Sans Souci Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00353705, NY00352230, NY00332692), the facility did not ensure that an allegation of abuse was thoroughly investigated for 6 (Resident #1, #2, #3, #38, #39, #40) of 6 residents reviewed. Specifically, (1) on 9/8/2024 Resident #1 reported to Licensed Practical Nurse #1 that Resident #2 had touched them inappropriately in their private area while they were roommates. Review of the facility incident report revealed the certified nurse aides assigned to the third-floor unit on 9/8/2024 did not provide any written statements regarding the incident. Review of the investigative summary revealed it was not dated and was not signed indicating it was not reviewed by the Medical Director; (2) On 8/22/2024 Resident #2 was witnessed by Certified Nurse Aide #1 hitting Resident #3 in the back of the head with a Flexi-bar (a rubber cylinder used in therapy). The facility investigative conclusion documented there was no cause to believe abuse had occurred.…

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 (NY00352230), the facility did not ensure a resident's right to be free from abuse for 1 out of 3 residents (Resident #3) reviewed for abuse. Specifically, on 8/22/2024 Certified Nurse Aide #1 witnessed Resident #2 with a known history of inappropriate behaviors towards staff and others, striking Resident #3 (who had a history of wandering behavior and was care planned for supervision) on the head with a flexi-bar (rubber cylinder used in therapy) from behind. The investigative conclusion documented there is no evidence that any alleged abuse had occurred. The Findings are: 1) Resident #2 was admitted to the facility on [DATE] with diagnoses including but not limited to Acquired Absence of Left Leg Above Knee, Unspecified Psychosis and Mood Disorder. Review of a Quarterly Minimum Data Set, dated [DATE] documented the resident was cognitively intact. The resident had impairment on one side of the lower extremity. The resident required 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 record review and interviews during an abbreviated survey (NY00331567), the facility did not ensure the accuracy of resident's assessments for 1 out of 3 residents (Resident #4) reviewed. Specifically, Resident #4 was admitted to the facility on [DATE] with a documented history of wandering but was not identified as at risk for elopement by the facility on admission. Resident #4 was placed in a room on the first floor of the facility and on 1/14/2024, the resident exited the facility front doors unescorted after they were buzzed out by the Receptionist. The findings are: The undated facility admission Assessment and Follow Up: Role of the Nurse policy documented the purpose of the procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and comprehensive required assessment instruments. Conduct an admission assessment (history and physical) including a summary 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 record review and interview during an abbreviated survey (NY00331567), the facility did not ensure a comprehensive patient centered care plan was developed for 1 out of 3 residents reviewed for care planning. Specifically, Resident #4 was admitted to the facility on [DATE] and had a documented history of wandering. Resident #1 exited the facility through the front doors unescorted on 1/14/2024, after being buzzed out by the Receptionist. Review of Resident #4's care plan revealed they did not have a wandering or potential for elopement care plan in place. The Findings are: The facility Care Plans, Comprehensive Person-Centered policy last revised March 2022 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00331567), the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision for 1 out of 3 residents (Resident #4) reviewed for elopement. Specifically, on 1/14/2024 Resident #4 exited through the front doors of the facility unescorted, after being buzzed out by the Receptionist at 3:33 PM. Resident #4 with a documented history of wandering, was assigned a room on the first floor of the facility. Resident #4 exited the facility and wandered into a neighboring home near the facility and the neighbor called 911. The facility was notified of Resident #4's whereabouts around 4:31 PM by emergency medical services after the resident was transferred to the hospital. The Findings are: The Facility Elopement policy last revised 7/2024 documented when a resident is reported missing, the following action plan will be initiated to conduct a prompt, thorough search to locate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00347185) surveys from 8/6/2024 to 8/13/2024, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 2 (Resident #88 and #213) of 3 residents reviewed for pain. Specifically, 1) Resident #88 was not administered pain medication in accordance with Physician's Orders, was not provided non-medication interventions to address pain, and had recommendations for pain management by a Physiatrist that were not reviewed by the Physician Assistant, and 2) Resident #213 was not administered pain medication in accordance with Physician's Orders. The findings are: The facility policy titled Pain Assessment and Management dated 6/2024 documented the medication administration record was reviewed to determine how often 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, interviews, and record review conducted during the recertification and abbreviated (NY00347185) survey from 8/6/2024 to 8/14/2024, the facility did not ensure sufficient nursing staff to provide nursing and related services to attain or maintain the well-being of each resident in accordance with the facility assessment. This was evident for 2 (2nd and 3rd Floor) of 3 units during staffing review. Specifically, 1) the Facility Assessment did not account for and plan to staff the 2nd and 3rd Floor with their higher resident capacity and census in comparison to the 1st Floor, 2) the projected staffing levels and actual staffing levels were less than the Facility Assessment's projected needs for the resident population of 2.2 Certified Nursing Assistant hours per resident per day, 3) F676 cited for activity of daily living care for Resident #95, and 4) residents reported delays in activities of daily living care related to the facility being short of staff. The findings are: 1) The Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure prompt resolution of a resident's grievance and did not establish a grievance policy including all necessary elements. that includes notifying residents of their right to file a grievance . This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, 1) the facility Grievance Policy did not include the method used to notify residents of the grievance process and the resident's right to obtain the decision in writing, 2) Resident #10's Designated Representative reported the resident was missing clothing and glasses and was not provided with a prompt resolution. The findings are: The facility policy titled Investigations of Grievances/Concerns dated 6/13/2024 documented a thorough investigation of all grievances will be completed, and the resident or resident representative will be informed of the findings of 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, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure an effective discharge planning process was developed and implemented focused on the resident's discharge goals, involved the resident and resident representative, and was updated. This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, upon return from the hospital and without the Designated Representative's involvement, Resident #10 was issued a Discharge Notice listing the destination as a skilled nursing facility that was not suitable for the resident's needs. The findings are: Resident #10 had diagnoses of schizoaffective disorder, bipolar disorder, catatonia, and major depressive disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #10 was moderately cognitively impaired, did not display mood symptoms, and was physically aggressive towards others. On 08/07/2024 at 04:55 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.

