The Gardens Of Fairfax Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to provide feeding assistance in a timely manner for dependent residents. This affected one (Resident #14) of seven residents reviewed. The census was 44. Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/22. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition and required supervision or hands on assistance for eating. Review of the plans of care revealed no plan related to nutrition or assistance needed for eating. Review of the nutritional assessment dated [DATE] revealed Resident #14 received a liberal renal pureed diet with nectar thickened liquid. Resident #14 required supervision, set-up, and assistance with eating. Resident #14 was…

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

Based on record review and interview the facility failed to develop a person-centered baseline care plan for one resident (#48) of two residents reviewed for baseline care plans. The facility census was 47. Findings include: Review of the medical record for Resident #48 revealed an admission date of 10/28/23. Medical diagnoses included hypertension, chronic atrial fibrillation, dementia, encephalopathy, gastro-esophageal reflux disease, and pressure ulcer of sacral region. Review of the physician orders for Resident #48 revealed an order dated 11/01/23 that stated to cleanse right lateral calf wound with normal saline, pat dry, apply oil emulsion gauze and cover with abdominal pad and wrap with Kerlix gauze every night shift every Monday, Wednesday, and Friday and as needed. Further review of the physician orders revealed an order dated 11/01/23 that stated to cleanse sacral wound with normal saline, pat dry, pack wound with Vashe moistened gauze and cover with foam every night shift. Review of Resident #48's care plan dated 11/01/23 revealed no care plan for wound care or skin…

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 develop a person-centered care plan for one resident (#9) of two residents reviewed for comprehensive person-centered care plans. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/11/20. Medical diagnoses included Alzheimer's disease, pulmonary hypertension, moderate protein-calorie malnutrition, chronic kidney disease, and chronic diastolic congestive heart failure. Review of the physician orders for Resident #9 revealed an order dated 05/26/20 for Do Not Resuscitate Comfort Care (DNR-CC). Review of Resident #9's care plan dated 05/11/20 revealed the care plan did not include residents code status wish. Interview on 12/05/23 at 3:02 P.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #9's comprehensive person-centered care plan did not reflect that Resident #9 had a DNR-CC in effect.

Based on record review, facility policy review, personnel file review and interview, the facility failed to implement the screening component of their abuse policy and procedure to ensure all potential new hires were checked against the state Nurse Aide Registry (NAR) to ensure no employee had findings concerning abuse, neglect, exploitation or misappropriation of residents' property. The facility also retained staff after 30 days when background check results were not received. This affected six out of 14 employees whose personnel files were reviewed and had the potential to affect all 45 residents in the facility. Findings Include: Review of 14 personnel records on 05/10/23 starting at 12:29 P.M. with Human Resource Coordinator (HRC) #202 revealed the following concerns: a. Review of State Tested Nursing Assistant (STNA) #218's personnel file revealed a re-hire date of 04/11/23. The file contained no evidence of STNA #218 being checked against the NAR and no evidence background checks had been completed upon re-hire. b. Review of Dietary Aide (DA) #204's personnel file revealed a…

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

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) was on-site eight hours a day, seven days a week as required. This had the potential to affect all 45 residents in the facility. Findings Include: 1. Review of posted staffing sheets from 04/01/23 to 05/06/23 revealed a RN was not in the facility on 04/01/23, 04/02/23, 04/03/23, 04/06/23, 04/07/23, 04/08/23, 04/09/23, 04/10/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/17/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/27/23, 04/28/23, 04/29/23 and 05/06/23. Interview on 05/09/23 at 9:14 A.M. with Scheduler #220 verified the identified dates did not meet the required eight hours of RN coverage as required. 2. Review of the staffing schedules for 04/30/23 to 05/06/23 with Scheduler #220 on 05/09/23 at 12:05 P.M. revealed the facility did not have an RN onsite on any shift on 05/06/23. Interview on 05/09/23 at 4:31 P.M. with the Administrator revealed if RN #235 was not working the facility tried to obtain an RN through a staffing agency but at times, staffing was tight. The Administrator was…

