Kadima Rehabilitation & Nursing At Luzerne

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident and staff interview it was determined the facility failed to develop and implement effective safety measures to prevent the ingestion of an illegal substance for one resident out of 15 residents sampled. (Resident 25). Findings include: A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder- people with this condition experience periods of extreme energy, irritability, and restlessness and/or periods of depressive episodes, low energy, and hopelessness), chronic pain, and polysubstance use disorder (includes use of drugs such as cocaine, misuse of alcohol, tobacco, or a prescription medicine such as opioids). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 28,…

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 review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for two residents out of 15 sampled (Residents 13 and 24). Findings include: Review of the facility policy titled Oxygen Concentrator last reviewed by the facility on September 16, 2024, revealed that precautions will be taken to maintain the integrity of the oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) unit and to promote safety during oxygen administration. Be sure the cabinet air filter is in place. The air filter is to be removed from the door in the back of the unit by nursing. Wash the filter in warm water and towel dry. Do not operate the unit without the air filter or while the air filter is still damp. Review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive…

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 review of select facility policy and clinical records, and staff interview, it was determined the facility failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one resident out of five residents reviewed (Residents 29). Findings include: A review of facility policy titled Influenza and Pneumococcal Pneumonia Vaccination and Immunization Program last reviewed September 16, 2024, revealed that each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated. Nursing staff will provide education information to the resident/authorized representative prior to the administration of each vaccine. Once education has been completed, a signed consent form is to be obtained prior to administration of the vaccine. A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of employee personnel files and select facility policy and interviews with facility staff, it was determined the facility failed to demonstrate that licensed nurses possess the necessary competencies and skills to accurately prepare and administer prescribed medications to residents for 1 out of 5 residents reviewed. (Resident A1) Findings include: According to the American Nurses Association the Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, out- comes identification, planning, implementation, and evaluation. Nurses' responsibility for medication administration includes ensuring that the right medication is properly drawn up in the correct dose and administered at the right time through the right route to the right patient. A review of a facility policy entitled Medication Administration - General Guidelines that was last reviewed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on July 23, 2024, at 9:09 AM revealed dirt and debris was on the floors throughout the hallway of the south side nursing unit. Observation in the common resident bathroom on this hall revealed hair and a dried yellow-urine like substance on the toilet. Observation in resident room [ROOM NUMBER] revealed dried feces on the toilet and toilet seat. Dirt and debris was observed on the bathroom floor. Dirt, debris and a dried red substance was observed on the floor of resident room [ROOM NUMBER]. [NAME] streaks were observed on the wall next to the door. Observation in resident room [ROOM NUMBER] revealed dried stain streaks on the wall next to the resident's dresser. There was an accummulation of dust and dirt stuck to these streaks on the wall. Observation in the resident shower room 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 observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and ready availability of clean bath linens, to at least three of the five residents sampled (Residents 1, 2, and 22) and on two of the two nursing halls. Findings include: During an interview on June 18, 2024, at 8:50 AM, Resident 1 stated the facility has a good part-time housekeeper. He stated that the bathrooms and hallways are dirty when this housekeeper is not working. He said he is upset because he uses a shared bathroom, and often finds feces on the toilet and floor in this bathroom that he shares with another resident. During a facility tour on June 18, 2024, at 9:00 AM, an observation of the resident shower room [ROOM NUMBER] revealed a soiled brief, used wash towels, and clothing on the floor. A used wet wash towel was observed hanging from the metal grab bar in the shower. A stained clothing protector was observed in the wash…

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 a review of clinical records and resident and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of five sampled (Resident 26). Findings include: Clinical record review revealed hospital documentation, prior to the resident's admission to this current long term care facility, dated April 18, 2024, noting that Resident 26 was discharged from another long-term care facility and not permitted to return. The documentation indicated that Resident 26 needs a locked dementia unit, requires one to one level of supervision (1:1), is an elopement risk, and was redirectable until recently. Resident 26 was admitted to this current long term facility on April 22, 2024, with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking,…

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 a review of clinical records and staff and resident interviews, it was determined that the facility failed to provide medically related social services for one resident out of the five sampled (Resident 22). Findings include: A clinical record review revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses that included hemiparesis (a weakness or inability to move one side of the body) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 19, 2024, revealed that Resident 22 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall…

