The Pavilion at Edgefield for Nursing and Rehabili

Based on record review, policy review, resident and staff interviews, the facility failed to develop comprehensive resident specific care plans and include resident and resident representative involvement in the care planning process. for Residents #04 and #15. The affected two (#04, #15) of 27 residents reviewed for comprehensive care planning. The facility census was 63.Findings include:1.Review of medical record of Resident #04 revealed admission to facility on 11/07/23 with diagnoses including heart failure, lung disease, contracture (deformity) of right hand, heart disease, anemia (low blood count), chronic back pain, high blood pressure, degenerative joint disorder of cervical (neck) and lumbar (mid back) regions. Review of the Minimum Data Sets 3.0 (MDS) assessment tool revealed completion of MDS 3.0 quarterly assessment on 12/24/24, quarterly assessment 03/24/25, annual assessment on 06/04/25, and quarterly assessment on 08/12/25. Review of Resident #04 Care Conference Summary Sheet 2.0 dated 01/07/25 revealed Resident #04's family and Resident #04 were not in attendance;…

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, observation, and interview the facility failed to provide personal hygiene care to a resident dependent on staff for provision of care. This affected one (#13) of six residents reviewed for personal hygiene care. The facility census was 63. Findings include: Review of Resident #13's medical record revealed a 11/25/23 admission with diagnoses including Alzheimer's disease, dementia, hypertension and anxiety. The resident had a 11/25/23 activity of daily living self care performance deficit plan of care related to Alzheimer's, anxiety, dementia, and psychoactive drug use. Interventions included the resident will accept assistance during bathing and/or showering. The resident had an 11/21/24 order for placement on secured memory care unit for therapeutic environment. Review of the 07/16/25 Quarterly minimum data set (MDS) assessment revealed the resident was severely impaired for daily decision making. Review of nurse notes May 2025 through September 2025 revealed no bathing or nail care refusals. Review of showers revealed no documented refusals of showers.…

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, the facility failed to ensure Resident #44's bilateral lower leg (BLL) wraps were applied as ordered by the physician. This affected one (#44) of two residents reviewed for edema and non-pressure skin conditions. The facility census was 63.Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/13/25 with diagnoses including Alzheimer's disease, dementia, left bundle branch block, lymphedema, edema, anxiety, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/25, revealed Resident #44's Brief Interview for Mental Status (BIMS) score was 08, which indicated moderately impaired cognition. The resident required staff assistance with activities of daily living. Review of the Care Plan, dated 3/11/25, revealed Resident #44 was at risk for impaired skin integrity related to edema and fragile skin with the intervention to apply ACE wraps to bilateral lower extremities in the morning and to be removed in the evening, Review of physician order, dated 3/12/25,…

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, observation, and interview, the facility failed to ensure residents received proper assistive devices to maintain hearing abilities. This affected on (#22) of two residents reviewed for communication and sensory issues. The facility census was 63.Findings include:Review of the medical record for Resident #22 revealed an admission date of [DATE]. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive disorder, vascular dementia unspecified without behavior disturbance, personal history of healed traumatic fracture, and generalized anxiety disorder. Review of care plan for Resident #22 revealed he had impaired communication related to anxiety, cognitive impairment,…

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, observation and interview, the facility failed to ensure residents were safe from accidents, hazards and adequate supervision was provided as needed to residents. The facility failed to properly secure Resident #22 in his wheelchair during transportation and failed to provide safety measures and neurological checks for Resident #15 following a fall. This affected two (#15, #22) of five residents reviewed for accidents. The facility census was 63.Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 02/20/17. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive disorder, vascular dementia unspecified without behavior disturbance,…

