George Washington Health & Rehabilitation

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of five residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to document in the clinical record, the findings of the Resident's report of a request for an unwanted sexual act. Review of facility synopsis of events submitted to the state agency dated 5/17/23 revealed R2 made an allegation of an unsolicited sexual act. Review of the facility synopsis of events revealed, in part: Resident made an allegation at approximately 7:00 am that a white male entered her room and stated, 'Can you suck my [expletive].' The resident denies being touched inappropriately and participating in any sexual activity. Resident was unable to identify the accused when presented with four random male choices. Further review of clinical record failed to reveal progress notes regarding the incident. On 11/1/23 at 8:45 a.m., ASM (Administrative Staff Member) #1, the administrator, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for one of 29 residents in the survey sample, Resident #36. The findings include: For Resident #36 (R36), the facility staff failed to evidence treatment to a pressure injury (1) initially observed on 4/5/2023. A treatment was not started until 4/12/2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/30/2023, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section M documented R36 having one unstageable pressure injury. On 6/13/2023 at 11:00 a.m., an observation was made of RN (registered nurse) #3, the wound nurse, providing wound care to R36's pressure injury to the left heel. There were no concerns with the pressure injury treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide monitoring of a resident receiving TPN (total parenteral nutrition) consistent with professional standards of practice for one of 29 residents in the survey sample, Resident #84. The findings include: For Resident #84 (R84), the facility staff failed to monitor blood glucose levels while receiving TPN (1). R84 was admitted on [DATE], hospitalized on [DATE], then readmitted and d/c'd on the same day 4/1/22. On the most recent MDS (minimum data set) an admission assessment with an ARD (assessment reference date) of 3/13/2022, the resident was assessed as receiving parenteral/IV (intravenous) feeding while at the facility and receiving 51% or more of their total calories through the parenteral feeding. The physician orders for R84 documented in part, - TPN Therapy per physician order (reminder: check for additional medications to be added by nurse): Solution: __ ; Volume: 2000 ;…

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, clinical record review and facility document review, it was determined that the facility staff failed to implement a pain management program per physician orders, for one of 29 residents in the survey sample; Resident #72. The findings include: For Resident #72, the facility staff failed to implement parameters for an as-needed (PRN) pain medication that was ordered for severe pain. The facility staff administered the medication for pain levels that were less than severe (mild or moderate) on a pain scale of 0-10 with 10 being the most severe level of pain. A review of the clinical record revealed a physician's order dated 4/28/23, discontinued on 5/5/23 and reordered on 5/6/23 for oxycodone-acetaminophen (1) 10-325 mg, give one tab every four hours as needed for severe pain. There were no orders for any PRN pain medication for levels that would be considered mild or moderate. A review of the Medication Administration Record (MAR) for May 2023 and June 2023 revealed the resident received this medication on the following dates for the following pain ratings…

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 respond to pharmacy recommendations for two of 29 residents in the survey sample, Residents #60 and #44 The findings include: 1. For Resident #60 (R60), the facility staff failed to respond to pharmacy recommendations dated 8/23/22 and 10/24/22 for lab tests. A review of R60's clinical record revealed a pharmacy recommendation dated 8/23/22 that documented to consider monitoring a liver function test, lipid panel and a basic metabolic panel on the next lab day, and a pharmacy recommendation dated 10/24/22 that documented to consider monitoring a digoxin level on the next lab day. Further review of R60's clinical record failed to reveal these pharmacy recommendations were addressed and failed to reveal the lab results. On 6/14/23 at 10:34 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that once the pharmacist has completed their review, the staff print out the pharmacy recommendations, give them to the doctor, and the doctor acts upon them. 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 staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for two of 29 residents in the survey sample, Residents #60 and #285. The findings include: 1. For Resident #60 (R60), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (1) medication Eliquis (2). A review of R60's clinical record revealed a physician's order dated 4/4/23 for Apixaban (Eliquis) 5 mg (milligrams) by mouth every 12 hours for atrial fibrillation. A review of R60's MARs (medication administration records) for April 2023 through June 2023 revealed the resident was administered Apixaban 5 mg every 12 hours every day. Further review of R60's clinical record (including the MARs, assessments and nurses' notes for April 2023 through June 2023) failed to reveal the resident was monitored for side effects (bleeding) from Apixaban (except for 4/5/23 and 6/9/23). On 6/13/23 at 4:27 p.m., 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to review an advance directive and/or have copies of the advance directive documents in the clinical record for two of 29 residents in the survey sample, Resident #48 and #60. The findings include: 1. For Resident #48 (R48), the facility staff failed to evidence documentation of a periodic review of the resident's advance directive. R48 was readmitted to the facility on [DATE]. The physician orders dated 6/6/2023 failed to evidence documentation of a code status. The Admit/Readmit Screener dated 6/6/2023 documented, Health care directives/code status - full code. On 6/13/2023 at 12:06 p.m., ASM (administrative staff member) #1, the administrator, stated there is no evidence of an advance directive discussion per what the records indicate. The social worker plans to address this at their next care plan meeting as the resident has expressed they wanted to discuss their advance directives. R48…

