Lane Nursing & Ventilator Care

Based on record review and interview, the facility failed to ensure the required number of staff were present when the mechanical lifts were operated for one (#1) of one resident reviewed for mechanical lifts. Findings: Resident #1 had diagnoses which included chronic pain, anxiety, and pulmonary edema A care plan, dated 08/11/23, documented the resident required two person assist with transfers using a Hoyer lift. An Incident Report, dated 03/05/24, read in part, .Staff attempted to put resident in his wheel chair using the Hoyer Lift. While trying to put resident back in .chair resident slid off the chair into the floor. Staff was educated on Hoyer use and the importance of two staff members when using lifts. On 03/11/24 at 2:00 p.m., CNA #4 was asked if they had received an in-service regarding the use of a mechanical lift. They stated, No. On 03/11/24 at 2:05 p.m., CNA #1 and CNA #2 were asked if they had received an in service regarding the use of a mechanical lift. They stated no. On 03/11/24 at 2:10 p.m., CNA #3 and CNA #5 were asked if they had received an in service…

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 an alleged violation of resident to resident abuse was reported to the state agency for two (#1 and #3) of three sampled residents reviewed for abuse. The administrator identified 41 residents resided in the facility. Findings: An Abuse Prohibition Policy and Procedure, revised 10/30/23, read in parts, .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law .Should a suspected violation or substantiated incident of .abuse (including resident to resident) be reported, the Administrator, or his/her designee, will promptly notify .The State licensing/certification agency responsible for surveying/licensing the facility . 1. Res #1 had diagnoses which included depression. A quarterly resident assessment, dated 11/20/23, documented the resident's cognition was intact. A social service note, dated 02/01/24, documented Res #1 was approached before breakfast time by another resident in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement their abuse policy to investigate an injury of unknown origin for one (#1) of one sampled resident reviewed for injuries of unknown origin. The administrator reported the census was 47. Findings: An undated policy titled Abuse Prohibition Policy and Procedure, read in part, .all staff are to carefully observe unexplained bruises or abrasions. Upon identification of such a change, the staff member should report the findings immediately to his/her immediate supervisor or the Abuse Coordinator (Administrator). If unable to reach the Abuse Coordinator the Director of Nurses should be notified .Signs of/ Actual Physical Abuse .Fractures, dislocations or sprains of questionable origin .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law . Resident #1 had diagnoses which included acute respiratory failure 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 record review and interview, the facility failed to ensure care plans were reviewed and revised after a quarterly assessment for three (#14, 25, and #33) of 13 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: 1. Res #33 admitted to the facility with diagnoses of chronic respiratory failure, attention to tracheostomy, chronic atrial fibrillation, and attention to gastrostomy. Review of the clinical record revealed the care plan for Res #33 was last revised on 04/20/23. A review of the clinical record for Res #33 revealed a quarterly assessment was completed on 08/07/23. 2. Res #14 admitted to the facility with diagnoses of attention to tracheostomy, anoxic brain damage, anxiety disorder, and attention to gastrostomy. Review of the clinical record revealed the care plan for Res #14 was last revised on 02/03/23. A review of the clinical record for Res #14 revealed a quarterly assessment was completed on 05/23/23. 3. Res #25 admitted to the facility with diagnoses of…

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

Based on record review and interview, the facility failed to ensure four (#14, 33, 36, and #46) of 13 sampled residents were turned and repositioned based on professional standards of practice. The Resident Census and Census and Conditions of Residents report, dated 08/20/23, documented 47 residents resided in the facility. Findings: A Repositioning policy, dated October 2010 documented residents who are in bed should be on an every two hour turning program. 1. Res #14 admitted to the facility with diagnoses of anoxic brain damage, attention to tracheostomy, attention to gastrostomy, contracture- unspecified knee, hand, and hip. A quarterly assessment, dated 05/23/23, documented the resident's cognition was severely impaired and required total assistance with all ADL's. An ADL log, dated August 2023, documented 13 missed opportunities to turn and reposition the resident. 2. Res #33 admitted to the facility with diagnoses of chronic respiratory failure, attention to tracheosotomy, attention to gastrostomy, and pain unspecified. A quarterly assessment, dated 08/07/23, documented 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 ensure physician orders were followed for obtaining monthly vital signs for three (#1, 7, and #30) of 13 sampled residents whose medical records were reviewed. The Resident Census and Census and Conditions of Residents report, dated 08/20/23, documented 47 residents resided in the facility. Findings: A Charting and Documentation policy, revised April 2008, documented all observations, medications administered, and services performed must be documented in the resident's clinical record. 1. Res #1 had diagnoses which included paraplegia, hypertension, and hyperlipidemia. A physician order, dated 04/24/19, documented to record vitals monthly. A care plan, revised 08/11/23, documented to monitor vital signs per orders. There were no vital signs documented for June 2023 or July 2023 in Res #1's clinical record. 2. Res #7 had diagnoses which included multiple sclerosis, hypertension, and acute kidney failure. A physician order, dated 01/26/23, documented to record vitals monthly. A care plan, dated 02/03/23, documented 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 observation, record review, and interview, the facility failed to ensure residents were assessed for the need of bed rails and informed consent was obtained prior to the use of bed rails for one (#5) of three residents reviewed for accident hazards. The ADON identified 19 residents whose beds were equipped with a bed rail of any type. Findings: A Proper Use of Side Rails policy, revised October 2010, read in part, .An assessment will be made to determine the resident's symptoms or reason for using side rails .Documentation will indicate if less restrictive approaches are not successful, prior to considering use of side rails .Consent for using restrictive devices will be obtained from the resident or legal representative, after presenting potential benefits and risks .While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request .The resident will be checked periodically for safety relative to side rail use . Res #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.

