Alexandria Rehabilitation And Healthcare Center

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control procedures during meal delivery for three of 37 residents in the survey sample, Residents #78, #33, and #310. The findings include: 1. For Residents #78 (R78) and #33 (R33), the facility staff failed to sanitize hands prior to delivering their meal trays on 4/1/24. On 4/1/24 at 12:14 p.m., CNA (certified nursing assistant) #1 was observed delivering meal trays. CNA #1 failed to sanitize her hands prior to picking up R78's tray from the meal cart. She delivered R78's meal tray, setting it on the resident's overbed table. CNA #1 touched some of the resident's personal items, bed linens, and the top of the overbed table. CNA #1 exited R78's room without sanitizing her hands. She picked up R33's meal tray, setting it on the resident's overbed table. She touched various items on the meal tray as she removed the cover from the plate, opened the iced tea, poured sweetener into the tea, and handled the resident's cutlery to prepare it for the…

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

Based on observation, staff interview and facility document review, the facility staff failed to maintain the dumpsters in a sanitary manner for two of two dumpsters containing trash. On 6/28/22, the sliding side doors of two dumpsters were observed open and multiple flies were inside the dumpsters. The findings include: On 6/28/22 at 2:48 p.m., an observation of the facility dumpsters was conducted. Two of two dumpsters containing trash were observed with both sliding side doors completely open. Multiple flies were inside the dumpsters. No staff was utilizing the dumpsters at this time. On 6/28/22 at 2:50 p.m., an interview was conducted with OSM (other staff member) #4 (the dietary manager). OSM #4 stated the side doors on the dumpsters are supposed to be closed so rodents, flies and birds aren't attracted to the area. On 6/28/22 at 2:58 p.m., an interview was conducted with OSM #7 (the housekeeping manager). OSM #7 stated the side doors on the dumpsters should be closed if staff is not dumping trash. OSM #7 stated rodents, flies and anything can crawl into the dumpsters. 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 staff interview and employee record review, it was determined that the facility staff failed to ensure that 5 of 10 CNAs (certified nursing assistants) received annual performance reviews. The findings include: On 06/28/2022 a record review was conducted of the annual performance reviews of five CNAs. This review failed to evidence the annual performance reviews for the following CNAs: 1. CNA # 3 - hire date 12/17/2019, no evidence of performance review between 12/17/2019 and 12/17/2020. 2. CNA # 4 - hire date 10/18/2019, no evidence of performance review between 10/18/2019 and 10/19/2020. 3. CNA # 5 - hire date 05/20/2019, no evidence of performance review between 05/20/2019 and 05/20/2020. 4. CNA # 6 - hire date 4/27/2018, no evidence of performance review between 04/27/2021 and 04/27/2022. 5. CNA # 7 - hire date 01/05/2017, no evidence of performance review between 01/05/2021 and 01/05/2022. On 06/29/2022 at approximately 1:05 p.m. an interview was conducted with ASM (administrative staff member) # 2, director of nursing and OSM (other staff member) # 8 director of human…

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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence bed inspection for risk of entrapment for 4 of 39 residents in the survey sample, Resident #16, Resident #66, Resident #96 and Resident #45. 1. The facility staff failed to inspect Resident #16's bed for risk of entrapment. Resident #16 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: psychotic disorder and anxiety disorder. Resident #16's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/20/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility and transfers. Observation of Resident #16 resting in bed on 6/27/22 at 1:45 PM, 6/28/22 at 10:00 AM and 6/29/22 at 8:30…

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, family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate a resident's need for a reclining chair for one of 39 residents in the survey sample, Resident #1 (R1). The facility staff failed to provide a reclining chair for R1 to enable the resident to get out of bed. The findings include: R1's diagnoses included, but not limited to, Parkinson's disease and diabetes. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/14/22, R1 was coded as having no cognitive impairment for making daily decisions. R1 was coded as requiring the extensive assistance of staff members for transferring from bed to chair. R1 was observed on the following dates and times: 6/27/22 at 1:47 p.m. and 5:14 p.m.; 6/28/22 at 9:29 a.m. At all observations, R1 was sitting up in bed, with eyes closed. R1 had tube feeding running, and oxygen was administered at 2 liters per minute…

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 resident interview, staff interview, facility document review and clinical record review it was determined that the facility staff failed to implement their abuse policy and procedures to ensure one of 39 residents in the survey sample was free from abuse, Resident #44. On 6/24/22, Resident #37 hit Resident #44, which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R44 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit.…