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, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for the use of an anticoagulant for one of 29 residents in the survey sample, Resident #285. The findings include: Resident #285 (R285) was admitted to the facility on [DATE]. Review of the clinical record failed to evidence a baseline care plan regarding use of an anticoagulant. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. The assessment failed to evidence documentation of R285 receiving anticoagulant medications. The assessment included baseline care plan triggers which failed to evidence documentation of anticoagulant medications. The physician orders for R285 documented in part, Apixaban Oral Tablet 5 MG (milligram) (Apixaban) Give 1 tablet by mouth every 12 hours for A Fib (atrial…

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 review and revise the comprehensive care plan for one of 29 residents in the survey sample, Resident #60. The findings include: For Resident #60 (R60), the facility staff failed to review and revise the resident's comprehensive care plan for the use of an incentive spirometer (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/2/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. R60's diagnoses included but not limited to, secondary pulmonary hypertension and obstructive sleep apnea. On 6/12/23 at 12:29 p.m., R60 was observed sitting up in bed. An incentive spirometer was observed sitting on the resident's nightstand. R60 stated they use the incentive spirometer every now and then. On 6/13/23 at 8:45 a.m., the incentive spirometer was observed on the resident's nightstand. A review of R60'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 observations, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services for two of 29 residents in the survey sample, Resident #285 and Resident #60. The findings include: 1. For Resident #285, the facility staff failed to obtain a physician's order for the use of oxygen. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. The assessment documented Resident #285 (R285) receiving oxygen at the facility. On 6/12/2023 at 1:57 p.m., an interview was conducted with R285 in their room. R285 was observed in bed wearing an oxygen nasal cannula. R285 stated that they wore oxygen at all times during the day and wore a CPAP (continuous positive airway pressure) at night due to congestive heart failure. R285 was observed to be receiving…

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, the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for one of 29 residents in the survey sample, Resident #27. The findings include: A review of R27's clinical record revealed a physician's order dated 6/12/23 for hemodialysis at (name of company) every Monday, Wednesday and Friday. A review of the facility dialysis contracts failed to reveal a contract for R27's dialysis provider. On 6/13/23 at 4:17 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 presented a commercial contract request intake form dated 1/21/22 and stated that she could not provide the dialysis contract. On 6/13/23 at 5:31 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding dialysis contracts.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for one of 29 residents in the survey sample, Resident #48. The findings include: For Resident #48 (R48) the facility staff inaccurately documented in the care plan that the resident was on hospice, had a urinary catheter, and was ventilator dependent. The comprehensive care plan dated 6/6/2023, documented in part, Focus: The resident has (SPECIFY Condom/Intermittent/Indwelling, Suprapubic) Catheter . Resident was admitted to hospice RT (related to) (diagnosis) with (Hospice Company) .The resident has a tracheostomy .The resident is ventilator dependent r/t. Observation was made of R48 on 6/12/2023 at approximately 12:15 p.m. The resident did not have a tracheostomy. A second observation and interview with R48 was conducted on 6/12/2023 at 4:47 p.m. The resident did not have a tracheostomy and there was no ventilator in the resident's room. When asked if they were on hospice care, R48 stated, no. When asked if they 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.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis [1] program for one of 34 residents in the survey sample, Residents # 45. The facility staff failed to have ongoing communication with Resident #45's dialysis treatment center and failed to ensure ongoing monitoring for potential complications as evidenced by the staff failure to assess Resident #45's AV [arterial/venous] dialysis fistula in the resident right upper arm for a thrill/bruit per the physician orders on 1/12/21, 12/27/21, 12/30/21 and 1/07/22. The findings include: Resident # 45 was admitted to the facility with diagnoses included but were not limited to: end stage renal disease [2]. Resident # 45's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/11/2021, coded Resident # 45 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being severely impaired of cognition for making daily decisions. Section O…

