Arbors At Springfield

Based on resident interview, staff interview, and review of staff schedules, the facility failed to ensure adequate staffing to meet residents needs. This had the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed he did not feel the facility had enough staff. Resident #41 stated there were long call light response times and they were longer on the three days per week the facility provided dialysis services. Resident #41 stated there was usually one nurse and one State Tested Nurse Aide (STNA) on each of the two halls. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths once a week and was scheduled to receive showers twice a week. Resident #15 stated there was not enough staff and it sometimes took longer than one hour for staff to respond to call lights. Interview on 12/20/23 at 9:35 A.M. with Registered Nurse (RN) #100 revealed the back hallway (200 hall) was an especially heavy hallway with residents who required a lot of assistance.…

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, resident interview, staff interview, review of Resident Council meeting minutes and review of facility policy, the facility failed to ensure residents had appropriately fitted wheelchairs. This affected one (#15) of three residents reviewed for accommodation of needs. Additionally, the facility failed to timely respond to call lights. This directly affected one (#22) resident, with the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of…

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

Based on medical record review, resident interview, staff interview, review of shower schedules and review of facility policy, the facility failed to ensure residents, who were dependent for care, received showers as scheduled. This affected two (#15 and #21) of three residents reviewed for activities of daily living (ADLs). The facility census was 40. Findings Include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, family interview, and staff interview, the facility failed to ensure transportation was arranged for scheduled outside appointments, resulting in missed appointments. This affected one (#15) of three residents reviewed for transportation needs. The facility census was 40. Findings Include: Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed…

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

Based on medical record review, resident interview, staff interview, review of a medication error investigation and review of facility policy, the facility failed to ensure medications were administered according to physician orders. This affected one (#15) of three residents reviewed for physician orders. The facility census was 40. Findings Include: Review of the medical record for Resident #15 revealed an admission date of 07/21/23 and a readmission date of 08/03/23. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to provide privacy during residents receiving incontinence care. This affected two (#11 and #12) of three residents reviewed for incontinence care. The facility census was 34. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 09/01/22 and admitted to Hospice on 10/05/22. Medical diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly impaired cognition and required extensive two-person assistance for bed mobility, total dependence for transfer, toileting and independent for eating. Documentation revealed she was always incontinent of urine and stool. 2. Review of medical record for Resident #12 revealed admission date of 02/04/21 and admitted to hospice on 10/08/22. Medical diagnoses included Alzheimer's Disease, depression, and lung cancer.…

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 interviews and catheter procedure review, the facility failed to maintain infection control procedures during incontinence care for residents. This affected two (#11 and #12) of three reviewed for incontinence care. The facility census was 34. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 09/01/22 and admitted to Hospice on 10/05/22. Medical diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly impaired cognition and required extensive two-person assistance for bed mobility, total dependence for transfer, toileting and independent for eating. Documentation revealed she was always incontinent of urine and stool. 2. Review of medical record for Resident #12 revealed admission date of 02/04/21 and admitted to hospice on 10/08/22. Medical diagnoses included Alzheimer's Disease,…

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 review of the performance evaluations, staff interview and policy review, the facility failed to provide annual evaluations for two State Tested Nursing Assistants (STNAs) potentially affecting all residents. The finding potentially affected all 37 residents. Findings include: On 11/08/22 at 9:20 A.M. the surveyor requested the performance evaluations for four State Tested Nursing Assistants (STNAs) from the Payroll and Benefits Coordinator (PBC) #2. At that time both the Administrator and PBC #2 verified there was no annual evaluation completed for either STNA #39 hired on 06/15/16 and STNA #40 hired on 03/20/20. Review of the policy titled Performance Appraisals dated 01/01/22 revealed all employees were evaluated at least annually. STNAs were evaluated by Registered Nurses or Licensed Practical Nurses. The Regional Human Resources staff was responsible for conducting audits to ensure compliance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had a care plan for antipsychotic medications, dialysis, feeding tubes, activities of daily living, anticoagulant medications and infection control isolation. This affected seven (#1, #6, #8, #14, #19, #20, and #24) out of fifteen residents reviewed for care plans. The facility census was 37. Findings include: 1. Review of the Resident #19's chart revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, pressure ulcer of sacral region stage four, other symptoms and signs involving the musculoskeletal system, contracture right ankle, contracture right knee, contracture left ankle, contracture of other specified joint, depression, weakness, muscle weakness, hyperlipidemia, gastro esophageal reflux disease, hypotension, alcohol abuse with alcohol induced anxiety disorder, and insomnia. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment…

