Mount Vernon Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure the urinary catheter tubing and collection bag were not in contact with the floor for one (Resident (R)67) of three residents reviewed for catheters and urinary tract infection. This failure placed the residents at risk for transmission of infection to the urinary tract.Findings include:Review of R67Resident (R)67 's admission Record located in the resident's electronic medical records tab Profile revealed the resident was admitted to the facility on [DATE] with diagnosis that included neuromuscular dysfunction of the bladder. Review of R67's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 03/19/26 revealed the resident had an external catheter to a urinary drainage bag. Observation on 04/22/26 at 12:16 PM revealed R67's urinary drainage bag dragging on the floor. Certified Nursing Assistant (CNA)1 had finished providing care to the R67. Observation on 04/22/26 at 12:45PM revealed R67…

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

Based on observation interview, facility policy review, the facility failed to ensure medications were maintained in accordance with expiration date requirements for one of two medication storage rooms. A total of five medication units were identified as expired and remained in active storage within the medication room refrigerator, and one Tuberculin vial that had been open and used out of and not dated, creating the potential for administration beyond pharmacy's expiration dates. This indicates a failure to ensure proper monitoring, removal, and disposal of expired medications in accordance with facility policy and regulatory standards.Findings include:During an observation on 04/22/26 at 4:03 PM with Licensed Practical Nurse (LPN) 1 of the first-floor medication storage room, revealed the medication storage refrigerator contained five bags of expired Fetroja, (an intravenous (IV) antibiotic) 2 GM, (gram)/100mg (milligram). One bag had a use by date of 04/16/26 and four bags had a use by date of 04/19/26. Continued observation of the medication storage refrigerator revealed 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 record review, observations, interview and review of facility policy, the facility failed to ensure that staff members were donning the appropriate personal protective equipment (PPE) for two of four residents (Resident (R)2 and R67) reviewed for enhanced barrier precautions (EBP) and contact isolation from a sample of 31 residents. The facility also failed to ensure the correct signage was posted for one resident (R2) with Methicillin Resistant Staphylococcus Aureus (MRSA). These failures had the potential to promote the spread of infectious diseases. Findings include:1. Review of R2's admission Record located in the electronic medical records (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included left hip open wound, resistance to multiple antimicrobial drugs, congestive heart failure, extended spectrum beta lactamase (ESBL) resistance, resistance to carbapenem, and cutaneous abscess of the left leg. Review of R2's Physician Orders for…

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

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #1, in a sample size of 3 residents. The findings included: For Resident #1, facility staff failed to utilize proper turning/repositioning technique while providing care. Resident #1 was discharged from the facility on 9/22/23 and therefore not available for observation and direct interview. On 11/14/23, a telephone call was placed to the last known number for Resident #1 and there was no answer. On 11/14/23, Resident #1's clinical record was reviewed in its entirety. A progress note dated 8/19/23 at 13:30 read, Resident is alert and verbally responsive and complained of pain in his right shoulder, he stated that the aid [certified nursing assistant-CNA] from last night pulled his right shoulder when she tried to turn him while doing the ADL [activities of daily living] care, upon assessment pain was rated 6/10, vital signs were stable . Resident #1 received Tylenol which…

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, and staff interview, the facility failed to post survey results in a place readily accessible to Residents and families, which had the potential to affect all 119 Residents residing in the facility. The findings included: On 09/13/22 at 11:00 AM, a resident Council meeting was conducted. When the group of Residents were asked if they knew where the survey results were located, all of the residents in the meeting indicated they did not know where the survey results were located. On 09/13/2022, Surveyor B toured the entire facility looking for the previous survey results, they were unable to be located. On 9/13/22 at 8:43 AM, the receptionist/Employee G, was asked where the survey results from prior surveys are located. Employee G said, They are normally kept right out in the open, they used to be on a table as you entered station 1, since they renovated I am not sure, let me ask. Employee G found a binder at the receptionist desk, located in the lobby, but noted that the binder was empty. Employee C then entered the lobby and when Employee G…

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 documentation review, the facility staff failed to post the required correct daily nursing staffing information which was visible to Residents, staff, and visitors, on four of four nursing units. The findings included: On 9-12-22 at approximately 11:30 AM, during initial tour of the building the daily staffing posting information was not correct, nor visibly posted. The posting continued to be incorrect on the second day of survey, 9-13-22. The posting simply had the name of staff members, and their arrival time. The posting was in a small back alcove with a desk behind the nursing station used for nurse and physician documentation and storage of documents. The posting was in the back of the alcove, not visible to anyone other than staff. On 9-13-22, the Director of Nursing (DON) was interviewed. The DON stated she would correct it immediately. On 9-13-22, during an end of day debrief with the facility Administrator and DON, they were made aware of the above findings. No further information was provided.

Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts effecting 4 Residents (Resident #2, 20, 91, and 70) in a survey sample of 60 Residents. The findings included: On 9/15/22, an interview was conducted with Resident #20. Resident #20 was asked if he gets statements quarterly as to how much money is in his trust account. Resident #20 said, No, I don't get statements and I would like to know how much is in there. On 9/15/22, Resident #2 was interviewed regarding trust statements. Resident #2 said he doesn't receive any statements from the facility. On 9/19/22, Resident #70 was interviewed and stated he doesn't receive trust statements and would like to know how much is in his account. On 9/19/22 at 3:15 PM, Surveyor B went to the business office and asked to see evidence of trust statements for the last 3 quarters. Employee J, the Regional Director of Revenue Cycle said she had discovered that there was no evidence that the statements from June…

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

Based on observation, and staff interview, the facility staff failed to provide required postings, including a list of names, addresses, and telephone numbers for State Agencies, and advocacy groups, which are mandated by regulation to be accessible and understandable for the resident population. The findings included; During the surveyor's initial tour of the facility on 9-12-22 observations included all resident rooms and common areas of the two floors where residents resided in the building. No posting which listed the required names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible, and understandable to residents, could be found. The Social worker was asked where the posting could be found, and she stated it had been posted by the elevators, but was taken down during renovations, and it had not been replaced. When asked how long ago that happened, she stated she could not remember, and further stated it was awhile ago. On 9-13-22 the LPN unit Manager was asked about the posting, and she stated they were going to replace it. On 9-14-22…

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, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain a Resident's personal privacy and failed to protect personal health information for 3 Residents (Resident #35, 268, and 78) in a survey sample of 60 Residents. The findings included: 1. For Resident #35, the facility staff failed to provide a privacy curtain to ensure the Resident's personal privacy and dignity were protected during ADL (activities of daily living) care. On 9/14/22 at 9:30 AM, Resident #35 was visited in his room. The Resident requested of the surveyor, Can you see about getting me a privacy curtain. Surveyor B observed that there was no privacy curtain around Resident #35's bed. When asked where he changes clothes or takes a bath he said, Well, now I have to go into the bathroom to do it. On 9/14/22 at approximately 9:45 AM, an interview was conducted with CNA D. CNA D was asked what the purpose of a privacy curtain is, CNA D said, To protect their privacy. When asked…

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 documentation review, and in the course of a complaint investigation, the facility staff failed to maintain a clean, comfortable and home like environment for one Resident (Resident #46) and on two of two nursing units. The findings included: 1. The facility staff failed to maintain Resident rooms and bathrooms in a clean, comfortable and homelike manner for multiple Residents residing on both of the nursing units. a. On 9/12/22, during initial tour Surveyor B observed that a Resident residing in a room on the first floor, Colonial hall that had splatters and lines of a tan colored substance running down the wall at the head of the bed that were dried. Throughout the entire survey, which concluded on 9/22/22, Surveyor B observed the splatters and lines without any improvements noted. b. On 9/14/22, Surveyor B observed the following in a Resident room on the first floor, [NAME] hall. A bathroom with a large section of wall paper missing 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 4. For Resident # 217, the facility staff failed to implement the policies on abuse/neglect Resident # 217 was admitted to the facility on [DATE] for skilled services in nursing and therapy with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the Resident # 217's closed clinical record revealed the most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 9/16/2021. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the closed clinical record was conducted on 9/12/2018 through 9/22/2022. Review of the Progress Notes revealed documentation of a nurses note dated 5/28/2020 at 8:19 a.m. which stated:…

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 interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to report allegations of abuse timely for 7 Residents (Resident #52, Resident #117, Resident #31, Resident #84, Resident #367, Resident #369, Resident #19) in a sample size of 60 Residents. The findings included: 1. For Resident #52, the facility staff failed to report the allegation of abuse to the state agency and adult protective services timely. On 09/13/2022 at 11:00 A.M., a Resident Council meeting with 6 Residents was conducted. At 11:18 A.M., the Social Worker entered the Resident Council meeting. When this surveyor asked the social worker why she was entering the meeting, Resident #88 stated he invited the social worker to the meeting. When the other Residents were asked about this, the other Residents in attendance also indicated they would like the social worker to be present. The meeting resumed and when the Residents were asked if call bells were answered timely, Resident #52 stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to revise the care plan for 7 Resident (Resident #318, Resident #78, Resident #68, Resident #318, Resident #86, Resident #35, Resident #14) in a sample size of 60 Residents. The findings included: 1. For Resident #318, the facility staff failed to address communication on the care plan. On 09/12/2022 at 3:50 P.M., Resident #318 was observed awake in her bed. When asked if she had any concerns about the care received at the facility, Resident #318 spoke in a foreign language. There were no communication aids or language line number observed at the bedside. On 09/13/2022, Resident #318's clinical record was reviewed. Under the Assessment tab in the electronic health record, there was no evidence Resident #78's understanding of the English language was assessed. According to the Face Sheet under the section Primary Language, it 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.

Based on staff interview and facility documentation review, the facility staff failed to ensure that required competencies were completed for 6 of 6 nursing staff members including, Registered Nurses (RN), Certified Nursing Aides (CNA), and Licensed Practical Nurses (LPN). The survey sample of 6 consisted of; (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Facility failed to complete required initial, and annual, competency training, and evaluations. The Findings included: On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed to the Administrator to ask for the other 2 missing documents. The Administrator stated We can find nothing for those…

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 facility documentation review, the facility staff failed to ensure that required annual performance reviews, with in-service training based on those reviews, were completed for 3 of 3 Certified Nursing Aides (CNA) in the survey sample, (CNA B), (CNA C), and (CNA F). The Findings included: On 9-14-22 a review was requested for CNA employee Performance reviews and training records. The facility Administrator was asked for employee records for the 3 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 two of the requested 3 CNA records were received. A call was placed to the Administrator to ask for the other missing documents. The Administrator stated We can find nothing for that employee. The 2 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none, and no mention was given for the other CNA (F), which…