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

Based on observation, interview and record review the facility failed to ensure food was served at safe and appetizing temperatures. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Review of the Fall/Winter Week Two menu for Monday corresponding to 05/08/23 revealed the meal to be served for lunch included Salisbury steak, garlic mashed potatoes, stewed tomatoes, wheat bread, margarine, coconut cream pie and beverage of choice. Observation on 05/08/23 at 11:37 A.M. revealed [NAME] #209 was taking temperatures for lunch tray service with the facility's self-calibrating electronic thermometer. Food temperatures obtained were as follows: sour cream (on ice) 33.5 degrees Fahrenheit (F); Salisbury steak, 203 degrees F; baked potato, 191 degrees F; stewed tomatoes, 173 degrees F; and mashed potatoes 196 degrees F. Trayline started 11:46 A.M. At 12:03 P.M. staff started making trays for the two carts for the first floor and a test tray was requested. The test tray was made at 12:22 P.M., on…

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

Based on observation, interview and record review the facility failed to ensure a clean and sanitary kitchen. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Observation of the kitchen on 05/07/23 from 8:54 A.M. to 9:45 A.M. with [NAME] #209 revealed the following concerns: • The walk-in cooler lacked an internal thermometer. On the shelves, two bags of shredded mozzarella cheese, a lemon meringue pie and a strawberry cream pie did not have dates on them. • On the bread cart, four loaves of bread had a use by date of 04/24/23 and two loaves of bread had a use by date of 05/02/23. Buns and wraps were present but also undated. • On a pull cart, three packs of ham were undated. • In the freezer, a bag of unidentifiable meat was not dated and had a lot of ice buildup. On the shelf, 11 pans of macaroni and cheese lacked a date. There was also no internal thermometer inside the freezer. • In the dry stock room, cans did not have a date received to ensure appropriate rotating. A bottle 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.

Based on observation, record review and interview the facility failed to ensure a clean and sanitary laundry service, privacy curtains were changed when visibly dirty, a comprehensive legionella program, and yearly screening for tuberculosis. This affected all 45 residents residing at the facility. Findings Include: 1. Observation on 05/10/23 at 10:29 A.M. with Building Manager #226 revealed in the soiled area of the laundry processing area there were two large washing machines and one smaller washing machine. The smaller washing machine had clothing inside. An attempt to open the door of the smaller washing machine revealed it would not open. The tops of both large washers had sticky liquid spills, and dust. Interview at the time of the observation with Building Manager #226 revealed he was unsure how long the small washer had not been in service nor how long the clothes locked inside had been there. Further observation of the clean side of the laundry processing area revealed a bath robe and additional clothing items on hangers hanging from a metal pipe just below the ceiling. A…

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

Based on record review and staff interview, the facility failed to implement a comprehensive antibiotic stewardship program. This had the potential to affect all 45 residents residing at the facility including Residents (#9, #15, #23, #27, #39 and #40) who received antibiotics between March 2023 and May 2023. Findings Include: Interview on 05/09/23 at 9:24 A.M. with the Director of Nursing (DON) revealed the facility kept a log of resident infections in a notebook which was tracked by type of organism, type of antibiotic used and mapped by room to identify potential patterns. If a physician ordered an antibiotic prior to obtaining culture and sensitivity results, the nurse wrote a progress note that McGreer's criteria (antibiotic surveillance definitions specific for benchmarking appropriate antibiotic usage) had not been met and the physician was notified. When an antibiotic was started prior to obtaining the culture and sensitivity results, and the lab results indicated the current antibiotic was an inappropriate antibiotic, the physician was notified. The DON stated the medical…

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 provide nail care for residents unable to carry out activities of daily living (ADLs) without assistance. This affected three (Residents #2, #8, and #26) of four residents reviewed for ADLs. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date of 06/04/21. Diagnoses included type II diabetes, heart disease, chronic kidney disease, blindness of one eye, and glaucoma. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/23, revealed Resident #8 had impaired cognition and required extensive assistance with bed mobility, limited assistance with transfers, total dependence for dressing and personal hygiene. Review of the plan of care dated 05/03/23 revealed Resident #8 had a self-care performance deficit related to blindness. Intervention included one person assistance for personal hygiene, bathing, and dressing. Observation on 05/07/23 at 3:27 P.M. of Resident #8's fingernails…

