Rock Creek Health and Rehabilitation

Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents reviewed for medication administration. (Resident's #72 and #73) 1. Resident #72's losartan potassium (blood pressure medication) was not held for a diastolic blood pressure of 63, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. 2. Resident #73's levetiracetam (anticonvulsant medication) was given late on 06/18/2024. 3. Resident #73's nifedipine (blood pressure medication) was not held for a diastolic blood pressure of 84, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: 1. During an observation on 06/18/2024 beginning at 8:02 AM, MA L obtained Resident #72's blood pressure. The blood pressure was 63 diastolic. MA L prepared Resident #72's medications for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for 3 of 37 residents (Resident #54, # 41 and #76) reviewed for food form in that: 1.The facility did not ensure Resident #54 had diet orders or received meals that addressed her potential for malnutition. 2. The facility did not ensure Resident #41 was given double protein portion as ordered by the physician. 3. The facility did not ensure Resident #76 chicken parmesan was chopped as ordered by the physician. This failure could place residents at risk of not receiving food to meet their needs. Findings Included: 1.Record review of the face sheet, dated 06/20/2024, revealed Resident # 54 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of major depressive disorder (a persistently low or depressed mood), hypothyroidism ( a common condition where the thyroid does not create or release enough…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not ensure: 1. Sanitization buckets were at the appropriate sanitization level on 06/17/2024. 2. DA V failed to wear a hair net while in the kitchen on 06/18/2024. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: During an observation and interview on 06/17/2024 at 10:10 a.m., the sanitation bucket was located on the bottom of the food preparation and serving area. The bucket was filled approximately 1/3 of the way with a brownish clear liquid and small debris floating on top. The test strip was performed and revealed no sanitizer was in the liquid inside the bucket. [NAME] U stated she had prepared the bucket earlier and the sanitation strip tested at 400. [NAME] U said the purpose of the sanitizer in the sanitation bucket testing at the appropriate level was to prevent the spread of bacteria.…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #68) reviewed for enhanced barrier precautions, 2 of 2 residents (Resident's #21 and #23) reviewed for respiratory care, 1 of 2 residents (Resident #69) reviewed for wound care, and 1 of 2 residents (Resident #2) reviewed for infection control practices with ADLs . 1. The facility did not ensure LVN F wore enhanced barrier precautions while administering IV medications through Resident #68's PICC line. 2. The facility did not ensure CNA C and CNA D did not contaminate clean linens with soiled linens while providing assistance with ADLs for Resident #2. 3. The facility did not ensure Resident #21, and Resident #23 were tested for the flu or COVID-19 when they developed signs and symptoms. 4. 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 observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #50) reviewed for resident rights. The facility did not ensure CNA S treated residents with dignity and respect when feeding two residents at the same time during the lunch meal. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: Record review of the face sheet, dated 06/18/2024, revealed Resident # 50 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), spinal stenosis, lumbar region without neurogenic claudication (compression of the spinal nerves in the lumbar (lower) spine), dysphagia (swallow difficulties). Record review of the MDS assessment, dated…

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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #2) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #2's call light was answered timely and within reach when leaving her room on 06/17/2024. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 06/19/2024, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (an umbrella term for conditions that impact the blood vessels in your brain), anxiety disorder (group of mental illnesses that cause constant fear and worry),flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), and obesity (condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #183) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #183 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings included: Record review of Resident #183's face sheet, dated 06/19/2024, indicated Resident #183 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included hypokalemia (low potassium). Record review of admission MDS assessment, dated 04/25/2024, indicated Resident #183 sometimes made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly resolve grievances for 1 out of 24 residents (Resident #41) reviewed for grievances. The facility did not ensure a grievance was filled out and followed up on after Resident #41 reported her watch was missing on 06/06/2024. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect. The findings included: Record review of the face sheet, dated 06/20/2024, revealed Resident #41 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of fracture of lower end of right femur (right hip fracture) and unspecified kidney failure (one or both of your kidneys no longer work on their own). Record review of the admission MDS assessment, dated 03/22/2024, revealed Resident #41 had clear speech and was understood by staff. The MDS revealed Resident #41 was able to understand others. The MDS revealed Resident #41 had a BIMS score of 13, which indicated no cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #48) reviewed for discharge MDS assessments. The facility did not ensure Resident #48's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of Resident #48's face sheet dated, 06/19/2024, indicated Resident #48 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included COVID-19 (a virus that causes a respiratory disease). Record review of a discharge summary note dated 01/14/2024 indicated Resident #8 was discharged to the hospital. Record review of a CMS Submission report indicated Resident #48's discharge MDS assessment dated…