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 the facility failed to provide residents who required supplemental oxygen with the needed support. This affected one (#34) of one resident who was reviewed for respiratory care. The facility census 63. Findings include: Review of the open medical records for Resident #34 revealed a readmission date 10/26/25. Diagnoses included acute and chronic respiratory failure with hypoxia, pleural effusion and shortness of breath. Review of the physician orders for September 2025 revealed continuous oxygen at four liters via nasal cannula every shift. Review of the plan of care dated 04/15/24 revealed Resident #34 had an impaired respiratory status related to hypoxia, respiratory failure, shortness of breath and sleep apnea. Interventions included oxygen via nasal cannula at four liters continuously and treatments as ordered by the physician. Observation on 09/15/25 at 3:04 P.M. of Resident #34 revealed she was lying in bed with her oxygen nasal cannula tubing on. Observation of the oxygen concentrator revealed the oxygen concentrator was not on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to recognize and address pain promptly when there was a change in condition. This affected one (#73) of one resident reviewed for pain management. The facility census was 63. Findings include:Review of the medical record for Resident #73 revealed an admission date of 04/24/25 . Diagnoses included but were not limited to acute diastolic heart failure, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, acute pulmonary edema, ulcerative pancolitis without complications, Alzheimer's Disease with late onset, atrial fibrillation, osteoarthritis right shoulder, mood disorder, and dementia in other diseases.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. A score of 13-15 would indicate cognitive intactness. The resident was assessed to have no behavioral issues or wandering behaviors. The MDS revealed him to be occasionally incontinent.…

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 staff interviews, the facility failed to ensure medical provider follow-up to monthly pharmacist recommendation for gradual dose reduction (GDR). This affected three (#01, #03, and #04) of five residents reviewed for GDR. The facility census was 63.Findings include:Review of the medical record of Resident #01 revealed admission to facility on 06/25/25 with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, attention deficit hyperactivity disorder, overactive bladder, anxiety, fibromyalgia (chronic pain to nerve endings), and anemia (low blood count).Review of the electronic medical record (EMR) of Resident #01 revealed monthly pharmacy reviews completed on 06/26/25, 07/09/,25, 08/05/25, and 09/02/25 with recommendations made by pharmacist on 06/26/25, 07/09/25, and 09/02/25. Further review revealed detailed recommendations made by the pharmacist to the medical provider on 06/26/25 for Resident #01. There was no documentation of the specific…

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, observation and interview, the facility failed to refer residents with lost or damaged dentures for dental services, or provide documentation of why a referral did not take place within three days. The facility also failed to provide a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility. This affected one (#22) of two residents reviewed for dental concerns. The facility census was 63.Findings include:Review of the medical record for Resident #22 revealed an admission date of 02/20/2017. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive…

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, the facility failed to ensure residents' food choices related to needs and preferences were honored. This affected two (#27, #1) of two residents reviewed for food. The facility census was 63.Findings include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, chronic ulcer of right lower limb, chronic heart failure, multiple sclerosis, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #27, dated 08/21/25, revealed the Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed the resident required staff assistance with activities of daily living (ADLs). Interview on 09/22/25 at 12:55 P.M. with Resident #27 revealed she did not have a good lunch because she orders omelets every day for lunch and hasn't had one for two days. The resident stated she complained…

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, the facility failed to ensure ice water was provided to residents between meals. This affected one (#10) of two residents reviewed for hydration/nutrition. The facility census was 63. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/24/25, revealed the Resident #10 was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs). Observation on 09/18/25 at 1:26 P.M. revealed Resident #10 was lying in bed with no ice water or other drink located on his bedside table. Observation on 09/18/25 at 3:28 P.M. revealed Resident #10 was lying in bed, tearful and requesting to be pulled up in his bed. Further observation revealed there was no ice water…

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, the facility failed to ensure an accurate medical record in the area of behaviors. This affected one (#12) resident of 27 resident records reviewed. The census was 63.Findings include: Review of Resident #12's medical record revealed a 05/17/25 admission with diagnoses including dementia, cerebral infarction, attention and concentration deficit, chronic kidney disease stage 2, abscess of breast and nipple, leiomyoma of uterus, restlessness and agitation, hypothyroidism, anemia, hypercholesterolemia, cognitive communication deficit, Vitamin D deficiency, anxiety disorder, difficulty in walking, essential hypertension, major depressive disorder, insomnia, muscle weakness, and chronic pain.Review of the 08/08/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making, inattention continuously, behaviors continuously present for disorganized thinking and altered level of consciousness. Wandering behavior occurs daily. The resident resided on the secure locked unit.On 09/16/25 at…