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 facility documentation review, the facility staff failed to ensure that required knowledge of, appropriate training for, and competencies were completed to care for residents with mental, psychological, and psycosocial disorders for 6 of 6 nursing staff members including, Registered Nurses (RN), Certified Nursing Aides (CNA), and Licensed Practical Nurses (LPN). The survey sample of 6 consisted of: (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Findings included: The Facility failed to complete required initial, and annual, competency training, and evaluations. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed 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.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 2 Residents (#'s 88, & 86) in a survey sample of 60 Residents. The findings included 1. For Resident #88 the facility staff failed to ensure the correct administration of the anticoagulant Lovenox (generic name Enoxaparin Sodium) was ordered and given as directed by the physician. On 9/13/22 at approximately 2:00 PM an interview was conducted with Resident # 88 who stated that he has been getting the wrong dose of medication for his blood clots and just found out this week it was the wrong dose. He stated his doctor that he sees for his blood clot had put him on shots in the stomach and the medication should have been 100 mg every 12 hrs. But that he was only getting 80 mg. A review of the clinical record revealed that Resident #88 had physician's orders that read: 8/11/22 8:15 PM Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 ml subcutaneously every morning and at bedtime for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to properly store Drugs and Biological's for 2 of the facility's 4 medication carts. The Findings Included: On 9/21/22 while completing the medication administration facility tasks Surveyor D made the following observations: At 2:50 PM on the Colonial Hall cart 1, observed artificial tears eye drops labeled with the Resident name and room number as well as the opened date on the box only, LPN L was asked was asked what the process was for labeling medications and she stated that the name, and date opened should be on the box on the bottle as well. When asked why she stated that if it's not labeled correctly the medication could get mixed up with someone else's. At 2:53 PM on the [NAME] Hall cart 1, observed artificial tears eye drops labeled with the Resident name and room number as well as the opened date on the box only, LPN M was asked was asked what the process was for labeling medications and she…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to establish and maintain an effective infection prevention control program to prevent the development and spread of diseases and infections for 1 Resident (#88), and the facility as a whole. In addition, 8 facility staff on 4 of 4 units failed to maintain an effective infection prevention and control program. The findings included: 1. For Resident #88 the facility staff failed to ensure proper care and cleaning of Resident #88's suprapubic catheter. A review of the clinical record revealed that Resident #88 was brought to the hospital by his fiancée on 8/5/22 and was admitted with a diagnosis of Poly-Microbial (more than one bacteria) UTI (Urinary Tract Infection). The identified bacteria were: Providencia Stuartii. Enterococcus Fecalis Providencia, P. rettgeri and P. stuartii are the most common cause of catheter-associated urinary tract infections, especially in the elderly with long-term indwelling urinary catheters. While, both of these bacteria are normal when found 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 clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 4 Residents, Residents #6, #35, #111, and #88, in a sample of 5 Residents reviewed for resident COVID-19 testing. The findings included: For Residents #6 and #35, facility staff failed to conduct COVID-19 testing for admission/re-admission to the facility and for Resident #111, facility staff did not document the results of COVID-19 testing in the clinical record. 1. For Resident #6, the facility staff failed to conduct COVID-19 testing upon her re-admission to the facility on 8/19/22. On 9/14/22, a clinical record review was conducted and revealed that Resident #6 was re-admitted to the facility on [DATE] following her admission to the local hospital on 8/12/22. There was no evidence of any COVID-19 testing until 8/22/22. 2. For Resident #35, the facility staff failed to conduct COVID-19…

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 facility documentation review, the facility staff failed to ensure that required training for Abuse/neglect, misappropriation, exploitation, dementia management, and abuse prevention were conducted for all 6 of the employees in the employee sample, (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Findings included: The Facility failed to complete required abuse and dementia competency training, and evaluations. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed to the Administrator to ask for the other 2 missing documents. The Administrator stated We can find nothing for those employees. The 4 that were received…

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 facility documentation review, the facility staff failed to ensure that the required 12 hours per year of in-service training was completed for Certified Nursing Aides (CNA's). The survey sample of of 3 CNA's consisted of; (CNA B), (CNA C), and (CNA F). The Findings included: The Facility failed to ensure 12 hours of training annually for CNA's. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 2 of the 3 included and a call was placed to the Administrator to ask for the other missing document. The 2 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none. No mention 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.

On 09/13/2022 at 9:30 A.M., Resident #90 was observed asleep in her bed with the head of the bed elevated approximately 60 degrees. Resident #90 had a plaid clothing protector on with food particles on it. The tray table with the breakfast tray was positioned over the bed and in front of Resident #90. All the food had been eaten off the plate. There was no staff in the room. At 9:36 A.M., Certified Nursing Assistant N (CNA N) entered Resident #90's room, took the tray off the tray table, exited the room, and placed the tray on the cart in the hall. CNA N then re-entered Resident #90's room, walked past Resident #90, and took the roommate's tray to the cart in the hall. CNA N then proceeded to the adjacent room and removed those breakfast trays. At 9:50 A.M., Resident #90 was observed still sleeping with the head of the bed elevated approximately 60 degrees, and the plaid clothing protector on with food particles on it. At 10:00 A.M., CNA N was interviewed. When asked about the process of assisting a Resident after mealtime, CNA N stated that afterwards, she would assist the 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, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications, for one Resident (Resident #35) in a survey sample of 60 Residents. The findings included: For Resident #35, who had medications stored in his room, the facility staff failed to assess if Resident #35 was safe to self-administer medications and removed the medications, stating it was not permitted. On 9/13/22 at 9:28 PM, Resident #35 was observed awake and sitting on the edge of his bed. A Resident interview was conducted and during this interview Resident #35 was observed with a bottle of Tums/antacid tablets on his bed and in the bottom of his bed side table several prescription bottles were observed. On 9/13/22 at 9:31 PM, an interview was conducted with LPN D. When asked if she has any Residents that self-administer medications and are permitted to keep them in their room, she said, No, we have to keep all medications in the medication cart, we don't allow…

