Kenton Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to implement fall interventions to potentially prevent falls. This affected one (Resident #90) of two residents reviewed for falls. The facility census was 100. Findings include: Review of the medical record for Resident #90 revealed an admission date 03/07/23. Diagnoses included traumatic subarachnoid hemorrhage, syncope and collapse, hearing loss bilateral, dementia, dysphagia, Alzheimer's Disease with late onset, and fall. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #90 had severely impaired cognition. The resident required extensive assistance of one person for bed mobility, walk in room, and dressing. The resident required extensive assistance of two persons for transfers. The resident had one fall with no injury since admission, reentry, or prior assessment. Review of the nursing note dated 07/03/23 at 1:30 P.M. revealed Resident #90 was wandering in front of the building in the main common…

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, staff interview, and facility policy review, the facility failed to properly administer medications via enteral gastrostomy tube. This affected one (Resident #74) of one resident reviewed for medication administration via gastrostomy tube. The facility census was 100. Findings include: Review of the medical record revealed Resident #74 was admitted on [DATE]. Diagnoses included Huntington's chorea, Alzheimer's dementia, Parkinson's disease, adult failure to thrive, aphasia, musculoskeletal impairment, gastrostomy tube, depression, and anxiety. Review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired with never or rarely making decisions. Further review revealed the resident required total dependence of two staff for activities of daily living including dressing, toileting, personal hygiene, bathing, with total dependence of one staff for intake of nourishment, and functional…

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

Based on observation, staff interview, and record review, the facility failed to follow fluid restrictions. This affected one (Resident #23) of one resident reviewed for fluid restrictions. The facility census was 100. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/13/20. Medical diagnoses included End Stage Renal Disease (ESRD), dependence on renal dialysis, diabetes mellitus, and non-compliance with medical regimen or treatment. Review of the physician's orders revealed Resident #23 had an order for a renal diet, with double portions. Additionally, a fluid restriction was ordered for Resident #23 on 06/14/22. The order stated Resident #23 was to be restricted to 1200 milliliters (ml) fluid intake daily. 720 ml total is to be provided by dietary each day, and 480 ml to be provided by nursing daily. The amount provided by nursing was further divided with 360 ml to be provided by nursing staff on the 7:00 A.M. to 7:00 P.M. day shift, and 120 ml to be provided by nursing staff on the 7:00 P.M. to 7:00 A.M. night shift. Observation 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, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #13) of one resident reviewed for significant medication errors. The facility census was 100. Findings include: Review of Resident #13's medical record revealed an admission date of 12/18/20. Diagnoses included paranoid schizophrenia, major depressive disorder, chronic kidney disease stage 3, mild cognitive impairment, alcohol abuse and dysphagia. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #13's Plan of Care (POC) dated 06/24/22 revealed Resident #13 utilized psychotropic medications with interventions to administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. Review of Resident #13's physician orders revealed an order dated 04/14/22 for Haldol Decanoate…

