Brentwood Extended Care & Rehab

Based on record review and interview, the facility failed to ensure quarterly resident assessments were completed within 14 days of the assessment reference date for two (#24 and #29) of four sampled residents whose resident assessments were reviewed. The administrator identified 49 residents who resided in the facility. Findings: 1. Res #24's quarterly resident assessment, dated 10/12/23, was not completed and signed until 11/09/23. 2. Res #29's quarterly resident assessment, dated 10/22/23, was not completed and signed until 11/28/23. On 03/21/24 at 1:12 p.m. the administrator reported the resident assessments should have been completed and signed within 14 days and could not explain why that was not done.

Based on record review and interview, the facility failed to ensure the PASARR for a resident with a mental health diagnosis was filled out correctly and referred to the OHCA for two (#18 and #41) of three sampled residents reviewed for PASARR evaluations. The Administrator identified 49 residents resided in the facility. Findings: 1. Res #18 admitted to the facility with diagnoses of major depressive disorder and anxiety. A PASARR level I, dated 03/04/20, did not document the resident had a mental health diagnosis. 2. Res #41 admitted to the facility with diagnoses of delusional disorders and major depressive disorder. A PASARR Level I, dated 06/14/21, did not document the resident had mental health diagnosis. On 03/22/24 at 8:30 a.m., the administrator reported mental health diagnosis should have been documented and OHCA should have been notified.

Based on observation, record review, and interview, the facility failed to ensure: a. baths were given as schedule for two (#15 and #16) of two sampled residents whose baths were reviewed; and b. assistance with eating was provided for one (#18) of one sampled resident who required assistance with eating. The administrator identified five residents who required assistance with eating and 47 residents who required assistance with bathing. Findings: 1. Res #15 had diagnoses which included chronic obstructive pulmonary disease, neuropathy, and rheumatoid arthritis. The Bathing Schedule documented Res #15 was to receive a shower on Mondays and Thursdays. There was no documentation Res #15 received a shower from 03/01/24 to 03/22/24. On 03/18/24 at 10:38 a.m., Res #15 complained they had not received a shower this month and reported they have gone three to four weeks without a shower before. On 03/22/24 at 11:30 a.m., MDS Coordinator #1 reported Res #15 frequently refused baths, but was not able to provide documentation regarding the refusals. The MDS Coordinator reported Res #15'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, interview, and record review, the facility failed to ensure care was coordinated with hospice to ensure resident's medications were available for administration for one (#100) of two residents reviewed for hospice. The administrator identified 13 residents who received hospice services. Findings: The undated,Hospice policy, read in part, .It shall be the policy .to remain responsible for primary care for all residents .staff will communicate and coordinate residents care with Hospice . The facility's Medication Ordering and Receiving from Pharmacy policy, dated 04/2018, read in part, .Reorder medication four days in advance of need .to assure an adequate supply is on hand . A document titled, Hospice-Skilled Nursing Facility Service Agreement, dated 03/18/24, read in part, .Coordination of Care .Hospice and Facility shall communicate with one another regularly and as needed for the Hospice Patient .to ensure that the needs of the Hospice Patient are met 24 hours per day . Res #100 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure pain medication was administered as ordered for one (#100) of one sampled resident who was reviewed for pain management. The administrator identified 29 residents who received pain management. Findings: The facility's Medication Ordering and Receiving from Pharmacy policy, dated 04/2018, read in part, .Reorder medication four days in advance of need .to assure an adequate supply is on hand . A document titled, Hospice-Skilled Nursing Facility Service Agreement, dated 03/18/24, read in part, .Coordination of Care .Hospice and Facility shall communicate with one another regularly and as needed for the Hospice Patient .to ensure that the needs of the Hospice Patient are met 24 hours per day . Res #51 was admitted to the facility on [DATE] with diagnoses which included chronic pain and opioid dependence. A baseline care plan, dated 03/19/24, documented Res #30 had diagnoses of chronic pain issues. The care plan did not document…

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 insulin and/or blood pressure medication was administered per physician's orders for two (#31 and #46) of three sampled residents whose medication regime was reviewed. The administrator identified 49 residents who resided in the facility. Findings: The facility's Medication Administration-General Guidelines policy, revised 01/2018, read in part, .Medications are administered as prescribed .A triple check .is recommended .Check #1: Select the Medication- label, container and contents .compared against the medication administration record .Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR .Check #3: Complete the preparation of the dose and re-verify the label against the MAR . 1. Res #31 had diagnoses which included hypertension and diabetes. A physician's order, dated 06/27/23, read in part, Insulin Detemir subcutaneous 100u/ml, administer 20u subcutaneously at 7am and 4pm. HOLD IF FSBS <100 . A physician's order, dated 08/09/23, read in part, Metoprolol…