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 review of clinical records and staff interview it was determined that the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and nutritional assessment for one (Resident 2) out of 13 residents reviewed. Findings include: During an interview conducted on February 27, 2024, at 9:15 AM the foodservice director confirmed that she worked full-time and was a certified dietary manager (CDM). The CDM stated that the facility no longer employed a qualified dietitian on a full-time, part-time, or consultant basis. Interview with the nursing home administrator on February 27, 2024, at 10:00 AM confirmed that the facility's qualified dietitian resigned on January 3, 2024. A review of the Certifying Board for Dietary managers (the credentialing agency for the Association of Nutrition and Food Service professionals) scope of practice for certified dietary managers, these individuals were able to conduct…

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

Based on observation and staff interview, it was determined that the facility failed to properly maintain garbage and refuse containers in garbage storage area in a sanitary manner. Findings include: Observation on February 27, 2024, at 8:15 AM revealed the dumpster lid was not closed and two bags of garbage were placed on the ground next to the dumpster. There was scattered debris including paper wrappers, a slice of bread, and empty plastic beverage bottles on the ground surrounding the dumpster. Observation on February 28, 2024, at 2:30 PM revealed two bags of garbage on the ground next to the dumpster. Interview with the foodservice director (FSD) on February 29, 2024, at 11:45 AM confirmed that both dietary and housekeeping used the dumpsters. The FSD garbage was to be placed in the facility's dumpster and dumpster lids were to be kept closed. The FSD confirmed that the area surrounding the dumpster was to be maintained in a sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management

Based on observation, review of the facility's infection control tracking logs and policy, and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during the medication administration for two out of two medication carts (North and South). Findings include: A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign 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.

Based on a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee. Interview with the nursing home administrator (NHA) on February 27, 2024, at approximately 8:45 AM, revealed that 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 a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to demonstrate that it had ascertained if a resident had an advance directive upon admission and whether the resident would like information to formulate an advance directive for three of 13 sampled residents (Residents 2, 13, and 21). The findings include: Review of facility's Advance Directives policy last reviewed by the facility October 20, 2023, indicated that an advance directive is a written instruction such as a living will or durable power of attorney for healthcare, recognized under state law, relating to the provision of health care when the individual is incapacitated. The document expresses wishes about treatment preferences and the designation of a surrogate if the patient is incapacitated. The facility process includes that the social worker will meet with the resident/family upon admission, quarterly, annually, and as needed to review (advance directives). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of two nursing units (North and South nursing units) and failed to ensure comfortable water temperatures including three residents out of the 13 sampled (Residents 13, 21, and 25), and three out of the six residents interviewed during a resident group interview (Residents 5, 23, and 28). Findings Include: An observation of resident room [ROOM NUMBER] on February 27, 2024, at 8:45 AM revealed the white window blinds were bent and missing fins. A dirt buildup was visible on the window sill between the window and the screen. During an interview on February 27, 2024, at 8:52 AM, Resident 21 stated that he gets a draft in his room through drill holes that are utilized to hold the air-conditioning unit in place during the summer months. Resident 21 explained that he 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 a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 13 sampled (Residents 3, 22, and 12). Findings include: According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment. The annual MDS Assessment of Resident 3 dated December 8, 2023, revealed Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. A review of Resident 3's clinical record revealed a Level I PASRR 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 review of select facility policy and controlled drug records and observation and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate administration, and records accounting for controlled drugs for five of eight residents sampled (Resident 13, 7, 24, 19, and 8), and reconciliation of controlled drugs on one of two medication carts (North). Finding include: A review of the facility policy Medication ordering, receiving, and storage (Controlled Substance), and Medication Storage in the facility (ID3: Controlled medication storage) last reviewed by the facility October 20, 2023, stated nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty will make the count together. They must document and report any discrepancies to the director of nursing services. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. If a major…