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 interview, review of manufacturer information for insulin, and review of facility policy, the facility failed to ensure insulin vials were labeled with resident names and staff could decipher opening dates vs expiration dates. This had the potential to affect three (Residents #30, #23, and #22) of three residents who received insulin from the 100 medication cart. The facility census was 100. Findings include: Observation on 07/27/23 at 8:01 A.M. of the 100 medication cart revealed five opened bottles of insulin in the top drawer: Humulin R dated 07/25/23, Novolog dated 07/11/23, Humalog dated 07/10/23 and Lispro dated 07/23/23 did not obtain the resident's name, open date, or expiration date. Lantus dated 07/21/23, expiration 08/21/23 did not obtain the resident's name. Interview on 07/27/23 at approximately 8:01 A.M. with Licensed Practical Nurse (LPN) #229 revealed the inability to determine which bottle of insulin belonged to which resident. LPN #229 further stated the inability to distinguish if the dates labeled on the bottles were opening dates 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, staff interview, medical record review, and facility policy review, the facility failed to follow appropriate infection control procedures for a resident with Clostridium difficile (C-diff). This affected one (Resident #298) and had the potential to affect 26 residents who resided on the 100 hall. Additionally, the facility failed to ensure proper infection control procedures were followed during medication administration. This affected one (Resident #346) of five reviewed for medication administration. The facility census was 100. Findings include: 1. Review of the medical record for Resident #398 revealed an admission date of 07/22/23. Medical diagnoses included recurrent Enterocolitis (inflammation of the inner lining of the small and large intestines) due to Clostridium difficile (C-diff, a bacteria that causes diarrhea and inflammation of the colon), intestine transplant status, and arthritis. Resident #398 had a sign on their door to see nurse before entering, contact isolation precautions were in place. Resident #398 resided on the 100-hall. Interview 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, staff interview, and review of the facility's policy, the facility failed to properly label and date opened food items in the upright kitchen refrigerator. This had potential to affect 87 of 88 residents who receive food from the kitchen. The facility identified one resident (Resident #21) did not receive food from the kitchen. Findings include: Observation of the facility's kitchen on 02/10/20 from 8:10 A.M. through 9:30 A.M., revealed an upright refrigerator with an opened block of cheese uncovered set in the original wrapper with no date, a bowl of noodles undated and unlabeled, a container of a dark gravy or meat like substance unlabeled and undated, and a small personal size container of ice cream in the refrigerator. Interview on 02/10/20 at 8:25 A.M. with Kitchen Manager #550 verified the opened block of cheese, undated and unlabeled bowl of noodles, and undated and unlabeled container of dark gravy or meat like substance and ice cream in the refrigerator. Kitchen Manager #550 immediately threw away the ice cream and removed the bowl of noodles. Review…

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, review of facility's maintenance documents, and review of the facility's policy, the facility failed to have appropriate Legionella monitoring. In addition, the facility failed to maintain infection control for one (Resident #26) of four residents observed for medication administration. This had the potential to affect all 89 residents residing in the facility. Findings include: 1. Review of the facility's monitoring control measures to prevent growth and spread of Legionella revealed no evidence of water temperatures being done in rooms or water heaters, no evidence of flushing of resident rooms/unused rooms, no evidence disinfectant level control, and no evidence of environmental testing for pathogens. Interview on 02/13/20 at 4:16 P.M. with Maintenance Supervisor #492 verified there was no evidence of Legionella prevention and Maintenance Supervisor #492 was not aware of the requirement until last month. Review of the facility's policy titled, Legionella Water Management Program, revised July 2017, revealed the water management program…

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 facility record review, observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 89 residents residing in the facility Findings include: 1. Observation of the smoking shelter house for resident use on 02/11/20 at 2:00 P.M. revealed multiple shingles had come off the shelter house and were scattered in the yard around the shelter house. It further revealed a large area on one side of the roof, approximately eight foot square had a bowed in, concave appearance, with the center of the area being more caved in. The underside of the roof from the inside of the shelter house revealed dark rings with open areas in the wood. This area was in close approximation to the deep concave area on the roof. Interview with Maintenance Supervisor #492 on 02/12/20 at 1:10 P.M. verified the roof to the smoking shelter had been leaking for over a year. He verified an area approximately eight foot long by eight foot wide was concave and multiple shingles were lying on the ground. He further verified the smoking shelter…

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 review of the facility's policy, the facility failed to treat residents in a dignified manner during meal times. This affected five residents (Resident #4, #9, #39, #4 #80) observed during meal time. The facility census was 89. Finding include: 1. Observation on 02/10/20 at 12:59 P.M. revealed State Tested Nursing Aide (STNA) #477 was assisting Resident #4 and Resident #80 eat lunch. STNA #477 alternated assisting Resident #4 and Resident #80 with spoonfuls of lunch walking back and forth alternating between residents and standing over them. At 1:02 P.M., Licensed Practical Nurse (LPN) #410 began to assist and STNA #477 sat down with Resident #4 while LPN #410 stood above Resident #80 while assisting him with his meal. STNA #477 and LPN #410 discussed vacations and the soap opera on the television in the dining room. At 1:04 P.M., LPN #438 entered the room and brought a chair to LPN #410. Interview on 02/10/20 at 1:24 P.M. with LPN #410 verified LPN #410 and STNA #477 did stand while assisting Resident #4 and Resident #80 with their meal. 2.…

