Hennis Care Centre Of Dover

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interviews and facility policy review the facility failed to ensure Resident #18, #29, #38, #57, and #287's call lights were maintained within their reach. This affected five of six residents reviewed for call light access. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, disorientation, major depressive disorder, anxiety disorder, hypertension, diabetes, hyperlipidemia, anorexia, atherosclerotic heart disease, right wrist contracture, congestive heart failure, left and right foot drop, right and left-hand fracture, chronic pain, and palliative care. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #57 had severely impaired cognition and required total assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Review of the plan of care dated 12/21/22 revealed…

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 minimum data set (MDS) assessments were completed and submitted within required timeframes. This affected 10 (Resident's #1, #4, #9, #39, #42, #49, #61, #66, #68, and #69 ) of 10 residents reviewed. The facility census was 68. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 11/09/21 and a discharge date of 12/24/22. Medical diagnoses included atrial fibrillation, dementia, and anxiety. Review of Resident #1's Quarterly MDS assessment, with an assessment reference date of 12/02/22, revealed the assessment was due to be submitted 12/30/22. The MDS assessment was not submitted until 01/10/23, 11 days late. Interview on 01/12/23 at 8:58 A.M. with Registered Nurse (RN) #522 confirmed the Quarterly MDS assessment for Resident #1 was not submitted within the required time frames. RN #522 included she was a new employee, new to MDS and was waiting for the credentials to submit MDS assessments. She was provided the ability to submit 01/10/23. Review of Long-Term Care 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, record review, interview, and review of manufacturer guidelines the facility failed to ensure their bowel protocol was implemented, measures were in place for peripheral edema and ear irrigation treatment was provided as ordered. This affected two (Residents #5 and #188) of two residents reviewed for edema, one (Resident #13) of one resident reviewed for communication, and one (Resident #25) of five residents reviewed for unnecessary medication. The facility census was 68. Findings include: 1. Review of Resident #13's medical record revealed a 07/30/19 admission with diagnoses including chronic respiratory failure with hypoxia, morbid severe obesity, type 2 diabetes with diabetic neuropathy, hyperlipidemia, chronic atrial fibrillation, congestive heart failure, hypertension, chronic obstructive pulmonary disease, dependence on renal dialysis, peripheral vascular disease, and depression. Review of the 09/30/22 Quarterly Minimum Data Set (MDS) assessment revealed Resident #13 was independent…

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 facility policy review the facility failed to provide food in a form to meet the nutritional needs of residents. This had the potential to affect eight residents (#23, #31, #32, #38, #42, #57, #61, and #286) receiving a pureed diet. The facility census was 68. Findings include: Observation on 01/10/23 at 8:55 A.M. revealed Dietary Aid (DA) #494 place seasoned cooked cubed chicken in the Robot Coupe and pureed the chicken. DA #494 added broth and continued to puree the chicken. When DA #494 was done, she tasted the chicken and reported it was ready to serve. Observation of the pureed chicken revealed the texture was rough. Upon tasting the pureed chicken it was stringy and needed to be chewed. Dietary Supervisor #499 looked at the pureed chicken as she was getting ready to taste it and stated she could tell from looking at it that the chicken puree was not the correct consistency. Dietary Supervisor #499 reported it did not look like mashed potatoes and it should. Review of the Diet Order Tally Report - All Special Diets dated 01/09/23, revealed…

