Embassy Of Lebanon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, interviews and policy reviews the facility failed to ensure urinary catheter care was provided in a dignified manner. This affected one (#19) out of three residents reviewed for resident rights. The facility census was 63. Findings include Review of medical record for Resident #19 revealed an admission date of 12/11/23. Diagnoses included neuromuscular dysfunction of bladder, inflammatory disorder of male genital organ, cystitis without hematuria, tracheostomy, and obstructive and reflux uropathy. Review of Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed an resident was cognitively intact. Resident #19 was substantial maximal assistance for toileting, and bathing. Resident #19 was coded with placement if an indwelling urinary catheter. Review of plan of care dated 09/19/24 revealed that Resident #19 was at risk for potential for complications related to the use of suprapubic catheter related to neurogenic bladder. Interventions included change…

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 interviews, the facility failed to ensure urinary catheter care was completed and documented as ordered. This affected one (#64) of three residents reviewed for catheter care. The facility census was 63. Findings include: Medical record review for Resident #64 revealed an admission on [DATE] and a discharge on [DATE] with diagnoses including but not limited to infection and inflammatory reaction due to other urinary catheter, neuromuscular dysfunction of the bladder, quadriplegia and history of sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed an intact cognition. Resident #64 was coded with delusions. Resident #64 was dependent on staff for eating, bed mobility, transfers and toileting. Resident #64 was assessed as having a urinary suprapubic catheter and a colostomy. Review of the plan of care for Resident #64 dated 05/21/24 revealed a potential for complications related to use of suprapubic catheter due 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, observation, staff interview and policy review, the facility failed to follow the physician orders for medication administration. This affected two (#30 and #64) of four residents reviewed for medication administration. The facility census was 63. Findings include: 1. Medical record review for Resident #30 revealed an admission on [DATE] with diagnoses of insomnia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 revealed a moderately impaired cognition. Resident #30 requires staff assistance for the completion of activities of daily living. Review of the physicians orders for Resident #30 revealed an order dated 10/04/24 and a for melatonin oral tablets 3 milligrams with directions for administration to give 3 mg by mouth at bedtime for insomnia and an order dated 07/03/24 for melatonin oral tablets 3 mg with directions to administer 3 tablets by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for the month of October…

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, review of medication manufacturer instructions, and review of facility policy, the facility failed to ensure a staff member primed (performed a safety test) when using an insulin pen-injector, resulting in a significant medication error. This affected one (#2) of five residents observed for medication administration. The facility census was 63. Findings include: Review of Resident #02's medical record revealed an admission date of 09/19/24. Diagnoses included type one diabetes mellitus. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was cognitively intact and received insulin injections. Review of the physician orders for Resident #02 revealed orders dated 11/07/24 for Lantus SoloStar Subcutaneous Solution Pen-injector 100 units per milliliter (long-acting insulin) inject 45 units subcutaneously when rising for diabetes mellitus and Humalog kwik pen Subcutaneous Solution pen injector 100 unit/ml inject per…

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, staff interviews and policy review, the facility failed to ensure staff accurately documented dietary intake of meals. This affected one (#64) of three residents reviewed for staff assistance with dietary intake. The facility census is 63. Findings include: Medical record review for Resident #64 revealed an admission on [DATE] and a discharge on [DATE] with diagnoses including but not limited to quadriplegia and history of sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed an intact cognition. Resident #64 was coded with delusions. Resident #64 was dependent on staff for eating, bed mobility, transfers and toileting. Review of the plan of care for Resident #64 is at risk for self care deficit related to diagnoses sepsis, paraplegia due to post motor vehicle accident and chronic pain. Resident is alert and oriented times three, communicates needs effectively, and requires total assistance with activities of daily living. Review of 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 observation, record review and staff interview the facility failed to ensure medication error rates were less than 5% when they gave Resident #39 the wrong medication and Resident #38 blood pressure medication was not held for low blood pressure. This affected two (Resident #38 and #39) of four residents observed for medication administration. There were two errors out of 25 opportunities for a medication error rate of 8 %. The facility census was 58. Findings include: 1 Record review of Resident #38 revealed an admission date of 01/19/21 with pertinent diagnoses of: hypertension, cognitive communication deficit, hyperlipidemia, and dementia. Review of the 07/26/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and used a wheelchair to aid in mobility. Review of the Physician Order dated 03/26/24 revealed Norvasc (a blood pressure medication) five milligrams by mouth one time a day for hypertension. Hold for systolic pressure under 110. Observation of a medication administration pass for Resident #38 on 10/08/24 at 8:50…

