Annandale Healthcare Center

Based on observation, staff interview, and facility document review, the facility staff failed to promote dignity for two of 63 residents in the survey sample, Residents #142 and #162. The findings include: 1. For Resident #142 (R142), the facility staff failed to serve lunch in a dignified manner. R142's roommate was served lunch on 10/2/24 at 1:20 p.m. and R142 was not served lunch until ten minutes later. On 10/2/24 at 1:20 p.m., R142 and the resident's roommate was observed in their bedroom. At this time, R142's roommate was served lunch. R142 was not served and fed by a CNA (certified nursing assistant) until 1:30 p.m. (ten minutes later). On 10/3/24 at 3:21 p.m., an interview was conducted with CNA #2. CNA #2 stated she does not serve and feed residents who require assistance until residents who eat independently are served. CNA #2 stated that if one resident in a room is eating and his roommate requires assistance, she will ask other CNAs to finish passing meal trays so she can feed the resident who requires assistance. CNA #2 stated a resident who requires assistance 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 observation, resident interview, staff interview and facility document review it was determined the facility staff failed to assess a resident for self-administration of over-the-counter eye drops that were on the over the bed table, for one of 63 residents in the survey sample, Resident #65. The findings include: For Resident #65 (R65), over the counter Opcon A eye drops were found on her over the bed table, there was no evidence of an assessment for self-administration of medications. Observation was made on 9/30/24 at approximately 6:35 p.m. of Opcon A eye drops, an over-the-counter medication, was observed on the over the bed table. The bottle of eye drops was noted again on the bedside table on 10/1/24 at 3:50 p.m. An interview was conducted with R65 on 9/30/24 at 6:35 p.m. R65 stated she uses these drops to help her eyes. Review of the physician orders failed to evidence a physician order for the above stated drops. Further review of the clinical record failed to evidence an assessment for the self-administration of medications. An interview was conducted with LPN…

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 report an injury of unknown origin within the required time frame for one of 63 residents in the survey sample, Resident #68. The findings include: For Resident #68 (R68), the facility staff failed to report a left-hand fracture of unknown origin to the state agency within two hours. A review of R68's clinical record revealed a nurse's note dated 3/14/24 that documented the resident presented with left hand swelling. Tylenol was administered with an effective effect and an x-ray was ordered. An x-ray result dated 3/16/24 documented, Undisplaced fracture mid portion left fourth metacarpal (a bone in the hand). Further review of R68's clinical record failed to reveal a known cause of the fracture. A facility synopsis of events submitted to the state agency documented, Report date: 3/18/24. Incident date: 3/14. Incident type: Injury of unknown origin. The facility received X ray results stating undisplaced fourth metacarpal of the left hand. The resident is not fearful and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide written notification to the resident and/or responsible party and failed to notify the ombudsman upon transfer for two of 63 residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to evidence a written notice was provided to the resident and/or responsible party and failed to notify the ombudsman upon transfer to the hospital on 7/4/25. The nurse's note dated, 7/4/24 at 3:31 p.m. documented, Critical Lab (laboratory) value: Creatinine 10.78, BUN (blood urea nitrogen) 121. Contributing DX (diagnosis) CKD (chronic kidney disease) Stage 4. Currently on Bumetanide (used to treat edema/fluid retention) (1) 6 mg daily. VS (vital signs) 128/70 (blood pressure), 97.8 (temperature), 72 (pulse), 17 (respirations)[NAME], sat (oxygen saturation) 98% RA (room air). NP (nurse practitioner) review results with resident via…

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 provide a bed hold notice at the time of transfer for two of 63 residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1, the facility staff failed to evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer to the hospital on 7/4/24. The nurse's note dated, 7/4/24 at 3:31 p.m. documented, Critical Lab (laboratory) value: Creatinine 10.78, BUN (blood urea nitrogen) 121. Contributing DX (diagnosis) CKD (chronic kidney disease) Stage 4. Currently on Bumetanide (used to treat edema/fluid retention) (1) 6 mg daily. VS (vital signs) 128/70 (blood pressure), 97.8 (temperature), 72 (pulse), 17 (respirations)[NAME], sat (oxygen saturation) 98% RA (room air). NP (nurse practitioner) review results with resident via video conference with nurse at bedside. Order obtained to transfer resident to ER (emergency room)…