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 provide evidence in the medical record to support the receiving provider received the appropriate resident care information for continuity of care. This affected one Resident (#62) of one resident reviewed for hospitalization. The facility census was 68. Findings include: Review of Resident #62's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, unspecified dementia, type two diabetes, essential hypertension, and major depressive disorder. She was discharged from the facility on 12/28/22. Review of Resident #62's medical record revealed a physician order dated 12/28/22 to send Resident #62 to the emergency room for evaluation and treatment. Review of Resident #62's medical record revealed no documentation in the nursing progress notes to support information was sent on 12/28/22 with Resident #62 to the acute care facility for continuity of care. An interview on 01/12/23 at 4:10 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 record review, interview, and review of the Minimum Data Set (MDS) manual the facility failed to ensure an annual comprehensive MDS assessment was completed timely. This affected one (Resident #39) of four residents reviewed for timely completion of assessment. Findings include: Review of Resident #39 medical record revealed a 12/24/21 admission with diagnoses including type 2 diabetes, schizophrenia, hypertension, and acute kidney failure. Review of Resident #39's Annual MDS 3.0 assessment, with an Assessment Reference Date (ARD) 12/01/22 revealed the MDS was not completed until 01/03/23. Interview 01/17/23 at 11:35 A.M. with Registered Nurse #522 verified the Annual MDS was not completed within 14 days which was 19 days late. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, Chapter 5 Submission and Correction of the MDS assessments included 5.2 timeliness criteria in accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the Minimum Data Set (MDS) manual, the facility failed to ensure a quarterly MDS was completed timely. This affected two (Resident #9 and #68) of four residents reviewed for timely completion of assessment. Findings include: 1. Review of Resident #9 revealed a [DATE] admission with diagnoses including congestive heart failure, type 2 diabetes, hallucinations and dementia. Review of Resident #9's Quarterly MDS 3.0 assessment, dated [DATE] revealed the MDS was not completed until [DATE]. Interview [DATE] at 11:35 A.M. with Registered Nurse #522 verified the Quarterly MDS was not completed within 14 days which was 19 days late. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 [DATE], Chapter 5 Submission and Correction of the MDS assessments included 5.2 Timeliness Criteria in accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessments were accurate. This affected two residents (#5 and #25) of seven residents reviewed for accuracy of assessments. The facility census was 68. Finding include: 1. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture of Thoracic 11 to Thoracic 12 vertebra, shortness of breath, and chronic peripheral venous insufficiency. Review of Resident #5's admission MDS 3.0 assessment, dated 11/08/22, revealed she was cognitively independent and had active diagnoses of fractures and other multiple trauma, coronary artery disease, shortness of breath, and received one diuretic in the last seven days. There was no diagnosis of chronic peripheral venous insufficiency. An interview on 01/17/23 at 11:44 AM with MDS Coordinator #522 verified Resident #5's MDS assessment was not coded correctly for active diagnoses. MDS Coordinator #522…

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 review of the medical record and staff interview the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was obtained after a new diagnosis of a mental disorder for Resident #31. This affected one resident (Resident #31) of one resident reviewed for PASARR. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the Preadmission Screening/Resident Review identification screen dated 03/29/18 revealed Resident #31 was seeking admission to the nursing facility, she had no diagnoses of dementia, Alzheimer's disease, organic mental disorder, serious mental illness, and did not require individualized…

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 develop comprehensive plans of care in the areas of activities of daily living (ADL) and activities. This affected two (Residents #20 and #51) of 21 residents reviewed. The facility census was 68. Findings include: 1. Review of Resident #51's medical record revealed a 10/25/22 admission with diagnoses including atrial fibrillation, fistula of intestine, hypertension, umbilical hernia with obstruction with surgical intervention of the digestive system, heart failure, and morbid obesity. Review of the 11/01/22 admission Minimum Data Set (MDS) assessment revealed the resident was independent for daily decision making, extensive assist of two for bed mobility, transfer, and toileting. The resident did not walk, was totally dependent for locomotion off the unit, and extensive assist of one for personal hygiene. Interview 01/09/23 at 3:54 P.M. with Resident #51 revealed his toe nails were long and he needed them cut. His big toenail was really thick. He said he asked to see a podiatrist and had not. He normally…

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, review of the medical record, staff interview and facility policy review the facility failed to ensure Resident #24 was shaved and the toenails of Resident #51 were trimmed per their preferences. This affected two residents ( Resident #24 and #51) of four reviewed for activities of daily living (ADLs). Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included pneumonia, multiple sclerosis, diabetes, atrial fibrillation, acute kidney disease, benign prostatic hyperplasia, hypertension, depression, venous insufficiency, and Parkinson's disease. Review of the 14-day Minimum Data Set assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and required extensive assistance of two staff members for personal hygiene. Review of the progress notes from 10/19/22 to 01/12/23 revealed no documentation Resident #24 had refused to be shaved. Review of the plan of care dated 11/28/22 revealed Resident #24 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, interview, record review and policy review the facility failed to provide activities to meet the residents' needs, and did not provide a scheduled activity calendar or activities on the weekends. This affected two residents (#20 and #187) of two residents reviewed for activities. The facility census was 68. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 10/26/22 with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified severe protein-calorie malnutrition, chronic obstructive pulmonary disease, weakness, and hypertension. Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/02/22, revealed the resident was cognitively independent. The assessment indicated she had minimal difficulty with hearing, her vision was adequate, and her speech was clear. Her very important activities included listening to music, keeping up with the news, and going outside when the weather was good for fresh air. Her somewhat important activities were having…