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 a review of the facility's abuse policy, select facility investigation reports, and clinical records, and staff interview, it was determined that the facility failed to ensure one resident out of 13 sampled was free from misappropriation of resident property, medication (Resident 13). Findings included: A review of the facility Abuse Protection Policy last reviewed October 20, 2023, revealed that the residents have the right to be free from verbal, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. abuse, neglect, misappropriation of resident property, and exploitation. Further it is indicated misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's permission. A review of the clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which include congestive heart failure and depression. 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 a review of clinical records and select facility investigations, and staff interviews, it was determined that the facility failed to timely develop a person-centered care plan to address a resident's high risk for falls and meet the safety needs of one resident out of 13 sampled (Resident 10). Findings include: A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions). A review of an annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2023, revealed a care area assessment (CAA- process provides guidance on how to focus on key issues identified during a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and select facility policy review, and staff interview it was revealed that the facility failed to monitor weight and evaluate nutritional and hydration requirements to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of 13 sampled (Resident 2). Findings include: Review of the facility Resident Weights policy last reviewed October 20, 2023, indicated that weights must be obtained routinely to monitor the parameters of nutrition over time, and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for two days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for four weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All weights will be transcribed (including weekly…

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 review of select facility policy and clinical records, observation and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for one of five residents sampled (Resident 8). Findings include: A review of the facility's policy Disposition of Medications last reviewed by the facility October 20, 2023, indicated it is the policy to establish guidance for the disposition of medications to implement safe and responsible disposition practices of discontinues medications in order to protect residents and staff from improper diversion or accidental exposure. Medications discontinues by prescriber order, are destroyed onsite with disposition being reported on a paper form which is then scanned into the electronic medical record. Medications are removed from the medication cart immediately upon receipt of an order to discontinue in an effort to avoid inadvertent administration. A review of Resident 8's clinical record…

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 a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: A review of the facility's infection control policy, provided by the facility during the survey of October 26, 2023, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee. Interview with the nursing home administrator (NHA) on October 26, 2023, at approximately 12:45 PM, revealed that the facility had been without 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.

Based on review of grievances lodged with the facility, the schedule of the facility's activities staff and activities programming and interviews with staff, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of two out of 8 sampled residents (Residents 18 and 21) Findings include: Review of grievance submitted by Resident 18 dated October 7, 2023, revealed that the resident was very upset that the Activity Director was not present in activities. The grievance further indicated that the resident was weepy at times and that she was bored. Resident 18 questioned if it was something the resident did wrong. Comfort and emotional support were provided at the time the resident's concern was expressed. Review of grievance submitted by Resident 21 dated October 8, 2023, revealed that the resident was very upset, there are no activities in the morning. The resident stated I don't even want to get out of bed anymore. I have nothing to look forward to. The resident stated that she was going to tell her…

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 a review of grievances lodged with the facility and the schedules of the employees of the facility's activities department and staff interviews it was determined that the facility was not administered in a manner that enables it to uses it staff resources to maintain the highest practicable mental and psychosocial well-being of each residents causing emotional upset to two of eight residents sampled (Resident 21 and 18). Findings included: Review of grievance submitted by Resident 18 dated October 7, 2023, revealed that the resident was very upset that the Activity Director was not present in activities. The grievance further indicated that the resident was weepy at times and that she was bored. Resident 18 questioned if it was something the resident did wrong. Comfort and emotional support were provided at the time the resident's concern was expressed. Review of grievance submitted by Resident 21 dated October 8, 2023, revealed that the resident was very upset, there are no activities in the morning. The resident stated I don't even want to get out of bed anymore. I have…