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 reviews, observations, staff interviews, and policy review, the facility failed to follow infection control procedures. This affected two (#10 and #13) residents out of the three residents reviewed. The facility census was 58. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 03/20/23 with medical diagnoses of anoxic brain damage, anxiety, dependence on ventilator, tracheostomy, and seizures. Review of the medical record for Resident #10 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #10 was rare/never understood or able to understand others. The MDS indicated Resident #10 was dependent upon staff for all activities of daily living (ADLs). Review the MDS revealed Resident #10 had a gastrointestinal tube (g-tube), tracheostomy, and was on a mechanical ventilator. Review of the medical record for Resident #10 revealed a physician order dated 06/26/24 for Enhanced Barrier Precaution (EBP) related to…

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

Based on observations, staff interview and policy review, the facility failed to ensure foods were labeled and dated and failed to ensure expired foods were discarded in resident refrigerators. Additionally, the facility failed to ensure kitchen equipment was maintained in sanitary condition. This had the potential to affect 56 out of 58 residents who received food from the kitchen, the facility identified two (#3 and #53) residents who do not receive their food/meals from the kitchen. The facility census was 58. Findings include: Observation on 10/05/22 at 10:00 A.M. revealed the kitchen hood screens above the cooking surfaces of the stove and grill had a coating of heavy grease and dusty debris. The hood cleaning sticker on the side of the hood revealed the next scheduled cleaning was to be on 09/20/22. Observation on 10/05/22 at 12:23 P.M. revealed a sign on the refrigerator stating label and date each item before putting in the fridge. After three days throw away. The following concerns were identified in the resident [NAME] Unit refrigerator: 1. Three open containers of juice…

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, and staff interviews, the facility failed to complete repairs to ensure a safe and comfortable environment for two (Residents #24 and #12) of four residents reviewed for environment. The facility census was 58. Findings include: 1. Record review of Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, neurocognitive disorder with Lewy Bodies, diabetes, hemiplegia, dementia, dysphagia, cognitive communication deficit, and acute kidney failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #24 had intact cognition. Observations on 10/04/22, 10/05/22, and 10/06/22 from 8:00 A.M. to 4:30 P.M. revealed in Resident #24's room, wallpaper was pulled away from the wall above the resident's head. The bathroom had holes and wall patching in the wall across from the toilet. There were four to five window blind slats preventing privacy for the resident when closed.…

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 and resident interview, the facility failed to ensure residents received timely assistance to transfer out of bed. This affected one (#33) of five residents sampled for activities of daily living (ADL) assistance. The facility census was 58. Findings include: Review of the medical record for the Resident #33 revealed an admission date of 09/01/2021. Diagnoses included but were not limited acute and chronic respiratory failure with hypoxia, type II diabetes, unspecified systolic heart failure, morbid obesity, unspecified bipolar disorder, irritable bowel syndrome, and unspecified schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #33 was a one to two-person physical assist, required limited assistance for bed mobility, total assistance for transfers, extensive assistance for dressing, toileting, and personal…