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 review of the medical record, observation, staff interviews and facility policy review, the facility failed to ensure Resident #31 was turned and repositioned every two hours, failed to have a treatment order in place for four days for a new open area, and failed to have weekly measurements and assessments documented in the resident's medical record. This affected one resident ( Resident #31) of two residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the quarterly Minimum Data set assessment dated [DATE] revealed Resident #31 had intact cognition, required extensive assistance od two…

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 the facility failed to ensure falls risk interventions were consistently implemented. This affected one out of two residents reviewed for accidents (Resident #16). The facility census was 68. Findings include: Review of Resident #16's medical record revealed diagnoses including schizoaffective disorder, vascular dementia without behavioral disturbance, delusional disorders, unspecified psychosis, bipolar disorder, major depressive disorder, insomnia, syncope, peripheral vascular disease, and osteoarthritis. A falls risk assessment dated [DATE] revealed Resident #16 was at risk for falls related to need for assistance with transfer, poor balance, syncope, and inability to walk without assistance. Review of the Minimum Data Set (MDS) assessment completed 11/10/22 revealed Resident #16 was cognitively intact and required extensive assistance for bed mobility and transfers. Review of the care plan interventions triggered from the MDS assessment completed 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 observations, interviews, and record review the facility failed to obtain an order for oxygen administration for Resident #9. This affected one of two residents (Resident #9) reviewed for oxygen administration. The facility identified 35 residents on oxygen therapy, Residents #3, #5, #6, #7, #9, #12, #13, #16, #18, #19, #21, #27, #31, #33, #34, #35, #36, #37, #38, #39, #46, #47, #48, #49, #53, #57, #59, #60, #66, #67, #71, #73, #184, #187, and #284. Findings include: Review of medical records for Resident #9 revealed diagnoses of acute on chronic systolic congestive heart failure, acute bronchospasm, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact and had continuous oxygen in use. Review of the Care Plan for Resident #9 dated 08/24/22 revealed the resident had altered respiratory status/difficulty breathing related to COPD. The care plan addressed signs and symptoms of poor…

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 an interview, the facility failed to assess a fistula for dialysis access. This affected one (Resident #13) of one resident reviewed for dialysis. The facility identified three (Residents #13, #51 and #70) residents in the facility receiving hemodialysis. Findings include: Review of Resident #13's medical record revealed a 07/30/19 admission with diagnoses including chronic respiratory failure with hypoxia, morbid severe obesity, type 2 diabetes with diabetic neuropathy, hyperlipidemia, chronic atrial fibrillation, congestive heart failure, hypertension, chronic obstructive pulmonary disease, dependence on renal dialysis, peripheral vascular disease, and depression. Further review of Resident #13's record revealed the fistula was placed in the left upper arm on 08/15/22. The discharge instructions included check your fistula/graft everyday. If the sensation/thrill feels different or you don't feel it at all, call your physician immediately. If the area is red, swollen, painful, oozing, has a bad odor, or feels bad when touched call your physician, If 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, interview, record review and policy review the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to their use. This affected two residents (#14 and #20) of five residents reviewed for accidents. The facility census was 68. Findings include: 1. Review of Resident #14's record revealed an admission date do 10/03/22 with the diagnoses of paroxysmal atrial fibrillation, essential hypertension, a history of falling, muscle weakness, and unspecified fall, subsequent encounter. Review of Resident #14's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22, revealed the resident was cognitively independent, needed extensive assistance of one person to assist with bed mobility, and needed limited assistance of one person to assist with transfer and toilet use. Review of Resident #14's bed rail assessment dated [DATE] revealed it was not completed. Review of Resident #14's current physician orders revealed no order for use of bed rails.…

