Pine Creek Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 out of 28 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the transfer or discharge was documented in the resident's medical record and that all the information was communicated to the receiving provider. The information provided to the receiving provider should include contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found to demonstrate what information was communicated to the receiving provider. Resident identifiers 8, 9, 14, and 19. Findings included: 1. Resident 9 was admitted to the facility on [DATE] and re-admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or included the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, in the medication refrigerator, one multi-dose vial was not labeled with an opened date, insulin pens did not have names or dates, one insulin pen was expired with an open date of [DATE], and a Prevnar 13 dose was expired and available to use. Findings included: On [DATE] at 7:35 AM, the medication refrigerator was inspected. A multi-dose vial of Tuberculin was observed open and available for use and an open date was not marked on the vial. A Prevnar 13 vaccine with an expiration date of [DATE] was available for use. A Tresiba insulin pen was observed to have been used with no opened date. A Lantus insulin pen was observed to be available for use with an open date of [DATE]. A Lantus insulin pen 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 record review and interview, it was determined that for 2 of 28 sample residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, there were at least two instances where the facility did not obtain International Normalized Ratio (INR) labs for a resident despite there being physician orders for the labs to be obtained every 4 weeks and one instance where the facility did not obtain a Basic Metabolic Panel (BMP) for another resident despite there being physician orders for the BMP to be drawn. Resident identifiers: 31 and 9. Findings Included: Resident 31 was admitted [DATE] with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, other asthma, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, unspecified combined systolic and diastolic heart failure, peripheral vascular disease, unspecified cirrhosis of liver, obsessive-compulsive disorder, and chronic embolism and thrombosis 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, it was determined that for 1 out of 28 sampled residents, the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized and the facility kept confidential all information contained in the resident's records. Specifically, resident's information was left open on a computer screen unsecured on two different occasions while residents were in the vicinity and no documentation of a resident's hospital visit was found in the medical record. Resident identifier: 14. Findings included: On 9/22/24 at 09:40 AM, an observation was made of Registered Nurse [RN] 4 walk away from the medication cart. The computer on top of the medication cart was left open with resident information available to view. An observation was made of residents 10 and 18 around the medication cart. On 9/22/24 at 12:40 PM, an interview was conducted with RN 4. RN 4 stated that any time the medication cart was left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine, and that the resident's medical record included documentation that indicated that the resident was provided education regarding the benefits and potential risks associated with the vaccine; documentation of each dose administered; and documentation of declinations or contraindications to the vaccine. Specifically, for 4 out of 5 sampled residents, the facility did not have evidence that each resident was provided education about the COVID-19 vaccine, was provided the COVID-19 vaccine, or declined the COVID-19 vaccine. Resident identifiers: 7, 18, 28, and 30. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of presence of right and left artificial shoulder joint, chronic obstructive pulmonary disease, hypertensive heart disease, pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was an accident involving the resident which resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment, or a decision to transfer or discharge the resident from the facility. Specifically, a resident had an injury of unknown origin identified and the physician was not notified. Additionally, the physician was not notified when a resident refused blood draws for laboratory orders. Resident identifiers: 14 and 18. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive…

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 and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident restrooms were found to be dirty and there were strong odors of urine in facility restrooms Findings Included: On 10/02/24 at 11:42 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a stain surrounding the base of the toilet. On 10/02/24 at 11:45 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a strong odor of urine. On 10/02/24 at 11:58 AM, an interview was conducted with the Housekeeper. The Housekeeper stated that the restroom in room [ROOM NUMBER] always smells like mold and mildew. The Housekeeper stated that she tries to get rid of the odor in the restrooms by scrubbing the toilet and shower with disinfectant. The Housekeeper stated that the odor in the restrooms goes away after she cleans the restrooms. The Housekeeper stated that the odor in the restroom is absent for 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 it was determined, for 1 of 28 resident's sampled, that the facility did not implement written policies and procedures that ensure reporting of all alleged violations to the Administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, an allegation of verbal abuse by a facility Certified Nurse Assistant (CNA) towards the resident was not reported to Adult Protective Services. Resident identifier 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that recommendations from the pre-admission screening and resident review (PASRR) level II determination and evaluation were implemented and included in the resident assessment, care planning and transitions of care. Specifically, a residents PASRR level II recommendations for specialized services for mental illness was not implemented. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not provide routine and emergency drugs and biological to its residents. Specifically, a resident was not provided their psychotropic medications for multiple days due to unavailability from the pharmacy. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. Resident 9's progress notes revealed the following: 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, it was determined that for 2 out of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not monitor the blood sugars of a resident receiving insulin, did not administer a resident's thyroid medication, address a resident's continued pain, or use non-pharmacological pain interventions. Resident identifiers: 9, 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, essential hypertension, hemiplegia and hemiparesis following a cerebral infarction, hyperlipidemia, and chronic obstructive pulmonary 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 interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, a resident's psychotropic medications were not monitored for behavioral episodes, non-pharmacological interventions, and adverse side effects of the medications. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety…