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 and staff interview, the facility failed to ensure a residents indwelling urinary (Foley) catheter bag was timely emptied and not being stored on the floor. This affected one (#12) of five residents reviewed for urinary catheter care. The facility census was 58. Findings Include: Record review of Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #12 included osteomyelitis left ankle and foot, diabetes, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and was receiving medications insulin, Aquaphor, Zofran, and mirtazapine. The resident was currently receiving Macrobid antibiotic for urinary tract infection and had an order for a urinary catheter. Further review of Resident #12's medical record revealed the resident had an physician orders for an indwelling urinary (Foley) catheter. 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 medical record review, observation, staff and resident interviews and policy review, the facility failed to ensure residents had mediations available as ordered. This affected one (#33) of five residents reviewed for medication administration. The facility census was 58. Findings include: Review of the medical record for the Resident #33 revealed an admission date of 09/01/2021. Diagnoses included but were not limited acute and chronic respiratory failure with hypoxia, type II diabetes, unspecified systolic heart failure, morbid obesity, unspecified bipolar disorder, irritable bowel syndrome, and unspecified schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #33 was a one to two-person physical assist, required limited assistance for bed mobility, total assistance for transfers, extensive assistance for dressing, toileting, and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and observation, the facility failed to ensure residents with broken or decayed teeth were provided dental services. This involved three (Residents #12, #39, #46) of three residents reviewed for dental care. Findings include: 1. Resident # 12 was admitted to the facility on [DATE]. Review of the admission minimum data set (MDS) assessment dated [DATE] identified Resident #12 as having intact cognition. The resident had obvious or likely cavities and broken teeth however had no mouth or facial pain or difficulty chewing. On 09/11/19, the facility completed an dental evaluation which identified Resident #12 had broken and missing teeth and only eight natural teeth. The physician wrote an order the resident may see the dentist. During interview on 10/28/19 at 4:02 P.M., Resident #12 revealed that he has broken and decayed teeth which hurt when eating. Upon observation, the resident's teeth were black and broken with many missing teeth. Resident #12 said he had not seen the dentist…

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 2. During observation on 10/28/19 at 12:19 P.M., Resident #61 was sitting at the dining room table sleeping. There were 13 other residents in the dining room eating their lunch except for Resident #61. Some of the residents were finishing up their meal or leaving the dining room. Resident #61 had a cup of coffee and a cup of lemonade in front of her. STNA #23 was feeding Resident #17 and STNA #24 was feeding Resident #32. Both STNA's were sitting behind Resident #61. During interview on 10/28/19 at 12:25 P.M. STNA #23 and #24 stated Resident #61 had not eaten and was waiting for her meal. At 12:30 P.M., STNA #23 served the resident her meal. During interview on 10/28/19 at 2:00 P.M., the Director of Nursing stated all meals should be served to all residents in the dining room before staff assist with feeding. Based on record review, observation, and staff interview, the facility failed to ensure residents were dressed during the day and failed to provide a dignified dining experience during lunch. This affected…

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 2. Resident #27 was admitted to the facility on [DATE]. Diagnoses included history of falling, dementia, major depression and muscle weakness. Review of the MDS assessment dated [DATE] documented impaired cognition, required extensive assistance of one person for bed mobility, transfer, and used a wheelchair to move about the facility on her own. During observation on 10/28/19 at 11:07 A.M., the resident was being assisted to get into her room. The roommate's wheelchair was up against Resident #27's bed, preventing her from wheeling over to her bed or being able to get in it. There were several pieces of equipment on the roommate's side including an over bed table and an oxygen concentrator. during observation on 10/28/19 at 11:16 A.M., Resident #27 could not navigate around her room as there was too much equipment cluttered throughout her room. The roommate's wheelchair continued to be right next to Resident #27's bed. At 1:30 P.M., the roommate's wheelchair was still up against the bed behind the privacy…

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, resident interview, family interview, hospital record review and outside clinical staff interview, the facility failed to ensure a resident could timely see a provider of their choice; and failed to ensure a resident was assisted to the bus on his outside workshop days. This affected two (Residents #36 and #62) of 25 sampled residents. The facility census was 64. Findings include: 1. Record review revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, anxiety disorder, and major depressive disorder. Review of the admission minimum data set (MDS) assessment, dated 09/18/19, revealed Resident #36 had intact cognition, required extensive assistance from staff for bed mobility, transfer and toileting. Review of the nursing notes dated 10/25/19 revealed the resident had complained of shortness of breath and chest pain. An assessment was completed and she was sent to the local…