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

Based on staff interview and clinical record review, the facility staff failed to maintain a complete MDS (minimum data set) assessment for one of 63 residents in the survey sample, Resident #125. The findings include: For Resident #125 (R125), the facility staff failed to assess the resident's BIMS (Brief Interview for Mental Status) for the 8/27/24 quarterly MDS assessment. Section C Cognitive Patterns of R125's quarterly MDS assessment with an ARD of 8/27/24 documented, C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents. A dash was coded, indicated the resident's BIMS was not assessed. On 10/8/24 at 10:23 a.m., an interview was conducted with RN (registered nurse) #2 (the mobile MDS coordinator). RN #2 stated the BIMS on R125's 8/27/24 MDS assessment was accidentally missed. RN #2 stated staff was in the process of completing a corrected MDS. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide the resident/RR (resident representative) with a written summary of the baseline care plan for two of 63 residents in the survey sample, Residents #468 and #469. The findings include: 1. For Resident #468 (R468) the facility staff failed to provide a written summary of the baseline care plan after admission on [DATE]. A review of R468's clinical record revealed she was admitted to the facility on [DATE]. A review of her clinical record, including assessments and progress notes, failed to reveal evidence that the resident and/or her RR had been given a written summary of her baseline care plan. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated the nursing and social services are responsible for developing the baseline care plan. She stated the social worker is responsible for giving the resident a written copy of the summary of the baseline care…

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 document review, it was determined the facility staff failed to follow professional standards of practice for one of 63 residents in the survey sample, Resident #164. The findings include: For Resident #164 (R164), the facility staff failed to clarify physician orders for administration of Acetaminophen and Ibuprofen. The physician orders documented in part, - Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for PAIN GIVE WITH IBUPROFEN. Order Date: 05/29/2024. - Ibuprofen Oral Tablet 200 MG (Ibuprofen) Give 2 tablet by mouth every 4 hours as needed for PAIN scale 1-3, GIVE WITH APAP. Order Date: 11/21/2023. The eMAR (electronic medication administration record) for R164 dated 8/1/24-8/31/24 documented the resident receiving the Acetaminophen 325mg 1 tablet on 8/24/24 at 1:38 p.m. The eMAR failed to evidence the resident receiving Ibuprofen. The eMAR for R164 dated 9/1/24-9/30/24 documented the resident receiving the Acetaminophen 325mg 1 tablet on 9/28/24 at 4:41…

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 develop a complete post-discharge plan of care for one of 63 residents in the survey sample, Resident #227. The findings include: For Resident #227 (R227) (who discharged on 3/30/24), the facility staff failed to develop a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of medications. The facility staff also failed to ensure R227 was able to obtain medications after discharge. A review of R227's clinical record revealed a nurse's note dated 3/30/24 that documented the resident discharged home, was provided discharge instructions, verbalized understanding, and signed. The note failed to document any further information regarding the discharge. A Discharge summary dated [DATE] documented the resident's vital signs and a social services section that included the discharge date , discharge location, and discharge goals. 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 clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 63 residents in the survey sample, Resident #219. The findings include: For Resident #219 (R219), the facility staff failed to provide incontinence care during dates in September and November of 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 9/15/22, the resident was assessed as being severely impaired for making daily decisions, requiring extensive assistance of one person for toileting and being frequently incontinent of bowel and bladder. Review of the ADL documentation for R219 dated 9/1/22-9/30/22 failed to evidence incontinence care, toileting assistance or personal hygiene assistance provided on night shift (11:00 p.m. to 7:00 a.m.) of 9/12/22 and 9/14/22. Review of the ADL documentation for R219 dated 11/1/22-11/30/22 failed to evidence incontinence care, toileting assistance or personal…