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 and interview, the facility failed to ensure Resident #26 did not receive excessive doses of antibiotics. This affected one (Resident #26) of two residents reviewed for antibiotic use. The facility identified six additional residents receiving antibiotics at the time of the survey (Residents #12, #22, #31, #70, #133 and #284). Facility census was 68. Findings include: Review of Resident #26's medical record revealed diagnoses including peripheral vascular disease, arthritis, anemia and depression. On 08/29/22, an order was written for administration of cephalexin (antibiotic) 500 milligrams (mg) four times a day for a wound to start 09/01/22. The order indicated the stop date for the antibiotic was to be determined at the next wound appointment. A wound center note dated 08/31/22 indicated Keflex was ordered by the Infectious Disease doctor. An order from the Infectious Disease doctor dated 08/31/22 indicated cephalexin 500 mg was to be administered three times a day. There was no evidence the order from the Infectious Disease doctor was transcribed or…

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

Based on observation and staff interview the facility failed to ensure ophthalmic (eye drops) medication was dated as to when opened and discarded after eight weeks. This affected one of 10 residents receiving eye drops, Resident #11. Findings include: Observation of medication storage on 01/11/23 at 9:39 A.M. with Registered Nurse (RN) #478 revealed one bottle of latanoprost eye drops for Resident #11 with a handwritten date of 10/31 with no year indicated. The pharmacy sticker on the bottle indicated to discard six weeks after opening if not refrigerated. RN #478 verified the latanoprost eye drops should have been discarded. Review of manufacturer guidelines for the storage and handling of latanoprost eye drops revealed unopened bottle should be stored refrigerated at 36 degrees Fahrenheit (F) to 46 degrees F. Once a bottle is opened it may be stored at 36 degrees F to 77 degrees F for eight weeks. Protect from light. Protect from freezing. Interview on 01/11/23 at 9:45 A.M. with Pharmacy Technician #701 indicated all eye drops were to be discarded after six weeks if not stored 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and interview, the facility failed to ensure appropriate infection control measures were implemented during dressing changes and pericare. This affected one (Resident #31) of two residents reviewed for pressure ulcers and one (Resident #57) resident observed for incontinence care. The facility census was 68. Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, legal blindness, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the 09/26/22 Quarterly Minimum Data Set Assessment revealed Resident #31 was independent for daily decision making, required extensive assistance of two staff members for bed mobility, was incontinent of bladder and bowel,…

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 facility policy review the facility failed to ensure sufficient information was obtained prior to initiation of antibiotics. This affected two Residents (#70 and #286) of four residents reviewed for infections. The facility census was 68. Findings include: 1. Review of Resident #70's record revealed the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, chronic kidney disease, intervertebral disc disorders with myelopathy thoracic regions. Review of Resident #70's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/13/22, revealed she was cognitively independent. Resident #70's most recent readmission to the facility was on 12/30/22. Review of Resident #70's nursing progress notes revealed she returned to the facility from an acute care facility on 12/12/22. Review of Resident #70's physician order, dated 12/12/22, revealed Daptomycin Solution Reconstituted (an antibiotic) 500 milligrams (mg), use 500 mg…

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 the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent contamination. This had the potential to affect 114 of 114 residents receiving nutritional services from the kitchen. The facility identified seven residents (#32, #56, #68, #90, #93, #102 and #117) not receiving nutritional services from the facility kitchen. The facility census was 121. Findings include: Observation of the kitchen on 03/10/2020 at 10:45 A.M. revealed a suspended heating unit above the food cook/prep area with a large amount of dust and grease build up and an extremely dirty air filter. Additional observation of the flat top back splash also revealed a moderate amount of grease and dust build up. Additional observation and interview with Dietary Staff #121 on 03/11/2020 at 9:00 A.M. verified the grease and dust to the suspended heating unit, dirty air filter to the heating unit and greasy and dusty flat top back splash.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure Hospice care was accurately reflected, care planned and coordinated for Resident #427 and failed to ensure an effective bowel regimen and/or bowel monitoring was completed for Resident #64, Resident #90 and Resident #110. This affected one resident (#427) of one resident reviewed for Hospice services and three residents (#64, #90 and #110) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #427 was admitted to the facility on [DATE] with stage four chronic kidney disease. Medical record documentation revealed the resident was admitted with Hospice services. However, further review of Resident #427's medical record revealed no evidence of a Hospice certification. There was no evidence the type of Hospice services the resident required including frequency of nursing, aides, chaplain or social service visits. Interview on [DATE] from 11:15 A.M. to 12:44 P.M. with Registered…