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 policy review, the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. This affected four residents (#2, #8, #11 and #41) out of five residents reviewed for unnecessary medications. The facility census was 45 residents. Findings Include: 1. Review of Resident #11's medical record revealed an admission date of 11/25/20 and diagnoses including type two diabetes, schizophrenia, anemia, hypertension and hypertension. Review of Resident #11's plan of care dated 11/25/20 revealed she used lexapro and trazodone. Interventions listed included: administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness each shift and monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline 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 observation, interview and policy review, the facility failed to ensure pureed foods were prepared in a manner that preserved nutritional value. This affected five residents (Residents #6, #15, #16, #24 and #34) receiving a pureed diet. The facility census was 45. Findings Include: Review of the Fall/Winter Week Two menu for Monday corresponding to 05/08/23 revealed the meal to be served for lunch included Salisbury steak, garlic mashed potatoes, stewed tomatoes, wheat bread, margarine, coconut cream pie and beverage of choice. Observation on 05/08/23 starting at 10:56 A.M. with [NAME] #209 revealed she was making pureed stewed tomatoes for the lunch meal. [NAME] #209 indicated she needed six purees but would make seven portions. [NAME] #209 then stated she needed four purees so would make five portions. [NAME] #209 put five #8-scoops of stewed tomatoes into the food processor along with 2/3 cup of vegetable broth and 1/2 cup of thickener. [NAME] #209 blended the product then added another 1/2 cup of broth. Interview with [NAME] #209 during the observation revealed she…

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 call lights were within reach and accessible for residents. This affected one resident (Resident #46) of two residents (Resident #12 and #46) reviewed for call light placement. Findings Include: Review of the medical record for Resident #46 revealed an admission date of 12/17/22. Diagnoses included but were not limited to cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, type II diabetes mellitus and adult failure to thrive. Review of the 04/08/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #46 revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Resident #46 required extensive assist of one for bed mobility, transfer, walk in room, locomotion off unit, dressing, toileting, personal hygiene, and supervision of one for locomotion on unit, and eating. Resident #46 was noted to frequently be incontinent of bladder. Review of the 04/20/23 revised care plan for Resident #46 revealed she…

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, self-reported incident (SRI) review, policy review and interview, the facility failed to report an allegation of potential abuse related to an injury of unknown origin as required. This affected one resident (Resident #29) of four residents (Residents #26, #29, #35, and #147) reviewed for abuse. The facility census was 45. Findings Include: Review of the medical record for Resident #29 revealed an admission date of 09/02/22. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, adult failure to thrive and osteoarthritis. Review of 02/22/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. Resident #29 required supervision of one for bed mobility, transfer, walking in room, dressing, eating, toileting, and personal hygiene. Resident #29 was noted to use a cane and wheelchair for mobility. Review of Resident #29's care plan revealed she has limited physical…

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, self-reported incident (SRI) review, policy review and interview, the facility failed to conduct a thorough investigation related to and injury of unknown origin for Resident #29 and an allegation of alleged sexual abuse for Resident #35. This affected two (Resident #29 and #35) of four residents (#26, #29, #35 and #147) reviewed for abuse. Findings Include: 1. Review of the medical record for Resident #29 revealed an admission date of [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, adult failure to thrive and osteoarthritis. Review of the [DATE] quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. Resident #29 required supervision of one for bed mobility, transfer, walking in room, dressing, eating, toileting, and personal hygiene. Resident #29 was noted to use a cane 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 record review and interview the facility failed to develop a baseline care plan. This affected one resident (Resident #148) of three residents reviewed for new admissions. Findings Include: Review of the medical record for Resident #148 revealed an admission date of 05/02/23. Diagnoses included heart disease, gout, osteoarthritis, repeated falls, and retention of urine. Review of the baseline assessment, dated 05/02/23 revealed Resident #148 experienced confusion, had a history of falls, an unsteady gait, poor balance, and was impulsive. Resident #148 used a walker. Review of the baseline care plan dated 05/03/23 revealed information regarding nutritional risk. The care plan did not include information regarding falls, unsteady gait, confusion, impulsiveness or urinary retention. Interview on 05/09/23 at 1:13 P.M. with Licensed Practical Nurse (LPN) #225 verified the baseline care only included Resident #148 had a nutrition risk and the care plan was not complete. LPN #225 stated she started the care plan but forgot to complete the care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide Resident #8's restorative nursing program for ambulation and lower extremity exercises as ordered by the physician and as recommended upon discharge from physical therapy. This affected one (Resident #8) of two residents reviewed for physical therapy. Finding Include: Review of the medical record for Resident #8 revealed an admission date of 06/04/21. Diagnoses included type II diabetes, heart disease, chronic kidney disease, blindness of one eye, and glaucoma. Review of the quarterly Minimum Data Set 3.0 assessment, dated 03/31/22, revealed Resident #8 had impaired cognition and required extensive assistance from staff for bed mobility, transfers and ambulation. Review of the plan of care dated 05/03/23 revealed Resident #8 had a self-care performance deficit related to blindness. Intervention included one a person assist for personal hygiene, bathing, and dressing. Review of the physician orders dated 02/17/23 revealed an order to refer…

