Steubenville Country Club Manor

Based on record review and investigation, the facility failed to ensure administrative staff maintained records in a secure and accessible area and failed to ensure incidents of elopement were investigated and evaluated to ensure safety of wandering residents. This affected all 46 residents. Findings include: 1. During an entrance conference with the Administrator on 05/16/24 at 12:51 P.M., a request was made for infection control surveillance logs for the past three months. On 05/16/24 at 4:50 P.M., the Administrator stated he could not locate evidence of infection control logs since February 2024. The prior Director of Nursing (DON)/Registered Nurse (RN) #200 kept the information on her personal ipad and her employment had ended on 05/15/24 and no records were available. On 05/21/24 at 9:15 A.M., RN #100 stated she was able to locate some infection control paper work through February 2024 but could find nothing since then. RN #100 stated she had been unable to find any information that showed an evaluation of the infection data and never recalled RN #200 discussing evaluations 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, interview, and policy review, the facility failed to provide evidence of infection control surveillance and failed to implement proper hand hygiene and use of personal protective equipment (PPE) during care of a feeding tube. This affected Residents #3 and #22 and had the potential to affect all residents. The facility census was 46. Findings include: 1. During an entrance conference with the Administrator on 05/16/24 at 12:51 P.M., a request was made for infection control surveillance logs for the past three months. On 05/16/24 at 4:50 P.M., the Administrator stated he could not locate evidence of infection control logs since February 2024. Registered Nurse (RN) #200 kept the information on her personal ipad and her employment had ended on 05/15/24 and no records were available. On 05/20/24 at 8:04 A.M., RN #100 stated since the facility had been unable to locate infection control logs/surveillance she had calls out to the pharmacy to get antibiotic reports and was looking at orders in…

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

Based on review of infection surveillance records and interview, the facility failed to ensure a minimum of one individual was qualified to perform the job of an infection preventionist. This had the potential to affect all 46 residents. Findings include: During the entrance conference with the Administrator on 05/16/24 at 12:51 P.M., he reported the Director of Nursing (DON) who had also been assigned as the facility's Infection Preventionist (IP) had a last day of employment at the facility on 05/15/24. On 05/21/24 at 9:15 A.M., Registered Nurse (RN) #100 verified the facility had no other staff member who had completed specialized training in infection prevention and control to serve as the IP.

Based on medical record review and interview, the facility failed to provide restorative nursing services, according to program instruction, to maintain residents' range of motion for four (Residents #2, #9, #10 and #42) of four residents reviewed for range of motion. The facility identified 11 residents on restorative programs for range of motion. The facility census was 46. 1. Review of Resident #10's medical records revealed diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus with diabetic neuropathy, malignant neoplasm of the glottis (center of the larynx (voice box) ), chronic peripheral venous insufficiency, heart disease, and macular degeneration. Review of a care plan initiated 02/05/24 revealed Resident #10 was on a restorative nursing program (RNP). Interventions included documenting participation in RNP, report to nursing complaints of pain during restorative active range of motion (AROM) programs and the registered nurse (RN) was to review compliance of and effectiveness of RNP. Review of restorative task revealed a program 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.

Based on medical record review, review of pharmacy recommendations, and interviews the facility failed to ensure pharmacy recommendations were acted upon timely. This affected four (Residents #10, #13, #34, and #40) of five residents reviewed for medication use. The facility census was 46. Findings include: 1. Review of Resident #13's medical record revealed diagnoses including hemiplegia (paralysis of one side of the body) affecting the right dominant side, rhabdomyolysis (condition in which damaged skeletal muscle breaks down rapidly, contracture of the right hand, heart failure, benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland)., gastroesophageal reflux disease, stiffness of the right shoulder, speech disturbance, acquired absence of the spleen, history of falling, hypertension, and muscle wasting. Review or a medication regimen review dated 03/13/24 revealed a diagnosis was needed to support the use of risperidal (an antipsychotic medication). The physician response was blank. A physician order 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 observations, interviews and review of Medscape online information regarding humalog insulin storage the facility failed to ensure the proper labeling and storage of medications. This affected five residents (Resident #1, #21, #33, #45 and #48) of 46 residents with medications secured in the two facility identified medication carts. Findings include. 1. While observing the 100/200 hall medication cart with Registered Nurse (RN) #135 on 05/16/24 at 1:38 P.M., Resident #21 had two bottles of opened humalog insulin. The insulin was not dated as to when it was opened. RN #135 stated the insulin vials were transferred with Resident #21 from another facility upon admission so she did not know how long they had been opened. Review of the Electronic Health Record (EHR) revealed Resident #21 was admitted to the facility on [DATE]. Review of Medscape information on humalog insulin revealed open vials could be stored/used for up to 28 days after opening the vial. 2. While observing the 100/200 hall medication cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the accuracy and completeness of medical records. This affected three known residents (Resident #13, 18, and #47) but had the potential to affect all residents in the facility. The census was 46. Findings include: 1. a Review of Resident #18's open medical record revealed diagnoses including dementia with agitation, type two diabetes mellitus, peripheral vascular disease, major depressive disorder, muscle wasting, anxiety disorder, long term use of insulin, vitamin B12 deficiency, and acute angle-closure glaucoma in bilateral eyes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired with a score of 9 out of a possible score of 15. The MDS indicated Resident #18 was able to make herself understood and was able to understand others. The assessment did not indicate any wandering during the specified time frame. Review of a nursing note dated 03/04/24 at 6:13 P.M. revealed the nurse…