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 identify the Preadmission Screening and Resident Review (PASRR) captured a resident's mental illness diagnosis. This affected one (Resident #42) of 25 sampled residents. The facility census was 64. Findings include: Record review revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, cognitive communication deficit, and osteoarthritis. Review of the level one PASRR screening dated 03/26/19 documented the resident had no mental illness or Alzheimer's disease, therefore the level two screening was not completed. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented a diagnosis of schizophrenia. During interview on 10/30/19 at 10:40 A.M., the Administrator and Admissions Coordinator #42 stated the mental illness diagnoses was not captured on the screening.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff and resident interview, the facility failed to implement a care plan for impaired vision. This affected one (Resident #47) of one resident reviewed for vision. The facility census was 64. Findings include: Review of medical record for Resident #47 revealed the resident was admitted to the facility on [DATE]. Review of the care plan dated 05/31/19 stated to apply eye glasses in A.M. and remove at bedtime. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] identified adequate vision with corrective lenses. During observation on 10/30/19 at 9:45 A.M., Resident #47 was watching television without wearing her eye glasses. The eye glasses were on the night stand and the resident was not able to reach them. During interview on 10/30/19 at 9:46 A.M., Resident #47 stated she could enjoy television more if she could see it. During observation on 10/30/19 at 12:24 P.M., Resident #47 was in bed with food next her on the bed side table. Her eye glasses were…

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 staff interview, the facility failed to ensure residents were dressed during the day, clean, and had oral care completed. This affected one (Resident #33) of 25 sampled residents. The facility census was 64. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, pemphigus vulgaris (is a rare autoimmune disease that causes painful blistering on the skin and mucous membranes), Alzheimer's and severe intellectual disability. Review of the quarterly minimum data set (MDS) assessment dated [DATE] documented he had impaired cognition, required extensive assistance of two people for activity of daily living, was independent with eating and had open lesions. Shower sheets dated 10/26/19 and 10/29/19 had no documentation to support he had gotten his scheduled twice weekly showers. Nursing notes dated 10/01/19 to 10/31/19 revealed Resident #33 was having a flare up of his skin condition. Review of the plan 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 observation, record review and interview the facility failed to ensure a nurse did not touch medications with her bare hands, failed to ensure a multi-dose inhaler was sanitized when it fell on the floor and failed to ensure an leg strap for an indwelling urinary catheter was changed when it became soiled. This affected one (Resident #12) of two residents reviewed. Findings include: Resident # 12 was admitted to the facility on [DATE]. The resident had an indwelling urinary catheter. During observation of medication pass on 10/28/19 at 8:35 A.M., Licensed Practical Nurse (LPN) #22 removed six medication cards and popped one tablet of medication into her hand prior to putting the medication in the cup. She then used her ink pen to poke holes in a packet of Protonix powder because she did not have scissors to cut open the packet. LPN #22 had the resident's inhaler in her hand and dropped it on the floor as she entered the resident's room to administer his medications. The cap came off, exposing the mouth…

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, record reviews and staff interviews, the facility failed to ensure residents receiving oxygen therapy had clean disposable oxygen supplies for six residents (#32, #45, #27, #261, #48, #30) residents and failed to ensure to post signage on doors of residents receiving oxygen therapy. This affected four residents (#32, #27, #261, and #4) of 12 residents (#33, #23, #29, #57, #52, and #211) receiving oxygen therapy within the facility. The facility census was 62. Findings include: 1. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic ischemic heart disease, anxiety disorder, dementia without behavioral disturbance, atherosclerotic heart disease, cognitive communication deficit, and malignant neoplasm of the large intestine. Observation of Resident #32 on 08/06/18 at 9:00 A.M., revealed two oxygen concentrators were in the room, one of which was near the resident's bed and had an undated saline humidifier bottle and 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 record review, observation, resident and staff interviews, the facility failed to assess residents for their preferences for a dignified existence. This affected two, (#8 & #49) of five residents reviewed for choices. Facility census was 62. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 06/15/18 with diagnoses including but not limited to intracerebral hemorrhage, attention deficit hyperactivity disorder, hypertension, hemiplegia, gastroesophageal reflux disease, major depressive disorder, contracture of left hand, and metabolic encephalopathy. Review of the residents Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, incontinent of bowel and bladder, and required extensive assistance of one to two staff for all activities of daily living. Observation on 08/07/18 at 12:01 P.M. revealed Resident #49 was up in a wheelchair in her room waiting for lunch. Observation on 08/08/18 at 7:25 A.M. revealed Resident #49 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview , Self-Reported Incident (SRI) review and policy review, the facility failed to report an allegation of staff to resident abuse to the administrator and the state agency when a resident expressed a staff member threatened her with physical harm. This affected one (Resident #49) of 24 residents reviewed in the initial pool process. Facility census was 62. Findings include: Review of Resident #49's medical record revealed an admission date of 06/15/18 with diagnoses including but not limited to intracerebral hemorrhage, attention deficit hyperactivity disorder, hemiplegia, major depressive disorder, contracture of left hand, and metabolic encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, incontinent of bowel and bladder, and required extensive assistance of one to two staff for all activities of daily living. Interview on 08/06/18 at 3:25 P.M. with Resident #49 revealed she had concerns with her treatment by…