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, record review, and policy review, the facility failed to ensure coordination of care communication between Resident #10's hospice provider and the facility. This affected one (#10) of one resident reviewed for hospice care. The facility census was 63.Findings include:Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/24/25, revealed the Resident #10 was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs).Review of physician order, dated 09/16/25, revealed Resident #10 was admitted to hospice services. Interview on 09/18/25 at 2:48 P.M. with the Director of Nursing (DON) confirmed Resident #10's electronic medical record (EMR) did not contain any hospice communication…

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, the facility failed to ensure the infection preventionist attended quarterly Quality Assurance meetings. This had the potential to affect all the residents in the facility. The census was 63.Findings include: Review of the Quality Assurance (QA)meeting sign in sheets revealed meetings were held 10/08/24, 01/07/25, 04/05/25, and June 2025. There was no evidence the facility's Infection Control Preventionist participated in the QA meetings other than in June 2025. Interview on 09/23/25 at 1:00 P.M. with Registered Nurse #500 revealed she has been the facility Infection Preventionist since 2019. She verified she was not attending the quarterly QA meetings.

Based on record review, observation, and staff interviews, the facility failed to follow proper hand hygiene and glove use when providing incontinence care for a resident. This affected one (#04) of one resident observed for incontinence care. The facility census was 63.Findings include:Review of the medical record of Resident #04 revealed admission to facility on 11/07/23 with diagnoses including heart failure, lung disease, contracture (deformity) of right hand, heart disease, anemia (low blood count), chronic back pain, high blood pressure, degenerative joint disorder of cervical (neck) and lumbar (mid back) regions.Review of Resident #04's most recent quarterly Minimum Data Set (MDS) 3.0 assessment tool dated 08/12/25 revealed the resident is dependent on staff for personal care, needs meal set-up for eating, has moderately impaired cognitive skills for daily decision making, requires wheelchair use for mobility and is always incontinent of bladder and bowels.Observation on 09/17/25 at 2:15 P.M. of Resident #04 receiving incontinence care revealed Certified Nurse Aide (CNA) #520…

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

Based on medical record review, review of the infection control log, interview, and policy review the facility failed to ensure the appropriate use of antibiotics. This affected one (#44) of six residents reviewed for unnecessary medications. This had the potential to affect all 63 residents residing in the facility. Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/13/25 with diagnoses including Alzheimer's disease, dementia, left bundle branch block, lymphedema, edema, anxiety, and muscle weakness. Review of Resident #44's physician order, dated 07/18/25, revealed the order to Nitrofurantoin Mono-Mac 100 milligrams (mg), one capsule by mouth in the morning and at bedtime for seven days for E. coli urinary tract infection (UTI). Review of the July 2025 Medication Administration Record (MAR) revealed the resident was started on Cefdinir 300 mg on 07/19/25. Review of the Infection Control Log, dated July 2025, revealed Resident #44 was ordered Nitrofurantoin Mono-Mac 100 milligrams (mg), one capsule by mouth in the morning and at bedtime…

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, record review, and facility policy review, the facility failed to maintain infection control procedures while administering medications. This affected two residents (#26 and #53) of four residents observed for medication administration. Findings include: 1. Review of Resident #53's medical records revealed an admission date of 07/17/24 with diagnosis of cerebral infarction and chronic pain syndrome. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had intact cognition. Observation on 06/25/25 at 9:39 A.M. of Licensed Practical Nurse (LPN) #286 revealed she did not perform hand hygiene before preparing nine medications for Resident #53. LPN #286 placed all medications in the medicine cup and at 9:44 A.M. applied gloves without performing hand hygiene. LPN #286 then entered the resident room and removed the Lidocaine patch from Resident #53's left shoulder area and applied a new Lidocaine patch. LPN #286 at 9:47 A.M. removed her gloves and did not perform…