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 interview, the facility failed to implement the use of a stop sign across a resident's room to deter wandering residents from entering her room. This affected one (Resident #29) of three residents reviewed for falls. The facility census was 46. Findings include: Review of Resident #29's medical record revealed diagnoses including dementia, need for assistance with personal care, and cognitive communication deficit. Review of a care plan initiated 01/14/14 indicated Resident #29 had a self care performance deficit with potential for fluctuations and/or decline related to dementia, forgetfulness and impaired decision making. The care plan was updated to initiate a stop sign to the doorway to deter wandering residents from entering starting 01/26/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was able to make herself understood and was able to understand others. Resident #29 was assessed as being severely cognitively impaired. 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, policy review, and interview, the facility failed to ensure Resident #18's family/responsible party and physician were notified when Resident #18 was located outside the facility unaccompanied by staff. This affected one (Resident #18) of three residents reviewed for elopement. The facility census was 46. Findings include: Review of Resident #18's open medical record revealed diagnoses including dementia with agitation, type two diabetes mellitus, peripheral vascular disease, major depressive disorder, muscle wasting, anxiety disorder, long term use of insulin, vitamin B12 deficiency, and acute angle-closure glaucoma in bilateral eyes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired with a score of nine out of a possible score of 15. The MDS indicated Resident #18 was able to make herself understood and was able to understand others. The assessment did not indicate any wandering during the specified time frame.…

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, the facility post-fall monitoring report and interview, the facility failed to ensure neurological checks (series of assessments which reflect a resident's brain and neurological function) where completed, after unwitnessed falls, for one (Resident #13) of three residents reviewed for falls. The census was 46. Findings include: Review of Resident #13's medical record revealed diagnoses that included right sided paralysis, muscle wasting, contracture of the right hand, heart failure, stiffness of the right shoulder, speech disturbance, history of falling and hypertension. A physician's order dated 01/07/24 revealed the bed was to be in the lowest position at all times. Review of the fall information with Registered Nurse (RN) #100 revealed the following information. a. A nursing note dated 01/19/24 at 6:48 P.M. indicated a State Tested Nursing Assistant (STNA) notified the nurse Resident #13 was on the floor, in the bathroom, laying on his left side. No injuries were noted. Resident #13 was educated on the importance of using the call light 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 medical record review, review of incident reports, policy review, review of manufacturer information for wanderguards, and interview, the facility failed to ensure elopement interventions were implemented, wanderguards and exit doors were monitored to ensure appropriate functionality, and failed to ensure a comprehensive fall prevention program was implemented. This affected two (Residents #13 and #18) of six residents reviewed for falls and elopement. The census was 46. Findings include: 1. Review of Resident #18's open medical record revealed diagnoses including dementia with agitation, type two diabetes mellitus, peripheral vascular disease, major depressive disorder, muscle wasting, anxiety disorder, long term use of insulin, vitamin B12 deficiency, and acute angle-closure glaucoma in bilateral eyes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired with a score of nine out of a possible score of 15. The MDS indicated Resident #18…

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, review of drug-related information on www.medscape.com, and interview, the facility failed to ensure a resident had adequate indications for use of a psychotropic medication. This affected one (Resident #13) of five residents whose medications were reviewed. The facility census was 46. Findings include: Review of Resident #13's medical record revealed diagnoses including hemiplegia (paralysis of one side of the body) affecting the right dominant side, rhabdomyolysis (condition in which damaged skeletal muscle breaks down rapidly)., contracture of the right hand, heart failure, BPH (a condition in which the flow of urine is blocked due to the enlargement of prostate gland)., gastroesophageal reflux disease, stiffness of the right shoulder, speech disturbance, acquired absence of the spleen, history of falling, hypertension, and muscle wasting. A physician order for risperidal (anti-psychotic) 0.25 milligrams every day was written on 03/04/24. On 05/21/24 at 8:28 A.M., Registered Nurse (RN) #100 stated she located a diagnosis of dementia to support the…