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 administer medications as order by the physician for two of 63 residents in the survey sample, Resident #82 and #221. The findings include: 1. For Resident #82 (R82), the facility staff failed to administer an antibiotic per the physician order. The physician order dated 9/20/24 documented, Ciprofloxacin HCL (hydrochloride) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days. The September 2024 MAR (medication administration record) documented the above order. On 9/20/24 the 6:00 p.m. dose documented a 5. A 5 indicates See Nurses Note. The nurse's note dated 9/20/24, documented, Not available. Review of the (Emergency backup medication system) contents revealed Ciprofloxacin 250 mg tablets were available in the backup system. The comprehensive care plan dated, 9/22/24, documented in part, Focus: Resident has an infection…

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 implement interventions to treat a contracture for one of 63 residents in the survey sample, Resident #62. The findings include: For Resident #62 (R62), the facility staff failed to implement a splint to prevent a right hand contracture from worsening. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) 6/25/24, R62 was coded as having no cognitive impairment according to the BIMS (brief interview for mental status). He was coded as having upper extremity range of motion impairment on one side. On 10/26/24 at 12:36 p.m. and 10/2/24 at 11:05 a.m., R62 was observed sitting up in bed. His right hand was contracted, and there was no splint visible. When asked if he ever was provided a splint for his right hand, he stated he had one in the past, but did not know what happened to it. He added that the staff did not know where the splint was located either. A review of R62's occupational…

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, it was determined the facility staff failed to provide care and services for an external catheter for one of 63 residents in the survey sample, Resident #82. The findings include: For Resident #82(R82), the facility staff failed to obtain a physician order for the use of an external catheter. Observation was made of R82 was made on 9/30/24 at approximately 6:50 p.m. The resident was in bed with a urinary collection bag hanging off the bed frame. The most recent MDS (minimum data set) assessment, with an assessment reference date of 8/8/24, in Section H - Bladder and Bowel, did not coded R82 as having an internal catheter or an external catheter. Review of the physician orders failed to evidence a physician order for an indwelling or external urinary catheter. On 10/2/24 12:43p.m. a second observation was made of R82. The personal aide showed this surveyor an external catheter that she was given to use for the resident and that was what was in place. On 10/3/24 at 11:26 a.m. an interview was…

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

Based on staff interview, employee record review, and facility document review, it was determined the facility staff failed to meet the CNA (certified nursing assistant) requirements for two of five employee records reviewed, CNA #7 and #8. The findings include: For CNA #7 and #8, the facility staff failed to evidence the two CNAs had completed their annual mandatory 12 hours of in-service training. CNA #7 was hired on 8/27/07. The training record documented he had 3.6 hours of in-service training in the past 12 months. CNA #8 was hired on 87/30/12. The training record documented he had 8.1 hours of in-service training the past 12 months. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 10/9/24 at 8:49 a.m. ASM #2 stated she tracks the staffing education. She stated she looks at the report from (name of electronic training program) and sees who is due for training. The percentage numbers of those completed are brought to the morning meeting. The program will tell her what is due, past due and what is completed. The staff members get…

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 document review, it was determined that the facility staff failed to provide medically related social services for 1 of 63 residents in the survey sample, Resident #132. The findings include: For Resident #132 (R132), the facility staff failed to identify the need for medically related social services and make attempts to ensure services were pursued. R132 lacked an effective support from family or community and no legal representative, was cognitively impaired with documented behavioral disturbances however the facility staff never contacted any outside services for evaluation. R132 was admitted to the facility with diagnoses that included but were not limited to dementia, unspecified severity with other behavioral disturbance (1), major depressive disorder (2) and psychotic disorder with delusions due to known physiological condition (3). The admission record for R132 documented the resident being their own responsible party and own emergency contact. On the most recent MDS (minimum data set), a quarterly…

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 pharmacy failed to provide medications for one of 63 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the pharmacy failed to provide Zosyn (1) for administration on 9/7/24. A review of R4's clinical record revealed the following order dated 9/6/24: Piperacillin Sod-Tazobactam So Solution (1) (Zosyn) Reconstituted 4-0.5 GM (grams) Use 4.5 gram intravenously every 6 hours for osteomyelitis (infection of the bone). A review of R4's progress notes revealed the following nurses' note dated 9/7/24: eMar - Medication Administration Note: Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM Use 4.5 gram intravenously every 6 hours for Osteomyelitis until 10/08/2024 .Resident meds (medications) are pending for pharmacy delivery. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3 was interviewed. After reviewing R4's progress notes and September 2024 MAR (medication administration record), she stated the Zosyn was ordered for R4 as a discharge…