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

Based on observations, staff interviews and policy review, the facility failed to provide a clean ice machine and clean scoop with container. The finding potentially affected all residents except for three (#16, #24 and #284) who did not consume ice from this machine. The census was 37 residents. Findings include: Observations during the kitchen tour on 11/07/22 at 10:00 A.M. with Food Services Director (FSD) #4 revealed the bottom of the scoop with container was black across from the ice machine. Inside the ice machine the white plastic piece had a brown/black film across the bottom. At that time, FSD #4 verified the finding and stated she was not aware of when or how often the scoop with container and ice machine was cleaned. Interview on 11/09/22 at 10:37 A.M. with the Director of Nursing (DON) identified three (#16, #24 and #284) residents who did not consume ice. Review of the policy titled Ice Storage dated 07/31/20 revealed the ice machines and ice storage/distribution containers provided a safe and sanitary ice supply for residents. The staff cleaned and sanitized the tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the ombudsman of a resident's discharge from the facility. This affected two (#16 and #24) out of five residents reviewed for hospitalizations. The facility census was 37. Findings include: 1. Review of the Resident #16's chart revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, gastrostomy status, dependence on respirator status, hypertension, persistent vegetative status, abnormal posture, weakness, other muscle spasm, barretts esophagus without dysplasia, anxiety disorder, contracture right knee, and unspecified convulsions. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetive state and Resident #16 required total dependence with bed mobility, toileting, eating, dressing, and personal hygiene. Review of Resident #16's progress note dated 01/22/22 revealed Resident #16 was admitted to the hospital on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to give notice of bed hold. This affected one (#24) out of five residents reviewed for hospitalizations. The facility census was 37. Findings include: Review of the Resident #24's chart revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, nontraumatic intracranial hemorrhage, heart failure, dysphagia, end stage renal disease, dependence on renal dialysis, encephalopathy, hypertension, weakness, chronic pain syndrome, hyperlipidemia, anemia, cardiomegaly, and generalized anxiety disorder. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and Resident #24 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #24 also required total dependence with transfers, and toileting and Resident #24 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 staff interviews, medical record review and policy review, the facility failed to review and revise care plans for two (Resident #1 and #8) out of 15 residents sampled for care plans. This had the potential to affect all the residents in the facility. The facility census was 37. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 12/19/19 with medical diagnoses of cerebral infraction, chronic obstructive pulmonary disease (COPD), hypertension (HTN), dysphagia, right sided hemiparesis, and anxiety disorder. Review of the medical record for Resident #8 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #8 had severe cognitive impairment. The MDS revealed Resident #8 was dependent upon staff for bed mobility, transfers, dressing, eating, toileting and bathing. Further review of the medical record for Resident #8 revealed an Activity of Daily Living (ADL) care plan which stated the resident was independent with eating. Interview on 11/08/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the proper care and services to a resident with a feeding tube. This affected one (#19) out of two residents reviewed for feeding tubes. The facility census was 37. Findings include: Review of the Resident #19's chart revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, pressure ulcer of sacral region stage four, other symptoms and signs involving the musculoskeletal system, contracture right ankle, contracture right knee, contracture left ankle, contracture of other specified joint, depression, weakness, muscle weakness, hyperlipidemia, gastro esophageal reflux disease, hypotension, alcohol abuse with alcohol induced anxiety disorder, and insomnia. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #19 required total dependence with bed mobility, toileting, dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to conduct ongoing assessment of a resident for dialysis related complications prior to and post dialysis. The facility also failed to communicate the resident's vital signs and medical status with the dialysis center. This affected the one (Resident #20) out of the two residents who were reviewed for dialysis. The facility census was 37. Findings include: Review of the medical record for Resident #20 revealed an admission date of 07/30/22 with medical diagnoses of end stage renal disease, diabetes mellitus (DM) with peripheral angiopathy, severe protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, atrial flutter, depression and hypertension. Review of the medical record for Resident #20 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #20 was cognitively intact. The MDS revealed Resident #20 required limited assistance with bed mobility and transfers and extensive assistance…

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 staff interview and medical record review the facility failed to ensure an intravenous antibiotic medication was provided for Resident #286 based on physician orders from an Infectious Disease physician. This affected one (Resident #286) out of four residents looked at for medication errors. The facility census was 37. Findings include: Review of the medical record for Resident #286 revealed an admission date of 10/29/22 and diagnoses of severe sepsis without septic shock, paroxysmal atrial fibrillation, encephalopathy, presence of cardiac pacemaker, pemphigus vulgaris, and mitral valve prolapse's. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #286 was cognitively intact. Her functional status is listed as extensive one to two person assist for all activities of daily living. The MDS also revealed the Resident has an indwelling catheter and is continent of bowel. Review of the care plan dated 10/29/22 revealed the resident has endocarditis. Interventions included to administer…