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

Based on medical record review, facility investigation review, personnel file review, facility policy review, and interviews, the facility failed to ensure a resident was free from misappropriation when a staff member accepted money from a resident. This affected one (Resident #44) of three residents reviewed for misappropriation. The facility census was 42. Findings include: Review of the closed medical record for Resident #44 revealed an admission date of 09/14/22. Diagnoses included fracture of left femur, muscle wasting and atrophy of multiple sites, cognitive communication deficit, acquired absence of right leg below the knee, and acquired absence of the left foot. Further review of Resident #44's medical record revealed the Minimum Data Set (MDS) 3.0 annual assessment, dated 09/22/23, indicated the resident had intact cognition. During interview on 03/06/24 at 11:49 A.M., Ombudsman #400 revealed on 02/13/24, during an advocacy visit to the facility, she interviewed Resident #44 and he stated he had given licensed practical nurse (LPN) #201 money and gifts for sexual favors,…

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, facility investigation review, personnel file review, facility policy review, and interviews, the facility failed to timely report an allegation of misappropriation when a staff member accepted money from a resident. This affected one (Resident #44) of three residents reviewed for misappropriation. The facility census was 42. Findings include: Review of the closed medical record for Resident #44 revealed an admission date of 09/14/22. Diagnoses included fracture of left femur, muscle wasting and atrophy of multiple sites, cognitive communication deficit, acquired absence of right leg below the knee, and acquired absence of the left foot. Further review of Resident #44's medical record revealed the Minimum Data Set (MDS) 3.0 annual assessment, dated 09/22/23, indicated the resident had intact cognition. During interview on 03/06/24 at 11:49 A.M., Ombudsman #400 revealed on 02/13/24, during an advocacy visit to the facility, she interviewed Resident #44 and he stated he had given licensed practical nurse (LPN) #201 money and gifts for sexual favors, 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 medical record review, facility investigation review, personnel file review, facility policy review, and interviews, the facility failed to ensure a complete and thorough investigation of misappropriation when a staff member accepted money from a resident. This affected one (Resident #44) of three residents reviewed for misappropriation. The facility census was 42. Findings include: Review of the medical record for Resident #44 revealed an admission date of 09/14/22. Diagnoses included fracture of left femur, muscle wasting and atrophy of multiple sites, cognitive communication deficit, acquired absence of right leg below the knee, and acquired absence of the left foot. Further review of Resident #44's medical record revealed the Minimum Data Set (MDS) 3.0 annual assessment, dated 09/22/23, indicated the resident had intact cognition. During interview on 03/06/24 at 11:49 A.M., Ombudsman #400 revealed on 02/13/24, during an advocacy visit to the facility, she interviewed Resident #44 and he stated he had given licensed practical nurse (LPN) #201 money and gifts for sexual…

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 interview, the facility failed to ensure a wound treatment was provided as ordered by the physician. This affected one (Resident #42) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/15/23. Diagnoses included congestive heart failure, hypertension, muscle wasting and atrophy, and osteoarthritis. Review of the Minimum Data Set (MDS) 3.0 admission assessment, dated 12/28/23, indicated the resident had severely impaired cognition and required moderate assistance with activities of daily living (ADLs). The resident was occasionally incontinent of urine. Review of the plan of care, dated 01/04/24, revealed the resident had a pressure ulcer with interventions including to encourage good nutrition and hydration in order to promote healthier skin, to follow facility protocols for treatment of injury, and to keep skin clean and dry. Review of the physician order, dated 02/28/24, revealed the order to cleanse left buttock with wound cleanser, pat dry, apply…

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, policy review, and interview, the facility failed to ensure weights were obtained as ordered by the physician. This affected one (Resident #42) of three residents reviewed for pressure ulcers. The facility census was 42 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/15/23. Diagnoses included congestive heart failure, hypertension, muscle wasting and atrophy, and osteoarthritis. Review of the Minimum Data Set (MDS) 3.0 admission assessment, dated 12/28/23, indicated the resident had severely impaired cognition and required moderate assistance with activities of daily living (ADLs). The resident was occasionally incontinent of urine. Review of the plan of care, dated 01/09/24, revealed the resident had a potential nutritional problem related to diagnoses including congestive heart failure, altered fluid status/diuretic, and skin alterations with interventions including to monitor/record/report signs and symptoms of malnutrition and to monitor intake and record every meal. Review of a physician…