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. blood pressure machine was disinfected between residents for three (#14, 39, and #46) of three sampled residents who were observed during medication administration; b. soiled linens were not placed on the floor; c. nebulizer mouth piece was stored in a manner to prevent cross contamination for one (#100) of two sampled resident who had breathing treatments; d. a surveillance system was in place to identify infections and communicable diseases; and e. the buildings water system was assessed, monitored, and measures put in place to prevent the growth of Legionella and other opportunistic waterborne pathogens. The administrator identified 49 residents who resided in the facility and three residents who received nebulizer treatments. Findings: The facility's Specific Medication Administration procedure, revised 01/2018, read in part, Nebulizer .Rinse and disinfect the equipment according to manufacturer's recommendations .Wash pieces with warm soapy water daily. Rinse with hot water. Allow to air dry…

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 have a system in place to assess residents for infections using standardized tools and criteria for the initiation of antibiotics. The administrator identified 49 residents resided in the facility. Findings: The facility's undated, Communication of Resident Condition and Treatment with Antimicrobial Orders, read in part, .when facility staff suspects a resident has an infection, the nurse should perform and appropriately document a comprehensive assessment of the resident using established and accepted assessment protocols. This assessment will determine if the resident's status meets minimum criteria for initiating antibiotics . The tracking and trending infection control book was reviewed and revealed the facility had not tracked antibiotic use since December 2023. An undated document, titled, Attention All Nurses, read in part, We are initiating a new tool to help with antibiotic stewardship .Please note that there are assessment forms for urinary tract infections, skin and soft tissue infections and respiratory…

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 SNF ABN to one (#23) of three sampled residents whose beneficiary notices reviewed. The MDS Coordinator identified four residents who were discharged from skilled services with Medicare benefit days remaining. Findings: Res #23 was admitted to skilled services on 01/18/24 and discharged from skilled services on 02/21/24 and remained in the facility. A SNF Beneficiary Protection Notification Review documented an ABN was not provided to the resident. On 03/20/24 at 11:10 a.m., the MDS coordinator reported Res #23 was not provided an ABN form.

Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed within 14 days of the assessment reference date for one (#26) of four sampled residents whose resident assessment were reviewed. The administrator identified 49 residents who resided in the facility. Findings: The facility's Resident Assessment Instrument policy, revised 10/2010, read in part, .The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following scheduled .When there has been a significant change in the resident's condition . Res #26's significant change assessment, dated 10/19/23, was not completed and signed until 11/09/23. 03/22/24 at 1:02 p.m., the administrator reported the resident assessment should have been signed within 14 days. The administrator could not explain why the assessment wasn't completed and signed within the required timeframe.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for two (#4 and #14) of four sampled residents whose resident assessments were reviewed. The administrator identified 49 residents who resided in the facility. Findings: 1. Res #4 had diagnoses which included congestive heart failure. A physician's order, dated 11/09/22, read in part, Aspir-Low (anti-platelet) Oral Tablet Delayed Release 81 mg, administer one tablet by mouth daily. A quarterly resident assessment, dated 01/05/24, documented in error Res #4 was on an anti-coagulant. Res #4 was not documented to be on an anti-platelet. A quarterly resident assessment, dated 10/07/23, documented in error Res #4 was on an anti-coagulant. Res #4 was not documented to be on an anti-platelet. On 03/22/24 at 1:10 p.m., the administrator and MDS Coordinator #1 reported they were not aware aspirin was an anti-platelet. The administrator report the MDS coordinator should have documented the aspirin as an anti-platelet and not an anti-coagulant. 2. Res #14 admitted to the facility with…

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 refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#23) of three sampled residents reviewed for PASRR. The Administrator reported 49 residents resided in the facility. Findings: Res #23 admitted to the facility with diagnoses of diffuse traumatic brain injury with loss of consciousness of unspecified duration. Review of the resident's diagnosis documented he was diagnosed with Mood disorder due to known physiological condition, unspecified on 12/23/19 and with Major depressive disorder, recurrent, severe with psychotic symptoms on 12/09/20. On 03/22/24 at 8:31 a.m., the administrator reported OHCA should have been notified of the new mental health diagnosis.

