Amelia Rehabilitation And Healthcare Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a potential need to alter treatment for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to notify the physician when the resident's medication Gemtesa (1) was not available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting 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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, #20, #5, and #62. The findings include: 1. For Resident #12, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 1/20/23 for The resident has alteration or potential for alteration in renal…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor residents weights per physician's orders for six of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, and #5. The findings include: 1. For Resident #12, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight weekly. Further review of the clinical record revealed that there were no weights obtained during the following weeks (below dates run a Sunday through Saturday time frame): Week of May 14 through May 20, 2023. Week of May 21 through May 27, 2023. Week of May 28 through June 3, 2023. Week of June 4 through June 10, 2023. Week of June 18 through June 24, 2023. Week of July 2 through July 8, 2023. Week of July 9 through July 15, 2023. Week of July 16 through July 22, 2023. Week of July 23 through July 29, 2023. Week of July 30 through August 5, 2023. Week of August 6 through August 12, 2023. Week of August 27…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence communication with the dialysis center for one of one residents receiving dialysis services, Resident #82. The findings include: For Resident #82, the facility staff failed to ensure there was communication with the dialysis center each visit. The physician orders dated, 8/18/2023, documented, Hemodialysis at (name of dialysis center) M, W, F (Monday, Wednesday, Friday) and time to be picked up 0900 (9:00 a.m.). Review of the clinical record revealed the facility staff did not have the communication form, or the forms were missing communication information from either party (nursing facility or dialysis center) as follows: 9/4/2023 - no communication form 9/6/2023 - no communication documented from dialysis center on form. 9/8/2023 - no communication documented from dialysis center on form. 9/11/2023 - no communication documented from dialysis center on form. 9/13/2023 through 9/29/2023 - there was no communication forms. 10/13/2023 - no…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to ensure the medication Gemtesa (1) was available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented,…

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

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 11/13/23 at 11:30 AM, the kitchen was inspected with OSM #5 (Other Staff Member) the Director of Dietary Services. The following items were noted: 1. A box of individual packages of animal crackers was on the floor in dry storage area. The box was open. 2. A baseball cap was on top of a box of thickened apple juice. 3. A large storage bin on wheels of thickener powder was left open with the bag of thickener also left open and exposed. There was no staff at the bin utilizing it. This bin was near the kitchen sink. 4. The stand mixer, which was clean and ready for use, and was covered, was stored next to meat slicer. The meat slicer was recently used for this day's lunch meal that was being prepared. It had been used to slice roast beef. A piece of roast beef (identified as such by OSM #5) was noted inside the mixing bowl of the stand mixer. On 11/14/23 at 2:47 PM, 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.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 42 residents in the survey sample, Resident #301 and Resident #45. The findings include: 1. For Resident #301, the facility staff failed to evidence complete and accurate documentation for incontinence care, bathing, and weights. A review of the ADL (activities of daily living) document for September 2023 and October 2023 revealed September Bathing documentation missing for three of twelve shifts: 9/21, 9/22, and 9/29/23; October Bathing documentation missing from five of nine shifts: 10/2, 10/2, 10/3, 10/4, and 10/5/23. A review of the ADL document for September 2023 revealed September incontinence documentation missing from three of twelve-day shifts 9/21, 9/22 and 9/29/23; two of twelve evening shifts 9/29 and 9/30/23, and four of twelve night shifts 9/22, 9/23, 9/24, and 9/26/23. A review of the ADL document for October 2023 revealed October incontinence documentation missing from five of nine-day…