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 residents and/or resident representatives were provided admission packet and admission information timely to allow the resident and/or resident representative to participate in the care process. This affected one (Resident #40) of three residents reviewed for admission information. The facility census was 46. Findings include: Review of Resident #40's medical record revealed an admission date of 07/19/23 with diagnoses that included diabetes mellitus and chronic obstructive pulmonary disease. Further review of the medical record including the Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 07/28/23 revealed Resident #40 was cognitively intact. Further review of the medical record found no evidence of any admission paperwork within the medical record. Interview with Resident #40's representative on 09/21/23 at 8:49 A.M. indicated the resident or herself were not provided with an admission packet upon admission. She indicated Resident #40 and herself were provided the admission packet…

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, interview, record review, and review of the facility policy the facility failed to ensure medication error rate was less than five percent. There were 30 medication errors out of 32 opportunities, resulting in a 93.75 percent medication error rate. This affected four residents (#26, #28, #31 and #37) out of four residents reviewed for medication administration. The facility census was 43. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 07/19/23 with diagnoses including malignant neoplasm of the upper lobe of the left lung, diabetes mellitus, and heart failure. Review of the physician's orders and Medication Administration Record (MAR) for August 2023 for Resident #37 revealed she had orders dated 07/19/23 for Amlodipine 5 milligrams (mg), one time a day at 8:00 A.M. for hypertension, Anastrozole (hormone based chemotherapy) 1 mg one time a day at 8:00 A.M., Aspirin one time a day at 8:00 A.M. for coronary artery disease, Vitamin D 250 micrograms (mcg) (supplement) one time a day at 8:00 A.M., Citalopram 40 mg…

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

Based on observations, interview, record review, and review of the facility policy the facility failed to maintain adequate infection control practices during administration of medications to residents. This affected four residents (#26, #28, #31 and #37) of four residents observed during medication administration. This also had the potential to affect two residents (#32 and #33) of two residents who received glucometer checks. The facility census was 43. Findings include: Medication administration observations were made on 08/02/23. At 6:49 A.M. Licensed Practical Nurse (LPN) #200 was observed to prepare Resident #37's medications, enter Resident #37's room, lay the glucometer on her tray table without a barrier underneath. LPN #200 put on gloves and obtained Resident #37's blood sugar reading and then administered her medications. Upon leaving the room, LPN #200 took off her gloves and went to the medication cart and laid the glucometer on top of the medication cart. She threw away used supplies and then put the glucometer into the medication cart without cleaning it. She did not…

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

Based on staffing schedule review and interview, the facility failed to ensure Registered Nursing services were provided at least eight hours per day. This had the potential to affect all residents within the facility. The census was 36. Findings include: Review of the facility staffing schedule for the week of 09/05/22 through 09/11/22 revealed no evidence of any registered nurses (RN) scheduled on 09/05/22 and 09/06/22. Interview with Scheduler #6 on 09/08/22 at 1:05 P.M. verified no RN coverage on 09/05/22 and 09/06/22.