Based on record review and interview, the facility failed to ensure a baseline care plan included hospice services and interventions for pain management for one (#100) of two sampled residents who were on hospice. The administrator identified 49 residents who resided in the facility. Findings: The facility's Care Plans-Preliminary policy, revised 04/2006, read in part, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident .To assure that the resident's immediate care needs are met and maintained .IDT to review all orders/treatments/medications and implement nursing care plans to meet residents' needs . Resident #100 was admitted the facility on 03/19/24 with diagnoses which included chronic pain. The resident was on hospice prior to admission to the facility. The baseline care plan was reviewed and revealed the baseline care plan did not document Res #100 was on hospice. The baseline care plan documented the resident had diagnosis of chronic pain. The care plan did not document interventions for pain or which services would be…

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 were offered assistance with splints for one (#30) of two sampled residents reviewed for limited ROM. The administrator identified one resident who had a contracture and 14 residents who had limited range of motion. Findings: Res #30 had diagnoses which included cerebrovascular disease with left sided hemiplegia. An ADL care, dated 01/23/24, read in part, .I have left sided hemiplegia with some contractures to LUE .I have a left hand spling (sic) I may or may not wear .Assist me with enough staff for safety . An assessment, dated 01/15/24, documented Res #30 had moderately impaired cognition, limited range of motion to upper and lower extremity on one side, and required moderate to partial assistance with upper body dressing. On 03/19/24 at 9:47 a.m., Res #30 stated the staff did not assist them with exercises for their arms or hands. Res #30's left hand was observed closed and they were unable to open their hand and did not have a splint on their left hand. 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 observation, record review, and interview the facility failed to have physician orders for maintaining an indwelling urinary catheter for one (#36) of one sampled resident whose indwelling urinary catheter was reviewed. The administrator identified six residents who had indwelling urinary catheters. Findings: Res #36 was admitted on [DATE] with an indwelling urinary catheter and diagnoses which included urinary retention, calculus of kidney and ureter. The How to insert, remove and care for a patient with a Foley catheter policy, undated, read in part, .j. If foley catheter is to remain indwelling for 30 days, obtain an order for foley catheter and bag change at 30 day intervals . A physician's order, dated 02/19/24, read in part, .provide catheter care per protocol every shift and as needed. A physician's order, dated 02/19/24, read in part, .obtain output and record every shift and as needed. There was no physician's order to the changing of the catheter and drainage bag at least every 30 days. The…

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

Based on observation, record review, and interview, the facility failed to follow physician's orders for oxygen therapy for one (#4) of one resident sampled for oxygen therapy. The administrator reported 49 residents resided in the facility. Findings: Res #4 admitted to the facility with diagnoses of acute respiratory failure and tracheostomy. A physician's order, dated 04/15/23, documented O2 @3.5 liters per minute per nasal cannula or trach mask, pulse ox Q shift, titrate to keep O2 sats >92% Fill humidifier bottle Q shift/PRN On 03/19/24 at 10:28 a.m., the resident's oxygen setting was observed at 2.5 liters per minute per nasal cannula. On 03/20/24 at 8:21 a.m., the resident's oxygen setting was observed at 2.5 liters per minute per nasal cannula. On 03/21/24 at 10:16 a.m., the resident's oxygen setting was observed at 2.5 liters per minute per nasal cannula. On 03/22/24 at 8:20 a.m., LPN #1 was asked what the resident's oxygen setting was set on. She reported she did not know what is was set at. LPN #1 reported she would have to look at the orders to see what it said.

Based on observation, record review, and interview the facility failed to document and retain the required staffing information. The administrator identified 49 residents who resided in the facility. Findings: On 03/18/24 at 12:00 p.m., and throughout the survey there were two white boards observed to be at each nursing station. The facility name, date, census and staff with titles were documented on each board. Staffing hours worked were not documented. 03/22/24 at 12:56 p.m., the administrator reported they were unaware of the requirements regarding posted staffing information and keeping staffing information for at least 18 months.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate indication for use one (#48) residents reviewed for unnecessary medications. The administrator identified 49 residents who resided in the facility. Findings: Res #48 had diagnoses which included ESRD. Current physician's orders, dated 01/11/24, read in part, .Eliquis Oral tablet 5mg diagnosis .Hypertension secondary to other renal disorder . (Eliquis is a blood thinner that reduces blood clotting.) A pharmacy review, dated 01/15/24. read in part, .Suggest clarification of Eliquis diagnosis, this is not for hypertension . The physician's response to the pharmacy recommendation, dated 01/21/24, read in part, I DO concur. On 03/25/24 at 11:53 a.m., the administrator was asked about diagnoses for Eliquis. The administrator called the medical director. The administrator stated the medical director reported the Eliquis was not prescribed for hypertension. They stated the diagnosis should have been changed. They stated it was a preventative…