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, record review, and review of facility policy, the facility failed to ensure Resident #37's wheelchair was in good repair. This affected one resident (Resident #37) out of three residents reviewed for wheelchairs in good repair. Findings include: Review of Resident #37's medical record revealed an admission date of 04/25/16 and diagnoses included schizoaffective disorder, bipolar type, obesity, and chronic pain syndrome. Review of Resident #37's Quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #37 was cognitively intact and required supervision of staff with set up help only for bed mobility, transfers, and toilet use. Resident #37 used a wheelchair. Review of Resident #37's care plan revised, 06/07/21, included Resident #37 was at risk for impaired skin integrity related to confined to a chair all or most of the time, depression, edema, impaired cognition, incontinent of bladder, pain, venous ulcers, and morbid obesity. Resident #37 refused to sleep in bed at times, slept in his wheelchair. Observation on 11/14/22 at 12:09 P.M. with…

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, record review, and facility policy the facility failed to ensure Resident's #31 and #232 had physician orders for oxygen administration. This affected two resident's (Resident's #31 and #232) out of three residents reviewed for oxygen orders. Findings include: 1. Review of Resident #232's medical record revealed an admission date of 11/11/22 and diagnoses included chronic respiratory failure with hypoxia, centrilobular emphysema, and chronic obstructive pulmonary disease with acute exacerbation. Review of Resident #232's admission Evaluation dated 11/11/22, revealed Resident #232 was lethargic and oriented to person and place. Further review of the admission Evaluation revealed Resident #232 had shortness of breath and used oxygen at four liters via nasal cannula. Review of Resident #232's progress notes dated 11/11/22 at 7:30 P.M. revealed the resident arrived to the facility at 7:30 P.M. and was on oxygen therapy at four liters per minute via nasal cannula. Review of Resident #232's medical record revealed oxygen saturations were documented 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 medical record review, staff interview, and review of facility Hospice Visit Notes, the facility failed to ensure Hospice services were thoroughly documented to maintain sufficient communication between the facility and Hospice to meet the needs of Resident #45. This affected one Resident (#45) of two reviewed for Hospice services. Findings include: Review of the medical record for Resident #45 revealed an admission date of 08/29/18. Resident #45's diagnoses included Alzheimer's disease, drug induced secondary Parkinsonism, paraplegia, acute respiratory failure, diabetes, chronic congestive heart failure, unspecified protein-calorie malnutrition, dementia with behavioral disturbances, major depressive disorder, metabolic encephalopathy, schizoaffective disorder, hallucination, chronic pain, fibromyalgia, and anxiety. Review of Resident #45's physician orders revealed she was admitted to Hospice on 07/15/22 for a diagnosis of Alzheimer's disease. Review of Hospice Aide Visit Notes revealed no notes were completed for Resident #45. Review of Hospice Interdisciplinary Team…

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 review of the facility cleaning schedule for the kitchen the facility failed to ensure meals were prepared under sanitary conditions. This had the potential to affect 74 of 75 residents currently residing in the facility who received meals prepared in the kitchen, with the exception of Resident #49, who did not take food by mouth. Findings include: Observations conducted on 01/13/20 from 10:28 A.M. to 11:52 P.M. of the general kitchen environment revealed the fire suppression hood and metal vents were covered with a moderate to thick amount of black dust. Food preparation, including including mushroom soup, Brussel sprouts, and hot dogs occurred directly under the dust covered hood and metal vents during the observation period. An interview was conducted on 01/15/20 at 12:53 P.M. with the Director Manager (DM #505) who verified the above findings. DM #505 explained that he was not sure about the last time the hood and vents were cleaned but would clean them that day. Review of the daily complete kitchen cleaning assignments for all positions in…

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

Based on record review and interview, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice Form (SNF ABN), Form CMS-10055, was provided to Resident #77. This affected one of one resident reviewed for liability notices. The facility census was 75. Findings include: Resident #77 was readmitted to the facility under skilled traditional Medicare part A services on 09/12/19. The facility issued a Notice of Medicare Non-Coverage form (NOMNC) for a last skilled Medicare day of 10/15/19 to Resident #77 on 10/11/19. Review of the facility provided forms revealed a SNF ABN form was not provided at the time the NOMNC was issued. The facility completed SNF Beneficiary Protection Notification Review form stated a SNF ABN form was not issued secondary to Resident #77 being a long-term resident and having Medicaid coverage. Staff interview with Licensed Social Worker (LSW) #500 on 01/13/20 at 2:38 P.M. revealed a SNF ABN form was not given to Resident #77 secondary to LSW #500's belief a SNF ABN form was not required if a resident also had Medicaid coverage. LSW…