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 act on the pharmacist's recommendation for one of 63 residents in the survey sample, Resident #130. The findings include: For Resident #130 (R130), the facility staff failed to act on the pharmacist's recommendations to perform laboratory tests and failed to address a recommendation regarding an as-needed psychoactive medication for multiple months in 2023 and 2024, . A review of R130's monthly pharmacy medication regimen reviews revealed, in part: 10/18/23 The following labs for Lipid panel and CMP (complete metabolic panel) (was due in August) are ordered .however the results for the lipids are currently not available. A review of R130's laboratory results revealed no lipid panel or CMP between 10/18/23 and 12/2/23. 12/29/23 Resident has a current order for Trazodone (1) which is a prn (as-needed) psychotropic medication without a stop date .State operations manual requires an assessment to continue a prn psychotropic medication beyond 14 days .Please reassess the prn…

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 interventions to prevent unnecessary medication administration for one of 63 residents in the survey sample, Resident #130. The findings include: A review of R130's physician orders revealed the following order dated 12/15/23: Trazodone Oral Tablet 100 mg (milligrams) Give 200 mg by mouth every 24 hours as needed for insomnia nightly. Further review of R130's orders revealed the order for the as-needed medication was not addressed by the provider until 2/21/24. On 10/8/24 at 1:57 p.m., ASMs (administrative staff members) #8 and #9, both of whom are nurse practitioners, were interviewed. ASM #9 stated she was aware that any psychotropic prn (as-needed) order could only last for 14 days. She stated: It is regulatory. She stated she tries to always put a 14 day stop order if a resident needs a temporary as-needed psychoactive medication. On 10/8/24 at 2:27 p.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated any psychoactive order 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.

Based on staff interview, facility document review, and clinical record review, the facility pharmacy failed to for one of prevent a significant medication error for one of 63 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to administer Zosyn (1) at noon on 9/7/24, resulting in a significant medication error. A review of R4's clinical record revealed the following order dated 9/6/24: Piperacillin Sod-Tazobactam So Solution (1) (Zosyn) Reconstituted 4-0.5 GM (grams) Use 4.5 gram intravenously every 6 hours for osteomyelitis (infection of the bone). A review of R4's progress notes revealed the following nurses' note dated 9/7/24: eMar - Medication Administration Note: Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM Use 4.5 gram intravenously every 6 hours for Osteomyelitis until 10/08/2024 .Resident meds (medications) are pending for pharmacy delivery. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3 was interviewed. After reviewing R4's progress notes and September 2024 MAR (medication…

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 clinical record review, the facility staff failed to provide food in a form to meet a resident's needs for one of 63 residents in the survey sample, Resident #170. The findings include: For Resident #170 (R170), the facility staff failed to cut the resident's food into bite-sized pieces, per a physician's order. A review of R170's clinical record revealed a physician's order dated 4/10/24 for a regular diet and to cut food into bite-sized pieces. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/25/24, the resident scored 12 out of 15 on the BIMS (brief interview for mental status, indicating the resident was moderately cognitively impaired for making daily decisions. On 10/1/24 at 9:21 a.m., R170 was served a meal tray that contained toast with sausage gravy. The meal ticket on the tray documented, CUT FOOD INTO BITE SIZE PIECES. The toast with sausage gravy was not cut into bite-sized pieces. On 10/1/24 at 1:23 p.m., R170 was served a meal tray that contained…