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 the microwave used to heat up resident food after hours was in good repair. The administrator identified 49 residents who resided in the facility. Findings: The facility's Maintenance Service policy, revised 12/2009, read in part, .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times . On 03/20/24 at 9:27 a.m., Res #42 stated they were not allowed to have a microwave in their room and the microwave the staff utilized to heat up their food after hours was broken. They stated the staff had told them the microwave would not be replaced for a few weeks. Res #42 stated the staff were unable to heat up their food last night (03/19/24). On 03/20/24 at 10:00 a.m., dietary aide #1 stated when the kitchen was closed the staff used the microwave in the employee break room to heat up the residents' food. On 03/20/24 at 11:58 a.m., the employee break room was observed with dietary aide #1. There was not a microwave located 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.

Based on observation and interview, the facility failed to place a call activation call button in an occupied room for one (#39) of one sampled resident reviewed for call lights. The administrator identified 49 residents resided in the facility. Findings: A facility policy titled Call Light, Use of, undated, read in part, .Bedside call light in functioning order . Res #39 was admitted to the facility with diagnoses of acquired absence of right leg above the knee and unspecified abnormalities of gait and mobility. On 03/19/24 at 10:19 a.m., an observation of the resident's room was conducted. There was no call light in the room. The resident reported he has not had one since he moved into the room. On 03/20/24 at 11:43 a.m., the administrator reported that every resident should have had a call light regardless of room changes.

Based on observation and interview, it was determined the facility failed to provide a safe, clean, sanitary, homelike environment. The facility failed to ensure the ceiling in between the dining area and the common area was free from water leakage. The administrator identified 78 residents resided in the facility. Findings: On 11/20/23 at 11:04 a.m., an observation was made of two wet and dirty blankets on the floor in between the dining area and the common area. There was also observation of water damage to the wall and paint over the doorway. On 11/20/23 at 11:20 a.m., an interview with Res #4 stated every time it rains hard they have to put blankets down and sometimes a mop bucket to catch the water that is leaking into the building. They also stated the water leak has been there for a while. On 11/20/23 at 11:35 a.m., an interview with the owner stated the water leak had been there for awhile related to the damage over the doorway. They also stated they had just hired a full time maintenance man and so the water leak would be one on the first things fixed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the physical environment of the facility was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report documented 46 residents resided in the facility. Findings: On 07/31/23 at 9:39 a.m., the main hallway was entered through the door separating the lobby area to the resident area of the facility. A urine smell was observed. On unit two the urine smell was observed to become stronger and the floor on unit two hall was observed to have a dark tacky/sticky substance on the floor tiles. On 07/31/23 at 9:44 a.m., Res #2 stated the floor was always dirty and sticky. Res #2 stated they cleaned their room once a week. The floor in Res #2's room was observed to be tacky and sticky. On 07/31/23 at 9:58 a.m., a spilled pink color substance was observed on the sink in room [ROOM NUMBER]. Flies were observed all over the sink. The resident in the room stated they did not know when the last time the room had been cleaned.…

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 interventions to prevent the reoccurrence falls were put in place for one (#6) of four residents sampled for falls. The corporate VPO identified 21 resident who had fallen in the past three months. Findings: Res #6 had diagnoses which included history of fracture of the right femur. An incident report, dated 02/12/23, documented a fall outside in the smoking area. Res #6 was sent to ER and had no injury. The intervention was to educate the resident when getting up from a sitting position to make sure and get balance under both feet and make sure the resident was steady on BLE. An incident report, dated 06/16/ 23, documented the resident was found in the floor in their room. The report documented the resident fell due to the water in floor from the shower. The report documented the resident had pain to right hip from the fall and was sent to the ER. The report documented an intervention of maintenance was notified to fix the drain.…