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, review of the facility's policy and staff and resident interview, the facility failed to ensure residents were provided with comprehensive discharge summaries with the required information upon discharge from the facility. This affected five residents (#136, #137, #138, #139, #141) of six residents reviewed for discharge. The facility identified 20 residents discharged from the facility in the last 60 days. The facility census was 89. Findings include: 1. Review of the medical record for Resident #137 revealed the resident was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses included urinary tract infection, repeated falls, hypertension, anemia, muscle wasting, difficulty walking, joint pain, low back pain, allergic rhinitis, gastro-esophageal reflux disease and urine retention. Review of the discharge return not anticipated Minimum Data Set (MDS) assessment, dated 01/13/20, revealed the resident had intact cognition. The resident required extensive…

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, review of chemical warning labels, staff interview and facility policy review, the facility failed to have safe storage of chemicals. This had the potential to affect nine residents (#32, #33, #51, #58, #32, #36, #49, #33 and #83) who were both cognitively impaired and independently mobile as identified by the facility. The facility census was 89. Findings include: 1. Observation of the central Bath room on the 400 hall revealed the door was unlocked and partially opened. Further observation of a cart in the room revealed an opened container of Sani-cloth bleach germicidal wipes. The container had Caution keep out of reach of children on the label. Interview with Licensed Practical Nurse #444 on 02/12/20 at 1:10 P.M. verified the central bath room was to be locked at all times. She further verified the sani germicidal wipes were a hazardous chemical that was supposed to be locked up at all times and should have been in a locked cabinet. 2. Observation on 02/11/20 at 8:52 A.M. of the central bath located on the 100-hallway revealed the door was not locked.…

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, staff interview, review of manufacturer's recommendations and review of facility policy, the facility failed to properly date and store medications. This affected two of three medication rooms and two of five medication carts. The facility census was 89. Findings include: Observation of the 100 hall medication room on [DATE] at 10:03 A.M. with Registered Nurse (RN) #418 revealed in the refrigerator, there was one opened and undated vial of Tuberculin purified protein. RN #418 verified the Tuberculin purified protein was opened and undated. Observation of the 200 hall medication cart and the 200 hall medication storage room on [DATE] at 10:11 A.M. with Licensed Practical Nurse (LPN) #431 revealed one Albuterol duoneb (treats bronchospasm) vial in the top drawer of the medication cart not in its prescription package and one Bisacodyl (laxative) 10 milligrams (mg.) suppository not in its package. LPN #431 verified the Albuterol was not in a prescription package and Bisacodyl was not in its…

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, resident and staff interview and review of the facility's policy, the facility failed to provide reasonable privacy when a resident's door could not close and not shutting the window curtains when providing care. This affected two (Resident #76 and #85) of 26 residents observed in the initial and final sample pool. The facility census was 89. Findings include: 1. Review of medical record for Resident #85 revealed an initial admission date of 01/29/20. Diagnosis included Alzheimer's disease, vascular dementia with behavioral disturbance, Parkinson's disease, generalized anxiety disorder, psychotic disorder with delusions due to known physiological condition, polyneuropathy and visual hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/05/20, revealed the resident was cognitively intact. The resident required extensive one person assistance with bed mobility, transferring, walking in room and corridor, locomotion off and on the unit, dressing,…