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

Based on observation, interview, facility record review and clinical record review the facility staff failed to ensure the right of self-determination for 1 Resident (#31) in a survey sample of 60 Residents. The findings included: For Resident #31, the Resident had made it clear to staff she wanted only female CNA's to work with her, as evidenced by the care plan entry dated 6/10/22, however, they continued to schedule male CNA's to be assigned to her. On 9/21/22 at approximately 10:30 AM an interview was conducted with Resident #31 who stated, I don't want none of those men undressing me. Resident #31 stated, I told him No and he got angry and banged his fist on the table it was threatening. I was afraid he would come back. On 9/20/21 an interview with the DON was conducted and she was informed of the Resident's complaint she stated she was aware and they had addressed it in the care plan meeting in June. When told that the Resident stated it had happened a few days ago, the DON stated that Resident #31 has dementia and is confused about the time. A review of the Concern Forms…

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 interviews and facility documentation review, the facility staff failed to permit Residents to access their personal funds/trust accounts on weekends and evenings, for Residents with trust accounts. The findings included: On 9/13/22 at 10:20 AM, an interview was conducted with the receptionist/Employee G. Employee G confirmed that a staff member is at the receptionist desk from 7 AM until 8 PM, Monday through Friday and on weekends from 8 AM until 8 PM. On 9/15/22, Resident #2 was interviewed regarding his access to his trust account. Resident #2 said he had to go downstairs to the business office to make withdrawals and they are only open Monday-Friday. On 9/19/22 at 3:15 PM, an interview was held with Employees CC/the assistant regional director of finance and Employee J, the divisional director of revenue cycle. They reported, We have banking hours. On 9/19/22 at 4:40 PM, an interview was conducted with Employee G/the receptionist. Employee G was asked how Residents access or withdraw money from their trust account. Employee G said, They go 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 staff interview, family interview, clinical record review and during the course of a complaint investigation, the facility staff failed to provide one resident ( Resident # 217) with a conveyance of funds within 30 days. Findings included: For Resident # 217, the facility staff did not convey funds within 30 days. Resident # 217 was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Resident # 217 did not return to the facility. Review of the Personal Funds account for Resident # 217 revealed documentation that the account was not reconciled until [DATE]. Resident # 217 transferred from the facility on [DATE]. A check was written on [DATE] but was not cashed. An audit in [DATE] revealed the check had not been cashed. The facility staff voided the check and wrote another check in [DATE]. The final check was written on [DATE] and cashed on [DATE]. On [DATE] at 2 p.m., an interview was conducted with the Regional Business Office Consultant (Employee J) who stated that the…

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

Based on Resident interview, staff interviews and facility documentation review, the facility staff failed to only withdraw funds authorized for the cost of care for one Resident (Resident #70) in a sample of 3 Residents reviewed for trust fund transactions. The findings included: For Resident #70, the facility withdrew funds monthly in excess of what was due to the facility for the Resident's cost of care as directed by Medicaid. On 9/19/22, Resident #70 disclosed during an interview concerns about money received not being deposited into his bank account/trust fund. On 9/19/22, Surveyor B asked for a transaction history of Resident #70's account and the patient liability (amount Resident is responsible to pay towards cost of care when on Medicaid) from the Virginia Medicaid web portal. The requested items were received and reviewed. The findings were as follows: 1. August 2021-September 2022, Medicaid indicated that Resident #70 was responsible to pay $838.00 per month as his patient liability. 2. For the months of August, September, October, November, and December 2021, 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, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 2 residents, Resident #35 and Resident #111, out of a sample of 10 residents reviewed for Advance Directives. The findings included: The facility staff failed to offer and/or provide Resident #35 or their Responsible Party (RP) with Advance Directive planning. On 9/14/22, clinical record review was performed for Resident #35 and Resident #111 which revealed the following: 1. Resident #35 was re-admitted to the facility on [DATE] following a hospital admission on [DATE]. Physician orders and patient profile read, Full Code status which indicated that Cardiopulmonary Resuscitation would be initiated in the event of cardiac and/or respiratory arrest. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) on 7/13/22 indicated that Resident #35 had a Brief Interview for Mental Status (BIMS) of 13, cognitively intact. 2. The facility 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 documentation review and clinical record review, the facility staff failed to complete a SNF (skilled nursing facility) NOMNC (notice of Medicare non-coverage) and ABN (advance beneficiary notice) timely and accurately for 2 Residents (Resident #417 and #35) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. The findings included: 1. For Resident # 417, the facility staff failed to issue a NOMNC timely, therefore the Resident was not afforded the opportunity to file an appeal if she so desired. Resident #417, was admitted to the facility on [DATE], for skilled care. Resident #417 was issued a NOMNC on 3/31/21, which notified her that her skilled stay would end on 4/1/22. This notice did not afford the Resident adequate time to file an appeal if she chose to. Per the NOMNC, it read, Your request for an immediate appeal should be made as soon as possible, but no later than noon the day before the effective date indicated above. The appeal would have had 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.