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, facility document review, and clinical record review, the facility staff failed to provide a dignified dining experience for one of 42 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to provide lunch in a dignified manner on 11/13/23. R16 was served a meal on a Styrofoam plate and given plastic utensils. A review of R16's clinical record failed to reveal documentation that R16 should be served meals on a Styrofoam plate or given plastic utensils (the resident was not on isolation and did not present with dangerous behaviors). On 11/13/23 at 1:20 p.m., R16 was observed sitting up in bed and eating lunch. The resident's meal was on a Styrofoam plate and the resident was eating with plastic utensils. On 11/14/23 at 2:50 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary director). OSM #5 stated that when she began employment 45 days ago, a lot of plates did not match, and she did not have enough plates. OSM #5 stated she requested four cases (each…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence the required clinical documents were sent to the hospital for a facility-initiated transfer for three of 42 residents in the survey sample, Residents #82, #32, and #5. The findings include: 1. For Resident #82 (R82), the facility staff failed to evidence what documents were sent to the hospital with the resident on 8/10/2023. The nurse's notes 8/10/2024 at 8:10 p.m. documented in part, I was called to resident room by assigned CNA (certified nursing assistant) of this resident. When I arrived in the resident room, he was noted laying on this left side, on the L (left) side of his bed, noted his left arm under him. Resident was noted with his left side of his face to the floor. Resident was wearing his eyeglasses at the time of the fall; Resident eyeglasses was noted broken on the floor beside him. When assessed, Resident was noted with swelling to his L. eye/L side of face, (2) Lacerations to L. Side temple/hair line area, L. eye red and swollen,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the State Long-Term Care Ombudsman of a facility initiated transfer for one of 42 residents in the survey sample, Resident #82. The findings include: For Resident #82 (R82), the facility staff failed to notify the ombudsman of a facility-initiated transfer on 8/10/2023. The nurse's notes 8/10/2024 at 8:10 p.m. documented in part, .Resident was noted with his left side of his face to the floor .When assessed, Resident was noted with swelling to his L. eye/L side of face, (2) Lacerations to L. Side temple/hair line area, L. eye red and swollen, C/O (complained of) L. shoulder/arm pain, Laceration to L. side of mouth .On call contacted and gave verbal order to send (R82) to hospital E.R (emergency room) for further evaluation and treatment. (Name of town) EMS (emergency medical services) contacted and transported (R82) to (Name of Hospital), R.P. (responsible party) made aware (name…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to accurately code the discharge MDS assessment with the ARD (assessment reference date) of 10/25/2023, with the correct discharge location. R98's most recent MDS, a discharge assessment with an ARD of 10/25/2023, coded R98 as having a planned discharge on [DATE] to a short term general hospital with a return to the facility not anticipated. The progress notes documented in part, - 10/17/2023 14:14 (2:14 p.m.) Note Text : SS (social services) and DT (director of therapy) spoke with Pt (patient) and Son about LCD (last covered day) of 10/24/2023 with a D/C (discharge) date of 10/25/2023. Pt and Son agreed, Son stated he would pick up Pt to take her home SS will set up home health PT has no preference. SS has sent referral 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 observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate respiratory care and services for three of 42 residents in the survey sample, Residents #77, #71, and #62. The findings include: 1. For Resident #77 (R77), the facility staff failed to store the resident's incentive spirometer (1) in a sanitary manner. A review of R77's clinical record revealed a physician's order dated 10/24/23 for an incentive spirometer. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 11/13/23 at 1:04 p.m., R77 was observed lying in bed. An uncovered incentive spirometer with the mouthpiece exposed to air was observed on the resident's overbed table. R77 stated the facility staff had not offered a cover for the incentive spirometer. On 11/14/23 at 8:22 a.m., the incentive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary psychotropic medications for one of 42 residents in the survey sample, Resident #71. The findings include: For Resident #71 (R71), the facility staff failed to attempt GDRs (gradual dose reductions) for the resident's use of Seroquel (1) and Cymbalta (2). R71 was admitted to the facility on [DATE]. A review of R71's clinical record revealed the following physician's orders: 9/21/22- Seroquel 25 mg (milligrams)- two tablets every morning and at bedtime for depression. 11/21/22- Seroquel 25 mg- two tablets every morning and at bedtime for dementia with behavioral disturbance. 5/10/23- Seroquel 25 mg- two tablets in the morning and three tablets at bedtime for hallucinations. 9/21/22- Cymbalta 30 mg- one capsule in the evening for depression. 11/21/22- Cymbalta 60 mg- one capsule every morning for major depression disorder. 12/14/22- Cymbalta 60 mg in the morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control procedures during medication administration for two of four residents in the survey sample, Residents #60 and #88. The findings include: 1. For Resident #60 (R60), the facility staff failed to prepare medications in a sanitary manner during medication administration observation on 11/14/2023. On 11/14/2023 at 8:35 a.m., an observation was made of LPN (licensed practical nurse) #8 preparing medications for R60. LPN #8 was observed to prepare the following medications in a medication cup prior to taking them into R60's room for administration : - Norvasc 2.5mg (milligram) 1 tablet. - Buspar 15mg 1 tablet. - Celexa 40mg 1 tablet. - Lasix 20mg 1 tablet. - Risperidone 0.5mg 1 tablet. LPN #8 was observed to use her ungloved fingers to remove the Buspar 15mg, Celexa 40mg, Lasix 20mg and Risperidone 0.5mg tablets from their packaging and place them into…