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, staff and resident interviews, and policy review, the facility failed to conduct quarterly care conferences. Additionally, the facility failed to ensure a resident and appropriate/required members of the interdisciplinary team (IDT) were invited to participate in the care planning process. This affected three (#8, #27, and #50) of four resident reviewed for care planning. The facility census was 89. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, venous insufficiency, diabetes mellitus type two, muscle wasting and atrophy, personality disorder, chronic embolism, heart failure, hypertension, chronic obstructive pulmonary disease, osteoarthritis, neuromuscular dysfunction of he bladder, Parkinson's disease, atrial fibrillation, anxiety, tremors, psychosis, morbid obesity, and major depressive disorder. Review of the quarterly Minimum Data…

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, observation, staff interview and facility policy review, the facility failed to complete accurate, routinely wound assessments for Resident #73. This affected one (#73) of four residents reviewed for non-pressure wounds. The facility census was 89. Findings include: Review of the medical record for Resident #73 revealed an initial admission date of 10/23/19. Diagnoses included hemiplegia/hemiparesis, end-stage renal disease, diabetes, morbid obesity, peripheral neuropathy, cellulitis and malignant neoplasm of the bone and articular cartilage. Review of the admission Clinic Health Status form, dated 10/23/19, revealed Resident #73 had a second toe plantar side ulcer and redness of the coccyx noted on the skin assessment. The body diagram identified the toe ulcer on the left foot. There was no other wound assessment information included for the coccyx wound or the foot wound. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview; the facility failed to obtain physician orders and provide care and services for a resident's indwelling urinary catheter. This affected one (#137) of three residents reviewed for urinary catheter. The facility identified eight residents with indwelling urinary catheters. The facility census was 89. Findings include: Review of the medical record for Resident #137 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle wasting, lower back pain and retention of urine. Review of the admission assessment, dated 02/08/20, revealed Resident #137 was admitted to the facility with an indwelling urinary catheter. Review of the medical record for Resident #137, which included admission orders, physician telephone orders, progress notes, the medication and treatment records, dated 02/2020, the 48-hour baseline care plan, and nurse aid activities of daily living tracking form dated 02/2020 revealed there was no evidence of care and services…

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, observations, staff interviews and review of the facility's policy, the facility failed to timely implement nutritional recommendations for the residents. This affected two (#23 and #71) of three residents reviewed for nutrition. The facility censes was 89. Findings Include: 1. Review of the medical record for the Resident #23 revealed an admission date of 12/16/19. Diagnosis included Alzheimer's disease, delirium, dementia, major depressive disorder, type two diabetes mellitus, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 01/01/20, revealed the Resident #23 required set up assistance for eating and substantial to maximal assistance for oral hygiene. Review of the care plan, dated 12/24/19, revealed the resident had imbalanced nutrition related to poor intake. Interventions included the facility would provide and serve supplements as ordered. The care plan was not updated to include the recommendations from 01/30/20 to 02/12/20. Review of the facility's form titled Medical Nutritional Therapy…

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, medical record review and staff interview, the facility failed to change oxygen supplies as physician ordered. This affected one (#8) of two residents reviewed for respiratory care. The facility identified 10 residents who receive respiratory care. The facility census was 89. Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD) and morbid obesity. Review of the plan of care, with implementation date of 10/23/14 with a target date of 02/21/20, revealed the resident had ineffective breathing pattern related to COPD and a history of pneumonia and as evidenced by cough, abnormal lung sounds, and a drop in oxygen saturation during rest and activity. Interventions included continuous oxygen at four liters per minute per nasal cannula and change oxygen supplies every week on Thursday. Review of the treatment administration record (TAR), dated…