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 that each resident in need of assistance, to carry out activities of daily living, received the necessary services in a timely manner for 1 of 5 residents reviewed for Activities of Daily Living. Specifically, Resident #95 was not provided incontinence care as need or as scheduled. Findings include: Resident #95 had diagnoses including urinary tract infection, paraplegia, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, and dependent on staff for transfer, ambulation, toilet use and personal hygiene. Resident #95 was frequently incontinent bowel and bladder. The grievance form dated 7/8/24 documented Resident #95 wanted their adult brief changed more often. The documented resolution was for Resident #95 to be changed every 2 hours and as needed when soiled. The nursing note dated 8/6/24 at 7:56 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey and Abbreviated survey (NY00341698) on 8/6/2024 to 8/14/2024, the facility did not ensure the necessary treatment and services, consistent with professional standards of practice, were provided to an existing pressure injury for 1 of 2 residents (Resident # 81) reviewed for pressure ulcer. Specifically Resident #81 was found with a skin opening on the sacrum on 8/1/2024 and a registered nurse did not assess the area or notify the physician until the following day. Findings include: The facility Policy on Pressure Injury Risk and Assessment, dated 5/24, documented information should be recorded in the resident's medical record to include any change in the resident's condition if identified, the condition of the skin if identified, initiation of a pressure or non-pressure form related to the type of alteration in skin if new skin alteration noted, documentation addressing MD notification if new skin alteration is noted.…