Based on observation, interview, and record review the facility failed to ensure the ice machine was clean and failed to ensure refrigerators in resident's rooms were monitored for temperature control. The ice machine being unclean had the ability to affect all 35 residents receiving food by mouth in the facility. The temperature monitoring of personal refrigerators had the ability to affect two Residents (#26 and #27) who had personal refrigerators in their rooms. The facility census was 36. Findings included: 1. Observation on 09/07/22 at 10:45 A.M. of the ice machine noted to have a black substance on the white plastic shield in the ice storage compartment. Interview at the time with Food Service Manager #12 stated, This ice machine doesn't look like it has been cleaned for a month. On 09/07/22 at 10:46 A.M. an interview with Dietary Manger #13 revealed the ice machine should be cleaned weekly. Review of the facility Weekly Cleaning Schedule revealed [NAME] Helper #15 was responsible for cleaning the inside, outside, and filter of the ice machine for the dates 09/01/22 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 review and interview the facility failed to notify the resident, resident's representative, and ombudsman in writing of the reason for transfer. This affected four Residents (#16, #18, #19, and #33) of four residents reviewed for hospitalization. The facility census was 36. Findings included: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, paroxysmal atrial fibrillation, essential hypertension, and encephalopathy. Review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Review of Resident #16's progress notes revealed she was transferred to the local hospital on [DATE] and 07/24/22. Review of Resident #16's medical record revealed no written notification of transfer to resident, resident's representative, or ombudsman. On 09/07/22 at 10:55 A.M. an interview with Social Service Designee (SSD) #51 revealed Resident #16, her representative, and the ombudsman did not receive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the resident or resident's representative in writing of the facility bed hold policy. This affected four Residents (#16, #18, #19, and #33) of four residents reviewed for hospitalization. The facility census was 36. Findings included: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, paroxysmal atrial fibrillation, essential hypertension, and encephalopathy. Review of Resident #16's Quarterly MDS dated [DATE] revealed she was cognitively intact. Review of Resident #16's progress notes revealed she was transferred to the local hospital on [DATE] and 07/24/22. Review of Resident #16's medical record revealed no proof of written notification of bed hold to the resident or the resident's representative. On 09/07/22 at 10:55 A.M. an interview with Social Services Designee (SSD) #51 revealed Resident #16 nor her representative were provided written documentation of bed hold notice.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an advanced directive was formulated upon admission. This affected two Residents (#86 and #186) of 16 residents reviewed for advanced directives. The facility census was 36. Findings included: 1. Review of Resident #186's record revealed she was admitted to the facility on [DATE] with the diagnoses of unspecified dementia, hypothyroidism, anxiety disorder, essential hypertension, hypokalemia. Review of Resident #186's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Review of Resident #186's physician orders in both the electronic health record and the hard copy/paper record revealed no order for advanced directives. Review of Resident #186's progress notes revealed the facility had contacted the physician on 08/31/22 to verify medication orders, but advanced directive information was not obtained. Review of Resident #186's hard copy/paper record revealed a Do Not Resuscitate Comfort Care form from the previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident's physician was notified regarding antibiotic medication delay. This affected one Resident (#19) of four residents reviewed for hospitalization. The facility census was 36. Findings included: Review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease without esophagitis, restless leg syndrome, generalized arthritis, essential hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #19's Significant Change Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Review of Resident #19's chest x-ray results dated 07/05/22 revealed there was a left base infiltrate (indicative with pneumonia) which had increased since the chest x-ray obtained on 06/25/22 and the resident was to start on Ceftin (an antibiotic) one gram intramuscularly for the respiratory infection. 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 record review and interview the facility failed to ensure transfer paperwork was completed and sent with the resident to the emergency department. This affected one Resident (#16) of four residents reviewed for hospitalization. The facility census was 36. Findings included: Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, paroxysmal atrial fibrillation, essential hypertension, and encephalopathy. Review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Review of Resident #16's progress notes revealed she was transferred to the local hospital on [DATE] and 07/24/22. Review of Resident #16's medical record revealed the facility form titled Referral Information Form was completed and sent with Resident #16 for her transfer on 06/24/22. However, there was no documentation to support the form was completed for her transfer on 07/24/22. On 09/07/22 at 8:22 A.M. and interview with Director 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 record review and interview the facility failed to ensure a baseline care plan was completed upon admission. This affected one Resident (#186) of one Resident reviewed for care plans. The facility census was 36. Findings included: Review of Resident #186's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of unspecified dementia, hypothyroidism, anxiety disorder, essential hypertension, hypokalemia. Review of Resident #186's admission MDS dated [DATE] revealed she was cognitively intact. Review of Resident #186's electronic health record and paper record revealed no documentation to support a baseline care plan was completed within 48 hours of admission. On 09/06/22 at 11:07 A.M. an interview with Resident #186 revealed she did not remember ever talking with anyone about her plan of care. On 09/06/22 at 2:44 P.M. an interview with Registered Nurse (RN) #39 verified she was unable to locate a baseline care plan for Resident #186. She also verified a baseline care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop a comprehensive person-centered care plan for respiratory infections. This affected two Residents (#16 and #19) of 16 residents reviewed for care plans. The facility census was 36. Findings Include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, paroxysmal atrial fibrillation, essential hypertension, and encephalopathy. Review of Resident #16's Quarterly MDS dated [DATE] revealed she was cognitively intact. Review of Resident #16's progress notes revealed she was transferred to the local hospital on [DATE] due to a complaint of not feeling well, a temperature of 101.7 degrees Fahrenheit and moaning upon transfer to bed. Resident #16 returned to the facility on [DATE]. Review of Resident #16's chest x-ray results dated 06/23/22 revealed left base infiltrate (indicative with pneumonia) and the resident was to start on Augmentin 875 milligrams (an antibiotic) orally twice 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.