Based on observations, Resident interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to promptly respond to grievances for 2 Residents (Resident #46, Resident #68) in a sample size of 60 Residents. The findings included: 1. For Resident #46, the facility staff failed to promptly respond after being notified of baseboards loose/missing in room as well as extensive scuff marks and stains on floor, baseboards, and walls. For Resident #46, the facility staff failed to maintain a comfortable homelike environment as evidenced by scuff marks and stains on the floor, baseboards, and walls. Also, there were strips of scotch tape on wall across from Resident #46's bed with ripped paper attached. Also, the baseboard next to Resident #46's bed was separating from the wall and the baseboard to the right of the bathroom door was gone, revealing a small hole in the wall and ripped drywall. On 09/13/2022 at 9:20 A.M., Resident #46 was observed lying in his bed. When asked about concerns 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 Resident interview, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed implement their policy with regards to reporting crimes affecting 3 Residents (Resident #35, #368, and 217) in a survey sample of 60 Residents. The findings included: 1. For Resident #35, whose wife was a former Resident #368, reported that money was missing from their joint bank account, the facility staff failed to report timely an allegation of misappropriation and exploitation in excess of $50,000. On 9/12/22 at 3:07 PM, an interview was conducted with Resident #35. Resident #35 said, I had trouble when I first came here, thieves got hold of the books and it was a minor thing to them. I woke up one morning and the checking account was down to zero. It was an inside job, no one cared about how the books were managed. On 9/15/22 at 4 PM, a follow-up interview was conducted with Resident #35. He stated, $70,000 was taken. We used a check 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 staff interview, clinical record review, and facility record review, the facility staff failed for 1 resident (Resident #119) to provide the resident with a necessary and safe discharge, in a survey sample of 60 Residents. The Findings included: The facility unnecessarily, and unsafely discharged Resident #119, did not apply for timely insurance coverage for a needed continuance of stay, and further failed to involve, evaluate, and provide Resident #119 with an interdisciplinary discharge plan. No community services were planned, no written discharge instructions were planned, nor given to the Resident, no medical equipment was obtained for discharge home, and the facility did not document a recapitulation of the Resident's stay in the clinical record. Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, 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, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the Long Term Care ombudsman of the discharge of one Resident (Resident # 217) in a survey sample of 60 residents and the facility staff failed to notify the Ombudsman of any discharges during a 4 month period of time (October 2021-January 2022). Findings included: 1. For Resident # 217, the facility staff failed to notify the Ombudsman of the transfer to the hospital on [DATE]. The facility staff did not notify the Ombudsman of any discharges in October 2021 to January 2022. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. The MDS coded Resident #217 as requiring extensive to total assistance of one 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 staff interview, clinical record review and in the course of a complaint investigation, the facility failed to issue an accurate written bed hold notice for 1 resident (Resident #217) of 60 residents in the survey sample. Findings included: For Resident # 217, the Bed Hold Authorization form was signed but incomplete. There were blanks in the documents. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism, and Morbid Obesity with BMI (Body Mass Index) 60-69. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the electronic clinical record was conducted 9/12/2022 - 9/22/2022, including a review of the miscellaneous forms, revealed a document…

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 documentation review, clinical record review,and in the course of a complaint investigation, the facility staff failed to ensure an accurate MDS/RAI assessment was completed for one resident (Resident #217) in a survey sample of 60 residents. Findings included: 1. For Resident # 217, the facility staff failed to complete Section C: Cognitive Patterns in a Quarterly assessment dated [DATE]. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism, and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the clinical record was conducted on 9/12/2022-9/22/2022. Review revealed the most recent MDS (Minimum Data Set) assessment was a Quarterly Assessment with an ARD of 9/16/2021. Review of Section C for Cognitive Patterns revealed Section C0100 asked the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observations, Staff interview, and clinical record review, facility staff failed to refer 1 Resident (Resident #77) with a serious mental illness for a level 2 PASARR, in a survey sample of 60 Residents. The findings included: For Resident #77 a PASARR II was not completed despite diagnoses of serious Mental Illness, schizophrenia, Bipolar I & II, delusions, psychosis, Cyclothymic disorder, psychotic disorder, behaviors, and behavior management. Resident #77 was readmitted on [DATE]. Diagnoses included the above, as well as, Diabetes, Hyperlipidemia, anemia, heart failure and renal insufficiency. The most recent Minimum Data Set (MDS) Assessment was a quarterly Assessment with an Assessment Reference Date (ARD) of 8-12-2020. The Brief Interview for Mental Status scored as 11 of a possible 15, indicating mild cognitive impairment. On 9-15-22, a review of Resident #77's record was conducted. The diagnoses associated with the Resident's serious mental illness were noted. The Director of Nursing (DON) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation, facility staff failed to ensure PASRR (Pre-admission Screening and Resident Review) prior to admission, for 1 Resident (#34) in a survey sample of 60 Residents. The findings included: For Resident #34 the facility staff failed to ensure a PASRR was completed prior to his admission on [DATE]. On 9/13/22 a review of the clinical record revealed that Resident #34 did not have a completed PASRR on admission. The Social Worker at the facility completed the PASRR after he arrived at the facility, however, she did not complete the PASRR. The Social Worker completed boxes 1-4 however she did not complete box #5 which is the box that read: Recommendation (either a or b must be checked) She did not check either a (recommending a level 2) or b (stating why a level 2 was not appropriate for this resident). On the morning of 9/15/22 the Social Worker was interviewed and she was asked if the PASRR is complete and she stated that it was not. When asked why…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a baseline care plan that includes instructions needed to provide and effective person-centered care for 1 Resident (#34) in a survey sample of 60 Residents. The Findings included; For Resident # 34 the facility staff failed to address the Resident's lack of communication as he does not speak English. On 9/12/22 at approximately 2:00 PM an interview was conducted with Resident #34's son. Resident #34's son stated that his father did not speak English. When asked how he communicates with the facility staff he stated, he doesn't. He stated that he has to speak for his father because his father cannot speak English. When asked if they had given the Resident some kind of pictures to show what he needs like food, drink, or toilet. He stated that he has been in the facility every day and has not seen anyone use communication board since his admission on [DATE]. On 9/14/22 an interview…