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, it was determined for 2 out of 28 sample residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 27 medication opportunities, on 9/24/24, revealed two medication errors which resulted in a 7.41% medication error rate. Specifically, wrong doses of medications were given. Resident identifiers: 12, 31. Findings included: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, traumatic subarachnoid hemorrhage, cerebral infarction, chronic obstructive pulmonary disease, temporal sclerosis, dementia, paranoid schizophrenia, anxiety disorder, and major depressive disorder. On 9/24/24 at 7:15 AM, Registered Nurse (RN) 1 was observed to spill the medication cup across the medication cart that contained resident 12's medications. One tablet of Haloperidol remained in the medication cup. RN 1 replaced two tablets 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 it was determined, for 1 of 28 sampled residents, that the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges, and only obtain laboratory services when ordered by a physician. Specifically, a resident's Basic Metabolic Panel (BMP) and lipid panel had results out of range and the provider was not notified and a BMP and lipid panel were obtained without a physician order. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for 1 of 28 sampled residents that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, there were two instances where a resident had physicians orders for a residents lithium levels to be checked, but the results of these lithium level checks were not filed or uploaded in the resident's electronic medical record. Resident Identifier: 31. Findings Included: Resident 31 was admitted [DATE] with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, asthma, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, unspecified combined systolic and diastolic heart failure, peripheral vascular disease, unspecified cirrhosis of liver, obsessive-compulsive disorder, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity. Resident 31's medical record was reviewed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 28 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, a resident's 12 lead electrocardiogram (EKG) was not in the medical records. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. 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.

Based on observation, interview, and record review, it was determined that for 2 of 28 sampled residents, that the facility did not ensure that each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were resident complaints about the food served at the facility, a test tray was pulled and found to be unappetizing, and there were resident council complaints regarding the food served at the facility. Resident Identifiers: 17 and 30. Findings Included: On 9/22/24 at 12:43 PM, Resident 17 was observed to complain that the lunchtime meal served was too cold during a lunchtime meal observation. At 12:46 PM, Resident 17 further complained that the food served would be good if it was warm. A resident council note dated 9/6/24 documented a resident complaint of pork that was served undercooked and too tough to chew. A resident council note dated 7/17/24 documented a resident complaint of burnt eggs that were…

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

Based on interview and record review it was determined that the facility did not ensure that the quality assessment and assurance committee met at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. The Quality Assessment and Assurance (QAA) Committee must be composed of, at a minimum: The Director of Nursing (DON); the Medical Director or his/her designee; at least three other members of the facility staff and one must be the Administrator; and the infection preventionist. Specifically, there was no evidence that the Medical Director participated in the quarterly QAPI meetings. Findings included: Review of the QAPI team revealed that the QAA committee members were the Administrator, the DON, Therapeutic Recreation Specialist (TRS), the Resident Advocate (RA), the Maintenance Director, the Business Office Manager, and the Dietary Manager. The QAA committee did not have the Medical Director listed as a participating member. The facility 2024 Quality Assurance and Performance Improvement (QAPI) Plan was reviewed…

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

Based on observation and interview it was determined, for 2 out of 28 sampled residents, that the facility did not 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. Specifically, medications were not administered in a sanitary manner. Resident Identifiers: 12 and 25. Findings included: On 9/24/24 at 7:12 AM, an observation was made of Registered Nurse (RN) 1 during the morning medication pass. RN 1 was observed preparing medications for resident 12. RN 1 did not perform hand hygiene prior to removing the medication from the medication packs. RN 1 was observed to drop medications out of the medication cup onto the medication cart and the floor. RN 1 was observed to scoop up a medication that was half in the medication cup and half on the medication cart. RN 1 was observed to put more medication into the same medication cup and give the medications to resident 12. On 9/24/24 at 7:23 AM, an observation was made of RN 1 during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving an antibiotic for a urinary tract infection and the facility did not follow up with the hospital for the culture and sensitivity results. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, Alzheimer's Disease, dementia, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, hyperkalemia, peripheral vascular disease, and gastro-esophageal reflux disease without esophagitis. Resident 19's medical record was reviewed on 9/22/24. Resident 19's progress notes were reviewed and revealed the following: a. On 9/4/24 at 3:21 AM, Orders - General…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 1 of 28 sampled residents, that the facility did not ensure that any individual working in this facility working as a paid feeding assistant had completed a State-approved training program for feeding assistants. Specifically, a staff member who was not a Certified Nursing Assistant (CNA), a Licensed Nurse, or a paid feeding assistant assisted a resident with a feeding. Resident Identifier: 28. Findings Included: Resident 28 was admitted [DATE] with diagnoses including aphasia following cerebrovascular disease, other frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, vitamin B12 deficiency anemia unspecified, and dementia in other diseases classified elsewhere moderate with agitation. Resident 28's medical record was reviewed. Resident 28's CNA documentation in the Point of Care Response History section was reviewed for the dates of 9/4/24 through 10/2/24. There were 4 occurrences where resident 28 was able to eat…