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, record review and policy review, the facility failed to provide appropriate catheter care and monitoring. This affected one resident (Resident #44) of one resident reviewed for catheter care. The facility census was 45 residents. Findings Include: Review of Resident #44's medical record revealed an admission date of 08/02/22 and diagnoses including acute kidney failure, chronic obstructive pulmonary disease, osteoarthritis, adult failure to thrive and gout. Review of Resident #44's bowel and bladder program screener dated 08/02/22 revealed a score of 19 indicating Resident #44 was a good candidate for retraining. Review of Resident #44's hospital paperwork revealed a urinary catheter was placed prior to his readmission to the facility on [DATE]. Review of a readmission bowel and bladder program screener dated 03/19/23 indicated Resident #44 scored a nine and was a candidate for scheduled toileting. The readmission bowel and bladder program screener did not mention a urinary catheter was 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, interview and policy review, the facility failed to obtain dialysis orders and ensure the dialysis care plan included individualized interventions which accurately reflected the care needs of the resident. This affected one of one resident (Resident #12) reviewed for dialysis. The facility identified two residents (Residents #2 and #12) receiving dialysis. Findings Include: Review of the medical record for Resident #12 revealed an admission date of 07/13/19. Diagnoses included but were not limited to dementia, end stage renal disease and chronic combined systolic (congestive) and diastolic heart failure. Review of the 03/14/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #12 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated Resident #12 was moderately cognitively impaired. Review of activities of daily living (ADLs) section of the MDS assessment revealed Resident #12 required extensive assist of one staff for bed mobility, total dependence of two staff for transfer, total dependence of one staff for locomotion 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 interview, record review and policy review, the facility failed to ensure pharmacy medication recommendations were timely addressed and followed up upon. This affected one resident (Resident #41) of five residents reviewed for unnecessary medications. The facility census was 45 residents. Findings Include: Review of Resident #41's medical record revealed an admission date of 05/05/21 and diagnoses including bipolar disorder, current episode manic severe with psychotic features, unspecified dementia, unspecified severity without behavioral disturbance, major depressive disorder, insomnia, history of COVID-19 and other specified mental disorders due to known physiological condition. Review of Resident #41's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 was cognitively impaired and received antipsychotics and antidepressants. Review of a pharmacy medication recommendation for Resident #41 dated 07/22/22 revealed if not recently obtained and if indicated would you…

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, the facility failed to ensure the facility was staffed sufficiently to ensure all residents had assigned nursing coverage at all times. The facility was also not staffed sufficiently to ensure timely and appropriate fulfillment of physician's orders. This affected the 25 residents residing on the first floor (Resident #37, #6, #22, #43, #12, #58, #61, #41, #65, #20, #16, #168, #54, #44, #45, #7, #23, #25, #46, #49, #36, #55, #26, #18, and #13). The facility also did not staff sufficiently to meet minimum staffing needs required by the state of Ohio, affecting all residents in the facility. In addition, the facility did not staff sufficiently to ensure residents had the option of eating in the dining room, affecting the twenty-one residents who usually eat in the second-floor dining room [ROOM NUMBER] residents (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The facility census was 64. Findings…