Based on medical record review, observation and staff interview the facility failed to ensure pressure relief interventions were in place as ordered by the physician. This affected one (Resident #32) of one residents reviewed for pressure ulcer wounds. The facility identified one resident with pressure ulcer wounds. Findings include: Review of Resident #32's medical record revealed an admission date of 03/27/08 with diagnoses that included multiple sclerosis and paraplegia. Further review of the medical record including pressure ulcer wound assessments revealed Resident #32 had a Stage 3 pressure ulcer wound (full thickness skin loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to the right heel, an Unstageable pressure ulcer wound (known but unstageable due to coverage of wound bed by slough or eschar) to the left foot first metatarsal and a Stage 2 pressure ulcer wound (partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed) to the left medial leg. Review of physician's orders indicated the use of prevalon boots…

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 resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion and failed to ensure restorative services were provided as ordered. This affected two (Resident #18 and Resident #32) of two residents reviewed for mobility. The facility identified three residents with contractures. Findings include: 1. Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses including Alzheimer's Disease, dementia, obesity, chronic kidney disease, peripheral vascular disease, and anemia. Review of the Minimum Data Set (MDS) annual assessment, dated 07/05/22, indicated Resident #18's Brief Interview for Mental Status (BIMS) score was 99, which indicated the interview was unable to be completed due to the resident rarely being understood. There were no behaviors or rejection of care. The resident was totally dependent of two-person assistance with bed…

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 dietitian recommendations were completed for a resident with weight loss. This affected one Resident (#16) of three residents reviewed for nutrition. The facility census was 36. Findings included: Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, paroxysmal atrial fibrillation, essential hypertension, encephalopathy, and protein-calorie malnutrition. Review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and she had noted weight loss with no prescribed weight-loss regimen. It also revealed she had no functional decline due to weight loss. Review of Resident #16's care plan dated 12/28/21 revealed she had a potential for nutritional problems related to obese Body Mass Index (BMI), multiple wounds/increased nutritional needs, anemia, protein/calorie malnutrition, hypertension, and nutrition related altered labs 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 observation, record review, and interview, the facility failed to ensure a resident's oxygen flow rate was set as ordered. This affected one (Resident #17) reviewed for respiratory care. The facility identified ten residents receiving respiratory treatments. Findings include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, bronchitis, muscle wasting and atrophy, and diabetes mellitus. Review of the Minimum Data Set (MDS) quarterly assessment, dated 07/05/22, indicated Resident #17's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. There were no behaviors or rejection of care. The resident required extensive, one-person assistance with bed mobility, dressing, and personal hygiene. The resident received oxygen therapy. Review of the Care Plan, dated 10/08/13, revealed Resident #17 had shortness of breath due to COPD with interventions including…

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, policy review and staff interview, the facility failed to ensure resident assessment and communication with resident dialysis center was completed. This affected one (Resident #35) of one residents reviewed for dialysis services. The facility identified three resident currently receiving dialysis services. Findings include: Review of Resident #35's medical record revealed an admission date of 01/16/21 with diagnoses that included end stage renal disease with hemodialysis and chronic obstructive pulmonary disease. Review of physician's orders revealed hemodialysis to be provided three times weekly at DCI Dialysis (DCI). Further review of the medical record including dialysis binder found no evidence of any resident pre dialysis assessment, post dialysis assessment or communication record with the dialysis provider. Review of the Memorandum of Agreement between the facility and dialysis provided signed by the dialysis provider and facility on 02/18/21 indicated the following: 1. Responsibilities of Long Term Care Facility (LTCF) indicates - b. LTCF…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure a bed rail assessment was completed and failed to obtain informed consent from the resident/resident representative. This affected one (Resident #28) of one resident reviewed for accident hazards. The facility identified nine residents who used bed rails. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, chronic kidney disease, history of falling, muscle wasting and atrophy, and cognitive communication deficit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 07/28/22, indicated Resident #28's Brief Interview for Mental Status (BIMS) score was 00, which indicated severe cognitive impairment. There were no behaviors or rejection of care. The resident required extensive, two-person assistance with bed mobility, transfers, walking in room, dressing, toileting, and personal hygiene. The mobility device used…

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 ensure a pharmacy recommendation for laboratory monitoring was addressed by the physician. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, anxiety, muscle wasting and atrophy, repeated falls, polyneuropathy, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) quarterly assessment, dated 06/07/22, indicated Resident #7's Brief Interview for Mental Status (BIMS) score was 00, which indicated severe cognitive impairment. There were no behaviors or rejection of care. The resident required extensive, two-person assistance with bed mobility and extensive, one-person assistance with transfers, dressing, and toileting. Review of a physician order, dated 04/01/21, revealed the order for Vitamin D 2,000…

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 staff interview, the facility failed to ensure resident specific behavioral monitoring with the use of psychotropic drugs. This affected three (Resident #7, #26, and #25) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/01/21 with diagnoses including Alzheimer's Disease, anxiety, muscle wasting and atrophy, repeated falls, polyneuropathy, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) quarterly assessment, dated 06/07/22, indicated Resident #7's Brief Interview for Mental Status (BIMS) score was 00, which indicated severe cognitive impairment. There were no behaviors or rejection of care. The resident required extensive, two-person assistance with bed mobility and extensive, one-person assistance with transfers, dressing, and toileting. Review of the Care Plan, dated 06/7/21, revealed Resident #7 uses antipsychotic medication and is at risk for effects with interventions including 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 review and interview the facility failed to ensure the correct hospice provider was documented in the Residents record. This affected one Resident (#19) of one residents reviewed for hospice and end of life care. The facility census was 36. Findings included: Review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease without esophagitis, restless leg syndrome, generalized arthritis, essential hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #19's Significant Change Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and was receiving hospice services for end of life care. Review of Resident #19's physician orders revealed she was receiving services from Hospice Provider #1. Review of Resident #19's hospice records revealed she was not receiving services from Hospice Provider #1, but from a different hospice provider. 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.