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 ensure call bell placement within resident reach for one of 34 residents in the survey sample, Resident #60. During observation on 1/19/22, Resident #60's call bell was out of reach. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (1) and history of a stroke. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/1/22, Resident #60 was coded as being moderately impaired for making daily decisions. She was coded as requiring the assistance of staff for bed mobility and transfers. On 1/19/22 at 1:17 p.m. and 3:49 p.m., Resident #60 was observed lying in bed. No call bell cord was visible. When interviewed about the call bell, Resident #60 stated she did not know where it is, and had not seen it all day. A review of 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 observation, staff interview and clinical record review, it was determined that facility staff failed to provide curtains, shades or blinds on Resident # 21's room window to promote personal privacy for one of 34 residents in the survey sample. The findings include: Resident # 216 was admitted to the facility with diagnoses that included but were not limited to: heart disease, swallowing difficulties and muscle weakness. Resident # 21's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/2021, coded Resident # 21 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Resident # 14 was coded as requiring supervision of one staff member for ADLs [activities of daily living]. On 01/19/22 at 1:03 p.m. an observation of Resident # 21 revealed they were sitting on the side of the bed. Resident # 21 stated that they did not have any window curtains. Observation of Resident # 21's room window reveal that there were no curtains, shades or…

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 clinical record review, it was determined that the facility staff failed to maintain a clean, home like environment for two of 34 residents in the survey sample, Resident #73 and Resident #216. The facility staff failed to change the resident's bloody draw sheet on 1/19/22 and 1/20/22, and failed to ensure Resident # 21's room window had curtains or a shade to provide privacy and a home like environment. The findings include: 1. Resident #73 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/27/21, Resident #73 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). The resident was coded as requiring the extensive assistance of two staff members for bed mobility, and as being dependent on two 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 34 residents in the survey sample, Residents #69, #16, #45, #60 and #73. The facility staff failed to implement Resident #69's comprehensive care plan intervention to for non-pharmacological intervention for pain management prior to administering pain medication on 1/12 and 1/16/2022; failed to develop a comprehensive care plan for Resident #16's behavior of wandering as assessed and triggered for care planning on the MDS (minimum data set) with and ARD (assessment reference date) of 11/2/2021 resident assessment; failed to implement Resident # 45's comprehensive care plan intervention for checking the thrill and bruit [1], and failed to develop a care plan for Resident #60's anticoagulant use and to include Resident #73's Foley catheter (1). The findings include: 1. Resident #69 was admitted to the facility on [DATE] with…

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

Based on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to review and/or revise the comprehensive care plan for one of 34 residents in the survey sample, Resident #65 and Resident #5. The facility staff failed to revise the comprehensive care plan of Resident #65 to include the use of bed rails. The findings include: 1. Resident #65 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1) and muscular dystrophy (2). Resident #65's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/2021, coded Resident #65 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. Section G coded Resident #65 as requiring extensive assistance from one staff member for bed mobility, eating, toilet use and personal hygiene. On 1/19/2022 at approximately 1:15 p.m., an observation was made of Resident #65 in their room.…

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 clinical record review, it was determined that the facility staff failed to provide care and services for a Foley catheter for one of 34 residents in the survey sample, Resident #73. The facility staff failed to evidence regular care of Resident #73's Foley catheter, and failed to position the catheter in a manner to prevent infection. On 1/19/22 and 1/20/22 observation revealed Resident #73's Foley catheter collection bag was lying in direct contact with the floor. The findings include: Resident #73 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/27/21, Resident #73 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). Resident #73 was coded as having an indwelling catheter in his bladder 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete pain management program for one of 34 residents in the survey sample, Resident #69. The facility staff failed to document the location of Resident #69's pain and failed to attempt/offer non-pharmacological interventions prior to administering pain medication to Resident #69. The findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), diabetes, and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 12/28/2021, coded the resident as scoring a 15 on 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, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to assess and obtain consent for the use of bed rails for one of 34 residents in the survey sample, Resident #65. The facility staff failed to evidence an assessment or consent for the use of a bed rail for Resident #65. The findings include: Resident #65 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1) and muscular dystrophy (2). Resident #65's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/2021, coded Resident #65 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. Section G coded Resident #65 as requiring extensive assistance from one staff member for bed mobility, eating, toilet use and personal hygiene. On 1/19/2022 at approximately 1:15 p.m., an observation was made of Resident #65 in their room. Resident #65 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the drug regime for one of 34 residents in the survey sample was free of unnecessary pain medication, Resident #69. Resident #69's physician ordered pain medication as needed every twelve hours for mild pain. On 1/17/22 the facility staff administered the as needed pain medication to Resident #69's when the residents documented pain level rating was zero indicating no pain. The findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), diabetes, and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment with…