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 8/6/2024 to 8/13/2024, the facility did not ensure the physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #88) of 25 total sampled residents. Specifically, the Physician Assistant did not review a Nursing Pain Evaluation or the Physiatrist's pain management recommendations for Resident #88. The findings are: The facility policy titled Pain Assessment and Management dated 6/2024 documented the physician and staff will establish a treatment regimen based on the resident's medical condition, course of illness, and treatment goals. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and adjust as indicated. On 08/06/2024 at 12:41 PM, Resident #88 was interviewed and stated they recently had a surgical amputation of their left leg above the knee and experienced persistent pain to the surgical site that was not relieved by their current pain medication. Resident #88…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure each resident received behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, Resident #10's behavioral health plan of care was not individualized, reviewed, and revised to address symptomology related to their mental illness diagnoses. The findings are: Resident #10 had diagnoses of schizoaffective disorder, bipolar disorder, catatonia, and major depressive disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #10 was moderately cognitively impaired, did not display mood symptoms, and was physically aggressive towards others. The Minimum Data Set 3.0 assessments, dated 4/10/2024 and 5/13/2024, documented Resident #10 was severely cognitively impaired and…

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

Based on observations, record review, and interviews conducted during the recertification survey from 08/6/24 to 08/14/24, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 2 of 25 opportunities (8%) resulted in error for 1 of 4 residents (Resident #5). Specifically, 1) Resident # 5 was administered a crushed form of Enteric coated aspirin instead of chewable and a crushed form of Depakote delayed release tablet. The findings are: The facility's policy titled Administering Medications dated 06/07/24 documented medications are administered in a safe and timely manner and are administered in accordance with prescriber's orders. Resident #5 was admitted to the facility with diagnoses including but not limited to seizures, schizophrenia, hypertension. The current physician orders as of 8/9/24 documented Aspirin oral tablet chewable 81 mg, give one tablet by mouth one time a day for prophylaxis and Depakote tablet delayed release 500 mg, give one tablet by mouth two times a day for mood disorder. In addition, 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, interview, and record review conducted during the Recertification and Abbreviated surveys (NY00341698) on 8/6/2024 to 8/14/2024, the facility did not ensure that rehabilitative services were provided for 1 of 2 residents (#81) reviewed for weight loss. Specifically, Resident #81 the physician's order for a Speech Therapy evaluation for slow eating and chewing, was not completed. Findings include: The facility policy titled Rehabilitation Services created on 5/2022 documented Physical Therapy, Occupational Therapy and Speech Therapy are provided in this facility for patients who present with mobility impairments, functional impairments, speech/language deficits, and swallowing deficits that require skilled intervention to either improve function or reduce caregiver burden. Upon admission to this facility, at any time a significant change of condition occurs and periodically throughout a resident's stay, the physician and staff will assess the resident's physical condition and functional…

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 a recertification survey (08/06/24 to 08/14/24), the facility did not ensure infection control prevention practices including hand hygiene were maintained to help prevent the development and transmission of communicable diseases and infections for 2 (#15 and #4) of 32 sampled residents. Specifically, 1) Certified Nurse Aide #1's hand came in contact with Resident #15 food a during lunch meal observation and Licensed Practical Nurse #11 did not follow proper hand hygiene during a wound care treatment for Resident #4. 1) Resident #15 was admitted with diagnoses which included Hypertension, Diabetes Mellitus, Coronary Artery Disease. The Minimum Data Set, an assessment tool dated 6/30/24 documented the resident had mild cognitive impairment and required tray set up for eating. During an observation on 08/06/24 at 12:14 PM Certified Nurse Aide #1 delivered the lunch tray to Resident #15, opened the tray, and began to open up utensils and beverage containers. The Certified Nurse Aide was observed with their uncovered…