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

Based on observation, staff interview, and facility document review, the facility staff failed to conduct regular bed inspections for two of 42 residents in the survey sample, Residents #16 and #32. The findings include: 1. For Resident #16 (R16), the facility staff failed to conduct a regular bed inspection. A copy of the bed inspections was requesting during the entrance conference on 11/13/2023 at 11:20 a.m. On 11/13/23 at 1:20 p.m. and 11/14/23 at 8:28 a.m., R16 was observed in bed. On 11/15/23 at 9:17 a.m., an interview was conducted with OSM (other staff member) #6, the director of maintenance. OSM #6 stated the maintenance department has not completed bed inspections since before the pandemic. On 11/15/23 at 9:38 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Bed Safety documented, To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to implement the care plan to monitor the urine output, on multiple days in September 2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/9/23, R1 was coded as having an indwelling urinary catheter. A review of R1's physician's orders revealed the following order dated 9/4/23: Foley catheter (1) 16 fr (French)/10 cc (cubic centimeters) monitor output q shift (every shift). A review of R1's clinical record revealed documentation of urinary out put on 9/7/23 at 3:26 p.m., 9/8/23 at 12:48 p.m., and 9/12/23 at 4:26 p.m. Other than these three entries in the nurses' notes, a review of R1's September 2023 MAR (medication administration record), TAR (treatment administration record), and nurses' notes revealed no evidence of urinary output documentation. A review 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.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor a resident's urine output as ordered by the physician for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to monitor the urine output on multiple days in September 2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/9/23, Resident #1 as having an indwelling urinary catheter. A review of R1's physician's orders revealed the following order dated 9/4/23: Foley catheter (1) 16 fr (French)/10 cc (cubic centimeters) monitor output q shift (every shift). A review of R1's clinical record revealed documentation of urinary out put on 9/7/23 at 3:26 p.m., 9/8/23 at 12:48 p.m., and 9/12/23 at 4:26 p.m. Other than these three entries in the nurses' notes, a review of R1's September 2023 MAR (medication administration record), TAR (treatment administration record), and nurses' notes revealed no evidence of urinary output documentation. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence written documentation to the Resident or RP (responsible party) upon transfer for six out of 36 residents in the survey sample who were transferred to the hospital; Residents #18, #71, #69, #81, #17 and #36. The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included but were not limited to: cerebrovascular accident with right hemiparesis and diabetes mellitus. Resident #18's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 1/21/22, coded the resident as scoring 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 11/30/21 at 4:20 PM, revealed the following, Resident aware of need for transfer, reason, RP aware of new order for transfer and reason. RP aware of bed hold policy 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 clinical record review and staff interview, the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 5 of 36 residents in the survey sample, Residents #11, #90, #81, #20, and #64. The findings include: 1. Resident #11 (R11) was admitted to the facility with diagnoses that included but were not limited to traumatic brain injury, post traumatic stress disorder, and schizoaffective disorder. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/10/2022, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Review of R11's clinical record failed to evidence a level 1 PASRR. On 4/6/2022 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for R11. On 4/6/2022 at 1:21 p.m., ASM #1 stated that they did not have a PASRR…

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, resident representative interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide adequate bathing for 2 of 36 residents in the survey sample, Residents #57 and #29. The findings include: 1. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/29/22, Resident #57 (R57) scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Section G coded R57 as requiring one person physical assistance with bathing. R57's comprehensive care plan dated 4/20/21 documented, The resident has an ADL (activities of daily living) Performance Deficit .Provide the resident with a sponge bath when a full bath or shower cannot be tolerated. On 4/5/22 at 2:06 p.m., a telephone interview was conducted with R57's representative. The representative stated sometimes staff does not provide R57 with regular showers like they should…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and service for a complete dialysis program for one of 36 residents in the survey sample, Resident # 59 (R59). The facility staff failed to provide dialysis communication forms for R59 and the dialysis center on 03/02/2022, 03/04/2022, 03/07/2022, 03/09/2022, 03/11/2022, 03/14/2022, 03/16/2022, 03/18/2022 and on 03/21/2022. The findings include: R59 was admitted to the facility with diagnoses included but were not limited to: end stage renal disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/24/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R59 for Dialysis while a resident. The physician's order for R59 documented in part, (Name of Dialysis Center with Name of Physician and Phone Number) on MON-WED-FRI…