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 a review of clinical records and staff interview it was determined that the facility failed to provide person-centered quality care by failing to follow physician orders for medication administration and accurately monitor bowel activity and administration of the bowel protocol as prescribed for one resident out of seven 7 sampled (Resident 11). Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses to include, stiff-man syndrome (a rare autoimmune neurological disorder that most commonly causes muscle stiffness and painful spasms that come and go and can worsen over time.) and chronic pain. The resident had physician orders dated August 28, 2023, for MS Contin (an opioid medication for pain) 15 milligrams (mg) by mouth two times a day (8:00 a.m. and 8:00 p.m.) for chronic pain, and Pregabalin (Lyrica- used to treat pain caused by nerve damage) 75 mg by mouth two times a day (9:00 a.m. and 9:00 p.m.) for chronic pain. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined that the facility failed to demonstrate an effective maintenance program of regular inspection of all bed frames, mattresses, and bed rails to assure that the mattress fit the bed frames properly limiting entrapment zones and promoting resident comfort and safety for 21 resident beds with side rails and further failed to ensure the availability of a functioning bed for all current licensed and certified resident beds (Resident rooms [ROOM NUMBER]). Findings include: Observations on April 20, 2023, at approximately 9:30 AM confirmed that side rails were in use on the residents' beds in Resident Rooms which included: Q3-1, Q7-1, Q7-2, 8-1, 8-2, 9-2, Q10-1, Q10-2, 11-2, 12-1, 14-1, 14-3, 15-2, 17-1, 17-2, 18-2, 19-2, 20-1, 21-2, 23-1, and 23-1. Side rails were in use on each resident bed noted. Interview with the administrator on April 20, 2023 at approximately 11:00 AM failed to provide documented evidence to demonstrate regular inspections of bed frames,…

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 a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three resident out of 14 sampled (Resident 9, 34, and 12). Findings include: The Significant change MDS Assessment of Resident 9, dated October 7, 2022, revealed that Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR admission screening process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. (Preadmission Screening and Resident Review {PASARR} is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated 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 clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two of three residents reviewed (Residents 12 and 4). Findings include: Review of clinical record of Resident 12 revealed diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident 12's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated March 17, 2023, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or 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 observation, a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to assess a resident's potential need for bed rails, including the risk for entrapment and a review of the risks versus benefits with the resident and/or the resident's representative for one of four sampled residents (Resident 36). Findings include: A review of the facility policy Use of Side Rails reviewed by the facility December 19, 2022, indicated Side rails may be used as resident mobility aids and the use of side rails as restraints will not be used unless necessary to treat a resident's medical symptom. Residents must be assessed for entrapment risk from bed rails prior to use of side rails. Guidelines for the policy included: Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another,…

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 review of clinical records and interviews with staff, it was determined the facility failed to provide therapeutic and medically related social services to promote the psychosocial well-being of one of two residents reviewed for discharge planning (Resident 6), coordination of required mental health services for two of three residents (Resident 12 and 4) and assisting and arranging to meet a resident's communication needs for one resident out of 14 sampled (Resident 32). Findings include: According to long term care regulatory guidelines, examples of medically-related social services include: o §483.15, Transitions of Care, §483.20, Resident Assessments (PASARR), and §483.21, Comprehensive Person-Centered Care Planning; o Assisting or arranging for a resident's communication of needs through the resident's primary method of communication or in a language that the resident understands; o Making referrals and obtaining needed services from outside entities o Transitions of care services (e.g., assisting…

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 a review of clinical records and facility documentation and staff interviews, it was determined the facility failed to provide a Notice of Medicare Provider Non-Coverage and for the appeal process for one of three records reviewed. (Resident 19). Finding include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the list of discharged residents, provided by the facility, from a Medicare covered Part A stay with benefit days remaining in the past six months revealed no…

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 clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of facility initiated transfer to the hospital identifying the reason for the transfer in a language and manner easily understand by one resident (Resident 9) and failed to provide written notice of the facility initiated transfer to the hospital to the resident's representative for one resident out of six sampled (Resident 34). Findings include: A review of Resident 9's clinical record revealed that the resident was transferred to the hospital on March 2, 2023, and returned to the facility on March 30, 2023. The identified reason for the resident's transfer was noted as low hemoglobin (A hemoglobin test measures the amount of hemoglobin in your blood. Hemoglobin is a protein in your red blood cells that carries oxygen to your body's organs and tissues and transports carbon dioxide from your organs and tissues back to your lungs. If a hemoglobin test reveals that your hemoglobin level is…

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 a review of clinical records and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of two residents reviewed for discharge planning (Resident 6). Findings Include: A review of Resident 6's clinical record revealed admission to the facility on August 19, 2022, with diagnoses including congestive heart failure (chronic condition in which the heart does not pump as well as it should) and depression. During interview with Resident 6 on April 18, 2023, at 10:00 AM the resident stated that he was satisfied at the facility, but if possible, would like to transfer to a facility, which allowed smoking. There was no evidence of the resident's discharge plans or assessment of the resident's potential for discharge to lesser level of care, identification of the resident's discharge goals or if the resident's placement was long term. Review of Resident 6's current plan of care, in effect at the time of the survey ending April 20, 2023, revealed no documented evidence of the resident's discharge goals…

