Villa Georgetown Rehabilitation And Healthcare Cen

Based on medical record review and staff interview the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (Residents #2 and #45) of three residents reviewed for PASARR documents. The facility census was 73 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/26/11 with diagnoses including psychotic disorder with delusions, dementia without behaviors, major depressive disorder, and hypertension. Review of the PASARR for Resident #2 dated 10/17/11 revealed it did not include the diagnosis of psychotic disorder recorded on the document. Review of the annual Minimum Data Set (MDS) assessment for Resident #2 dated 06/04/24 revealed the resident was severely cognitively impaired, used a wheelchair to aid in mobility, and was always incontinent of bowel and bladder. Interview on 06/27/24 at 10:25 A.M with Director of Business Development (DOB) #142 confirmed Resident #2's PASARR did not include the…

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

Based on medical record review, observation, interviews, and staff interview. the facility failed to ensure care and services were implemented to prevent worsening of contractures. This affected one (Resident #53) of four facility-identified residents with contractures. The facility census was 73 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 02/08/24 with diagnoses including hemiplegia, dysarthria, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #53 dated 05/13/24revealed the resident had mildly impaired cognition and had functional limitation in range of motion to one side of the upper extremities. Review of the active care plans for Resident #53 revealed there was no plan of care developed for contractures or splint/orthotic use. Review of the active physician's orders for Resident #53 revealed there were no orders for the application or removal of splints/orthotics. Review of the occupational therapy (OT) discharge summary for Resident #53 dated 05/02/24 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.

Based on observations, staff interviews, and record review, the facility failed to maintain laundry dryers in a safe manner and prevent a build up of dryer lint in the facility dryers. This had the potential to affect all 81 residents who resided in the facility. Findings include: Observation on 07/22/21 at 11:28 A.M. of Dryer #2 lint screen revealed lint hanging from the lint screen and balled up in the base of the dryer. Interview on 07/22/21 at 11:28 A.M. with Laundry #58 confirmed the lint had built up in the dryer. Laundry #58 stated the dryers were cleaned tree times a day of dryer lint. Observation on 07/22/21 at 11:40 A.M. with Maintenance Director #500 revealed a build up of lint in Dryer #1 with lint collected in soccer size balls under Dryer #1. Interview on 07/22/21 at 11:40 A.M. with the Maintenance Director #500 verified the large amount of lint collected until Dryer #1. He stated the lint trap should be cleaned after every three loads and stated the new linens the facility received gave off more lint than older linens. Review of the laundry staff lint trap signed out…

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 the facility's policy, and resident and staff interviews, the facility failed to develop and implement care plans to address dental care, hospice care, and fluid restrictions. This affected five (#4, #8, #36, #42, and #46) of 19 residents reviewed for care planning. The facility census was 81. Findings include: 1. Medical record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, and personal history of coronavirus (COVID 19). Review of Resident #36's progress note, dated 04/06/21, revealed Resident #36 had seen the dentist briefly, but resident stated he was planning to discharge back to the community, and he wanted to see his own dentist. Review of Resident #36's annual Minimum Data Set (MDS) assessment, dated 06/09/21, revealed the resident was cognitively intact and required supervision with personal hygiene. Resident #36 was reported 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 medical record review, resident interview, and staff interview, the facility failed to ensure the resident was invited to her care plan conference meetings to provide input to her plan of care. This affected one (#32) of three residents reviewed for participation in care planning. The facility census was 81. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, major depressive disorder, and gastro-esophageal reflux disease. The resident was her own responsible party. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/21, revealed the resident had no impaired cognition for decisions. Record review revealed Resident #32 has not been offered to attend care conference meeting within the past 12 months. Interview on 07/19/21 at 2:10 P.M. with Resident #32 reported not attending a care plan meeting once since she was admitted and nothing after that. Interview on 07/21/21…

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, medical record review, and staff interview, the facility failed to ensure a revision was made to a resident' care plan for falls. This affected one (#53) of 19 residents reviewed for care plans. The facility census was 81. Findings include: Medical record review for Resident #53 revealed an admission date of 12/12/16. Diagnoses included arthropathy, muscle weakness, and atrial fibrillation. Review the annual Minimum Data Set (MDS) assessment, dated 07/01/21, revealed the resident was cognitively intact. Review of the care plan, dated 12/11/20, revealed the resident was at high risk for falls related to muscle weakness, diabetes, depression, heart disease, anemia, and chronic pain. Interventions included for staff to ensure the resident has slipper socks on when in bed, a floor mat by her bed, and non-skid socks always when not wearing shoes. Observations on 07/20/21 at 2:15 P.M. and on 07/21/21 at 1:15 P.M. revealed Resident #53 was in bed and had no fall mat in place and no non-skid socks on feet Observation on 07/21/21 at 1:24 P.M., revealed Licensed…