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, review of the facility's policy and staff interview, the facility failed to follow a pharmacy recommendation and physician order. In addition, the facility failed to ensure medications were not left unattended at the resident's bedside. This affected one resident (#1) of five residents reviewed for unnecessary medications and affected one (#26) of 26 residents observed on the initial and final sample. The facility census was 89. Findings include: 1. Review of the medical record for the Resident #1 revealed an admission date of 08/08/19. Diagnosis included heart failure, type two diabetes, dysphagia, urgency of urination, benign prostatic hyperplasia, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/12/19, revealed the resident had intact cognition and no behaviors exhibited in the seven-day look-back period. Review of the pharmacy recommendation, dated 10/30/19, for Omeprazole (treats heartburn) 20 milligrams (mg.) capsule to be given by mouth daily and to be taken 30 minutes before meals.…

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, staff interview and facility policy review, the facility failed to maintain a medication error rate less than 5%. There were three medication errors out of 32 opportunities, which was a 9.38% medication error rate. This affected two (#26 and #76) of four residents observed for medication administration. The facility census was 89. Findings include: 1. Observation of medication administration on 02/11/20 at 8:22 A.M. with Registered Nurse (RN) #418 revealed she completed an accucheck with a result of 183 for Resident #76's blood sugar level. RN #418 then obtained medications for Resident #76, including Novolog insulin per flexpen, two units and one multivitamin tablet. RN #418 verified all the medications, then administered Resident #76's medications, including the multivitamin tablet and the insulin per subcutaneous injection at his right mid-abdomen. Review of the most recent recapitulated physician orders, dated 01/22/20 and signed by the physician on 01/28/20, revealed Novolog Flexpen administration to inject subcutaneously per sliding…

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 staff interview, the facility failed to obtained physician ordered laboratory blood tests. This affected one (#8) of five residents reviewed for unnecessary medication. The facility census was 89. Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, venous insufficiency, diabetes mellitus type two, muscle wasting and atrophy, personality disorder, chronic embolism, heart failure, hypertension, chronic obstructive pulmonary disease (COPD), osteoarthritis, neuromuscular dysfunction of the bladder, Parkinson's disease, atrial fibrillation, anxiety, tremors, psychosis, morbid obesity, and major depressive disorder. Review of the physician orders, dated 12/30/19, revealed Resident #8 was to have the laboratory test prothrombin time and international normalized ratio (PT/INR) completed on 01/02/20. (PT/INR is laboratory blood tested used to help detect 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 observation, staff interview and facility policy review, the facility failed to clean and store dishes and utensils under sanitary conditions. This had the potential to affect 92 residents of 92 residents receiving their meals from the facility kitchen. Residents #15 and #67 did not receive meals from the kitchen. The facility census was 94. Findings include: Observations of dish washing on 03/06/19 at 11:17 A.M. revealed Dietary Aid (DA) #222 was handling dirty dishes, rinsing them with water then loading them in trays to wash them in the facility dish machine. DA #222 proceeded to run the dish machine until the were three trays of clean dishes on the clean side of the dish machine. DA #222 then proceeded to clean dishes on the other side of the dish machine without washing her hands. DA #222 emptied the clean dishes from the trays and stacked them for resident use. The dishes included plastic plate holders and metal plate holders that were still wet from the dish machine. RA #222 stacked the metal and plastic plate holders in an up-right position while they were still…

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

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were treated with dignity during their dining experience. This affected one (Resident #30) of three residents observed receiving assistance in the dementia unit dining room. The facility identified 12 residents who were dependent on staff for eating. The facility census was 94. Findings include: Review of Resident #30's medical record revealed an admission date of 09/19/13. Diagnoses included dementia with behavioral disturbance, Alzheimer's disease, chronic obstructive pulmonary disease, dependence on a wheelchair, mental disorder and major depressive disorder. Review of Resident #30's Minimum Data Set (MDS) assessment, dated 01/06/19, revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #30 was unable to complete the interview. Resident #30 was totally dependent on eating and displayed no behaviors during the review period. Interview on 03/05/19 at 3:08 P.M. with State Tested Nursing Assistant (STNA) #200 revealed Resident #30…