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 a review of clinical records and interviews with staff and resident it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one resident with communication needs out of 14 sampled residents (Resident 32). Findings included: An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated March 10, 2023, revealed Resident 32 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact) and that the resident's preferred language was Spanish. A review of clinical record revealed that Resident 32 was admitted to the facility on [DATE], with diagnoses to include diabetes, anxiety, acute respiratory failure with hypoxia, tracheostomy, and gastro-esophageal reflux disease (GERD). A nurses' note dated March 3,…

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 clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain the functional abilities and declines in range of motion for one of three sampled residents (Resident 22). Findings include: A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (in its most severe form, complete paralysis of half of the body) and Hemiparesis (unilateral paresis, is weakness of one entire side of the body) following cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) affecting the left non dominant side. An occupational therapy Discharge summary dated [DATE], indicated that Resident 22 was to wear a left had orthotic (splint or brace) at bedtime to prevent further contracture and manage tone. A Restorative Nursing Program (RNP) was to be established for the splint. There was no documented…

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 a review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to ensure the provision of necessary supervision during meals to promote resident safety while eating as required by one resident out of 14 residents sampled Findings include: A review of Resident 7's clinical record revealed that she was admitted to the facility February 12, 2020, with diagnoses to include dementia, anxiety, protein - calorie malnutrition, dysphagia (difficulty swallowing), and malignant neoplasm of the larynx, and tongue. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 31, 2023, revealed that the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact), and required staff supervision with eating, with one person…

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

Based on review of select facility policies and procedures and clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for one of five residents reviewed (Resident 31). Findings include: The facility policy entitled, Oxygen Administration, last reviewed December 19, 2022, revealed that the first step in the procedure for oxygen administration is to verify the physician's order. Observation of Resident 31 on April 18, 2023, at 11:12 a.m. revealed the resident was in his room with supplemental oxygen in place via an oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) with the liter flow set at 2.0 liters per minute (l/m). Observation of Resident 31 on April 19, 2023, at 9:00 a.m. revealed the resident was in his room with supplemental oxygen in place via an oxygen concentrator with liter flow set at 5.0 liters per minute (l/m). Clinical record review for Resident 31 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of 14 sampled residents (Resident 19). Findings include: A review of facility policy entitled Protocol - when to call the physician or physician extender, last reviewed by the facility December 19, 2022, the physicians caring for residents in your facility want to respond in an appropriate and timely manner to changes in condition. Types of situations which frequently arise which require physician notification includes pain. The nursing staff is expected to notify the physician based on the urgency of the situation as outlined in the accompanying chart and in the following time frame: Emergency - Notify the physician at the time of the event. The physician is expected to respond within 30 minutes. A review of the clinical record revealed that Resident 19 was most recently admitted to the facility on [DATE],…

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 review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide, or secure, dental services for one resident out of 14 sampled (Resident 4). Findings include: A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Observation and interview with Resident 4 on April 18, 2023 at approximately 9:30 AM revealed that the resident expressed concerns about his teeth and stated that he has multiple cavities. When the resident smiled, darkened areas, that appeared to be cavities, were observed on the resident's front bottom teeth. An admission MDS dated [DATE] indicated that Resident 4 had obvious or likely cavity or broken natural teeth. Review of the CAA (care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed timely ascertain a resident's eligibility to receive the influenza and pneumococcal immunizations and provide immunization if eligible as desired by one of five residents reviewed (Resident 15). Findings include: A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE]. The resident's consent form for the influenza and pneumococcal immunizations was signed by the resident on December 5, 2022, noting that the resident wanted to receive both the influenza and pneumococcal vaccines unless medically contraindicated. However, until surveyor inquiry at the time of the survey on April 19, 2023, the facility had not consulted with the resident's resident's physician to determine any possible medical contraindications for the resident's immunizations. Interview with the Director of Nursing on April 20, 2023, at approximately 9:30 a.m. confirmed that Resident 15 consented to receive…

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.