Based on record review and interview, the facility failed to perform annual nurse aide performance reviews. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: On 08/22/23 at 2:00 p.m., the annual nurse aid performance reviews were requested. On 08/22/23 at 3:19 p.m., the ADON stated she could not locate the annual nurse aid performance reviews.

Based on record review and interview, the facility failed to explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement and explicitly grant the resident or their representative the right to rescind an arbitration agreement within 30 calendar days of signing it. The administrator documented 35 residents had entered into binding arbitration agreements. Findings: A Mandatory Arbitration excerpt, undated, was reviewed for explicit language documenting the resident's right to not sign and/or the right to rescind the agreement within 30 days of signing. The document did not contain the explicit statements. On 08/21/23 at 9:47 a.m., the administrator was asked to review the mandatory arbitration excerpt from the admission packet. The administrator stated they were unaware of the required explicit statements and would probably remove the arbitration agreement from the facility's admission packet going forward. On 08/28/23 at 10:58 a.m., the social services director was asked how the arbitration agreement was presented to residents. They…

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 arbitration agreements provided for the selection of a venue that was convenient to both parties and the selection of a neutral arbitrator agreed upon by both parties. The administrator documented 35 residents had entered into binding arbitration agreements. Findings: The arbitration agreement was reviewed and did not reveal a statement which provided for the selection of a neutral arbitrator agreed upon by both parties or venue which was convenient for both parties. On 08/21/23 at 9:47 a.m., the administrator was asked to review the mandatory arbitration excerpt from the admission packet. The administrator stated they were unaware of the required explicit statements and would probably remove the arbitration agreement from the facility's admission packet going forward. On 08/28/23 at 10:58 a.m., the social services director was asked how the arbitration agreement was presented to residents. They stated it was part of the admission packet and they explained the agreement during admission on how to file a complaint or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#5) of three residents reviewed for accident hazards. The ADON identified 19 residents whose beds were equipped with a bed rail of any type. Findings: A Bed Safety policy, revised December 2007, read in parts, .To try to prevent death/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks .The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA…

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 accurate coding of MDS assessments for anticoagulant use for one (#35) and for antipsychotic use for one (#25) of 13 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: 1. Res #35 admitted to the facility with diagnoses which included respiratory failure, atrial fibrillation, and hypertension. A quarterly assessment, dated 05/23/23, documented Res #35 received an anticoagulant seven out of seven days of the look back period. Res #35's records were reviewed and did not document an order for an anticoagulant during the review period. 2. Res #25 admitted to the facility with diagnoses which included anxiety. A quarterly assessment, dated 06/20/23, documented the resident had received an antipsychotic seven out of seven days of the look back period. Res #25's records were reviewed and did not document an order for an antipsychotic during the review period. On 08/22/23 at 10:23 a.m., the MDS Coordinator #1…

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 complete a new PASARR Level I assessment when a new serious mental illness diagnosis was received for one (#1) of one sampled resident reviewed for PASARR assessments. The Resident Census and Census and Conditions of Residents report, dated 08/20/23, documented 47 residents resided in the facility. Findings: A Level I PASARR, dated 05/12/17, documented Res #1 did not have a serious mental illness. On 04/12/21, Res #1 had new diagnosis of delusional disorder. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 08/21/23 at 7:27 a.m., the MDS coordinator was asked to provide documentation the OHCA was notified when Res #1 had new diagnosis of delusional disorder to see if a Level II PASARR was required. On 08/22/23 at 10:42 a.m., the MDS coordinator stated the facility did not contact the OHCA.