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 interview, the facility failed to ensure resident assessments accurately reflected residents' status for five (#30, 33, 36, 45, and #46) of 14 residents whose assessments were reviewed. The facility failed to accurately code for: a. GDR dates were correct for Res #33. b. pressure ulcers for Res #36. c. diagnoses for Res #46. d. the presence of a urinary catheter for resident #45. e. GDR for Res #30. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included major depressive disorder, schizoaffective disorder, delusional disorders, and Alzheimer's disease. A MRR, dated 10/12/22, documented a request for a dosage reduction attempt for Seroquel from 25 mg in the morning and 50 mg in the evening to 25 mg twice daily. The physician documented he did concur and signed the MRR on 10/22/22. A physician order, dated 10/23/22, documented Seroquel 25 mg administer one tablet two times a day for schizoaffective disorder, depressive type. A MRR, dated 01/11/23,…

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 interview, the facility failed to develop a comprehensive person-centered care plan for three (#16, 33, and #45) of 14 residents whose care plans that were reviewed. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included diabetes mellitus and Alzheimer's disease. A physician order, dated, 07/22/20, documented Aricept 10 mg daily for Alzheimer's disease. A physician order, dated 11/05/22, documented the facility was to administer Lispro insulin administer per sliding scale for diabetes mellitus. A physician order, dated 12/21/22, documented the facility was to administer Glargine insulin for diabetes mellitus. A annual assessment, dated 01/22/23 documented the resident was severely impaired with cognition and required supervision to limited assistance with most activities of daily living. The assessment documented the resident received insulin injections seven days during the look back period. The resident care plan was reviewed. The care plan did…

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 interview, the facility failed to revise the care plan for one (#36) of 14 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: Res #36 had diagnoses which included CHF, pulmonary embolus, and diabetes mellitus. A significant change assessment, dated 11/01/22, documented the resident was intact with cognition and required extensive assistance with most activities of daily living. A physician order, dated 01/25/23, documented hospice to evaluate and treat. A care plan, reviewed 02/15/23, documented the resident was on hospice care for CHF and signed a DNR on 06/28/22. The heading of the resident's EHR documented the resident was a full code. On 02/16/23 at 2:07 p.m., the corporate VPO stated the resident was a full code he had revoked his DNR on 10/31/22. On 02/16/23 at 2:23 p.m., Res #36 was in a geri chair in the day room in front of the television. Res #36 stated he wanted to be a full code now. He stated he had a girlfriend and he wanted 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 record review and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#33) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility who receive antipsychotic medications. Findings: 1. Res #33 had diagnoses which included major depressive disorder, schizoaffective disorder depressive type, and delusional disorders. A MRR, dated 04/12/22, documented a request for a dosage reduction attempt for Seroquel from 50 mg twice daily to 25 mg in the morning and 50 mg in the evening. The physician responded he concurred and the MRR was dated 04/16/22. A physician order, dated 06/06/22, documented Seroquel 50 mg administer once a day in the evening for delusional disorders. A physician order, dated 06/07/22, documented Seroquel 25 mg administer once a day in the a.m. for delusional disorders. A review of the resident EHR, documented the Seroquel was not changed on the MAR until 06/06/22. The medication was not decreased 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.

Based on record review and interview, the facility failed to ensure physician ordered laboratory tests were obtained for three (#6, 33 and #46) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included atrial fibrillation, schizoaffective disorder, and diabetes mellitus. A physician order, dated 01/15/21, documented to obtain a HgbA1c (venipuncture) every three months in January, April, July, and October. The resident's EHR did not have a HgbA1c completed in April or July of 2022. A physician order, dated 01/15/21, documented obtain CBC, CMP, TSH, and lipid panel (venipuncture) every six months in January and July. The resident's EHR did not document a CBC, CMP, TSH and lipid panel was obtained in July 2022. A annual assessment, dated 01/22/23, documented the resident was severely impaired with cognition and received antipsychotic medication. On 02/21/23 at 11:54 a.m., the corporate VPO stated she was unable to find the April or July…

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 interview, the facility failed to ensure: a. the kitchen was clean and maintained in good repair. b. the staff prepared food in a sanitary work space. The corporate VPO identified 46 residents received services from the kitchen. Findings: On 02/21/23 at 11:10 a.m., during an observation of the kitchen, a hole was observed in the wall of the kitchen where the freezer lid hit the wall. Walls in the kitchen had damaged drywall behind the freezer and around the door facings. Trim was observed to be missing at the bottom of a door facing and the dry wall was damaged. Broken tiles were observed under the fryer and in the dish room. A bowl containing a flour like substance was observed sitting unattended on the top of the freezer. On 02/21/23 at 11:15 a.m., during a meal service, the wall behind the steam table was observed to have areas where the dry wall was damaged. On 02/21/23 at 11:21 a.m., DA #1 was observed with the bowl which was on the top of the freezer. The DA #1 was standing at the three compartment sink making pumpkin bars. Two sanitizer buckets were…

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

Based on record review and interview, the facility failed to ensure the arbitration agreement documented the required wording. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: On 02/22/23 the facility arbitration agreement was reviewed and did not reveal a statement that the resident or resident's representative would not be prohibited from contacting state or federal surveyors, other health department employees or the office of the ombudsman. On 02/22/23 at 9:51 a.m., the corporate VPO reported she had reviewed the arbitration agreement with the facility attorney and the above wording was not documented in the agreement. She stated they would update the agreement to be in compliance.