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 ensure Resident #64 was provided the right to participate in the development and implementation of her person-centered plan of care. This affected one resident (#64) of two residents reviewed for care conferences. Findings include: Review of Resident #64's medical record revealed an admission date of 09/15/19 with diagnoses which included heart disease, chronic kidney disease stage 2 and diabetes mellitus type II. Review of Resident #64's most current Minimum Data Set 3.0 assessment revealed the resident was cognitively intact. Interview on 03/09/20 at 11:14 A.M. with Resident #64 revealed she had never been to a care conference or any type of meeting regarding her care since admission. Interview on 03/11/20 at 11:41 A.M. with Social Service Worker #19 revealed the facility had not set up quarterly care conferences for the resident as of this date and she must have been missed since her admission in September 2019. Review of the facility policy titled, Care Plan Conference Policy, dated 11/28/16 revealed 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, interview and policy review the facility failed to ensure Advanced Directives were consistent between facility documentation and accurately reflected on Resident #64, #107 and #110's medical chart. This affected three residents (#64, #107 and #110) of five residents reviewed for advanced directives. Findings include: 1. Review of Resident #64's medical record revealed an admission date of [DATE] with diagnoses that included hypertension, chronic obstructive pulmonary disease (COPD) and chronic pain. Review of the resident's [DATE] physician's orders revealed an order dated [DATE] for a DNRCCA code status. However, review of the facility hard/paper chart revealed a paper stating to, Proceed with CPR. Interview on [DATE] at 4:23 P.M. with the DON confirmed the inaccurate/inconsistent code status documentation for Resident #64. Review of the undated facility policy titled Resuscitation Code Status revealed it was the policy of the facility to provide resuscitative efforts, including, but not…

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 Resident #15 and Resident #117, remaining in the facility received the required liability notices once Medicare Part A services ended. This affected two residents (#15 and #117) of three residents reviewed for liability notices. Findings include: 1. Review of Resident #117's medical record revealed an admission date of 08/13/19 with diagnoses that included chronic respiratory therapy, quadriplegia and dysphagia. Review of the Notice of Medicare Non-coverage (NOMNC) revealed the resident's skilled services would end on 12/08/19, and the resident would remain in the facility. It was further noted the facility had not completed and issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) to the resident at the time services ended. Interview on 03/11/20 at 9:22 A.M. with Assistant Administrator #14 confirmed the facility failed to complete and provide a SNFABN to Resident #117 and/or his representative at the time services ended on 12/08/19 as required. 2. Review of Resident #15's 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.

Based on observation, staff interview and policy review the facility failed to ensure Resident #53 and Resident #108's wheelchairs were maintained in a clean and sanitary manner. This affected two residents (#53 and #108) of two residents reviewed for equipment. Findings include: Observation on 03/09/20 at 8:50 A.M.,10:25 A.M. and 3:22 P.M. and on 03/10/20 at 8:24 A.M. revealed Resident #53's wheelchair was observed to be very dirty with dust and food debris on it. Observation on 03/09/20 at 8:33 A.M.,10:41 A.M. and 3:30 P.M. and on 03/10/20 at 8:35 A.M. revealed Resident #108's wheelchair was very dirty with dust, food debris and an unknown white substance on it. Interview on 03/10/20 at 11:42 A.M. with Registered Nurse (RN) #21 verified the condition of Resident #53 and 108's were very dirty. The RN revealed resident wheelchairs were supposed to be cleaned on midnight shift. Interview on 03/10/20 at 4:10 P.M. with the Director of Nursing (DON) revealed the task of cleaning the wheelchairs was given to the housekeepers to free up some tasks from the nursing assistants. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to ensure Resident #53, #107 and #108, who required staff assistance for activities of daily living (ADL) received timely and necessary care to maintain proper grooming/hygiene related to fingernail care. This affected three residents (#53, #107 and #108) of three residents reviewed for ADL care. Findings include: 1. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia without behaviors, major depressive disorder, generalized anxiety disorder, muscle weakness, lack of coordination, chronic venous hypertension, diverticulosis, gastro-esophageal reflux disease, irritable bowel syndrome, pain, edema and constipation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/17/19 revealed Resident #53 had severely impaired cognition and required total assistance from staff for personal hygiene. Review of the nursing progress notes from 01/01/20 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 pressure ulcer treatments and/or pressure revealing interventions were implemented as ordered/care planned. This affected two residents (#115 and #427) of five residents reviewed for pressure ulcers. Findings include: 1. Record review revealed Resident #115 was admitted to the facility on [DATE] with diagnoses including pressure ulcers, type two diabetes, heart disease and difficulty walking. Review of Resident 115's current orders, dated 03/2020 revealed on 02/13/20 orders were received to cleanse pressure ulcer on left great toe daily with normal saline, apply Aquacel AG (absorbent dressing) to wound bed and cover with dry dressing, and apply Kerlix daily. Review of Resident #115's medication/treatment administration record dated 02/13/20 to 03/12/20 revealed no evidence a treatment was administered daily to the left great toe. Observation on 03/12/20 at 10:25 A.M., with Registered Nurse (RN) #401 revealed the resident had an…