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, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 3 residents reviewed for care plans. (Resident #57) The facility did not ensure Resident #57's ADL care plan accurately reflected her current ADL status with transfers. This failure could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: Record review of the face sheet, dated 06/20/2024, revealed Resident #57 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by problems with your metabolism, such as low glucose or high toxins) and mild cognitive impairment (slight decline in mental abilities, like memory and reasoning, that doesn't interfere with daily life). Record review of the quarterly MDS…

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 a resident with limited mobility received appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 resident reviewed for mobility. (Resident #50) The facility did not provide interventions to prevent deterioration of Resident #50's range of motion in her right arm. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings included: Record review of the face sheet, dated 06/18/2024, revealed Resident # 50 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), spinal stenosis, lumbar region without neurogenic claudication (compression of the spinal nerves in the lumbar (lower) spine), dysphagia (swallow difficulties). Record review of the MDS assessment, dated 04/25/2024, revealed Resident #50 had 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 observation, interview, and record review, the facility failed to ensure the resident remained as free of accident hazards as possible for 1 of 2 residents (Resident # 50) reviewed for accidents and hazards. The facility failed to ensure Resident #50 had a safe transfer when the CNA allowed Hoyer lift cradle to hit her above the right eye on 06/18/2024. These failures could place residents at risk for injury. The findings included: Record review of the face sheet, dated 06/18/2024, revealed Resident # 50 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), spinal stenosis, lumbar region without neurogenic claudication (compression of the spinal nerves in the lumbar (lower) spine), dysphagia (swallow difficulties). Record review of the MDS assessment, dated 04/25/2024, revealed Resident #50 had a BIMS score of 00, which indicated severe cognitive impairment. The MDS revealed Resident…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #69) reviewed for incontinence. The facility failed to ensure Resident #69 was provided proper incontinent care and catheter care. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings Included: Record review of the face sheet, dated 06/18/2024, revealed Resident # 69 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute cystitis with hematuria (blood cells in the urine, paraplegia, unspecified (paralysis that occurs in the lower half of the body), encephalopathy (damage or disease that affects the brain), pressure ulcer of sacral region, stage 4 ( the blood supply has been so severely cut off that the wound tunnels down through all…

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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #68) resident reviewed for intravenous fluids. The facility did not ensure LVN F followed the policy and procedure for Resident #68's PICC line (a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) when the patency was not assessed, and resistance was met during the 10 mL saline flush. This failure could place residents at risk for PICC line associated complications such as occlusion (blockage), thrombosis (blood clot), and infection. The findings included: Record review of the face sheet, dated 06/19/2024, revealed Resident #68 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of pneumonia (lung infection). Record review of the admission MDS assessment, dated 05/30/2024, 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 observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and were stored in a locked compartment and only accessible by authorized personnel for 2 of 24 residents (Residents #3 and #13) reviewed for medication storage. 1. The facility did not ensure Resident #3's hydrocortisone cream (topical treatment for skin conditions) 1% was properly safe and secured. 2. The facility did not ensure Resident #13's eye drops were properly safe and secured. This failure could place residents at risk for misuse of medication and overdose, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: 1. Record review of the face sheet, dated 06/19/2024, indicated Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included orthostatic hypotension (drop in blood pressure that occurs when moving from 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 interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 24 residents (Residents #3 and #22) reviewed for laboratory services. The facility did not obtain a physician's ordered CBC (used to measure different parts and features of blood), CMP (test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipids (levels of cholesterol and other fats in the blood), TSH (test used to measure hormone), T4 (test used to measure thyroxine in the blood) for Resident #3. The facility did not obtain a physician's ordered CBC (used to measure different parts and features of blood), CMP (test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipids (levels of cholesterol and other fats in the blood), TSH (test used to measure hormone) for Resident #22. These failures could place residents at risk of not receiving lab…