Based on record review and interview, the facility failed to ensure the arbitration agreement documented the required wording. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: On 02/22/23 the facility 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 02/22/23 at 9:51 a.m., the corporate director of operations reported she had reviewed the arbitration agreement with the facility attorney and the above wording was not documented in the agreement. She stated they would update the agreement to be in compliance.

Based on record review and interview, the facility failed to electronically submit direct care staffing data based on the facility payroll. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: The Quality Improvement and Evaluation System was reviewed and did not reveal PBJ data for the facility during the previous two quarters. On 02/22/23 at 8:40 a.m., the corporate VPO stated the facility had hired an outside company to submit the PBJ data for them. She had contacted human resources for the facilities owner and stated they had not followed up to ensure the data had been submitted as required.

Based on record review and interview, the facility failed to ensure a DNR was signed by an individual with the authority to do so for one (#45) of 24 residents whose records were reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 12 residents had advanced directives. Findings: Res #45 had diagnoses which included Alzheimer's disease, blindness, and severe intellectual disability. A DNR form for Res #45, dated 04/19/22, documented a signature of a family member. A significant change assessment, dated 01/27/23, documented Res #45 was severely impaired in cognitive skills for daily decision making. On 02/15/23 at 12:22 p.m., Res #45's EHR was reviewed and revealed a POA for financial only which documented the family member was to make financial decisions for the resident. The POA form did not document a health care proxy. On 02/16/23 at 2:25 p.m., the corporate VPO confirmed the resident did not have a POA, health care proxy, or guardianship documentation for Res #45 on file at the facility. She stated the form should not have been signed…

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 a significant change assessment was completed when a resident experienced a major decline for one (#46) of 14 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form revealed 49 residents resided in the facility. Findings: Res #46 had diagnoses which included unspecified dementia with behavioral disturbance and a traumatic brain injury. A quarterly assessment, dated 10/06/22, documented Res #46 was moderately impaired in cognition, had no behaviors, and was frequently incontinent of urine and bowel. A quarterly assessment, dated 01/04/23, documented Res #46 was severely impaired in cognition, had verbal behaviors directed toward others, and was always incontinent of urine and bowel. On 02/12/23 at 12:22 p.m., the DON - MDS coordinator reported he did not think the resident had experienced a change in condition. The DON reviewed the quarterly MDS assessment, dated 01/04/23, and confirmed this should have been a significant change assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of a level I PASRR for one (#36) of one resident who reviewed for PASRR evaluations. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: Res #36 was admitted on [DATE] and had diagnoses which included anxiety disorder dated 04/21/21, post-traumatic stress disorder, chronic dated 04/21/21, and major depressive disorder, recurrent, severe with psychotic symptoms dated 06/30/21, Review of the resident's clinical record revealed a negative Level 1 PASRR was completed on 09/15/21. A significant change assessment dated , 01/25/23, documented the resident was intact with cognition and received an antipsychotic medication during the look back period. On 02/16/23 at 2:04 p.m., the corporate VPO stated the PASRR I was not filed out correctly.

Based on record review and interview, the facility failed to ensure they followed their staff COVID vaccination policy by ensuring staff members completed the primary vaccination series or had obtained an exemption. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: An undated facility policy, titled Mandatory COVID-19 Vaccination Policy, read in parts, .Newly hired Covered Employees .have (4) weeks from the date of hire .Employees who do not comply with this vaccine requirement within the time period allowed will be suspended without pay for thirty (30) days. Suspended Employees who do not comply with this vaccine requirement by the end of their thirty-day suspension will be terminated . The BOM provided a staff COVID vaccination report which documented one staff member had not completed their primary COVID vaccination series. On 02/21/23 at 1:20 p.m., the BOM stated CNA #1, who was hired on 03/17/22, had received the first dose of COVID-19 vaccination in May of 2022 and had not received their second dose. On 02/21/23 at…

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