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 facility policy review, the facility failed to ensure Advanced Directives listed in the medical record were accurate for Resident #73. This affected one (Resident #73) of 32 residents review for Advanced Directives. The facility census was 94. Findings Include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. Review of Resident #73's current care plan, dated 11/09/18, listed the resident as a full code. Review of Resident #73's physician order, dated 11/03/18, revealed an order for full code. Review of Resident #73's Medication Administration Record (MAR) dated March 2019 under Advanced Directives listed the resident as a full code. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (Resident #73) of six residents reviewed for PASARR. The facility census was 94. Findings include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. The assessment listed the resident as having schizophrenia, bipolar, and depressive disorder. Review of the form titled Hospital Exemption from Preadmission Screening ([NAME]) dated 11/02/18 revealed a diagnosis of schizophrenia. No level two screening had been completed. Interview on 03/07/19 at 2:00 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 medical record review, staff interview and review of social services job description, the facility failed to provide social services to assist in identifying a guardian for a cognitively impaired resident for decision making needs. This affected one (Resident #73) of one resident reviewed for social services. The facility census was 94. Findings include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. The assessment listed the resident as having schizophrenia, bipolar, and depressive disorder. Review of Resident #73's care plan, dated 11/09/18, under discharge planning listed the resident will be discharged to home. The resident had impaired cognition related to mental illness.…

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 review of manufacturer guidelines, the facility failed to properly administer medications to residents. This affected two (Resident #40 and #54) of four residents observed for medication administration. The facility census was 94. Findings include: Observation of the medication pass on 03/06/19 at 7:28 A.M. revealed Licensed Practical Nurse (LPN) #200 administered vilanterol/Fluticasone furoate (Breo Ellipta) (corticosteriod) 25 micrograms (mcg.) with 100 mcg. per inhalation to Resident #40 and did not instruct the resident to rinse his mouth with water and spit it out. Interview on 03/06/19 at 7:28 A.M. with LPN #200 further verified she had not instructed Resident #40 to rinse his mouth and spit after the administration of the inhaled medication. Observation of the medication pass on 03/06/19 at 7:41 A.M. revealed LPN #210 administered Flovent HFA (corticosteriod) 220 mcg. inhalation, one inhalation, to Resident #54 and did not instruct the resident to rinse and spit afterward. Interview on 03/06/19 at 7:44 A.M. with LPN #210 verified 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 record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide residents who required mechanically altered diets with meals of the proper texture. This affected one (Resident #7) of four residents reviewed for nutrition. The facility identified 10 residents who received a mechanically altered diet. The facility census was 94. Findings include: Review of Resident #7's medical record revealed an admission date of 04/12/18. Diagnoses included cerebral infarction, type II diabetes, muscle weakness, moderate protein calorie malnutrition, neuropathy, pseudo bulbar affect and muscle spasms. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 02/22/19, revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #7 was moderately cognitively impaired. Resident #7 received a mechanically altered and therapeutic diet. Resident #7 was totally dependent on staff for eating. Review of Resident #37's care plan updated 02/09/19 revealed supports and interventions for nutrition 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 observation, staff interview, and policy review, the facility failed to maintain infection control practices during medication administration when nursing touched oral medications intended for oral administration. This affected two (Resident #40 and #54) of four residents observed for medication administration. The facility census was 94. Findings include: Observation of the medication pass on 03/06/19 at 7:28 A.M. revealed Licensed Practical Nurse (LPN) #200 touched the Buspar (antianxiety) five milligram (mg.) tablet and the Venlafaxine (antidepressant) 37.5 mg. tablet, intended for Resident #40, with her bare hands. She approached Resident #40 with the medications and was stopped by this surveyor before administering the contaminated medications. Interview on 03/06/19 at 7:28 A.M. with LPN #200 provided verification of the break of infection control practices when she touched the Buspar and Venlafaxine. Observation of the medication pass on 03/06/19 at 7:41 A.M. revealed LPN #210 touched the aspirin 81 mg. tablets intended for administration to Resident #54. 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.