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 conducted 08/06/24 to 08/14/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #51) reviewed. Specifically, there was no documented evidence Resident #51 was offered, declined, or educated on the pneumococcal immunization. Findings include: The facility policy titled Pneumococcal Vaccine last revised October 5, 2017, documented the facility will ask residents on admission if they have received the pneumococcal vaccine and the medical record will be reviewed to confirm this information. If the resident has not received the pneumococcal vaccine, information will be given to the resident/resident representative concerning pneumococcal vaccine and the Vaccine Information Sheet will be reviewed. The resident will be given the opportunity to ask questions concerning risks and benefits. If the resident wishes to receive the vaccine the resident/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 interviews conducted during an abbreviated survey (NY00334044), the facility did not ensure residents right to be free from abuse for 1 of 3 residents (Resident #3) reviewed for abuse. Specifically, on 2/21/24, Dietary Aide #15 was witnessed by a Certified Nurse Aide #14, verbally threatening Resident #3 and pulling on Resident #3 beaded necklace. Resident #3 written statement documented that a staff member entered his room and held them by the shirt and chest area and verbally threatened him. Resident #3 was assessed with no injuries. Facility Investigation concluded abuse occurred. Findings include: The facility policy, 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating' approved 6/3/24 documented that the facility process was to report abuse and thoroughly investigate all reports of abuse, and to provide a follow-up investigation report within 5 business days of the incident. Resident #3 was admitted with diagnoses which included osteoarthritis right shoulder, depression, and dementia. The Annual Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during an abbreviated survey (NY00342153) the facility did not develop or implement a comprehensive person-centered care plan for Resident #1. Specifically, the heels of Resident #1 were not offloaded and or heel booties were not applied as per physician order and as per care plan. Findings are: The policy and procedure titled Pressure Injury Risk and Assessment dated 5/27/24 documented the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. Multiple risk factors including but not limited to, impaired/decreased mobility and decreased functional ability, exposure of skin to urinary and fecal incontinence or other source of moisture. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure…