Based on record review and staff interview, the facility failed to ensure documented evidence of providing pneumococcal immunization education, the administration, or the refusal of the vaccine. This affected one (Resident #29) of five residents reviewed for immunizations. The facility census was 36. Findings include: Review of the medical record for Resident #29 revealed an admission date of 11/17/21 with diagnoses including dementia without behavioral disturbance, dysphagia, chronic kidney disease, muscle wasting and atrophy, diabetes mellitus, chronic obstructive pulmonary disease, and anemia. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/05/22, indicated Resident #29's Brief Interview for Mental Status (BIMS) score was 12, which indicated mild cognitive impairment. There were no behaviors or rejection of care. The resident required limited, one-person assistance with bed mobility, transfers, dressing, and toileting. During review of Resident #29's medical record, there was no documentation of the information/education provided regarding the benefits 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 and staff interview the facility failed to ensure medications observed in the 100/200 hall medication cart, the 400/500 hall medication cart, the medication room and the treatment cart were properly labeled to ensure they were not used after expiration and/or properly stored to prevent unauthorized access. This affected five residents (#10, #22, #28, #33 and #42) from the 100/200 hall medication cart, four residents (#19, #24, #45 and #250) from the 400/500 hall medication cart and had the potential to affect all 48 residents residing in the facility. Findings include: 1. Observation on 11/25/19 at 10:15 A.M. of the 400/500 medication cart with Licensed Practical Nurse (LPN) #142 revealed two Novolog insulin flexpens and one Levemir flexpen were not dated when opened for Resident #45, one Levemir flexpen was not dated when opened for Resident #250, one bottle of Visine eye drops was not dated when opened for Resident #19, and one vial of Novolog insulin was not dated when opened for Resident #24. An interview at the time of the observation with LPN #142 verified…

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 the accuracy of medical records for Resident #33, #36, #44 and #47. This affected four residents (#33, #36, #44 and #47) of 14 residents whose medical records were reviewed. Findings include: 1. Review of Resident #33's medical record revealed diagnoses including gout and osteoarthritis. Resident #33 had a physician's order, dated 06/23/18 for Ultram (pain medication) 50 milligrams (mg) to be administered every six hours as needed. Review of the September 2019 Medication Administration Record (MAR) indicated since 09/04/19, 12 doses of Ultram were administered. The October MAR indicated three doses of Ultram were administered. The November MAR indicated 8 doses of Ultram were administered from 11/01/19 to 11/17/19. Review of the Controlled Drug Administration records revealed in September, starting 09/04/19, 23 doses of Ultram were removed for administration. In October, 23 doses of Ultram were removed for administration. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #41's written advance directive consent form was thoroughly completed. This affected one resident (#41) of 17 residents whose records were reviewed. Findings include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus, dementia without behavioral disturbances, hypertension and cardiac murmur. Review of Resident #41's physician's orders dated 05/21/19 revealed the resident had advance directives including an order for a Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #41's physician signed advanced directive, Do Not Resuscitate Comfort Care form, dated 05/24/19, revealed the form was not complete, as the DNRCC and the DNRCC-Arrest options were both left blank, with neither option selected. Interview on 11/26/19 at 9:15 A.M., with Minimum Data Set (MDS) Registered Nurse (RN) #151 verified the signed advance directive form was not complete and did not…