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

Based on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens, and on one nursing unit. The findings include: On 04/05/2022 at approximately 10:50 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) # 2, a cook. Observation of the meat slicer located in the facility's kitchen on a food preparation table was conducted with OSM # 2. When asked if the meat slicer was cleaned and ready for use OSM # 2 stated yes. An observation of the meat slicer revealed food debris on the surface of the base under the gauge plate and on the knife cover. When asked if the mixer was clean OSM # 2 stated no. When asked how often the meat slicer is cleaned OSM # 2 stated that it should be cleaned after every use. An observation of the inside of the facility's walk-in refrigerator revealed a three quart container with approximately 12 slices of ham with a use-by-date of 04/01/2022, available for use. When asked if the ham should be available for use OSM # 2…

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 provide a homelike environment for one of 36 residents in the survey sample, Resident # 64. The facility staff failed to clean a black substance on the floor around the base of the sink and the wall behind and to the right of the sink and failed to repair a hole in the wall behind R64's head-of the-bed. The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/04/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. On 04/05/22 at approximately 1:51 p.m., R64 was interviewed and expressed concerns about a black substance around the base of the pedestal sink and the base of the wall behind and to the right of the sink. The pedestal sink was and the base of the wall behind and to the right of the sink was observed and confirmed R64's statement. R64 also expressed concerns about about insects in the corner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 1 of 36 residents in the survey sample, Resident #191. The facility staff failed to administer oxygen to Resident #191 (R191) per the physician prescribed rate of two liters per minute. The findings include: R191's diagnoses included but were not limited to shortness of breath. R191's admission minimum data set assessment was not complete. R191's admission nursing assessment dated [DATE] documented the resident was alert but not oriented to person, place, time or situation. A review of R191's clinical record revealed a baseline care plan dated 3/28/22 that documented, Pulmonary management. Provide treatments per orders . R191's April 2022 physician's order sheet documented a physician's order dated 4/1/22 for oxygen at two liters per minute as needed for shortness of breath or an oxygen saturation level below 90%. On 4/5/22 at 11:45 a.m., 4/5/22 at…

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 facility documentation review, it was determined that the facility staff failed to serve food in a dignified manner in two of one facility dining rooms, (main dinning room); and for three of 45 sampled residents, (Resident #501, #39 and #50). 1. During a meal observation in the main facility dining room on 4/2/19 residents were observed being served and eating the lunch meal on trays cafeteria style and not in a homelike dining manner. 2. The facility staff failed to ensure a dignified dining experience during the lunch meal on 4/2/19. Resident #501 was observed seated at a table waiting approximately eleven minutes for her lunch meal to be served, while her tablemate's and other residents were eating their lunch meal. 3. During a meal observation in the assisted dining room on 4/2/19, Resident #39, was not provided her meal and fed by CNA #7 (Certified Nursing Assistant) until 12:55 p.m., approximately 15 minutes after her tablemate began eating his meal. 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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the abuse policies for reporting allegations of abuse for four of 47 residents in the survey sample, Residents #63, #146, #53 and #16. 1. The facility staff failed to implement their policies for reporting Resident #63's allegation of abuse within 2 hours to the state agency and other required agencies. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. The facility staff failed to implement their abuse policies and procedures for a resident-to-resident incident between Resident #146 and Resident #53. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for the incident but failed to conduct an investigation and failed to submit a final report to the State Agency within five working days. 3. The facility staff failed to implement the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report allegations of abuse immediately, but not later than 2 hours and/or failed to report to the state agency the final findings of an investigation for four residents in the survey sample, Residents #63, #146, #16, #53 and #2. 1. The facility staff failed to immediately (or within 2 hours) report, Resident #63's allegation of abuse to the state agency and to other officials in accordance with State law through established procedures. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. The facility staff submitted a FRI (facility reported incident) on 10/26/19 for a resident-to-resident incident between Resident #146 and Resident #53, but failed to complete an investigation and report the results to the State Agency and to other officials within five working days.…