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 conducted during a Recertification Survey the facility did not ensure labeling, dating and the monitoring of refrigerated food was maintained in accordance with Professional Standards of Food Safety. Specifically, prepared and frozen foods in the kitchen refrigerator and in the dry food storage room were not labeled and or not dated. The findings are: On 10/18/2021 during the recertification survey, an initial tour of the kitchen was conducted at 9:40 AM, and the following issues were noted; The kitchen refrigerator was examined at 9:40 AM and it was noted that there were two paper plates with food wrapped in plastic wrap and the plates were not labeled and were not dated. In an interview at the time of the finding at approximately 9:45 AM, the Dietary Director stated that the food on the plates were leftover food for two separate residents The Dietary Director further stated that the plates were not labeled because the Dietary Director and staff are aware of the residents whom the plates belong when the plates were placed in 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 F583 Based on observation and interviews conducted during recent recertification survey the facility did not ensure privacy was maintained for 1 of 1 resident (#72) reviewed for privacy. Specifically, 2 residents (#72 and #9) of the opposite sex were placed in adjoining rooms with a shared bathroom. The findings are: The facility's policy titled Quality of Life-Dignity dated 11/2020 documents staff promote, maintain and protect resident privacy. Resident #72 was admitted on [DATE] with diagnoses Right Fracture of the Right Femur, Attention Deficit Disorder and Generalized Anxiety Disorder. Per Minimum Data Set (MDS an assessment tool) MDS quarterly assesment dated 9/6/21 resident #72 is moderately cognitively impaired and independent with toilet use. MDS admission assessment dated [DATE] states resident #72 needs extensive assistance for toileting with one-person physical assistance. Resident #9 was admitted to the facility 4/11/19 with diagnoses of Pneumonia, Parkinson's disease and Dementia without behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during recertification survey, for 1 of 1 resident (Resident #158) reviewed for catheters, and 1 of 3 residents reviewed for infection control (Resident # 96,) the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infections. Specifically, Resident #158 catheter (urinary drainage tube) drainage bag (bag for collecting urine from the urinary drainage tube) was observed uncovered and on the floor on multiple days of survey, and Resident #96, had uncovered oxygen tubing and humidification bottles on several observations. The findings are: The facility policy Foley Catheters/Care dated 11/19/20 stated foley catheter drainage bags are to be kept below the residents bladder and off of the floor to keep from causing potential urinary tract infections. Catheter bags are to be covered when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure that each resident, or designated representative of cognitively impaired residents, was given the opportunity, if so desired, to formulate a written advance directive. This was evident for 2 of 3 residents reviewed for advanced directives (#102 and #46). Specifically, (1) the designated representative for Resident #102 was not educated regarding the right to have an advanced directive formulated for the resident not to be resuscitated and (2) Resident #46 had a physician's order not to be intubated and there was no documented evidence that Resident #46 gave written consent for this order. The findings are: 1. Resident #102 was admitted to the facility on [DATE]. The resident's diagnoses included Dementia, Schizophrenia, and Chronic Obstructive Pulmonary Disease. A review of the resident's clinical record revealed no evidence that the resident's designated representative was educated on her right to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure that it implemented written policies and procedures for reporting an allegation of abuse made by a resident for 1 of 4 residents (#82) reviewed for abuse. The findings are: Resident #82 was admitted to the facility on [DATE] with diagnoses including Fractured Hip. The admission Minimum Data Set (MDS; a resident assessment tool) dated 6/7/18 documented the resident had a Brief Interview for Mental Status Score of 15 out of 15, indicating no cognitive impairment, and required extensive to total assistance of two persons to perform activities of daily living. A resident council meeting was conducted on 7/31/18 at 1:30 PM with Resident #82 present. The resident stated that she was admitted for rehabilitation for a fractured leg and that she felt she was handled in a rough manner by an aide during her first few weeks in the facility. She stated the aide was rough with her during cares. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] A. Based on record review and interview conducted during a recertification survey, the facility did not ensure that all Minimum Data Set (MDS; a resident assessment and screening tool) were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of the final completion date for 3 of 4 residents reviewed for resident assessment. Specifically, residents (R) #1, #3, and #4 did not have the MDS data submitted within 14 days of completion of the MDS assessment. The finding is: The following residents were reviewed for Resident Assessment: - R #1 had an MDS admission Assessment with an ARD (assessment reference date) of 7/3/18, a completion date of 7/10/18 was submitted on 7/31/18; - R #3 had an MDS admission Assessment with an ARD of 7/4/18, a completion date of 7/10/18 was submitted on 7/31/18; - R#4 had an MDS Quarterly Assessment with an ARD of 2/17/18, a completion date of 3/3/18 was submitted 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, record review and interview conducted during a recertification survey, the facility did not provide the necessary care and services for 1 of 1 resident (#5) reviewed for respiratory care. Specifically, the facility did not provide Resident #5 who had a tracheostomy (an incision is made on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) with a device to enable the resident to speak more normally and/or communicate with others. The finding is: Resident # 5 had diagnoses including Malignant Neoplasm of the bronchus and lungs and Respiratory Failure. The admission Minimum Data Set (MDS; a resident assessment and screening tool) of 12/27/17 indicated the resident had no cognitive impairment and required tracheostomy care. A Tracheostomy Care Plan initiated 12/25/2017 and remained in effect at the time of the review included interventions to provide means of communication. This care plan did not indicate the methods of communication that would 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.

Based on observation, record review and interview conducted during a recertification survey, the facility did not provide the necessary care and treatments to prevent skin breakdown for 1 of 1 resident (#28) reviewed for non pressure related skin ulcer/wound. Specifically, the treatment plan was not revised to prevent further recurrence of a chronic skin irritation. The finding is: Resident # 28 was a admitted with diagnoses including Seizure Disorder and End Stage Renal Disease. The Quarterly Minimum Data Set (a resident assessment and screening tool) of 5/2/18 documented the resident scored 11 out of 15 on the Brief Interview of Mental Status (a test used to measure orientation and memory recall) indicating she was moderately cognitively intact. The resident was interviewed on 7/31/18 at 10:20 AM and she stated the skin below her breast had some redness and she felt a burning sensation. The resident then lifted her shirt revealing redness below both breasts with residue from a cream which had been applied by the staff. She also pointed to her left and right inguinal areas stating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure that an audiology evaluation was performed as ordered by the medical provider for 1 of 2 residents (#46) reviewed for vision and hearing. The finding is: Resident #46 has diagnoses including Diabetes Mellitus, Cardiovascular disease, and Renal Insufficiency. The Annual MDS (Minimum Data Set; a resident assessment and screening tool) dated 2/14/18 documented that the resident scored a 15 out of 15 on the BIMS (Brief interview for Mental Status) indicating the resident is cognitively intact. The MDS further indicated that the resident's hearing was adequate and did not use hearing aids. A subsequent Quarterly MDS dated [DATE] documented adequate hearing and no hearing aid was being used. The patient-centered comprehensive care plan (CCP) of 10/2/17 revealed no evidence of a care plan to address communication. The physician's orders form dated 5/21/18 revealed an order for an audiology consult and follow up…

