Rae-Ann Westlake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review the facility failed to ensure Resident #152 received timely incontinence care. This affected one (Resident #152) of two residents reviewed for incontinence care. The facility census was 110. Findings include: Review of the medical record for Resident #152 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of anterior wall of bladder, COVID-19, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/04/24 revealed Resident #152 had a self-care performance deficit related to ambulatory dysfunction and cervical myelopathy with interventions that included provide physical assistance with toileting of two…

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 record review the facility failed to ensure Resident #6 was receiving an adequate amount of fluids to meet her basic needs. This affected one of one resident reviewed for hydration. The facility census was 110. Findings include: Medical record review revealed Resident #6 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, and disorders of electrolyte and fluid balance. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired and required hands on assistance of two staff persons for completing activities of daily living. Observation on 02/05/24 at 11:22 A.M. revealed Resident #6 sitting in a Broda wheelchair (a wheelchair that provides supportive positioning through a combination of tilt, recline, enhancing patient safety and support) in her room, a Styrofoam cup with a lid and a straw filled with water was sitting on the bedside table placed behind Resident #6, where she was unable to…

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

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate assessment before applying side rails to a bed. This affected one (Resident #44) of five residents reviewed for accident hazards. The total census was 110. Findings include: Observation on 02/05/24 at 9:34 A.M. revealed Resident #44 had a raised side rail on each side of his bed. Record review of Resident #44 revealed he was admitted to the facility 11/14/23 and had diagnoses including lumbar fracture, muscle weakness, and obesity. His current care plan did not include any mention of side rails. Review of his assessments since admission revealed no evidence he was assessed for entrapment risk or appropriate use of bed rails. Interview with the Director of Nursing on 02/07/24 at 12:24 P.M. confirmed the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, medication error/incident report review, order summary review, facility investigation time line review and staff interview the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #101) of one resident reviewed for admission medications and one (Resident #71) of five residents reviewed for unnecessary medications. Findings include: 1. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of the medication error/incident report dated 11/17/23 timed 2:00 P.M. revealed Resident #101 was admitted to the facility on the evening of 11/16/23. On the following day 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 a complete and accurate medical record for Resident #101. This affected one of thirty sampled residents. The facility census was 110. Findings include: Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, epilepsy and unspecified intellectual disabilities. Review of the Medicare five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was moderately cognitively impaired and required hands on assistance of one staff person for completing activities of daily living (ADLs). Review of census records for Resident #101 revealed Resident #101 was discharged to an acute care hospital on [DATE] and did not return to the facility. Review of the electronic and hard chart revealed no information related to the reason Resident #101 was discharged to hospital or condition at the time Resident #101 left the facility to go to the hospital. Interview with 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 observation, record review, staff and resident interview, and policy review, the facility failed to ensure smoking assessments and care plans were completed in a timely manner. This affected two residents (#58 and #152) of two reviewed for smoking. The facility identified twelve residents (#2, #22, #24, #42, #58, #59, #68, #92, #102, #103, #104, #152) who smoked. The facility census was 110. Findings include: 1. Review of the medical record for Resident #152 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of anterior wall of bladder, COVID-19, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/04/24 revealed Resident #152 had no care plan in place 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 observation, staff interview, record review, and policy review, the facility failed to maintain infection control practices to prevent the potential spread of COVID-19. This had the potential to affect 16 (#89, #24, #51, #68, #41, #96, #99, #5, #57, #9, #93, #74, #66, #73, #75, and #30) of 16 residents residing on the affected hall. The facility census was 101. Findings include: Review of the medical record for Resident #89 revealed an admission date of 09/12/22, with a current diagnosis of COVID-19. Review of the Annual Minimum Data Set (MDS) for Resident #89 dated 09/06/23, revealed Resident #89 was cognitively intact. Resident #89 required assistants, was not steady, and used a wheelchair for mobility. Review of the Care Plan for Resident #89 dated 11/07/23 revealed Resident #89 had an active COVID-19 diagnosis. Interventions included to maintain infection control per Centers of Disease Control (CDC) Prevention guidelines latest recommendations. Review of the physician orders for Resident #89 dated 11/07/23 revealed droplet precautions due to COVID-19 infection.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews and policy review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all 65 residents who received food from the kitchen. The census was 65. Findings include: 1. Initial tour of the kitchen was conducted on 09/27/21 5:58 A.M. to 6:25 A.M. with Registered Dietitian (RD) #44. Above a stainless-steel food preparation table holding the uncovered meat slicer and food processor was a heavily soiled ceiling and side wall of the hood fire suppression unit. The ceiling and side wall had dried on splatters of food crumbs and staining. RD #44 said she believed while processing food some had blown up to the ceiling and had not been cleaned up yet. Next to the hand washing sink were two black plastic polymer dish carts having multiple dividers to separate and stack dishes inside the carts. Both were uncovered, full of dishes and thermal dome covers leaving the clean dishes and domes open for back…