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 document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 63 residents in the survey sample, Resident #224. The findings include: For Resident #224 (R224), the facility staff failed to maintain an accurate medical record including consultation report documentation from the facility consulted dermatologist. The physician orders for R224 documented in part, - Dermatology consults if the blister open/un-opened does not get better, one time only for consult for 1 day. Order Date: 03/28/2023. - Resident is schedule for a Dermatology appointment on Thursday 4/20/2023 at 11:45 am. [Address and phone number]. Order Date: 04/17/2023. - Dermatologist appointment on 05/11/2023 at 11:45 a.m. [Address and phone number]. Order Date: 04/20/2023. The progress notes for R224 documented the resident going to the dermatology appointment with their POA (power of attorney) on 4/20/23 and 5/11/23. The progress notes further documented, 4/27/2023 13:55 (1:55 p.m.) Note…

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 implement infection prevention interventions for one of 63 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to wear appropriate PPE (personal protective equipment) when they provided wound care to R4 on 10/4/24. On 10/4/24 at 10:55 a.m., RN (registered nurse) #5, the wound nurse, was observed changing R4's pressure injury dressings. At no time during the process of changing R4's dressings did RN #5 wear a protective gown. She only wore gloves. A review of R4's orders revealed the following order written 9/6/24: Enhanced barrier precautions .related to IV (intravenous) therapy .wounds. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated if a resident has orders for enhanced barrier precautions, any nurse providing wound care should be wearing both gloves and gown. She stated this is not only to protect the nurse and the resident who is receiving…

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

Based on staff interview, employee record review and facility document review, it was determined that one of five employee record reviews, failed to meet the training requirements for QAPI (quality assurance performance improvement), OSM (other staff member) #13. The findings include: For OSM #13, the facility staff failed to provide evidence of documentation of the facility's QAPI training. The review of OSM #13's completed trainings failed to evidence documentation of training in the QAPI process. An interview was conducted with OSM #11, the director of rehabilitation, on 10/8/24 at 2:50 p.m. OSM #11 stated, QAPI training is not required for the therapy department, but they do attend QAPI. The facility policy, Staff Education and Competency Testing documented in part, Procedure: I. Assessment of Needs: a. Areas to be evaluated are determined by facility needs including but not limited to areas that are .6) Annual regulatory requirements. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations,…

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, employee record review and facility document review, it was determined that one of five employee record reviews, failed to meet the training requirements for behavioral health training, OSM (other staff member) #13. The findings include: For OSM #13, the facility staff failed to provide evidence of documentation of the facility's behavioral health training. The review of OSM #13's completed trainings failed to evidence documentation of training in behavioral health. An interview was conducted with OSM #11, the director of rehabilitation, on 10/8/24 at 2:50 p.m. OSM #11 stated, that behavioral health training is not required for the therapy department, many times if anything we need to know, we will get an in-service by the staff in the building. The facility policy, Staff Education and Competency Testing documented in part, Procedure: I. Assessment of Needs: a. Areas to be evaluated are determined by facility needs including but not limited to areas that are .6) Annual regulatory requirements. ASM (administrative staff member) #1, the executive director,…

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 document review, it was determined that facility staff failed to maintain three of three facility dumpsters in a sanitary manner. The findings included: On 3/2/21 at 3:00 p.m., observation of the facility dumpster was conducted with OSM (Other Staff Member) #1, the Dietary Manager. More than 15 plastic gloves were observed on the ground around the facility dumpsters. These gloves did not appear to be visibly soiled. Plastic bottles and other debris were also observed around the facility dumpsters. All three dumpsters were shut, however bags of trash were observed on top of each dumpster. On 3/2/21 at 3:00 p.m., an interview was conducted with OSM #1, the Dietary Manager. OSM #1 stated that dietary as well as housekeeping and maintenance were all responsible for ensuring the dumpster area was clean. When asked how often the garbage truck made visits, OSM #1 stated, Once daily. When asked if trash bags should be thrown on top of the dumpsters, OSM #1 stated that it should not. OSM #1 confirmed that the dumpster area was not clean. On 3/2/21 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 observations, staff interviews and review of facility documentation, the facility failed to ensure emergency medical equipment was in place and operational, and that staff were able to demonstrate they were able to provide the required emergency care to residents on 6 of the facility's 6 units. The findings include: According to the review of the facility's assessment dated 12/2019 through 11/2020, it indicated the following: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day to day operations and emergencies. The assessment also indicated that another purpose of the assessment was to to ensure the capabilities to provide care and services to the residents in the facility, using a competency based approach that focused on the provision of care to each resident in order to attain and maintain their highest physical well-being. The competencies required and demonstrated proficiency included specialized care-oxygen administration,…