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

Based on interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 2 residents (#94) reviewed for urinary incontinence that the necessary care to promote and maintain bladder continency to the extent possible was provided. Specifically, the type of urinary incontinence was not identified and a patient-centered care plan, based on the type of incontinence and maintenance versus restorative goals and interventions, was not developed to address the bladder incontinence across all shifts. The findings are: Resident #94 is a non-ambulatory resident whose diagnoses include End Stage Renal Disease and Diabetes Mellitus. The resident receives dialysis treatment three days weekly, leaving the facility on the day shift and returning on the evening shift. The Minimum Data Set (MDS; a resident assessment and screening tool) dated 3/17/18, documented that the resident had moderately impaired cognition, required extensive assistance with toileting, and was occasionally incontinent of urine (defined in MDS as less than 7 episodes of incontinence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey, the facility did not ensure for 2 out of 7 residents reviewed for nutrition (#46 and #94) that there was coordination between nursing and dietary to ensure that the fluids offered to the resident did not exceed the physician's order to prevent fluid overload. The findings are: 1. Resident #46 has diagnoses and conditions including Diabetes Mellitus, cardiovascular disease, Renal Insufficiency and receiving dialysis three times a week. The Annual Minimum Data Set (MDS: a resident assessment and screening tool) dated 2/14/18 documented the resident scored 15 out of 15 on the Brief Interview for Mental Status (a test used to measure memory and orientation) which suggested that the resident is cognitively intact; resident eats with set-up help and supervision; height 72 inches; weight was 284 pounds; no signs of weight loss or gain > than 5% in one month or 10% in 6 months; and received a therapeutic diet. The subsequent Quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a recertification survey, the facility (1.) did not provide for 1 of 1 residents (#5), reviewed for respiratory care, a device to enable the resident to speak more clearly and to be more easily understood during conversation with others. Additionally, (2.) manual resuscitative devices (ambu bags) were not easily accessible in case of an emergency for resident (#5) and for one random resident (#51) with a tracheostomy (trach) tube on the First floor unit. A tracheostomy is a surgical procedure which consist of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The findings are: 1. Resident #5 had diagnoses including Malignant Neoplasm of the bronchus and lungs and Respiratory Failure. The admission Minimum Data Set (MDS; a resident assessment and screening tool) of 12/27/17 indicated the resident had no cognitive impairment and required tracheostomy care. The Tracheostomy Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a recertification survey, the facility did not provide ongoing evaluation and management of pain for 1 of 4 residents (#46) reviewed for pain management. The findings are: Resident #46 has diagnoses and conditions including complete traumatic amputation at level between knee and ankle, Diabetes Mellitus, and Gastroesophageal Reflux Disease (GERD) without Esophagitis, and Osteomyelitis. The Annual Minimum Data Set (MDS; a resident assessment and screening tool) dated 2/14/18 documented the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS; a test used to measure memory and orientation) which suggested that the resident is cognitively intact; received scheduled pain medication during the assessment period; had frequent pain with an intensity of 5; had medications in the previous 7 days which included an opioid in 4 of 7 days; and did not receive therapies. The Pain Management assessment dated [DATE] revealed that the resident's pain…

