 4/10/24 at 9:35 AM Resident #25's window curtain was ripped, hanging down 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 the recertification and abbreviated survey (NY00315011) conducted from 4/08/24 to 4/17/24, the facility did not ensure that the written description of the facility policy to implement advance directives was followed for one of one residents (Resident #0) of reviewed for Advance Directives. Specifically, cardiopulmonary resuscitation was administered and the resident was not sent to the hospital as per request for Resident #0 with orders for Do Not Resuscitate and orders to send to the hospital if necessary. The finding are: The facility policy titled Advanced Directives dated 5/4/18, documented the facility will honor the wishes of the resident/representative regarding medical concern, by honoring the existing advanced directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advanced directives. Resident #0 was admitted with diagnoses including acute sepsis, acute hyperkalemia, and altered 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.

Based on record reviews and interviews conducted during an abbreviated survey (NY00306613, NY00323689), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source are reported immediately but no later than 2 hours, and the submission of the investigative report to the New York State Department of Health (NYSDOH) within 5 working days. This was evident in 2 of 4 residents (Residents #1 & #2) reviewed for Abuse. Specifically, (1) the facility reported a staff to Resident #1 abuse to the NYSDOH on 12/08/2022. The facility did not submit the required 5-day investigative report until 12/23/2022; (2) Resident #2 was observed with a bump on the left side of forehead measuring 8 cm x 6 cm (3.15 inches x 2.4 inches) and bruising to the left upper extremity measuring 18 cm x 10 cm (7 inches x 3.9 inches) on 09/11/2023 at 12 PM. The facility reported to the NYSDOH on 09/12/2023 at 8:30 AM. The findings are: The Facility Policy entitled Abuse Prohibition Program revised on 11/01/2019 documented that all alleged violations and results…

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 conducted during an abbreviated survey (NY00313016), the facility did not to ensure that the Family Representative (RR) of 1 of 4 residents (Resident #3) reviewed for notification was promptly informed of a change in the resident's physical status. Specifically, (1) Resident #3 had a room change for Covid isolation on 12/23/2022 and the family became aware when they visited the resident two days later; (2) Resident #'s RR was not notified when their right heel scab opened on 03/09/2023 new treatments were initiated. The findings are: The Facility Policy titled Change in a Resident's Condition or Status dated 06/01/2017 documented that if there is a significant change in the resident room or roommate assignment and a significant change that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the family/family representative are to be notified within 24 hours. Resident #3 had diagnoses that included malignant neoplasm of the prostate, morbid obesity, and Diabetic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during an abbreviated survey (NY00313016), the facility did not ensure prompt efforts were made to resolve a resident's grievance. This was evident for 1 of 3 residents (Resident #3) reviewed for Grievance. Specifically, (1) Resident #3's Family Representative (FR) complained to the facility on [DATE] that they were not notified about the presence of a right heel wound and that the scheduled wound dressing changes were not rendered but there was no documented evidence that the complaint was addressed; (2) there was also no evidence that a grievance form was initiated and completed for the residents' concerns in accordance with the facility policy. The Findings are: A review of the undated facility policy titled Investigation of grievance concerns documented the facility will complete a prompt, thorough investigation of all grievances and/ or concerns filed with the facility. Concerns may include but are not limited to care issues, issues of alleged discrimination,…

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 conducted during an abbreviated survey (NY00306613), the facility did not ensure that 1 out of 4 sampled residents (Resident #1) was free from physical, verbal, and emotional abuse. Specifically review of facility surveillance camera with no audio dated 12/06/2022 at 12AM revealed Resident #1 striking Certified Nursing Assistant (CNA #1) on the right shoulder as they sat in the day room. CNA #1 quickly stood up and with an intimidating stance, spoke and gestured for Resident #1 to return to their room. Resident #1 was observed cowering but did not leave. CNA #1 then physically turned and pushed Resident #1's upper back for the resident to return to their room. CNA #1 was observed grabbing Resident #1's right arm, but the resident was able to move their arm away. This incident was also witnessed by CNA #2 on the video footage. CNA #2 did not stop the interaction between Resident #1 and CNA #1 and did not report the incident to the administration. The findings are: The Facility Policy entitled Abuse Prohibition Program 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 observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that the interdisciplinary team (IDT) determine if a significant change assessment was warranted in the required 14-day period after a decline was identified for a resident who decline in functional status. Specifically, 1 of 1 resident (Resident # 9) reviewed for Activities of Daily Living (ADLs) had a functional decline in 2 or more areas based on 2 comparative Minimum Data Set (MDS, an assessment instrument); 2 a significant change MDS was not done within the required 14-day period after the decline was identified in order to determine appropriate plan of care and treatment. The findings are: Resident # 9 has diagnoses and conditions not limited to Diabetes Mellitus, Major Depression, and Dementia. According to the 3/20/19 Annual MDS, the resident had severe impaired cognition, and required extensive assistance of one person with bed mobility, transfer, dressing, personal/oral…