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 6. The facility staff failed to evidence that Resident # 36's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 12/31/18. Resident # 36 was admitted to the facility on [DATE] with the most recent readmission date of 01/03/19. His diagnoses included but were not limited to acute bronchitis (1), hypertension (2), and umbilical (belly button area) hernia (3). Resident # 36's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 02/01/19. The Brief Interview for Mental Status (BIMS) coded Resident # 36 as scoring a 11 on BIMS of a score of 0 - 15, 11 - indicating moderately impaired for making daily decisions. A review of Resident # 36's clinical record was conducted on 04/04/19. A nurse's note dated 1/03/19 at 5:29 p.m., documented Resident # 36 had been sent to the hospital for surgical hernia repair. The nurse's note did not document if comprehensive care plan goals were sent along with the resident to 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, staff interview and facility document review, it was determined that the facility staff failed to ensure expired medications were not available for use in two of two medication carts, (South Back Unit medication cart and the facility's North Front Unit medication cart). The facility staff failed to ensure four expired inhalers, three Advairs (1) and one Flovent (2) were not available for use on two of two medication carts. The findings include: On 04/05/19 at approximately 2:00 p.m., an observation of the facility's South Back Unit medication cart was conducted with LPN (licensed practical nurse) # 8. Observation of the bottom drawer of the medication cart revealed the following: Advair 100/50 mcg (microgram) with an open date documented on the inhaler of 12/16/18. One Advair 500/50 mcg, open without an open date documented on the Advair box or inhaler and Flovent 100 mcg open without an open date documented on the Flovent box or inhaler. On 04/05/19 at approximately 2:20 p.m., 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.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one facility kitchen. 1. An unopened three pound bag of an unlabeled item reported to be 'ginger liver' by OSM (other staff member) #1 was observed stored in the freezer without manufacturer expiration date, or use-by-date and no labeling of the contents on the bag. 2. The facility staff failed to maintain the food mixer in a sanitary manner in the facility kitchen. The findings include: On 04/02/19 at approximately 11:21 a.m., observation of the kitchen was conducted with OSM (other staff member) #1, dietary manager. Observation of the walk in freezer revealed an unopened three-pound bag of frozen item. OSM #1 stated the bag contained ginger liver. The ginger liver bag was missing any indication of when it was received in the facility, when it was stored in the freezer, the manufacturer expiration date, the use-by-date, and the name of the item in the bag. When OSM # 1 was asked how he knew when the item was put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure accommodation of resident needs and preferences for one of 47 residents in the survey sample, Resident #64. The air mattress box located on the footboard of Resident #64's prevented Resident #64 from independently accessing her nightstand and bathroom. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, anxiety disorder, peripheral vascular disease [any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart (1)], and depression. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 3/2/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident 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 resident interview, staff interview and facility document review it was determined that the facility staff failed to provide prompt delivery of the resident's postal mail and the facility staff failed to protect the resident's private information for two of six residents in the medication observation, Resident #73 and Resident #23. 1. The facility staff failed to maintain postal mail delivery for the residents on Saturdays. During the Group Resident meeting, residents stated they did not receive mail on Saturdays. 2. The facility staff failed to protect Resident #73's private information during medication administration. LPN (licensed practical nurse) #1 left a box of medication on the top of the medication cart unattended with Resident #73's name on the label, visible to anyone who may have passed by the medication cart. 3. The facility staff failed to protect Resident #23's private information during medication administration. LPN #2 was observed leaving the computer screen on the medication cart open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review ad clinical record review, it was determined the facility staff failed investigate an allegation of abuse and failed to protect residents during an investigation for three of 47 residents in the survey sample, Residents #63, #146 and #53. 1. The facility staff failed to ensure Resident #63 and other residents were protected during the investigation of Resident #63's allegation of abuse. The employee, LPN (licensed practical nurse) #11 named in the allegation was not suspend, and worked on 12/31/18, during the investigation. 2. The facility staff failed to investigate an allegation of abuse between Resident #146 and Resident #53. The findings include: 1. The facility staff failed to ensure Resident #63 and other residents were protected during the investigation of Resident #63's allegation of abuse. The employee, LPN (licensed practical nurse) #11 named in the allegation was not suspend, and worked on 12/31/18, during the investigation. Resident #63 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification to the ombudsman of a facility initiated transfer for one of 47 residents in the survey sample, Residents # 3. The facility staff failed to notify the ombudsman when Resident # 3 was transferred to the hospital on [DATE]. The findings include: Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), bipolar disorder (2), and spondylolysis (3). Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The nurse's Progress Notes, dated 12/21/2018 for Resident # 3 documented, 3:01 PM (p.m.) Staff notified that resident found in bedroom around 230pm (2:30 p.m.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident # 34. The facility staff failed to accurately code Resident # 34's 14-Day MDS (minimum data set), assessment with an ARD (assessment reference date) of 03/23/19, for a pressure ulcer. The findings include: Resident # 34 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), diabetes mellitus (2), and major depressive disorder (3). Resident # 34's most recent MDS (minimum data set), a 14-day assessment with an ARD (assessment reference date) of 03/23/19, coded Resident # 34 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 34 was coded as requiring extensive assistance of one staff member for activities of daily living…