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 medical supervision was provided for 1 of 5 residents (#45) reviewed for nutrition. Specifically, the physician or the Nurse Practitioner (NP) did not address the resident's significant unplanned weight loss and the abnormal nutritionally-related laboratory values in light of adequate protein, calories and fluid consumption. The finding is: Resident #45 was admitted to the facility on [DATE]. The resident's admitting diagnoses included Anemia, Diabetes Mellitus, and Chronic Kidney Disease. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) done on 2/2/18 noted that the resident had severe cognitive impairment, required total assistance for all activities of daily living, weighed 116 lbs. (same weight noted on MDS of 11/10/17), was on a therapeutic diet (No Added Salt, Diabetic), and had two Stage 1 pressure ulcers and one Stage IV pressure ulcer. 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, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 6 residents (#267 and #38) observed during a medication pass for a total of 3 out of 31 opportunities for error resulting in a medication error rate of 9.6%. The findings are: 1. Resident #267 has diagnoses including Hypertension, Major Depressive Disorder, and Anemia. A medication pass observation was conducted on 8/2/18 at 9:18 AM on the First floor unit. The Licensed Practical Nurse (LPN #2) administered the medications, which included one Multiple Vitamin tablet from a facility stock bottle. Review of the physician orders dated 7/13/18 revealed that the resident should have received one Multiple Mineral tablet orally daily for supplement. LPN #2 was interviewed on 8/2/18 at 1:15 PM following review of the physician's orders and stated that she administered the red Multiple Vitamin tablet and did not realize that the order indicated multiple mineral tablet. 2. Resident #38 had diagnoses…

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 the necessary dental services were provided in a timely manner including arrangements to obtain dentures for 1 of 3 residents (Resident #94) reviewed for dental services. The findings are: Resident #94 was admitted to the facility on [DATE] with diagnoses and conditions including Diabetes Mellitus, Gastroesophageal Reflux Disease and Anemia . The Annual Minimum Data Set (MDS; a resident assessment tool) of 3/10/17 indicated resident has moderately impaired cognition and no dental issues were identified. A review of the resident's dental evaluation dated 9/28/17 revealed that the dentist noted at that time that the resident had only one top tooth and that the resident wanted it to be extracted. The evaluation further documented that the resident wanted upper dentures and that this would be addressed at the next visit. The follow-up visit occurred on 10/9/17 and the dentist documented that…

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 recertification survey, the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 7 out of 10 alert and oriented residents from 2 out of 3 units, that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack they were not provided with an evening snack. The findings are: A resident council meeting was conducted on 7/31/18 at 1:30 PM. Seven out of 10 ten residents in attendance stated they were not provided or offered evening snacks and if they asked for an evening snack, they were told by the staff that there was not enough snacks, no snacks were available, or that the kitchen was closed. During an observation on 7/31/18 at 7:00-7:30 PM on 2 of the 3 units (2nd and 3rd), evening snacks were placed at the nursing station waiting to be distributed to the residents. The 2nd floor unit had a tray of 15 cookie packages and one large container of juice and 3 small cans of ginger ale. The 3rd floor unit also 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 observation, record review and interview conducted during a recertification survey, the facility did not ensure that measures were in place to prevent the spread of infection and cross contamination for 1 of 1 resident reviewed for respiratory care (Resident #5). The resident was observed on multiple occasions using his bare fingers to cover his tracheostomy tube (a type of airway inserted directly into the trachea) to communicate with others after touching objects and surfaces, potentially contaminating the tracheostomy (trach) tube without using proper hand hygiene. Additionally, resident care items including oxygen tubes and feeding supplies were stored in containers that were placed directly on the floor on 2 out 3 facility units (1st and 3rd). The findings are: 1. Resident # 5 had diagnoses and conditions including malignant neoplasm of bronchus and lung, and Respiratory Failure. The resident was interviewed on 7/30/18 at 1:12 PM and he stated that he was waiting for a speaking device to assist him in communicating with others which was not available at this time. 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.