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, Self-Reported Incident (SRI) review and policy review, the facility failed to implement their abuse policy and report an allegation of staff to resident abuse to the administrator and state agency. This affected one (Resident #49) of 24 residents reviewed in the initial pool process. Facility census was 62. Findings include: Review of Resident #49's medical record revealed an admission date of 06/15/18 with diagnoses including but not limited to intracerebral hemorrhage, attention deficit hyperactivity disorder, hemiplegia, major depressive disorder, contracture of left hand, and metabolic encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, incontinent of bowel and bladder, and required extensive assistance of one to two staff for all activities of daily living. Interview on 08/06/18 at 3:25 P.M. with Resident #49 revealed she had concerns with her treatment by State Tested Nurse Assistant (STNA) #33. Resident…

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 notify a resident, the resident's representative or the Ombudsman of a resident's transfer and the reasons for the resident's transfer to the hospital. This affected one (#62) of three closed records reviewed. The facility census was 62. Findings include: Review of Resident # 62's record indicated the resident was admitted [DATE]. Diagnoses included femur fracture, chronic respiratory failure, Alzheimer's disease, iron deficiency, spinal stenosis, muscle weakness, cognitive communication deficit and dysphagia. The resident was transferred out to the hospital on [DATE] and admitted to the hospital with a diagnosis of sepsis. The resident's record had no evidence that resident, the resident's representative or the Ombudsman had been notified of the residents transfer to the hospital or notified of the reason for the resident's transfer to the hospital. During interview on 08/09/18 at 3:29 P.M. Business Office Manager (BOM) # 7 verified the 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 record review and staff interview, the facility failed to provide written bed hold information to residents upon transfer to the hospital. This affected one (#62) of three closed records reviewed. The facility census was 62. Findings include: Review of Resident # 62's record indicated the resident was admitted [DATE]. Diagnoses included femur fracture, chronic respiratory failure, Alzheimer's disease, iron deficiency, spinal stenosis, muscle weakness, cognitive communication deficit and dysphagia. The resident was transferred out to hospital on [DATE] and admitted to the hospital with a diagnosis of sepsis. The resident's record revealed no evidence that bed hold information was provided to the resident or representative at the time of the transfer to the hospital. During interview on 08/09/18 at 3:29 P.M. Business Office Manager (BOM) #7 verified the facility had not provide the resident or the resident's representative bed hold information upon transfer to the hospital and stated the facility had only…

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 accurately assess one resident's contractures. This affected one (#13) of two residents reviewed for accuracy of resident assessments. The facility census was 62. Findings include: Review of Resident #13's medical record indicated the resident was admitted on [DATE]. Diagnoses included Parkinson's disease, protein-calorie malnutrition, contracture left and right knee, muscle weakness, adult failure to thrive, abnormal posture, contracture of muscle; multiple sites, dysphagia, schizophrenia, bipolar disorder, hyperlipidemia and hypertension. Review of the resident physical therapy evaluation and plan dated 09/27/17 indicated the resident had impaired range of motion (ROM) in both her lower right and left knees and impaired ROM range of motion of both her right and left hands. Review of therapy screen dated 03/22/18 indicated the resident had no changes to her ROM. Review of a occupation therapy (OT) assessment dated [DATE] indicated the resident…