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 resident interview, staff interview, facility document review and clinical record review it was determined that the facility staff failed to report to the State Survey Agency timely, an allegation of abuse, for one of 39 residents in the survey sample, Resident #44; which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. On 6/27/2022 at 5:14 p.m., an interview was conducted with R44 in their room. R44 was observed lying in bed and was observed to have a splint wrapped with an elastic bandage on the 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete a significant change MDS for one of 39 residents in the survey sample, Resident #82. Resident #82 was admitted to hospice on 12/22/21. There was no significant change MDS completed for the provision of hospice services. The findings include: On the most recent MDS (Minimum Data Set) a quarterly assessment with an ARD (Assessment Reference Date) of 6/8/22, Resident #82 scored a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact in ability to make daily life decisions. The resident was coded as requiring supervision for eating and extensive to total care for all other areas of activities of daily living. A review of the clinical record revealed a physician's order dated 12/22/21 and rewritten again on 4/1/22 for hospice services. Further review of the clinical record revealed a nurse's note dated 12/22/21 that…

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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to complete an accurate MDS (minimum data set) assessment for one of 39 residents in the survey sample, Resident #90. The facility staff failed to complete an accurate annual assessment MDS for Resident #90. The findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses that included but not limited to: paranoid schizophrenia, nicotine/cigarette dependence, arthritis and abnormal gait. Resident #90's most recent MDS, an annual assessment, with an assessment reference date of 3/29/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section J1300- coded the resident as current tobacco use no. A review of Resident #90's care plan dated 9/17/19 revealed the following, FOCUS: Resident is a smoker. INTERVENTIONS: Instruct resident about smoking risks…

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 resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide a written summary of the baseline care plan for 3 of 39 residents in the survey sample, Residents #301, #303 and #299. The findings include: 1. The facility staff failed to provide a written summary of Resident #301's (R301) baseline care plan to the resident and/or the RR (resident's representative). R301 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/27/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of R301's clinical record revealed a baseline care plan dated 4/20/22. Further review of R301's clinical record (including the baseline care plan and progress notes since admission) failed to reveal documentation that R301 or the RR was provided a written…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 39 residents in the survey sample; Resident #82. Resident #82 was admitted to hospice on 12/22/21. There was no revision to the comprehensive care plan to address the provision of and coordination with hospice services. The findings include: On the most recent MDS (Minimum Data Set) a quarterly assessment with an ARD (Assessment Reference Date) of 6/8/22, Resident #82 scored a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact in ability to make daily life decisions. The resident was coded as requiring supervision for eating and extensive to total care for all other areas of activities of daily living. A review of the clinical record revealed a physician's order dated 12/22/21 and rewritten again on 4/1/22 for hospice services. Further review of the clinical record revealed a nurse's note dated 12/22/21 that documented, 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.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to respond to a pharmacist's monthly medication review recommendation for one of 39 residents in the survey sample, Resident #62 (R62). The facility staff failed to follow up on the pharmacist recommendation to obtain blood tests to determine R62's kidney function. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/18/22, R62 was coded as being severely impaired for making daily decisions, having scored 6 out of 15 on the BIMS (brief interview for mental status). A review of the monthly medication regimen reviews for R62 revealed a review dated 5/27/22. The review documented: [R62] has not had an assessment of renal (kidney) function within the past six months .Please monitor [blood tests to reveal kidney function] on the next convenient lab day and at least every six months thereafter. Further review of R62's clinical record failed to reveal any laboratory tests ordered…

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, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to serve food at a palatable temperature for 3 of 39 residents in the survey sample, Residents #50, #34 and #37. The findings include: On Resident #50's (R50) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/5/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. On 6/27/22 at 1:42 p.m., an interview was conducted with R50 and the resident stated the facility food was cold. On Resident #34's (R34) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/21/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. On 6/27/22 at 2:59 p.m., an interview was conducted with R34 and the resident stated the food was usually cold when…

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, staff interview and facility document review, the facility staff failed to store food in a safe manner in 1 of 3 unit nourishment room refrigerators, the second floor nourishment room. The second floor nourishment room refrigerator contained multiple food items that were past the manufacturers' use by and best by dates. The findings include: On 6/28/22 at 2:10 p.m., observation of the second floor nourishment room refrigerator was conducted with LPN (licensed practical nurse) #4. The following was observed: one 2 pound block of sharp cheddar cheese with a best by date of 8/14/21, one 13 ounce can of whipped topping with a best by date of 12/25/21, one 6.5 ounce can of whipped topping with a use by date of 3/31/22, one 15 ounce bottle of creamy French dressing with a best if used by date of 10/5/21 and one ham and cheddar cracker stacks lunchable with a use by date of 9/4/21. At that time, an interview was conducted with LPN #4. LPN #4 stated the temperature of the refrigerator is supposed to be checked by a nurse every day and at that time, the nurse should…