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 clinical record review the facility's staff failed to afford 1 of 14 residents (Resident #203) the opportunity to participate in their care plan meeting. The findings included: Resident #203 was originally admitted to the facility 8/18/17 and has never been discharged . Resident #203's diagnoses included; Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #203's cognitive abilities for daily decision making were intact. In section E (Behavior) the resident was coded for no behaviors. In section G (Physical functioning) the resident was coded as requiring total care of two people with toileting, total care of one with bathing, extensive assistance of two with bed mobility and transfers, extensive assistance of one person with locomotion, personal hygiene and dressing and supervision of one person after set-up with eating. 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.

Based on resident interview, staff interviews, and clinical record review the facility's staff failed to make reasonable accommodation according to resident's needs and preferences for 1 of 14 residents (Resident #203), in the survey sample. The findings included: Resident #203 was originally admitted to the facility 8/18/17, and had never been discharged . Resident #203's diagnoses included; Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #203's cognitive abilities for daily decision making were intact. In section E (Behavior) the resident was coded for no behaviors. In section G (Physical functioning) the resident was coded as requiring total care of two people with toileting, total care of one with bathing, extensive assistance of two with bed mobility and transfers, extensive assistance of one person with locomotion, personal hygiene and dressing and supervision 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 clinical record review, staff interview and facility documentation, the facility failed to execute the opportunity to provide an advance directive for two Residents. Resident #69 and Resident #149 out 51 Residents in a survey sample. 1. The facility staff failed to execute the opportunity to provide an advance directive for Resident #69. The findings include: Resident #69 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. With a past medical history that included anxiety, depression and Alzheimer's disease. The current Minimum Data Set (MDS) a quarterly revision with an Assessment Reference Date (ARD) of [DATE] coded the resident as having a (BIMS) of 1 which indicated severe cognitive impairment. A review of the clinical record on [DATE] revealed there was no advance directive in the clinical record. 2. The facility staff failed to execute the opportunity to provide an advance directive for Resident #149. The Findings include: Resident #149 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals for 2 of 51 residents (Resident 159 and 509) after being transferred and admitted to the hospital. The findings included: 1. The facility staff failed to ensure that Resident #159's Plan of Care Summary to include his care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #159 was originally admitted to the facility on [DATE]. Diagnosis for Resident #159 included but not limited to Congestive Heart Failure. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 09/01/20 coded the resident with a 06 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On 04/14/20, according to the facility's documentation, Resident #159, departed facility via 911 (local hospital) for hypoxia. Resident had labored…

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 record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing discharge for 1 of 51 residents (Resident #160) in the survey sample. The findings included: The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #160's transfer home on [DATE]. Resident #160 was originally admitted to the facility on [DATE]. Diagnosis for Resident #160 included but not limited to Anemia. The current Minimum Data Set (MDS), a 14-day assessment with an Assessment Reference Date (ARD) of 12/09/20 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessments was dated for 12/18/20 - discharged assessment - return not anticipated. On 12/18/20, according to the facility's documentation, Resident was discharge home this morning, head to toe skin assessment done no skin issue noted,…

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 interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 2 of 51 resident's (Resident #159 and 509) after being transferred to the local hospital. The findings included: 1. The facility staff failed to ensure that Resident #159 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. Resident #159 was originally admitted to the facility on [DATE]. Diagnosis for Resident #159 included but not limited to Congestive Heart Failure. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 09/01/20 coded the resident with a 06 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On 04/14/20, according to the facility's documentation, Resident #159, departed facility via 911 to (hospital) for hypoxia. Resident had…