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, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and/or implement a comprehensive care plan for 3 Residents (Resident #90, Resident #23, Resident #34) in a sample size of 60 Residents. The findings included: 1. For Resident #90, the facility staff failed to include Activities of Daily Living on the comprehensive care plan. On 09/13/2022 at 9:30 A.M., Resident #90 was observed asleep in her bed with the head of the bed elevated approximately 60 degrees. Resident #90 had a plaid clothing protector on with food particles on it. The tray table with the breakfast tray was positioned over the bed and in front of Resident #90. All the food had been eaten off the plate. There was no staff in the room. At 9:36 A.M., Certified Nursing Assistant N (CNA N) entered Resident #90's room, took the tray off the tray table, exited the room, and placed the tray on the cart in the hall. CNA N then re-entered Resident #90's room, walked past…

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 record review, the facility staff failed for 1 resident (Resident #119) to provide the resident with a discharge plan that met the needs of the Resident, in a survey sample of 60 Residents. The facility failed to involve, evaluate, and provide Resident #119 with an interdisciplinary discharge plan. No community services were planned, no written discharge instructions were planned, nor given to the Resident, and no medical equipment was obtained for discharge home. The Findings included: Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, and hypertension. The most recent Minimum Data Set (MDS), which was a 30-Day Assessment was reviewed and coded Resident #119 as having intact cognition. The Resident was his own responsible party. On 9-21-22, a review was conducted…

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 record review, the facility staff failed for 1 resident (Resident #119) to provide a recapitulation of the Resident's stay upon discharge, in a survey sample of 60 Residents. The facility failed to document a recapitulation of the Resident's stay in the clinical record after his discharge. The Findings included: Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, and hypertension. The most recent Minimum Data Set (MDS), which was a 30-Day Assessment was reviewed and coded Resident #119 as having intact cognition. The Resident was his own responsible party. On 9-21-22, a review was conducted of Resident #119's clinical record. The Resident discharged home on 7-8-22. There was no record of discharge planning, no discharge plan completed in the care plan nor in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide necessary care and services to ensure Residents have the means to communicate with others for 3 Residents (Resident #78, Resident #318, Resident #34) in a sample size of 60 Residents. The findings included: 1. For Resident #78 (whose primary language is not English), the facility staff failed to provide interpretive services as a means to effectively communicate. On 09/12/2022 at 12:45 P.M., Resident #78 was observed in bed awake. When I asked if she had any concerns about the care received at the facility, Resident #78 motioned to their neck and pointed to her roommate, Resident #38. Roommate (Resident #38) stated that [Resident #78] cannot speak but responds to yes/no questions. The Roommate (Resident #38) also stated that [Resident #78]'s primary language is not English. This surveyor observed there were no communication aids in the room and no information about a language…

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 observations, Resident interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide necessary services to maintain grooming and personal hygiene for 3 Residents (Resident #38, Resident #34 and Resident #35) in a sample size of 60 Residents. The findings included: 1. For Resident #38, the facility staff to provide showers for her in August and September 2022 which was her personal preference. On 09/13/2022, the facility staff provided a copy of their policy entitled, Routine Resident Care. In Section (3)(a)(b)(i)(1) documented, Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse. (b) Routine care by a nursing assistant includes but is not limited to the following (i) assisting or provides for personal care (1) bathing. On 09/20/2022 at 11:30 A.M., Resident #38 was interviewed. When asked about receiving assistance with bathing, Resident #38 stated she gets bed baths but would really prefer a shower. Resident #38…

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 documentation review, the facility staff failed to ensure an environment free from accident hazards for one Resident (Resident #27) of 60 residents in the survey sample. The findings included: For Resident #27 the facility staff failed to supervise a confused known fall risk resident who recently suffered facial fractures as the result of an unwitnessed fall. The Resident was in his room in a geri (reclining) chair with the bedside curtain closed obscuring the Resident from view, no fall mats in place, and his helmet off. Resident #27 was admitted to the facility on [DATE] with diagnoses including; Covid-19, Rhabdomyolysis, Dementia, psychotic disturbance, anxiety, and history of multiple falls. The Resident required total dependence on staff for all activities of daily living. The Resident was able to stand independently. On 9-15-22 at 4:00 p.m. Resident #27 was observed by 2 surveyors alone in his room. The privacy curtain had been…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure services for care of a suprapubic catheter consistent with professional standards of care, the comprehensive care plan and Resident preferences for 1 Resident (#88) in a survey sample of 60 Residents. The findings included: For Resident #88 the facility staff failed to ensure proper and timely care for a suprapubic catheter (a suprapubic catheter is a tube inserted into the bladder through an incision in the abdomen, to drain urine into a collection bag.) On 9/12/22 at 12:00 PM and again on the morning of 9/13/22 Resident # 88 was observed with this suprapubic catheter collection bag hanging from the back of his wheel chair near the handle above his waist height. On 9/13/22 at approximately 10 AM an interview was conducted with Resident #88 and he was asked if it was usual practice for the staff to hang his collection bag for his catheter on the wheel chair handle and he stated that it was. On 9/13/22 at approximately 11:00 AM, during a Resident Council meeting,…