Based on interview and record review, the facility failed to ensure residents/resident representatives were notified of positive COVID-19 cases in the facility for five of six opportunities in August and September 2021. The DON identified 39 residents who resided in the facility. Findings: An undated policy, titled Infection Control for COVID-19 Suspected or Confirmed in Facility, read in part, .Any confirmation of a positive COVID 19 [sic] shall be communicated to residents who are their own person or POA/Family members by5 [sic] pm the next calendar day . A list of COVID-19 test results documented an employee had tested positive for COVID-19 on 08/05/21, 08/12/21, 08/22/21, 08/23/21, 08/24/21, and 09/05/21. Review of letters the facility had provided residents/responsible parties revealed they had been notified of the positive COVID-19 case on 08/05/21. No documentation had been provided residents/responsible parties had been notified of the other dates employees had tested positive for COVID-19. On 10/29/21 at 10:47 a.m., the administrator was asked who was responsible to notify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) accurately reflected the resident's current status for one (#40) of 15 sampled residents whose MDSs were reviewed. The DON identified 39 residents who resided in the facility. Findings: Resident #40 had diagnoses which included cerebral palsy. The Functional Maintenance Plan, dated 06/01/20, documented the resident was to receive bilateral upper and lower active/passive range of motion from the CNA's to help maintain her current level of functioning two to three times per week. An annual MDS, dated [DATE], documented the resident had no limitation in range of motion for the upper or lower extremities. On 10/26/21 at 11:54 a.m., the resident was observed in bed with her eyes closed. Her right arm/hand was observed to be bent at the elbow/wrist. During random observations throughout the survey the resident was observed to utilize her left arm/hand at times but…

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, interview and record review, the facility failed to ensure a care plan had been developed for residents with limited range of motion for one (#40) of two sampled residents who were reviewed for position/mobility. The DON identified 16 residents who were on a functional maintenance plan for limited range of motion. Findings: Resident #40 had diagnoses which included cerebral palsy. The Functional Maintenance Plan, dated 06/01/20, documented the resident was to receive bilateral upper and lower active/passive range of motion from the CNA's to help maintain her current level of functioning two to three times per week. Review of the resident's care plan, updated 04/22/21, did not reveal a care plan, goals, or interventions had been implemented regarding the resident's limited range of motion or the functional maintenance plan. On 10/26/21 at 11:54 a.m., the resident was observed in bed with her eyes closed. Her right arm/hand was observed bent at the elbow/wrist. During random observations throughout the survey the resident was observed to utilize her left arm/hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide a written reconciliation of medications upon discharge for one (#42) of three resident reviewed for discharges. The director of nursing identified three residents who discharged from the facility to the community during the past 12 months. Findings: Resident #42 was admitted on [DATE] with diagnoses which included cellulitis and hypertension. A Discharge summary, dated [DATE], documented in the area provided for medication instructions, the resident would discharge to home and medications were sent home with the resident. The summary did not include a reconciliation of medications (a document which compares a resident's admission medications with the medications she would take at home after discharge). On 10/28/21 at 3:56 p.m., the Director of Nursing (DON) was asked if the resident had been given a written reconciliation of medications. She stated they had not been doing that for resident's who discharged to home. She stated…

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, interview, and record review, the facility failed to ensure residents with limited range of motion received services on their functional maintenance plan to prevent further limitation for one (#40) of two sampled residents who were reviewed for position/mobility. The DON identified 16 residents who were on a functional maintenance plan for limited range of motion. Findings: Resident #40 had diagnoses which included cerebral palsy. The Functional Maintenance Plan, dated 06/01/20, documented the resident was to receive bilateral upper and lower active/passive range of motion from the CNAs to help maintain her current level of functioning two to three times per week. Review of the resident's care plan, updated 04/22/21, did not reveal a care plan, goals, or interventions had been implemented regarding the resident's limited range of motion or the functional maintenance plan. Review of the October 2021 ADL sheets did not reveal the resident had received range of motion services from 10/01/21 through 10/19/21. An annual Minimum Data Set (MDS) (a resident assessment…

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

Based on interview and record review, it was determined the facility failed to ensure residents who were ordered levothyroxine were monitored per the physician's order for one (#32) of five sampled residents who were reviewed for unnecessary medications. The DON identified seven residents who were ordered levothyroxine. Findings: Resident #32 had diagnoses which included hypothyroidism. Review of the October 2021 physician orders documented the following: A. Levothyroxine 25mcg every morning for hypothyroidism on 07/17/12; and B. Lab orders for TSH every six months on 07/29/19. Review of the clinical record revealed a TSH lab test had been completed on 12/10/20. On 10/29/21 at 10:07 a.m., the MDS/CP coordinator was asked how residents who were ordered Levothyroxine were monitored to ensure therapeutic medication levels. She stated all residents who were ordered Levothyroxine were also ordered annual TSH lab testing. She was asked why resident #32's TSH had not been completed per the physician's order since 12/10/20. She reviewed the clinical record and stated she had not realized…

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.