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, resident and staff interview, the facility failed to provide an adequate and accurate care plan for one (Resident #45) of twenty residents reviewed during the investigation phase. The facility identified one resident (Resident #45) receiving dialysis. The facility census was 62. Findings include: Resident #45 was admitted to the facility on [DATE] with a brief interview mental status (BIMS) score of 15 indicating resident was cognitively intact. The resident was admitted with diagnoses including diabetes, congestive heart disease and chronic kidney disease. The minimum data set (MDS) dated [DATE] identified Resident #45 receives dialysis. Resident #45's care plan, related to dialysis, dated 05/23/18 revealed the care plan identified blood pressure should not be taken in arm with graft and did not identify left or right arm. The care plan did not identify the dialysis access site. The care plan did not identify the name of the dialysis provider, location, contact information…

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 revise one resident's care plan to address the care of the resident's contractures. This affected one (#13) of 20 residents reviewed during the investigation stage. The facility census was 62. Findings include: Review of Resident #13's medical record indicated the resident was admitted on [DATE]. Diagnoses included Parkinson's disease, protein-calorie malnutrition, contracture left and right knee, muscle weakness, adult failure to thrive, abnormal posture, contracture of muscle; multiple sites, dysphagia, schizophrenia, bipolar disorder, hyperlipidemia and hypertension. The resident's minimum data set (MDS) assessment dated [DATE] indicated the resident required extensive to total dependence with activities of daily living and had functional limitation in range of motion on one side of her upper extremities. The assessment did not indicate the resident had any functional limitation in range of motion if either of her lower extremities. 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 observation, resident and staff interview and record review the facility failed to provide adequate dialysis care, including the monitoring of the dialysis access site, to one resident (Resident #45). Resident #45 is the only resident at the facility receiving dialysis. The facility census is 62. Findings include: Resident #45 was admitted to the facility on [DATE] with a brief interview mental status (BIMS) score of 15 indicating resident was cognitively intact. The resident was admitted with diagnoses including diabetes, congestive heart disease and chronic kidney disease. The minimum data set (MDS) dated [DATE] identified Resident #45 receives dialysis. Resident #45's care plan, related to dialysis, dated 05/23/18 revealed the care plan identified blood pressure should not be taken in arm with graft and did not identify left or right arm. The care plan did not identify the dialysis access site. The care plan did not identify the name of the dialysis provider, location, contact information or chair…

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 interviews, the facility failed to ensure a resident's drug regimen was free from unnecessary medications by not adequately monitoring the resident and by not attempting non-pharmalogical interventions prior to administration of pain medication. This affected one resident (#30) of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses of essential hypertension, dementia without behavioral disturbances, dysphagia, paranoid personality disorder, functional intestinal disorder, lumbosacral fractures of spine and pelvis, anxiety disorder, and hypothyroidism. Review of Medication Administration Record (MAR) for August, 2018 noted an order was written by the resident's physician on 09/01/17 for Lasix 20 milligrams by mouth one time a day for diuretic, hold if blood pressure was less than 100/50. Blood pressure was not documented for…

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, staff interview and review of Medscape Medication information, the facility failed to use antipsychotic medication to treat an appropriate specific diagnosed condition. This affected one (Resident #19) of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with a brief interview mental status (BIMS) score unable to be completed. The resident was admitted with diagnoses including epilepsy, anxiety disorder and Alzheimer's Disease. The minimum data set (MDS) dated [DATE] revealed resident #19 received an antipsychotic medication. Additionally, the MDS identifies Resident #19 to has a diagnosis of anxiety disorder and Alzheimer's Disease. Resident #19's MDS does not identify a psychotic disorder or mood disorder. A care plan dated 7/3/18 relative to psychotropic medications revealed individualized interventions related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, the facility failed to ensure outside resources were provided when a urology consultation was ordered and an appointment was not made. This affected one resident (#23) of one resident reviewed for urinary catheters. The facility census was 62. Findings include: Review of Resident #23's medical record revealed the resident was admitted on [DATE] with diagnoses of chronic kidney disease stage four, flaccid hemiplegia affecting right dominant side, sepsis, cognitive communication deficit, cerebral infarction, type two diabetes, neuromuscular dysfunction of bladder, benign prostatic hyperplasia, hypocalcemia, diabetic neuropathy, essential hypertension, altered mental status, and supra-pubic catheter. Review of Resident #30's medical record revealed an order written by the resident's physician on 07/27/18 to schedule a urology follow-up as soon as possible. Interview of with Resident #23's family member on 08/08/18 at 2:00 P.M. revealed the resident had an order for a…

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