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

Based on record review and interview, the facility failed to ensure the Administrator attended the quality assurance committee meetings. This had the potential to affect all 39 residents. Findings include: Review of the Quality Assessment and Process Improvement sign in sheets dated 01/10/19, 02/19/19, and 03/19/19 revealed the Administrator did not attend any of the quality assurance committee meetings held on these dates. Interview with the Director of Nursing on 10/03/19 at 1:48 P.M. verified the administrator did not attend the quality assurance committee meetings held on 01/10/19, 02/19/19, and 03/19/19. Review of the policy titled Quality Assurance and Process Improvement Committee, last revised 11/28/16, revealed attendance must include at least three other facility staff members, at least one must be the administrator, owner, board member, or other individual in a leadership role.

Based on observations and staff interview, the facility failed to ensure the environment was in good repair. This affected five (Residents #30, #7, #6 and #28) of 39 residents reviewed for environment. The census was 39. Findings include: An observation was conducted on 09/30/19 at 12:56 P.M. for Resident #30's room revealed there was a large section of the wall behind the recliner that had paint chipping off of the wall. An observation was conducted on 09/30/19 at 1:30 P.M. for Resident #7's bathroom revealed the linoleum was peeling away from the wall by the toilet and a quarter of a plastic strip on the front of the bathroom door was hanging off of the door. An observation was conducted 09/30/19 at 1:49 P.M. for Resident #6's bathroom had molding separating from the wall by the floor, by the toilet and the door entering into the bathroom was scarred up at the bottom of the door. An observation was conducted on 09/30/19 at 3:59 P.M. for Resident #28's bathroom door revealed there were several holes on the bottom of the inside of the door that reached halfway across the bottom of…

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

Based on record review and interview, the facility failed to ensure grievances were addressed in a timely manner. This affected one (Resident #3) of two residents reviewed for grievances. The census was 39. Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/02/16 with diagnoses including vascular dementia, anxiety, and depression. Review of grievance form for Resident #3 dated 09/25/19 revealed Resident #3's missing personal wheelchair was not mentioned on the grievance form. Interview with Resident #3's family member on 09/30/19 at 1:00 P.M. revealed Resident #3's personal wheelchair was found missing on 09/25/19 when Resident #3 returned to the facility from the hospital. Interview with Social Services Designee (SSD) #57 on 10/01/19 at 3:27 P.M. revealed she was informed by Resident #3's family on 09/25/19 that the resident's personal wheelchair was missing. The wheelchair had been left at the facility while the resident was in the hospital and that staff looked for it, but never found it. SSD #57 stated that when a resident is missing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure care plans were revised to reflect the resident's current status. This affected two (Residents #18 and #27) of 18 residents reviewed for care plans. The census was 39. Findings include: 1. Medical record review for Resident #18 revealed an admission date of 07/06/19. Medical diagnoses included schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the care plan dated 07/08/19 for Resident #18 revealed he had a potential or actual skin impairment to skin integrity. Observation of Resident #18 on 09/30/19 at 6:40 P.M. revealed he was sitting in his room talking to someone that wasn't there. He had lesions on both arms and his abdomen. Some lesions were scabbed and some were open. Interview with Director of Nursing (DON) on 10/01/19 at 4:54 P.M. revealed she didn't revise the care plan for the skin for the open and closed lesions on Resident #18's…

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 drug reference review, the facility failed to ensure a subcutaneous injection was administered according the the standards of practice. This affected one (Resident #1) of one resident who received an injectable blood thinner. The census was 39. Findings include: Medical record review for Resident #1 revealed an admission date of 11/30/18. Medical diagnoses included respiratory failure and quadriplegia. Review of physician orders dated 08/21/19 revealed Enoxaparin Sodium Solution (anticoagulant) 30 milligram (mg)/0.3 milliters subcutaneous, to give once a day for blood clots. Observation of medication administration on 10/02/19 at 9:25 A.M. revealed Licensed Practical Nurse (LPN) #42 administered the injection to the resident's right abdomen. LPN #42 did not pinch up the skin at the injection site prior to giving the medication. Interview with LPN #42 on 10/02/19 at 9:40 A.M. revealed she should have placed the injection two inches away from the belly button and squeezed up the skin to inject the Enoxaparin. She stated she knew she was supposed…