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 staff interview, facility document review and clinical record review, the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for one of 39 residents in the survey sample, Resident #85. The findings include: On Resident #85's (R85) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/9/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. An admission notification form dated 5/20/22 documented R85 required dialysis. A review of R85's clinical record revealed a physician's order dated 6/21/22 for dialysis every Monday, Wednesday and Friday. A review of the facility dialysis contracts failed to reveal a contract for R85's dialysis provider. On 6/28/22 at 12:12 p.m., ASM (administrative staff member) #2 (the director of nursing) provided a letter addressed to ASM #1 (the executive director) and dated 6/28/22. The letter 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 resident interview, staff interview, facility document review and clinical record review it was determined that the facility staff failed to maintain a complete and accurate medical record for one of 39 residents in the survey sample, Resident #37. The findings include: Resident #37's (R37) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/2/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. On 6/27/2022 at 1:56 p.m., an interview was conducted with R37 in their room. R37 was observed to have a staff member sitting outside of the room in a chair monitoring the room. R37 stated that the previous Friday they had a fight with another resident who lived across the hall and now a staff member sat outside their door and went with them whenever they went outside to smoke. R37 stated that they had been in the hospital recently for chest…

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 staff interview and clinical record review, it was determined that the facility staff failed to offer, obtain consent and/or provide education regarding the pneumococcal vaccines for one of five residents in the immunization record review, Residents # 56 (R56). The findings include: The facility staff failed to offer, obtain consent and provide education regarding the pneumococcal vaccines for (R56). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 05/11/2022, the resident was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. Under Section O Special Treatments, Procedures and Programs (R56) was coded as not being offered the pneumococcal vaccine. A review of the (R56's) clinical record and EHR [electronic health record] failed to evidence that the pneumococcal vaccine was offered and consent and education was provided. On 06/29/2022 at approximately 8:22 a.m., an interview was conducted ASM (administrative staff…

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, staff interview, and facility document review it was determined that the facility staff failed to serve and store food in a sanitary manner. The findings include: 1. The facility failed to fully dry and store cookware in a sanitary manner in the kitchen and dispose of refrigerated food items past their expiration date in the facility kitchen stand up refrigerator. On 1/28/20 at approximately 6:10 p.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #4, the dietary manager. Observation of the kitchen revealed a double door stand up refrigerator, which contained two five-pound containers of cottage cheese. One five-pound container of cottage cheese was observed opened with the date 12-24 written on the top lid. OSM #4 stated that the 12-24 meant that the container had been opened on 12/24/19. Observation of the container revealed it was approximately one-half full and labeled by the manufacturer with Best if used by 1/25/20. The other container was observed unopened and labeled by the manufacturer with Best if used 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a dignified dining experience for four of 51 residents in the survey sample, Residents #33, #58, #42, #80. The facility staff failed to serve lunch to Resident #33, #58 and #42 in a dignified manner. Other residents seated at the same tables as Resident #33, 58 and #44 were served a meal, a meal for Resident #33 and #58 was not served and the residents assisted until 11 minutes later. Resident #42' was not served a meal until 22 minutes later. The facility staff failed to feed Resident #80 lunch in a dignified manner. CNA (certified nursing assistant) #5 stood up and left Resident #80 multiple times while feeding the resident. The findings include: 1. Resident #33 was admitted to the facility on [DATE]. Resident #33's diagnoses included but were not limited to intellectual disabilities, high blood pressure and thyroid disorders. Resident #33's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure the medication regimen was free from unnecessary medication for two of 51 sampled residents, Resident #37 and # 87. The facility staff failed attempt non-pharmacological interventions prior to the administration of the prn (as needed) pain medication, Ibuprofen to Resident # 37 and prior to the administration of the as needed pain medication, Oxycodone for to Resident # 87. The findings include: 1. The facility staff failed attempt non-pharmacological interventions prior to the administration of prn pain medication of Ibuprofen to Resident # 37. Resident # 37 was admitted to the facility with diagnoses that included but were not limited to: muscle spasms and arthritis. Resident # 37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/03/19, coded Resident # 37 as scoring an 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12…

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 staff interview it was determined that the facility staff failed to failed to store medications with a visible manufacturer expiration date in one of three medication carts observed, second floor medication cart The findings include: On [DATE] at 11:15 a.m., an observation was made of the medication cart located on the second floor medication cart with LPN #10. Observation of the medication cart revealed a bottle of 100 tablets of Senna (medication used as stool softener) 8.6mg (milligram) approximately one-quarter full. Further observation revealed the bottle did not contain a manufacturer's expiration date. When asked about the bottle LPN #10 confirmed that she did not see an expiration date on the bottle. LPN #10 stated that she had not used that medication during her medication pass. LPN #10 stated that she had opened another new bottle of Senna that morning and used that one during her medication pass and proceeded to produce an opened bottle of Senna from the medication cart with 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.

Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodation of resident needs by ensuring the call bell [a device with a button that can be pushed to alert staff when assistance is needed ] was within reach for one of 51 residents in the survey sample, Resident # 68. The findings include: Resident # 68 was admitted to the facility with diagnoses that included but were not limited to: lack of coordination, and Parkinson's disease [1]. Resident # 68's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/03/19, coded Resident # 68 as scoring an 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Resident # 68 was coded as requiring extensive assistance of one staff member for activities of daily living. Section G0400 Functional Limitation in Range of Motion coded Resident # 68 as No impairment of their upper extremities [shoulder, elbow, wrist, hand] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure one of 51 residents, (Resident #47), right to be free from abuse from abuse by another resident (Resident #98). The findings include: A review of the facility policy, Abuse, Neglect Exploitation & Misappropriation documented, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Resident #47 was admitted to the facility on [DATE]; diagnoses included but are not limited to stroke, dysphagia, gastrostomy, aphasia and high blood…

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 resident interview, staff interview and clinical record review it was determined that the facility staff failed to implement the comprehensive care plan for two of 51 residents in the survey sample, Resident #37 and #53. The facility staff failed implement the comprehensive care plan for non-pharmacological interventions prior to the administration of prn (as needed) pain medication to Resident # 37. The facility staff failed develop a care plan to address Resident # 53 tube feeding. The findings include: 1. Resident # 37 was admitted to the facility with diagnoses that included but were not limited to: muscle spasms and arthritis. Resident # 37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/03/19, coded Resident # 37 as scoring an 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Resident # 37 was coded as requiring extensive assistance of one staff member for activities of daily living. Section J Health Conditions coded…

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, resident interview, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to safely transfer on one 51 residents in the survey sample, Resident #10. During observation of a transfer of Resident #10 by Hoyer lift on 1/29/2020, the facility staff failed to prevent Resident #10's toes from bumping the wall multiple times, and failed to lock the wheelchair. The findings include: Resident #10 was admitted to the facility on [DATE]; and most recently readmitted on [DATE], with diagnoses including, but not limited to: history of a stroke, dysfunctional bladder, diabetes (1), spinal stenosis (2), and peripheral neuropathy (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/7/19, Resident #10 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #82 was admitted to the facility 01/04/2018 with a readmission on [DATE] with diagnoses, that included but were not limited to pneumonia (1) and sepsis (2). Resident #82's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/11/20, coded Resident #82 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Resident #82 was coded as requiring extensive assistance of one staff member for bed mobility. An observation on 1/28/20 at 7:30 p.m. revealed Resident #82 in bed with bilateral upper quarter bed rails on the bed. When asked about the bed rails, Resident #82 stated that he used them to grab on to turn in bed and position himself. When asked if the facility staff reviewed the risks and benefits of using bed rails and had him sign anything regarding the bed rails Resident #82 stated he did not think so, but he liked having them on the bed and would sign something…

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 staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 51 residents in the survey sample, Resident #39. The facility staff failed to document a complete pain assessment and attempted non-pharmacological interventions when prn (as needed) pain medication was administered to Resident #39 on multiple dates in January 2020. The findings include: Resident #39 was admitted to the facility on [DATE]. Resident #39's diagnoses included but were not limited to paralysis, muscle weakness and major depressive disorder. Resident #39's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/4/19, coded the resident as being cognitively intact. Section J coded Resident #39 as reporting almost constant pain rated, as a six, on a scale from zero to ten. Resident #39's comprehensive care plan dated 10/12/18 documented, (Name of Resident #39) has acute pain r/t (related to)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement infection control practices for one of 51 residents in the survey sample, Residents #10. During observation of care for Resident #10 on 1/29/2020, the facility staff failed to cleanse hands between glove changes. The findings include: Resident #10 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including, but not limited to: history of a stroke, dysfunctional bladder, diabetes (1), spinal stenosis (2), and peripheral neuropathy (3). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 11/7/19, Resident #10 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having no impairment for understanding others or for being understood 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.