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 documentation review, the facility staff failed to provide comprehensive behavioral health services for one Resident (Resident #68) in a sample of 60 Residents. The findings included: Resident #68 was not receiving supportive therapy as recommended by the Mental Health Nurse Practitioner. Resident #68's clinical record was reviewed. According to Resident #68's quarterly Minimum Data Set with an Assessment Reference Date of 08/02/2022, Resident #68's medical diagnoses included but were not limited to Bipolar disorder. A nurse's note dated 06/01/2022 at 4:53 P.M. documented, Note Text: Writer was called to resident [#68] room by activity staff that the resident pushed his roommate's [Resident #70] face. Immediately writer went to the resident's room and the activity staff said she came to the resident's room to do an assessment on the resident's roommate at about 10:20 am. While the activity staff was conducting her UDA assessment on the resident'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.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide routine and emergency drugs to meet the needs of residents and failed to provide safekeeping of hard scripts for controlled drugs, for 2 Residents (Resident #86 and 68) in a survey sample of 60 Residents. The findings included: 1. For Resident #86 the facility staff failed to obtain ordered narcotic pain medication, causing the Resident to wait 3 days for ordered pain medicine. On 9/12/22 a review of Resident #86's clinical record revealed she had pain medication ordered as follows: Oxycodone 5 mg [milligrams] / 5 ml [milliliters 5 ml via PEG-Tube every 8 hours for pain beginning on admission 8/13/22. The following are excerpts from Resident #86's nursing progress notes: 9/2/22 3:09 PM-eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5 MG/5ML Give 5 ml via PEG-Tube every 8 hours for pain Pharmacy stated resident needs script . 9/8/2022 4:24 PM eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5…

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 record review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 1 Resident was free from unnecessary medications (Resident #101) in a survey sample of 33 Residents. The findings included: Resident #101 received Atenolol anti-hypertensive medication, Dexamethasone anti-inflammatory steroid medication, and Metronidazole antibiotic medication against physician ordered parameters. Resident #101 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; hypertension. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. Review of the physician's orders and Medication Administration Record (MAR), in the clinical record, revealed the following; 1. Ordered 7-10-22 - Atenolol for high blood pressure - 100 MG (milligrams) in the morning, hold for systolic blood pressure (SBP) less than 110. The Atenolol unnecessary medication 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, interview, clinical record review and facility documentation the facility staff failed ensure the nutritional needs and special diet orders 1 Resident (#86) in a survey sample of 60 Residents. The findings included: For Resident #86 the facility staff failed to obtain orders for the tube feeding formula (i.e. Jevity 1.2); the facility staff only received orders for the tube feeding flushes on admission. On 9/12/22 at approximately 4:00 PM the following observation was made: Tube feed Jevity 1.2 was hanging and infusing via enteral pump at 45 ml per hour. The 60 ml piston syringe was not dated and the tube feeding was not dated nor was the tubing. On 9/13/22 a review of the clinical record revealed that Resident # 86 was admitted on [DATE] with diagnoses that included dysphasia, failure to thrive, and a peg tube had been inserted at the hospital. Per signed admission orders the Resident had orders for flushing the G Tube both PRN (as needed) and routine flushing before and after feeding 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.

Based on staff interview and facility documentation review, the facility staff failed to have an accurate system to track the immunization status, provide COVID-19 immunizations, and provide COVID-19 booster immunizations for two employees (Employee GG and CNA-X) in a survey sample of 6 employees reviewed. The findings included: On 9/12/2022, the facility staff provided the survey team with a copy of the staff vaccination matrix. On 9/13/2022 at 10:30 a.m., review of the matrix revealed five employees listed as not vaccinated. There were 19 employees listed as not Boosted. On 9/13/2022 at 2:45 p.m., an interview was conducted with the Infection Preventionist who stated all of the employees were fully vaccinated and that there were no employees with an exemption. When asked about the 5 employees listed as unvaccinated, the Infection Preventionist stated the Administrator must have scanned the wrong documents. She stated she updates the forms every day and that there were multiple copies. The Infection Preventionist stated she would send the correct copy of the vaccination matrix. She…

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 and facility documentation review, the facility staff failed to provide a functional bedside table for one Resident (Resident #35) in a survey sample of 60 Residents. The findings included: On 9/14/22 at 9:30 AM, Surveyor B visited Resident #35 in his room. Surveyor B observed the bedside table, which had 3 drawers. The top drawer had no handle and the second drawer the handle was broken and attached on only one side. Resident #35 was asked how he accesses items in the top drawer and he said he couldn't. On 9/14/22 at approximately 9:45 AM, an interview was conducted with Employee F, the Maintenance Director. Employee F described the process by which he is made aware of items needing repair as an electronic system that any employee is able to enter maintenance requests into. Employee F provided Surveyor B with a listing of maintenance work orders that had not been completed and Resident #35's bedside table was not noted on the list. Employee F accompanied Surveyor B to the room of Resident #35. Employee F made an observation…