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 incontinence care was provided after a resident was soiled. This affected one (Resident #6) of one reviewed for incontinence care. The facility identified 26 incontinent residents. Findings include: Medical record review for Resident #6 revealed an admission dated of 07/01/15. Medical diagnoses included schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired. She was an extensive assistance for toilet use and was always incontinent for bowel and bladder. During observation on 10/01/19 at 10:29 A.M. with Registered Nurse (RN) #49 and State Tested Nursing Assistant (STNA) #4, the resident's incontinent brief was removed to provide wound care. The brief was soiled with urine. After the wound care was provided, a clean incontinent brief was placed on the resident, but no incontinence care was performed. Interview with STNA #4 on 10/01/19 at 10:35 A.M.…

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

Based on observation, record review and staff interview, the facility failed to ensure a dressing to a peripherally inserted central catheter (PICC) line was changed in a timely manner. This affected one (Resident #12) of one reviewed for PICC line dressings. The facility identified five PICC lines in the facility. Findings include: Medical record review for Resident #12 revealed an admission date of 06/20/19. Medical diagnoses included dementia and respiratory failure. Review of physician orders dated 07/06/19 revealed to change dressing to the PICC line every seven days. Review of the Treatment Administration Record (TAR) dated 09/01/19 through 09/29/19 revealed the only documentation of a dressing change was on 09/24/19 by Licensed Practical Nurse (LPN) #22. Observation of the PICC line for Resident #12 on 09/30/19 at 11:30 A.M. revealed the PICC dressing was dated 09/14/19. Interview with LPN #42 on 09/30/19 at 11:52 A.M. verified the PICC line dressing was dated 09/14/19 and was out of date and should have been changed. She did not know why it wasn't changed and it was 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, staff interview and policy review, the facility failed to ensure a recommendation for a splint was completed for a contractured hand. This affected one (Resident #6) of three residents reviewed for contractures. Findings include: Medical record review for Resident #6 revealed an admission dated of 07/01/15. Medical diagnoses included schizophrenia. Review of discharge occupational therapy notes dated 07/11/19 for Resident #6 revealed the resident was measured for a splint for positioning and contracture management. Observation of Resident #6 on 09/30/19 at 1:51 P.M. and 3:45 P.M. revealed she had a contracture in her left hand and did not have a splint on her hand. Observation on 10/01/19 at 7:34 A.M. revealed there wasn't a splint on her left hand. Interview with Therapy Program Director (TPD) #58 on 10/02/19 at 3:59 P.M. revealed there was a transition in the therapy department around the time Resident #6's splint was ordered. She stated the splint was in the facility but had never been placed on the resident.

Based on observation, staff interview and policy review, the facility failed to ensure insulin pens were dated for 28 days after opening. This affected two (Residents #11 and #28) of seven who received insulin. Findings include: Observation of the medication cart with Licensed Practical Nurse (LPN) #41 on 10/02/19 at 8:30 A.M. revealed there was a Novolog FlexPen and Lantus Solostar that wasn't dated for Resident #11. An interview at the same time of the observation revealed the pens didn't have a seal on them and verified they should have been dated 28 days after taking them out of the refrigerator . For Resident #28, the medication cart also contained a Novolog FlexPen that wasn't dated and a Lantus Solostar that was dated what looked like 08/25/19 and was changed to 09/25/19 as the opening date for Resident #28. During interview at the time of the observation, LPN #41 said it looked like the date had been changed on the Lantus pen and the Novolog pen should have been dated 28 days after removing it from the refrigerator. Review of the faciltiy policy titled Stability of 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.

Based on record review, staff interview and review of the hospice contract, the facility failed to ensure documentation of hospice visits were readily available in the resident's record. This affected one (Resident #12) of one resident reviewed for hospice care. The facility identified one resident who was receiving hospice care. The facility census was 39. Findings include: Medical record review for Resident #12 revealed an admission date of 06/20/19. Medical diagnoses included dementia and respiratory failure. Review of physician orders dated 07/18/19 revealed hospice care for Resident #12 for a terminal prognosis related to dementia. Interview with a family member on 09/30/19 at 10:16 A.M. revealed hospice was signing in that they were providing the care but wasn't visiting the resident. Interview with the Director of Nursing (DON) on 10/03/19 at 10:04 A.M. revealed the staff from the hospice center was visiting Resident #12 and wrote their own notes on their own computers. She denied they were signing in and not visiting the resident because there wasn't a sign-in sheet. 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.