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 review of Quality Assessment and Assurance (QAA) process, the facility did ensure the medical director participated in the QAA committee. This had the potential to affect all 64 residents in the facility. Findings include: Review of the QAA committee process revealed the medical director was not included in the QAA meetings. Interview with the Medical Director on 10/23/19 at 8:49 A.M. revealed that he had been the medical director of the facility since 04/2019 and had never participated in or been invited to a QAA meeting at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions for one resident (Resident #19) with clostridium difficile (C-diff), cleaning of glucometers for two residents (Residents #20 and #5) and failed to have Legionella and Tuberculosis assessments. This had the potential to affect all 64 residents who resided in the facility. Findings include: 1. Review of the medical record revealed Resident #19 was readmitted to the facility on [DATE] with epilepsy, stage five kidney disease, protein malnutrition, diabetes mellitus, enterocolitis due to clostridium difficile (C-diff). Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and was always incontinent of bowel. On 10/21/19 at 7:40 A.M., tour of the laundry and interview with Laundry Aide #6 revealed that he did not know which linens were from isolation rooms because they were not separated, and he…

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 interview, the facility failed to provide residents with their choice of eating in the dining room for meals. This affected the twenty-one residents who usually eat in the second-floor dining room (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The census was 64. Finding include: Observation on 10/20/19 at 4:45 P.M. revealed no residents were in the second-floor dining room. On 10/20/19 at 4:48 P.M. Resident #9 was heard asking Nurse Manager #49 why the dining room wasn't open today. Nurse Manager #49 stated that residents were going to eat in their rooms that evening. Interview on 10/22/19 at 9:57 A.M. with Dietary Supervisor #3 and Dietary Manager #16 revealed the dietary department had a list of which residents had chosen to usually ate in the second-floor dining room. The list included 21 residents (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The food for the second-floor residents was brought up in a steam table…

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 the facility failed to ensure Resident #8 and Resident #28 received the assistance they needed to receive regular showers. This affected two residents of 22 residents assessed for activities of daily living (ADL). The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required limited assistance for bed mobility. Transfers, locomotion, eating and toilet use were coded as only occurred once or twice. Dressing and personal hygiene were coded as not assessed. The Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. A review of the Task Sheet for Showers/Bathing for 09/24/19 through 10/22/19 revealed only two showers were completed, on 9/27/19 and on…

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

Based on observation and interview, the facility failed to ensure the first floor was staffed sufficiently to ensure timely fulfillment of physician's orders and management of resident care needs. This affected the 25 residents residing on the first floor (Residents #37, #6, #22, #43, #12, #58, #61, #41, #65, #20, #16, #168, #54, #44, #45, #7, #23, #25, #46, #49, #36, #55, #26, #18, and #13). The facility census was 64. Findings include: Observation of the first floor of the facility, containing 25 residents, (Residents #37, #6, #22, #43, #12, #58, #61, #41, #65, #20, #16, #168, #54, #44, #45, #7, #23, #25, #46, #49, #36, #55, #26, #18, and #13) on 10/20/19 at 8:20 A.M. revealed no nurses engaged in any direct resident care. Interviews with State-Tested Nursing Aides (STNA) #53 and #71 on 10/20/19 at 8:23 A.M. revealed there was no nurse currently taking care of residents on the first floor. The night-shift nurse had departed, and the day-shift nurse had not yet arrived. Interview with STNA #53 on 10/20/19 at 10:16 A.M. revealed there was still no nurse assigned to provide care on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Ombudsman and resident representatives were notified in writing of hospital transfers and rights. This affected two (Resident #28 and #69) of three residents reviewed for hospitalization and discharge. The facility census was 64. Findings include: 1. Record review of Resident #69 revealed she was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. She had not returned to the facility as of the time of the survey. The record review revealed no evidence the Ombudsman or representative had received written notice of the transfer or the rights to an appeal or bed-hold. Interview with Licensed Social Worker (LSW) #10 on 10/22/19 at 1:37 P.M. revealed when residents are hospitalized , their responsible parties were informed via telephone. The facility only notified the Ombudsman of hospital transfers if they were not anticipating the resident would return. Interview with LSW #10 on 10/22/19 at 4:17 P.M. confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment was coded accurately for Residents #26, #28, and #48. This affected three of 22 resident's reviewed for MDS 3.0 assessment accuracy. The facility census was 64. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including dysphagia, diabetes mellitus, facial weakness and cerebral infarction. Review of the MDS 3.0 assessment dated [DATE] indicated the resident was rarely understood and eating was coded as the activity did not occur. Review of resident #26's medical record revealed physician's orders, medication administration records (MAR) and treatment administration records (TAR) for October 2019 revealed Resident #26 received nothing by mouth. The resident received enteral feeding (nutrition taken through a tube that goes directly into the stomach or small intestine) from 9:00 A.M. to 9:00 P.M. daily. Interview on 10/23/19 at 10:09…