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

Based on observation and interview, it was determined the facility failed to provide a clean and comfortable homelike environment. Specifically, a continuous high pitched alarm in the dining area, dirt and debris was observed on the resident room doors and bed rails, area of flooring and seating pads of chairs in the dining room were in disrepair, trash and debris blocked the air duct in the facility day room, a set of broken closet doors, and paint peeling from the walls in resident rooms. Residents identifiers: 4, 5, 16, 17, 20, 25, 29, and 30. Findings include: ALARM On 2/27/23 at 10:20 AM, an observation was made of a high pitched alarm going off in the dining room. An immediate interview was conducted with the Administrator (ADM), Chief Operating Officer (COO) and the Activities Coordinator (AC). The ADM stated he was unsure what the sound was but would find out. The AC stated the alarm was from the call lights down the hallway, but it only made noise and did not light up. The ADM, COO and AC were then observed to walk down the hallway and the alarm stopped. The alarm 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 record review and interview it was determined for 1 of 18 sample residents that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Specifically, one resident was not provided the opportunity to document his life-saving preferences. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with diagnoses which included sequelae of cardiovascular disease, traumatic brain injury, chronic obstructive pulmonary disease, type II diabetes, acute hepatitis c, dysphagia, hypertension, pain and psoriasis. On 2/28/23 resident 2's electronic medical record (EMR) was reviewed. A physician order dated 12/6/21, revealed resident 2 had an order to be a Full Code. There was no advanced directive or physician order for life sustaining treatment (POLST) located in resident 2's EMR. On 3/1/23 at 11:05 AM, an interview 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 interview and record review it was determined, for 1 of 18 sample residents, that the facility did not coordinate assessments with the pre-admission. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 4. Findings include: Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type II diabetes, hypertension, gastroesophageal reflux disease, bipolar disorder, anxiety, major depressive disorder, obesity and dementia. On 2/28/23 the electronic medical record for resident 4 was reviewed. A review of resident 4's Pre-admission Screening Application/Resident Review (PASRR) dated 4/11/2019 revealed there was no serious mental illness diagnoses. The form 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 observation, interview, and record review, the facility failed to ensure that the residents environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, a resident with multiple falls was not provided an adequate walker, and a resident on supervised smoking was observed smoking outside without staff supervision. Resident identifiers: 29 and 31. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, asthma, neuropathy, hypertension, protein-calorie malnutrition, anxiety, schizophrenia, bipolar disorder, muscle weakness, insomnia, chronic pain syndrome, nicotine dependence, and toxic encephalopathy. On 2/27/23 at 10:39 AM an interview with resident 29 was conducted. Resident 29 stated that she had multiple falls at the facility due to being unsteady on her feet. Resident 29 stated that she did not have any serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was revealed that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, two residents were receiving blood pressure medications outside of the ordered parameters and a resident had a medication held without orders to hold the medication. Resident identifiers: 19 and 30. Findings include: 1. Resident 30 was initially admitted to the facility on [DATE] and again on 12/16/22 with diagnoses of pneumonia, respiratory syncytial virus, protein calorie malnutrition, metabolic encephalopathy, atrial fibrillation, major depressive disorder, essential hypertension, pain, unspecified dementia, bariatric surgery status, cystitis. On 2/27/22 resident 30's medical records were reviewed. Resident 30 had an order for Furosemide that stated, Give 20 mg [milligrams] by mouth one time a day related to essential (primary) hypertension Hold for BP [Blood pressure] less than 120. The start date for the order was 1/3/23. A review of 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 interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Specifically, two residents did not have documentation in their electronic medical record indicating if they had or had not received the pneumococcal vaccine. Resident identifiers: 2 and 29 Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, asthma, neuropathy, hypertension, protein-calorie malnutrition, anxiety, schizophrenia, bipolar disorder, muscle weakness, insomnia, chronic pain syndrome, nicotine dependence, and toxic encephalopathy. A review of resident 29's medical record was conducted. Resident 29's vaccination records did not show documentation regarding the pneumococcal vaccine. 2. Resident 2 was admitted to the facility 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 interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal. Specifically, one resident did not have documentation in their electronic medical record indicating if the facility offered a resident the COVID-19 vaccination. Resident identifier: 31 Findings Include: 1. Resident 31 was initially admitted to the facility on [DATE] and again on 1/30/23 with diagnoses which included pneumonia, acute respiratory failure, sepsis, severe protein-calorie malnutrition, dementia, muscle weakness, unsteadiness on feet, chronic obstructive pulmonary disease, cognitive communication, hypothyroidism, insomnia, chronic pain, major depressive disorder, nicotine dependence, and personal history of suicidal behavior. Resident 31's electric medical record was reviewed. Resident 31's immunization history, not…

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.