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 provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Resident #53, Resident #5 and Resident #282) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Resident #53, Resident #5, and Resident #282. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/10/2023 revealed, Resident #53 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive memory loss), type 2 diabetes mellitus (too much sugar in the blood) and hypertension (high blood pressure). Record review of the MDS assessment dated [DATE] revealed, Resident #53 was usually understood by others and sometimes made herself-understood. The MDS assessment 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: food items were dated, labeled, and sealed appropriately. expired food items were discarded. Temperature checks were completed on the salad bar These failures could place residents at risk for foodborne illness. Findings included: During an observation on 05/08/2023 starting at 9:00 AM with DM G: Freezer 2 flat buffet hams not dated 1 opened southern biscuit box with no open date Refrigerator Box of onions with no date or label 2 bags of coleslaw with best by date 05/04/23 1 box of cabbage dated 04/19/23 with brown discoloration on the leaves 3 bags of a green substance with no label or date Dry Storage 2 unopened loaves of bread with best by date 04/16/23 1 open bottle of welches jelly with no date During an observation and interview on 05/09/23 at 11:30 AM, DM H did not check the temperatures on the salad bar for the: lettuce, peaches, ranch…

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 interviews and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set (MDS) specified by the state and approved by CMS for 1 of 4 resident (Resident #18) reviewed for quarterly assessments. The facility failed to ensure Resident #18's MDS assessment was completed within three months of her last assessment. This failure could place residents at risk for not having their assessments completed timely and not having their individually assessed needs met. The findings included: Record review of Resident #18's face sheet, dated 05/10/2023, revealed Resident #18 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified fracture of lower end of right humerus, subsequent encounter for fracture with routine healing (broken arm near the elbow that was healing with no complications). Record review of Resident #18's electronic medical record, accessed on 05/10/2023, revealed an admission MDS assessment with an ARD 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 interview and record review, the facility failed to ensure an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 2 of 5 residents (Residents #24 and #49) reviewed for MDS assessments transmissions. The facility did not ensure Resident #24's and Resident #49's discharge MDS assessments were transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: 1. Record review of Resident #24's face sheet, dated 05/10/2023, revealed Resident #24 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of nondisplaced fracture of first metatarsal bone, right food, subsequent encounter for fracture with routine healing (fracture of a bone in the foot with normal healing). Record review of Resident #24's discharge MDS assessment, dated 02/17/2023, revealed the MDS…

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 an accurate MDS assessment was completed for 1 of 21 residents reviewed for MDS accuracy. (Resident #40) The facility failed to accurately document Resident #40's bladder status of having an indwelling urinary/foley catheter (tube inserted into the resident's bladder to drain urine) on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #40's face sheet dated 5/09/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #40 had diagnoses of urinary retention (difficulty urinating or emptying the bladder) and history of a cerebral infarction (stroke-parts of the brain die due to a lack of adequate blood supply to the brain cells). Record review of Resident #40's quarterly MDS dated [DATE] did not indicate the resident had a urinary catheter. Record review of Resident #40's comprehensive care…

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 interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 5 residents (Resident # 36) reviewed for MDS completion. The facility failed to ensure the RN signed Resident #36's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status. The findings included: Record review of Resident #36's face sheet, dated 05/10/2023, revealed Resident #36 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of COVID-19 (acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Record review of Resident #36's MDS assessment, dated 01/06/2023, revealed no RN signature in section Z. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 21 residents reviewed for care plans. (Resident #40). The facility failed to develop and implement a care plan for Resident #40 having a urinary/foley catheter (tube inserted into the resident's bladder to drain urine). This failure could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #40's face sheet dated 5/09/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #40 had diagnoses of urinary retention (difficulty urinating or emptying the bladder) and history of a cerebral infarction (parts of the brain die due to a lack adequate blood supply to the brain cells). Record review of Resident #40's quarterly…

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 respiratory care was provided consistent with professional standards of practice for 1 of 5 residents (Resident #7) reviewed for respiratory care and services. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #7. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings include: Record review of Resident 7's order summary report, dated 05/10/2023, indicated Resident #7 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included chronic respiratory failure (not enough oxygen in the blood), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (the heart does not pump blood as well as it should). The order summary report indicated Resident #7 received oxygen at 2 liters per minute via nasal cannula every…

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 interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #56) The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #56. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #56's face sheet, dated 05/10/2023, revealed Resident #56 was an [AGE] year-old-female who admitted to the facility on [DATE], with diagnoses of end stage renal disease (condition where the kidney reaches advanced state of loss of function) and anemia (low amount of red blood cells that carry oxygen to all parts of the body). Record review of the order summary report, dated 05/10/2023, revealed Resident #56 had an order, which started 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.