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

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 34 residents in the survey sample was free from unnecessary psychotropic medications, Resident #16. The facility staff failed to ensure specified targeted behaviors for qualitative quantitative monitoring for the administration and use of the antipsychotic medication Seroquel for Resident #16. The findings include: Resident #16 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (1), dementia (2) and major depressive disorder (3). Resident #16's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/2/2021, coded Resident #16 as scoring a 7 (seven) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 7- being severely impaired for making daily decisions. Section E documented Resident #16 displaying wandering behaviors daily. Section N 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 observation, staff interview, and facility document review it was determined facility staff failed to serve and store food in a sanitary manner. The Facility staff failed to document an opened date on dry goods in the kitchen, failed to store thickening agents covered when not in use, failed to store staff food separately from resident food in the stand-up refrigerator and failed to discard food past its use by date in the walk in refrigerator. The findings include: On 10/8/19 at approximately 11:25 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #2, the dietary manager. Observation of the kitchen area revealed a silver food preparation table containing four opened bags of pasta. Further observation of the bags revealed one ten pound bag of macaroni noodles approximately one-half full, a one pound bag of gluten free penne pasta approximately one-fourth full, a ten pound package of fettucine approximately three-quarter full, and a ten pound bag of vegetable bow tie pasta approximately one-third full. Observation of the packages…

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 food in a sanitary manner in the main dining room during the lunch meal on 10/8/19. When removing the plates from the tray, CNA (certified nursing assistant) #2, was observed with his thumb on the food, contact surface area of the residents' plates for the resident he served. The findings include: On 10/8/19 at 12:45 p.m. an observation of the dining service was conducted in the main dining room of the facility. Ten residents were observed seated at tables consisting of two to four table settings in the dining room. CNA (certified nursing assistant) #2 was observed serving residents drinks table to table. At 12:55 p.m., after serving all residents drinks, CNA #2 was observed obtaining a large carrying tray containing two lunch plates from the dining service line located in the dining room. CNA #2 served two residents seated at a table together from the large tray. CNA #2 was observed picking the plate up with his right hand while holding the large tray in his…

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 ensure a functioning to call light system for three of 39 residents in the survey, Resident #54, Resident #66 and Resident #290. The findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: cerebrovascular accident [hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack resulting in loss of ability to move body part or speak. (1)], atrial fibrillation [rapid and random contraction of the atria of the heart causing irregular heartbeat. (2)] and major depressive disorder (dejected state of mind with feelings of sadness, discouragement and hopelessness often accompanied by reduced activity (3)]. The MDS (minimum data set) assessment, a 14 day Medicare assessment, with an ARD (assessment reference date) of 9/10/19, coded the resident as scoring a 13 out of 15 on 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement their policies for reporting an elopement to the state agency for one of 39 residents in the survey sample, Residents # 20. The facility staff failed to implement their policies to report an alleged incident of neglect to the state agency when Resident #20 eloped on 5/29/19, and was found two blocks away from the facility. The findings include: The facility policy, Patient Protection: Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention documented in part, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the events that cause 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to report an elopement to the State Agency for one of 39 residents in the survey sample, Resident #20. The facility staff failed to report a potential incident of neglect to the state agency when Resident #20 eloped on 5/29/19, and was found two blocks away from the facility. The findings include: Resident #20 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: high blood pressure, diabetes, dementia and depression. The most recent MDS (minimum data set) assessment, a significant change/Medicare five day assessment, with an assessment reference date of 8/3/19, coded the resident as scoring as scoring a 14 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive to limited assistance of one staff member 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 3. The facility staff failed to code Resident #91's Discharge Status accurately on the MDS (minimum data set) assessment, with an assessment reference date of 8/19/19. Resident #91 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: facial injuries from a robbery attack. The most recent MDS (minimum data set) assessment, a Medicare five day assessment combined with a discharge assessment - return not anticipated, with an assessment reference date of 8/19/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating he was capable for making daily cognitive decisions. The resident was coded as being independent to requiring extensive assistance of one staff member for his activities of daily living. In Section A2100 - Discharge Status, the resident was coded as being discharged to 03 indicating he was transferred to an acute hospital. The social services note dated 8/19/19 at 1:58 p.m. documented in part, Pt (patient) is…