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, staff interview and policy review, the facility failed to ensure residents were re-weighed timely when weight loss of greater than five pounds was identified and failed to document residents' meal intakes. This affected two (#37 and #49) five residents reviewed for nutrition. Findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of muscle weakness, edema, malignant neoplasm of the bone, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment, dated 12/08/19 revealed Resident #37 had severely impaired cognition, required supervision with meals, weighed 111 pounds and did not have weight loss. Review of the weights for Resident #37 revealed the following weights: On 09/03/19- 117 pounds On 10/03/19- 115.7 pounds On 11/06/19- 114.6 pounds On 12/03/19- 110.6 pounds On 12/31/19- 111 and 97.8 pounds were both documented (with no reweight of the 97.8 pounds) Review of a weight…

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 ensure weights, fluid restriction monitoring and access site assessments were completed for Resident #59 related to hemodialysis. This affected one resident (#59) of one resident reviewed for hemodialysis. Findings include: Review of Resident #59's medical record revealed an admission date of 12/13/18 with diagnoses that included end stage renal disease, chronic kidney disease stage 4 and diabetes mellitus type II. Review of the resident's 12/29/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact. Review of Resident #59's March 2020 physician's orders revealed the resident was on an 1800 milliliter (ml) fluid restriction and the resident was to receive daily weights. Interview on 03/09/20 at 10:05 A.M. with Resident #59 revealed he had a fistula in his left arm that was used for hemodialysis treatments. The resident reported the nurses only assessed the site sometimes. Review of the Weekly Audit of Dialysis Quality Check Sheets for January, February, and March 2020 revealed…

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, interview and policy review the facility failed to ensure proper infection control practices were maintained following perineal care for Resident #56 to prevent the spread of infection. This affected one resident (#56) of one resident observed for catheter care. Findings include: Review of Resident #56's medical record revealed an admission date of 12/13/19 with diagnoses that included acute kidney failure, neuromuscular dysfunction of the bladder and cerebral infarction. Review of the resident's March 2020 physician's orders revealed the resident had an indwelling urinary catheter that was to be cleansed every shift with peri cleanser. Observation of perineal care on 03/10/20 at 1:06 P.M. revealed State Tested Nursing Assistant (STNA) #50 washed her hands, gathered supplies, applied gloves and began perineal care. After completing perineal care, prior to removing her soiled gloves, STNA #50 began repositioning the resident by lifting his arms onto pillows. She then used the remote on the side of the bed to raise the resident's head of bed 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, interview and policy review the facility failed to ensure Resident #16, who received antibiotics for urinary tract infections was comprehensively assessed to determine appropriate indication for antibiotic use via the antibiotic stewardship program. This affected one resident (#16) of seven residents reviewed for antibiotic use. Findings include: Review of Resident #16's medical record revealed an admission date of 04/06/2018 with admission diagnosis including cerebrovascular accident with hemiplegia. Further review of the medical record revealed antibiotic use on 02/27/2020, 01/31/2020, 09/17/2019, 08/02/2019 and 06/25/2019 for urinary tract infections. However, there was no evidence of any assessment completed to determine the appropriate indication for antibiotic use was found within the medical record. Interview with Resident #16 on 03/09/2020 at 10:55 A.M. revealed she had several urinary tract infections and it would not go away. Review of the facility policy, titled Infection Tracking and Surveillance and Antibiotic Stewardship Policy, dated 01/2020…

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.