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 recent recertification survey, the facility did not ensure that care plans with measurable goals, time frames and interventions were developed to address each resident's medical care needs. Specifically, care plans had not been developed to address issues related to: (1) multiple medical diagnoses with prescribed medications (Resident #53), (2) pain management for a resident with a spinal fracture (Resident #46), and ( 3) medical diagnoses of cirrhosis of the liver and hypothyroidism (Resident #37). The findings are: 1. Resident #53 was admitted with diagnoses including Dementia, Hypertension, and Depression. The 1/2/20 Significant Change MDS (Minimum Data Set: an assessment tool) revealed that resident #53 received 7 days of antidepressant and anticoagulant medicatoin and 1 day of antibiotic therapy. The January 2020 Physician's orders included but were not limited to the following medications: Namenda 5mg daily, Lexapro 10mg daily,…

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 recent recertification survey, the facility did not ensure care plans were reviewed and revised to address issues related to smoking and anxiety. Specifically, no interventions were initiated to address non-compliance with the facility's no smoking policy (Resident #2). and the plan of care addressing anxiety was not evaluated to address the continued use of 3 psychoactive medications (Resident #23). The findings are: 1. Resident #2 was admitted to the facility with diagnosis including Chronic Renal Failure and Type II Diabetes. The physician's orders indicated the resident receives hemodialysis three times weekly off site. Based on admission MDS The resident is cognitively intact, can make needs known and self-propels in a wheelchair. An Accident/Incident report from 1/6/20 7:30 pm, the resident was observed on the second floor unit in a back bathroom rolling his wheelchair and smoking cigarettes. On 1/7/20 morning the resident was once again found 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 observation, interview and record review conducted during a recent recertification survey, the facility did not provide the necessary care and devices needed maintain or prevent further contracture for 1 resident (Resident # 41) reviewed for limited range of motion. The findings are: Resident #41 has current diagnoses and conditions including but not limited to Generalized Muscle Weakness, Spasm, and Contracture of Upper and Lower Extremity. According to the 12/5/19 Quarterly Minimum Data Set (MDS; an assessment instrument), the resident had severe impaired cognition, and was totally dependent on staff for Activities of Daily Living (ADLs) (e.g. bathing, dressing, grooming etc.) A Splint/Cast/Brace/Immobilizer Care Plan initiated 9/19/19 and in effect at the time of the review documented the resident uses splints to both hands for contracture. The current physician orders in effect at the time of the review had orders for bilateral hand splints daily, to be applied in the AM, and taken off at hours of sleep. The resident was observed lying in bed on 1/14/20 at 10:33 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 1 resident reviewed for respiratory care was provided appropriate care consistent with standards of practice and in accordance with a written plan of care. Specifically, the resident was being administered 3 liters of oxygen not in accordance with the physician's orders or written plan of care. The findings are. Resident #23 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety Disorder. On 1/14/20 at 8:45 AM the resident was observed receiving oxygen at about 2.5 Liters via a nasal cannula. The resident was observed receiving 3 liters of oxygen at other times when out of bed to include: 1/14/20 at 11:20 AM, 1/16/20 at 11:13 AM and 1/16/20 at 12:38 PM . However, according to the physician's order, the resident was to be administered 3 liters of oxygen via a BiPAP machine…

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 most recent recertification survey, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for pain management and the treatment of hypertension. This was evident for 2 of 5 resident's reviewed for unnecessary medications (Residents #37 and #23) and 1 of 2 resident's reviewed for pain management (Resident #49). Specifically, there was inadequate pain monitoring for the use of opioids for Residents #37 and #49) and inadequate monitoring of vital signs for the use of an antihypertensive medication (Resident #23). The findings are: 1. Resident #37 was admitted to the facility with diagnoses including Chronic Hepatitis C, Cancer, Cirrhosis of the liver, Depression and Hypothyroidism. The resident was also admitted with the history of psychoactive substance abuse. The significant change Minimum Data Set (MDS, an assessment instrument) dated 12/12/19 revealed that the resident had no cognitive impairment, 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 recent recertification survey, the facility did not ensure that facility staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 1 of 3 residents (Resident #59) reviewed for pressure ulcer. The findings are: Resident #59 has diagnoses and conditions not limited to Acute Kidney Issues, Diabetes Mellitus, Stage 3 left heel Pressure Ulcer (PU), and Unstageable Deep Tissue Injury (DTI) PU to Right Heel. According to the 1/7/2020 5-Day Minimum Data Set (MDS; an assessment tool), the resident had a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated moderately impaired cognition. The MDS also noted that Resident #59 required extensive staff assistance with Activities of Daily Living (ADLs). Physician's orders dated 1/7/20 had a directive to clean Resident #59's right and left heel with Normal Saline, apply Skin Prep, and leave open to air. During a wound observation conducted on 1/16/20 at 11:26AM on the South side unit, the Licensed Practical Nurse (LPN…

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.