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

Based on review of Self Reported Incident (SRI) documentation and staff interview the facility failed to effectively implement their abuse policy and procedure to ensure all allegations of abuse were thoroughly investigated. This affected three residents (#2, #32 and #37) of three residents reviewed in three facility SRI reports. Findings include: 1. Review of the SRI tracking number 187111 revealed on 01/14/20 an allegation/suspicion of physical, emotional, and verbal abuse was made invovling Resident #32. The SRI revealed Resident #32 voiced complaints State tested nursing assistants (STNA) #26 was to rough during care and that inappropriate comments where being made while care was provided. Review of the SRI revealed the investigation included three statements. RN #49 who overheard STNA #26 say to the resident your not baby, I'm not going to treat you like a baby. You need to help pull up your own pants. You need to do more for yourself. RN #49 went in the room and asked the aide to leave and she finished helping her. STNA #26's statement indicated she was encouraging the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of Self Reported Incident (SRI) documentation and staff interview the facility failed to ensure all allegations of abuse were thoroughly investigated. This affected three residents (#2, #32 and #37) of three residents reviewed in three facility SRI reports. Findings include: 1. Record review revealed Resident #32 was admitted to the facility on [DATE]. The resident was assessed to be alert and oriented with episodes of forgetfulness. The resident had primary diagnoses of anemia, anxiety and depression. Review of the SRI tracking number 187111 revealed on 01/14/20 an allegation/suspicion of physical, emotional, and verbal abuse was made involving Resident #32. The SRI revealed Resident #32 voiced complaints State tested nursing assistants (STNA) #26 was to rough during care and that inappropriate comments where being made while care was provided. Review of the SRI revealed the investigation included three statements. RN #49 who overheard STNA #26 say to the resident your not baby,…

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 develop and implement an individualized and comprehensive activities program for Resident #47 in accordance with the resident's preferences. This affected one resident (#47) of ten residents interviewed regarding activities. Findings include: Review of Resident #47's medical record revealed diagnoses including dementia and anxiety disorder. A plan of care initiated 11/04/15 (no revision date) revealed Resident #47 had little or no activity involvement related to her wishes not to participate, preferring to remain in her bed watching television, reading, and playing games on a hand held unit. One of the interventions was to explain the importance of social interaction to the resident and encourage participation. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #47 was moderately cognitively impaired but had no behavioral symptoms. Review of activity participation logs for September 2019 through November 2019…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure timely implementation of interventions after identifying significant weight loss, failed to notify the physician, and failed to timely re-weigh Resident #37 following a hospitalization. This affected one resident (#37) of three residents reviewed for nutrition. Findings include: Review of Resident #37's medical record revealed an admission date of 03/19/18 with diagnoses including history of cardiovascular accident, dysphagia, diabetes mellitus, and chronic kidney disease. Review of the physician orders, dated 03/19/18, revealed an order for monthly weights Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/20/19 revealed the resident had severe cognitive impairment. The resident required extensive assistance of one staff member for activities of daily living including eating. Review of the resident's weights revealed the following: On 10/14/19 198.3 pounds On 10/22/19 198.4 pounds On 11/05/19 197.2 pounds On 11/11/19 178.3 pounds (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.

Based on observation, record review and interview the facility failed to ensure Resident #47's dialysis access site was monitored in accordance with physician orders, failed to monitor fluid intake due to fluid restrictions and failed to ensure a fluid restriction worksheet was consistent with the ordered fluid restriction and failed to schedule and administer medication in accordance with guidelines provided by dialysis. This affected one resident (#47) of one resident reviewed for dialysis. The facility identified three residents on dialysis. Findings include: Review of Resident #47's medical record revealed diagnoses including dementia and end stage renal disease. Resident #47 had orders for dialysis three times a week. On 08/05/17, an order was written to clean the permcath (dialysis access site) according to policy, apply bactroban and a dry dressing as necessary. On 09/27/18, an order was written to assess the permcath site every shift. A permcath is a long, flexible tube that is inserted into a vein most commonly in the neck (internal jugular vein) and less commonly in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure laboratory (PT/INR) testing was completed for Resident #44 who received the anticoagulant medication, Coumadin to ensure the resident received the appropriate dosage of the medication. This affected one resident (#44) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with the diagnoses of heart failure, gout, urinary tract infections, chronic kidney disease, congenital malformation of the eye, dementia, chronic pain, edema, arteriosclerotic heart disease, sick sinus syndrome, cardiac pacemaker, schizoaffective disorder, Alzheimer's dementia, atrial fibrillation, colitis and long-term use of anticoagulants. Review of the plan of care, dated 06/24/19 revealed Resident #44 was on anticoagulant therapy related to atrial fibrillation. Intervention included to administer anticoagulant medication as ordered, laboratory tests as…

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 obtain a stop date or obtain an appropriate rationale for the continued use of the as needed (prn) antianxiety medication, Lorazepam for Resident #250. This affected one resident (#250) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #250's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, peripheral vascular diseases, absence of right and left legs, hypertension, hypokalemia, hyperlipidemia, hemiplegia following cerebral infarction affecting left dominant side, muscle weakness, transient cerebral ischemic attack, acute kidney disease, morbid obesity and anemia. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/13/19 revealed Resident #250 had intact cognition and received an antianxiety medication seven days a week. Review of the physician's orders, dated November 2019 revealed Resident #250 had an order for 0.5…

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.