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 documentation review and clinical record review, the facility staff failed to follow professional standards for three Residents (Resident #86, #107, #2) in a survey sample of 43 Residents. The findings included: 1. For Resident #86 the facility staff failed to following nursing standard of practice by failure to observe a Resident (Resident #86) take medication, and left medication at the bedside. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident #86 was coded as having had a BIMS (brief interview for mental status) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to maintain respect and dignity for one resident (Resident #261) in a sample size of 43 residents. The findings included: 1. For Resident # 261, the facility staff failed to ensure a dignified experience during an admission skin assessment. Resident # 261 was woken up between 1:00 am and 1:30 am for a skin assessment. Resident # 261 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anxiety Disorder, Insomnia, Gastroesophageal Reflux Disease, Wedge Compression Fracture of first Lumbar Vertebra, Low Back Pain, muscle weakness and lack of coordination. Resident #261 did not have a Minimum Data Set (MDS) because she had only recently been admitted . Resident # 261 stayed in the facility for 3 days and was discharged on 6/25/2018. Review of the clinical record was conducted on 11/6/2019 at 2:30 PM. Review of a Facility Reported Incident (FRI) dated 6/25/2018 revealed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to assess a Resident to determine if they were safe to administer medications, before leaving medications at the bedside for one Resident (Resident #86) in a survey of 43 Residents. The findings included: For Resident #86 the facility staff left medications at the bedside for the Resident when the Resident had not been assessed or determined to be clinically appropriate to self administer medications. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to provide accommodations to call for assistance for 1 resident (Resident #41) in a survey sample of 43 residents. The findings include: For Resident #41, the callbell was located beyond his reach, making it unavailable for him to call for assistance. Resident #41, an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to muscle weakness, anemia, and contracture of the right knee. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/2019 was coded as an annual assessment. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 9 out of possible 15, indicating moderately impaired cognition. He was coded requiring extensive assistance for all of his ADL's (activities of daily living). On 11/5/19 at approximately 10:15 am during initial tour, Resident #41 was observed lying…

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 documentation review, the facility staff failed to: 1) provide notification of non-coverage in a timely fashion for one of three sampled residents (Resident #315 ) and 2) complete an Advanced Beneficiary Notice (ABN) for one of three sampled residents (Resident #12 ) The findings included: A review of Resident #315's Notice to Medicare Provider Non-Coverage (NOMNC) while on survey revealed that the effective date coverage would end was 07/17/2019 and Resident #315 signed and dated the NOMNC 07/16/2019. A review of the ABN for Resident #12 revealed that although it was signed and dated by the responsible party, an option pertaining to the care and cost was not selected. On 11/08/19 at 09:33 AM, an interview with Employee P, the social worker, was conducted. When asked about the process for issuing NOMNCs and ABNs, Employee P stated that the NOMNC and ABN should be signed 48 to 72 hours, mostly 72 hours in advance. When asked why it was important to have more than a one day notice, Employee P stated To have enough notice…

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 and staff interview facility documentation and clinical record review the facility staff failed to develop and implement a comprehensive care plan for 3 Residents (#73, 75, #66) in a survey sample of 43 Residents. The findings included: 1. For Resident #73 the facility staff failed to care plan scheduled nebulizer treatments and changing of tubing for nebulizer. Resident #73, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Chronic Respiratory Failure, COPD (chronic obstructive pulmonary disease), Trach, G-Tube, dysphagia, dementia, major depressive disorder, psychosis, anxiety disorder, and seizures. Resident # 73's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] codes the Resident as being extensive assist with 2 person physical assistance for bed mobility, transfers and dressing and total assistance with physical assistance of 1 for bathing, feeding, and mobility. Resident #73 uses a wheel chair…

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, clinical record review, and facility documentation review, the facility staff failed, for one resident (Resident # 79) in the survey sample of 43 residents, to review and revise the plan of care. The Findings included: 1. For Resident #79, the facility staff failed to review and revise the care plan after the development of unstageable pressure ulcers on his left ankle and left heel. Resident #79 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #79's diagnoses included Cerebral Infarction, Generalized Muscle Weakness, Dementia, Major Depressive Disorder Hypertension, and Congestive Heart Failure. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 10/11/19 was reviewed. Resident #79 had a Brief Interview of Mental Status Score of 12, indicating mildly impaired cognition. He was coded as requiring the extensive physical assistance of at least two people for bed mobility, 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 facility documentation review and clinical record review the facility staff failed to ensure residents are free of significant medication errors for one Resident (Resident #107) in a survey sample of 43 Residents. The findings include: 1a. For Resident #107 the facility staff failed to administer insulin as ordered by the physician on 6 of 16 scheduled doses. Resident #107, was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to: sepsis, osteomyelitis of vertebra sacral and sacrococcygeal region, pressure ulcer sacral region stage 4, pressure ulcer of right upper back stage 4, unspecified dementia without behavioral disturbance, type 2 diabetes mellitus without complications, and hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side. Resident #107's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/26/19 was coded as an admission assessment. Resident #107 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 Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to maintain an accurate clinical record for one Resident (Resident #86) in a survey sample of 43 Residents. The findings included: For Resident #86 the facility staff documented administration of medication which had been left at the bedside and was not taken. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident #86 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated intact cognitive skills. Resident #86 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.

Based on observation, resident interview, and staff interview, the facility staff failed to maintain shower equipment and the shower room in a sanitary manner to prevent the spread of infection in 1 of 4 shower rooms. The findings included: On 11/6/19 at approximately 2:18 PM during the group Resident Council meeting, it was shared that the shower room on the 2nd floor was dirty. The Resident council reported specifically that the floor drain was clogged and the shower bench was dirty and discolored. On 11/6/19 at 2:47 PM the bathing suite on the 2nd floor was observed and the following was noted: * the shower drain was obstructed with a gray matter covering 1/2 of the drain holes in the floor drain of the shower stall. * the shower bench back was observed and revealed heavy discoloration of pink and black substances throughout the entire back. On 11/6/19 at approximately 3:15 PM, Employee N, the housekeeping supervisor accompanied the surveyor to the 2nd floor bathing suite. When asked about the process for cleaning, the housekeeping supervisor stated, we do the toilet and floors,…

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.