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

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 implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication [Ultracet] for one of 39 residents in the survey sample, Resident # 19. The facility staff failed to attempt non-pharmacological interventions per the comprehensive care plan prior to administering pain medication to Resident #19, on multiple dates in August and September 2019. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: osteoarthritis [2], left shoulder pain and muscle weakness. Resident # 19's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/30/19, coded Resident # 19 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition…

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 provide treatment and care in accordance with professional standards of practice, and the comprehensive care plan, for one of 39 residents in the survey sample, Resident # 19. The facility staff failed to follow physician's orders to obtain vital signs for seven days. The staff only obtained Resident #19's vital signs for 6 days. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: left shoulder pain and muscle weakness. Resident # 19's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/30/19, coded Resident # 19 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. The Physician's Interim/Telephone Orders for Resident # 19 dated 06/24/19 documented in…

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 and facility document review it was determined that facility staff failed to ensure hazardous chemicals were stored in a safe manner for one of 39 residents in the survey sample. Two cans of pesticides were stored on the floor in front of the wardrobe in Resident #35's room. The findings include: Resident #35 was admitted to the facility 05/15/2017 with a readmission on [DATE] with diagnoses, that included but were not limited to diabetes mellitus (1) and hypertension (2). Resident #35's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/23/19, coded Resident #35 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. On 10/8/19 at 4:57 p.m., an observation of Resident #35's room revealed a 17.5 ounce can of [Brand Name] ant killer and an 18 ounce can of [Brand Name] flying insect killer on the floor to 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.

Based on staff interview and employee record review it was determined that the facility staff failed to ensure that two of ten CNA (certified nursing assistant) records reviewed received the required 12 hours of annual training, (CNA (certified nursing assistant) #9 and #10). Review of CNA #9 and #10's training transcripts revealed the required 12-hours of annual training was not completed. The findings include: On 10/03/19 at 8:15 a.m., a review of the facility's CNA [certified nursing assistant], annual training was conducted. Review of ten CNA training transcripts revealed two of ten CNAs selected for review did not meet the required 12-hours of annual training. Review of CNA # 9's training transcript documented a hire date of 02/15/2016. Further review of the training transcript dated 12/15/17 through 12/15/18 documented, Total Hours: 8.74. Review of CNA # 10's training transcript documented a hire date of 02/20/2015. Further review of the training transcript dated 02/20/18 through 02/20/19 documented, Total Hours: 6.75. On 10/10/19 at 2:10 p.m., an interview was conducted with…

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

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 the drug regimen must be free from unnecessary drugs for one of 39 residents in the survey sample, Resident # 19. The facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medication [Ultracet] on multiple dates in August and September 2019. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: osteoarthritis [2], left shoulder pain and muscle weakness. Resident # 19's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/30/19, coded Resident # 19 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Section J0400 Pain Frequency coded Resident # 19 as Frequently and section J0600…

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 three of ten CNA (certified nursing assistant) records reviewed, received required in-service training for dementia, (CNA [certified nursing assistant] #9, #10, and #11). The findings include: On 10/10/19 at approximately 10:00 a.m., a review of the facility's CNA [certified nursing assistant], annual training was conducted by this surveyor. Review of ten CNA training transcripts revealed three of ten CNAs selected for review did not complete the required training regarding dementia as part of their annual training. Review of CNA # 9's training transcript documented a hire date of 02/15/2016. Further review of the training transcript dated 12/15/17 through 12/15/18 failed to evidence dementia care training. Review of CNA # 10's training transcript documented a hire date of 02/20/2015. Further review of the training transcript dated 02/20/18 through 02/20/19 failed to evidence dementia care training. Review of CNA # 11's training transcript documented a hire date 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.