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, review of facility policy and staff interview, the facility failed to ensure baseline care plans were completed in 48 hours and a copy was provided to the resident. This affected one (Resident #19) of one resident reviewed for baseline care plans. The facility census was 64. Findings include: Review of the medical record revealed Resident #19 was readmitted to the facility on [DATE] with diagnoses including epilepsy, stage five kidney disease, protein malnutrition, diabetes mellitus, enterocolitis due to clostridium difficile (C-diff). Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Interview on 10/23/19 at 10:09 A.M. with MDS Nurse #54 verified the baseline care plan was not completed and stated that baseline care plans are not completed. Review of the undated facility's policy entitled Advance Care Planning/Baseline Care Plan revealed that upon admission the resident and/or the responsible party shall be informed…

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 policy review, the facility failed to ensure comprehensive care plans were reactivated for Resident #28 after readmission, were developed related to dialysis for Resident #33 and were developed for antipsychotic medications and behaviors for Resident #40. This affected three residents of 22 residents reviewed for care plans. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required limited assistance for bed mobility. Transfers, locomotion, eating and toilet use were coded as only occurred once or twice. Dressing and personal hygiene were coded as not assessed. The Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Two care plans relative 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 observation, record review and interview, the facility failed to ensure tube feed was given according to physician's orders and quality standards of care. This affected one (Resident #26) of two residents at the facility who receive tube feeds (Resident #10 and #26). The facility census was 64. Findings include: Observation of Resident #26 on 10/20/19 at 10:18 A.M. revealed he had tube feed running into a gastric tube at 75 milliliters (ml) per hour. The feed bag was unlabeled and contained no information about the formula being fed, the date and time hung, the rate it was to run, and the time it was to come down. The feed bag was almost empty. The resident was not interviewable. Observation of Resident #26 on 10/20/19 at 10:37 A.M. and 10:59 A.M. revealed his tube feed bag was empty. The tube feed administration pump read feed error and was stopped. Tube feed formula was still visible in the tubing entering the resident's gastric tube. Interview with Registered Nurse (RN) #49 on 10/20/19 at 11:11 A.M.…

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 medical record review and staff interview, the facility failed to indicate why the administration of an as needed antipsychotic medication was necessary for one resident (Resident #61) of five residents reviewed for unnecessary medication use. The facility census was 64. Findings Include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus, Alzheimer's disease and dependence on renal dialysis. Review of Resident #61's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was rarely understood and received antipsychotic medications three days of the seven-day during the assessment reference period. Review of Resident #61's medical record, physician's orders, medication administration records (MAR) and treatment administration records (TAR) for September and October 2019 revealed Resident #61 received Haldol Solution (antipsychotic) intramuscularly one hour in the morning 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.

Based on observation, interview and record review, the facility failed to ensure there was enough personal protective equipment (PPE) for staff to wear during care with residents on isolation precautions. This affected one resident (Resident #19) and had the potential to affect all 64 residents who resided in the facility. Findings include: Observation and interview on 10/21/19 at 07:59 A.M. with State Tested Nurse Aide (STNA) #27 revealed that she was observed coming out of Resident #19's room without wearing any PPE on of any kind. Resident #19 had a diagnosis of clostridium difficile (C-diff). Interview of STNA #27 on 10/21/19 at 8:00 A.M. revealed there were no disposable gowns or masks in the PPE container hanging on the door. STNA #27 stated that the linen was put in a separate container and was double bagged. The first bag was dissolvable, and the clear bag went around it. She went to get a gown to go back into the room, and there were no disposable gowns available in the building. Observation and interview with Director of Nursing (DON) on 10/21/19 at 8:05 A.M. revealed 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.