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 facility record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for three of 47 residents in the survey sample, Residents #2, #60, #45, and #83. 1. The facility staff failed to implement the comprehensive care plan for a physician ordered treatment for Resident #60. 2. The facility staff failed to implement the care plan for when a resident has behaviors for Resident #45. On 12/8/18 the facility staff only attempted the intervention of redirection and failed to implement other intervention identified on the care plan for her behaviors 3. The facility staff failed to implement Resident # 83's comprehensive care plan for the administration of oxygen to the resident as ordered. The findings include: 1. The facility staff failed to implement the comprehensive care plan for a physician ordered treatment for Resident #60. Resident #60 was admitted to the facility on [DATE] with diagnoses that included but were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for one of 47 residents in the survey sample, Resident # 3. The facility staff failed to update Resident # 3's comprehensive care plan concerning a fall on 03/08/19. The findings include: The facility staff failed to update Resident # 3's comprehensive care plan concerning a fall on 03/08/19. Resident # 3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure (1), bipolar disorder (2), and spondylolysis (3). Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The facility's Progress Notes dated 03/08/2019 for Resident # 3 documented, Resident was found on the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #60) of 47 sampled residents, received the care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to administer a treatment to Resident #60 per the physician orders. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, and peripheral vascular disease [any abnormal condition, including atherosclerosis, affecting blood vessels outside the heart (1)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/1/19, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating she is capable of making daily cognitive decisions. Resident #60 was coded as requiring limited to extensive assistance of one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote the healing pressure ulcers for one of 47 residents in the survey sample, Resident #83. The facility staff failed to ensure weekly measurements were completed to assess and monitor the healing of Resident #83's multiple pressure ulcers. The findings include: The facility staff failed to complete weekly assessments including measurements and wound description to determine wound healing or decline, to evaluate / monitor the healing of Resident #83's sore. Resident # 83 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: malignant neoplasm (1) of brain (2), epilepsy (3), and chronic obstructive pulmonary disease (4). Resident # 83's most recent MDS (minimum data set), a 14-day assessment with an ARD (assessment reference date)…

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 policies review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 47 residents in the survey sample, Resident # 83. The facility staff failed to administer Resident # 83's oxygen according to the physician's orders. The findings include: Resident # 83 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: pneumonia (1), chronic obstructive pulmonary disease (2), and acute respiratory failure (3) with hypoxia (4). Resident # 83's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/27/2019, coded Resident # 83 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being no cognitive impairment for making daily decisions. Resident # 83 was coded as requiring extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #45) of 47 sampled residents were free of unnecessary psychotropic medications. The facility staff restarted an antipsychotic medication without proper indications for Resident #45. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder, dementia, and high blood pressure. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 2/15/19, coded the resident as scoring a 6 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. The resident was coded as having disorganized thinking and physical behavior directed towards others on one-three days of the look back period. Resident #45 was coded as requiring extensive assistance of one or more 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 observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow infection control practices for one of 47 residents in the survey sample and for one of six residents in the medication administration observation, (Resident #23), and in one of one facility dining rooms, (main dining room). 1. The facility staff failed to follow infection control practices during a wound are observation for Resident # 34. 2. The facility staff popped Resident #23's pills into a gloved hand that had just touched the medication cart and then administered the medication to Resident #23. 3. The facility staff failed to serve food to the residents in a sanitary manner during a dining room observation. Staff were observed touching the food surface of plates that were then served to residents. The findings include: 1. The facility staff failed to follow infection control practices during a wound care observation for Resident # 34. Resident # 34 was admitted…

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.