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

Based on record review, observation and interviews, the facility failed to ensure the residents on the secured unit had a dignified dining experience. This affected eleven (Resident's #5, #7, #14, #27, #30, #36, #46, #47, #50, #51 and #53) eating in the dining room during the observations and had the potential to affect all 13 residents living on the unit. The facility census was 65. Findings include: Record review was conducted of the resident council minutes dated 06/23/21 and 07/21/21 and signed by the Administrator. A concern was noted on 06/23/21 residents would like to have their dining room trays come out with the person they sit with. It was noted to resolve the problem a seating chart was put in the kitchen to assist with loading up trays in an orderly fashion. On 07/21/21 minutes it was noted the residents stated their trays were coming out at a closer time with their lunch mates. 1. Observation was conducted on 09/27/21 from 8:15 A.M. to 8:53 A.M. of the breakfast meal service within the secured unit. The meal consisted of cereal, eggs, toast, juice, milk, and other…

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 resident interview, staff interview, record review and policy review, the facility failed to ensure smoking breaks were provided for Residents #49 and #266. This affected two of three (Resident's #10, #49 and #266) resident's that smoked. The facility census is 65. Findings include: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease, major depressive disorder, and cirrhosis of liver. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact and required assistance of two staff for transfers and one staff for other activities of daily living except for eating. 2. Review of the medical record revealed Resident #266 was admitted on [DATE] with diagnoses including muscle weakness, dysarthria, and anarthria. Review of the quarterly MDS 3.0 assessment revealed it was in progress. Interview and observation on 09/27/21 at 1:15 P.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 observation, record review and interview the facility failed to properly store resident food and maintain sanitary conditions in the nursing unit B refrigerator to prevent contamination and potential food borne illness. This had the potential to affect nine residents (Resident #81, #344, #50, #72, #53, #28, #294, #93 and #32) who resided on unit B. The facility census was 83. Findings include: Observation on 05/13/19 at 9:13 A.M. with Dietary Manager (DM) #500 of nursing unit B refrigerator revealed in the freezer one short, dark colored strand of hair and a nickel sized brown, dried spill near the center of the floor of the freezer compartment. There was also a dried lighter brownish stain/spill along the left side of the bottom shelf, almost in the crease of the floor of the freezer and wall. The refrigerator had a medium sized plastic, clear bowl with a red top with an unidentifiable food in it. The bowl was not labeled or dated. Interview on 05/13/19 at 9:13 A.M. with DM #500 verified the above findings and stated housekeeping staff were responsible for keeping the…

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

Based on record review and interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice to Medicare Provider Non-Coverage (NOMNC) as required to Resident #33's responsible party/guardian. This affected one resident (Resident #33) of three residents reviewed for beneficiary notices. Findings include Review of the SNFABN form for Resident #33 revealed beginning on 03/30/19 the resident would have to pay out of pocket for care if she did not have other insurance that might cover the cost. A note printed on the bottom of the SNFABN revealed Social Service Designee (SSD) #510 attempted to call Resident #33's guardian on 03/29/19. After she was unable to contact the guardian, the SSD then contacted the house manager at the group home the resident resided in prior to admission. SSD #510 requested the house manager contact the guardian. Review of the beneficiary NOMNC for Resident #33 revealed skilled services would end on 04/03/19. A similar note dated 03/29/19 printed at the bottom of the NOMNC indicated the SSD requested the same…

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 plan of care for Resident #42 related to hemodialysis, for Resident #69 related to hospice and for Resident #91 related to a urinary tract infection. This affected one resident (Resident #42) of one resident reviewed for hemodialysis, one resident (Resident #69) of two residents reviewed for hospice services and one resident (Resident #91) of five residents reviewed for urinary tract infections and catheter care. Findings include: 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, dementia, and renal dialysis dependence. The resident had orders dated 02/26/19 for assessments pre and post dialysis every Tuesday, Thursday, and Saturday. No order was present identifying the time of the procedure or the nurse's role in arranging scheduling and transportation. There was no care plan developed related to the resident's need for dialysis care or the facility staff'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure respiratory equipment (nasal cannulas) were stored when not in use in a manner to prevent the potential spread of infection. This affected one resident (Resident #20) of one resident reviewed for oxygen use. The facility identified 15 resident with with oxygen. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, shortness of breath, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was severely cognitively impaired, needed extensive assistance with transfers, was frequently incontinent of urine, and used oxygen. Resident #20 had a physician order dated 03/10/19 for oxygen at two liters per minute via nasal cannula continuously to maintain a pulse oximeter of 92 percent for shortness of breath. On 05/13/19 at 8:57 A.M., an observation 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.