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 resident and staff interviews, the facility failed to provide activities of daily living (ADL) for for residents who were dependent on staff for their care. This affected three (#16, #39, and #277) of seven residents reviewed for ADLs. The facility census was 81 residents. Findings include: 1. Record review for Resident #39 revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, multiple sclerosis, aphasia, hallucinations, epilepsy, and dementia. Review of the ADL plan of care, dated 01/09/21, revealed the resident was a two-person physical assistance for bathing. Review of the five-day Minimum Data Set (MDS) assessment, dated 07/14/21, revealed the resident had severely impaired cognition and required an extensive assistance of one staff person for bathing. Review of the facility's bath record for Resident #39 revealed a shower was given on 07/14/21…

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 interviews, the facility failed ensure resident oxygen tubing was changed per the physician orders. This affected two (#12 and #35) of three residents reviewed for respiratory care. The facility identified 15 residents who utilized oxygen. The facility census was 81. Findings include: 1. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic respiratory failure with hypoxia, and other asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/08/21, revealed the resident was moderately cognitively impaired. Review of the physician's order, dated 06/21/21, revealed Resident #35 was ordered to have his oxygen tubing changed weekly. Review of the Treatment Administration Record (TAR), dated July 2021, revealed Resident #35 was ordered to change his oxygen tubing weekly every night shift, every Thursday. Resident #35 had his oxygen tubing changed on 07/08/21 and 07/15/21…

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

Based on staff interview and record review, the facility failed to have written authorization to handle a resident's personal funds. This affected one (Resident #8) of five residents reviewed for resident accounts. The facility identified 37 residents with personal funds account. The facility census was 70. Findings include: Review of Resident #8's medical record revealed an admission date of 12/11/18. Diagnoses included schizophrenia, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) assessment, dated 12/27/19, revealed the resident was severely cognitively impaired. Review of the undated 'Resident Fund Management' services form on 03/12/20 at 3:16 P.M. revealed there was not a signature for the facility to handle Resident #8's funds. Review of Resident #8's Resident Statement Landscape on 03/12/20 revealed her account was opened on 01/20/20 and had a current balance of $969.04. Interview with Business Office Worker #88 on 03/12/20 at 3:16 P.M. verified Resident #8's account was opened since 01/20/20 and the facility did not have a signed authorization to handle…

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

Based on medical record review, staff interview, and facilities policy review, the facility failed to update and revise a resident's care plans. This affected one (Resident #226) of 20 residents reviewed for care plan accuracy. The facility census was 70. Findings include: Review of the medical record for Resident #226 revealed a re-admission date of 03/05/20. Diagnoses included dementia, anxiety, bipolar, hypertension and diabetes mellitus. Review of the nursing re-admission assessment, dated 03/05/20, revealed Resident #226 had two stage one pressure ulcers to the left and right buttock (intact skin with non-blanchable redness of a localized area), and three unstageable pressure areas (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) to the left great toe and to the left and right heels. Review of the wound assessment, dated 03/05/20, revealed Resident #226 had an unstageable area to the left great toe, an unstageable area to her right heel and had a stage two pressure ulcer to his left buttock. There was a reddened area…

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, observations, staff interview and policy review, the facility failed to timely dispose controlled substances after resident's were discharged . This affected two (#230 and #229) of three controlled substance medication administration records reviewed. Facility census was 70. Findings include: Review of Resident #230 medical record, revealed an admission date of [DATE]. Diagnoses include Alzheimer. Review of the physician orders revealed an order for tramadol. Further review of the record revealed Resident #230 on respite care and discharged to home on [DATE]. Review of discharged Resident #230 medication administration record (dated February 2020) on [DATE], revealed last documented dose of controlled substance on [DATE] at 9:10 A.M., leaving four tablets of tramadol in the blister pack. Review of Resident #229 medical record, revealed an admission date of [DATE]. Diagnoses include dementia, quadriplegia, cerebral infarction, and encephalopathy. Review of the physician orders…

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 staff interview, the facility failed to timely respond to monthly pharmacy recommendations. This affected two (#74 and #75) of five residents reviewed for pharmacy recommendations. Facility census was 70. Findings include: 1. Record review of Resident #74 revealed an admission date of 11/11/19. Diagnoses include type two diabetes mellitus, hypertension, gastro-esophageal reflux disease, anemia, hyperlipidemia, major depressive disorder, congestive heart failure and anxiety disorder. Review of the 02/25/20 quarterly Minimum Data Set (MDS) revealed Resident #74 was cognitively intact and required total dependence for bed mobility, transfer, and toilet use, She required extensive assistance for personal hygiene, dressing and locomotion off unit. Review of the 12/13/19 Monthly Pharmacy Review revealed Resident #74 was prescribed Promethazine (an antiemetic drug) for treatment of nausea/vomiting. The drug is currently listed on beers list as an inappropriate drug to use in geriatric patients. The form was not seen by the physician until 02/26/20. 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.