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 the facility failed to ensure written notification of transfer to the hospital was provided to Resident #68 and Resident #76. This affected two of two residents reviewed for transfers and had the potential to affect all 75 residents currently residing in the facility. Findings include: 1. Resident #68's medical record revealed an admission date of 04/10/19 with diagnoses including cardiomyopathy, end stage renal disease, chronic congestive heart failure, and chronic obstructive pulmonary disease. Nurses notes revealed on 08/21/19 at 11:06 A.M. Resident #68 sent was to a hospital for treatment of chronic renal failure and was admitted . Resident #68 was hospitalized from [DATE] through 08/22/19 and was then re-admitted to the facility. The medical record lacked evidence of written notification of the transfer provided to Resident #68 or their representative. 2. Resident #76's medical record revealed an admission date of 09/05/19 with diagnoses including atrial fibrillation,…

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, the facility failed to accurately complete and submit a Preadmission Screening and Resident Review (PASARR) for Resident #48. This affected one of one resident reviewed for PASARR assessments. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes, and cognitive communication deficit. Review of Resident #48's hospital paperwork revealed a Hospital Exemption form, JFS 07000, dated 11/18/19, which stated the anticipated length of Resident #48's skilled nursing facility stay was anticipated as less than 30 days. The Hospital Exemption form stated Resident #48 had a diagnosis of mental retardation and did not evidence of a severe mental illness. Review of the PASARR assessment completed 12/12/19 by Licensed Social Worker (LSW) #500 revealed Resident #48 had a diagnosis of developmental disability. The diagnosis manifested before the age of 22, and did not result in functional limitations prior 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 record review, interview and review of facility policy the facility failed to ensure Resident #48 was not given an antibiotic (Tetracycline) which she was allergic to. This affected one resident (Resident #48) of six residents reviewed for unnecessary medications. The facility census was 75. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, urinary tract infection, urine retention, type two diabetes, and depression. Review of the resident's electronic record revealed the resident profile listed Tetracycline (an antibiotic) as an allergy. Review of the Minimum Data Set (MDS) 3.0 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of nine which indicated mild cognitive impairment, and required extensive assistance with care. Review of the progress notes dated 12/26/19 revealed Resident #48 had a change in condition at 12:58 A.M. Resident #48 was short of breath, using accessory muscles for breathing, and her oxygen…

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, interview and review of facility policy the facility failed to ensure complete and accurate documentation of a physician's order and administered medications Resident #48. This affected one resident (Resident #48) of six residents reviewed for unnecessary medications. The facility census was 75. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, urinary tract infection, urine retention, type two diabetes, and depression. Review of the Minimum Data Set (MDS) 3.0 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of nine which indicated mild cognitive impairment, the resident required extensive assistance with care, and had an indwelling urinary catheter. Review of the progress notes dated 12/26/19 revealed Resident #48 had a change in condition at 12:58 A.M. Resident #48 was short of breath, using accessory muscles for breathing, and her oxygen saturation was 89 percent (below normal range of 90 -…

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, staff interview and policy review the facility failed to ensure proper technique for infection control during tracheostomy care. This affected one (Resident #45) of one resident with a tracheostomy who was reviewed for tracheostomy care. Findings include: Observation on 01/15/20 at 3:09 P.M. of tracheostomy (an surgically created opening in the front of the neck for the purpose of facilitating breathing) care for Resident #45 revealed Licensed Practical Nurse (LPN) #507 failed to maintain proper aseptic (sterile) technique during care. LPN #507 applied her sterile glove and proceeded to remove Resident #45's dirty inner cannula from the tracheostomy. LPN #507 then applied clean (non-sterile) gloves and continued tracheostomy care using sterile gauze to clean the tracheostomy. LPN #507 then removed the sterile inner cannula from the package, with the same dirty gloves, and inserted it into the tracheostomy opening. Interview on 01/15/20 at 3:45 P.M. with LPN #507 verified that she handled the new/sterile inner cannula with dirty gloves. LPN #507 verified 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.