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 clinical record review the facility's staff failed to accurately code the Minimum Data Set (MDS) assessment to include behavioral symptoms not directed toward others (resident placing herself on the floor) for 1 of 14 residents (Resident #203), in the survey sample. The findings included: Resident #203 was originally admitted to the facility 8/18/17, and had never been discharged . Resident #203's diagnoses included; Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #203's cognitive abilities for daily decision making were intact. In section E (Behavior) the resident was coded for no behaviors. In section G (Physical functioning) the resident was coded as requiring total care of two people with toileting, total care of one with bathing, extensive assistance of two with bed mobility and transfers, 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 staff interview, facility document review and clinical record review, it was determined that facility staff failed to revise the care plan with a change in coded status from Full Code to DNR on [DATE] for one of 51 residents in the survey sample; Resident #93. The findings included: Resident #93 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary, muscle weakness, age related cognitive decline, and major depressive disorder. Resident #93's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of [DATE]. Resident #93 was coded as being intact in cognitive function scoring 14 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #93's face sheet documented the following: DNR (Do Not Resuscitate), CPR (Cardiopulmonary resuscitation). Review of Resident #93's current POS (Physician Order Summary) revealed the following active orders: Full Code. This order…

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 clinical record review the facility's staff failed to develop, monitor and implement a behavioral plan to support a resident to attain the highest practicable well-being for 1 of 14 residents (Resident #203), in the survey sample. The findings included: Resident #203 was originally admitted to the facility 8/18/17, and had never been discharged . Resident #203's diagnoses included; Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #203's cognitive abilities for daily decision making were intact. In section E (Behavior) the resident was coded for no behaviors. In section G (Physical functioning) the resident was coded as requiring total care of two people with toileting, total care of one with bathing, extensive assistance of two with bed mobility and transfers, extensive assistance of one person with locomotion, personal…

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 the observation of 4 medication carts and 3 medication rooms; the facility staff failed to dispose of expired medications for two units. The East Unit and the Emerald/Quarantine Unit. The facility staff failed to dispose of an expired medications on the East and the Emerald/Quarantine units. The findings include: On 3/02/21 at 12:38 P.M. a medication cart inspection was conducted on the East Unit with RN #2. Upon visual inspection, One House Stock bottle of sodium bicarbonate 1000 tablets (BOTTLE 1/4 FULL) with an expiration date of 10/20 was seen. RN #2 stated that the expired bottle should have been discarded. On 3/02/21 at 3:45 P.M. a medication cart inspection was conducted on The Emerald/Quarantine Unit with RN (Registered Nurse) #3. One bottle of ONCE DAILY MULTI Vitamins with an Expiration date of 2/2 was seen. RN #3 stated that the bottle of vitamins should have been discarded. The Policy reads: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose 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 staff interview, facility document review and clinical record review, it was determined that facility staff failed to discontinue a code status order for Full Code, when code status had changed to a DNR (Do Not Resuscitate) on [DATE] for one of 51 residents in the survey sample; Resident # 93. The findings included: Resident #93 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary, muscle weakness, age related cognitive decline, and major depressive disorder. Resident #93's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of [DATE]. Resident #93 was coded as being intact in cognitive function scoring 14 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #93's face sheet documented the following: DNR (Do Not Resuscitate), CPR (Cardiopulmonary resuscitation). Review of Resident #93's current POS (Physician Order Summary) revealed the following…

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 interviews and facility document review, the facility staff failed to ensure 1 resident (Resident #47) wore his face mask correctly to prevent the spread of possible COVID-19 infection and failed to ensure the facility's Infection Prevention and Control Program (IPCP) was reviewed at least annually. The findings included: 1. Resident #47 was admitted to the facility on [DATE] with diagnoses that included but were not limited to status post stroke with hemiplegia, high blood pressure, diabetes, and CAD (Coronary Artery Disease). Resident #47's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/13/20. Resident #47 was coded as being intact in cognitive function scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 3/4/21 at 10:11 a.m., an observation was made of Resident #47. Resident #47 was sitting up in the lobby wearing his face mask on his chin. His face mask was not covering his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 3 of 42 residents in the survey sample (Resident #45, #142 and #91). 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #45's discharge to the hospital on 4/6/18. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #142's discharge to the hospital on 6/20/18. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #91's discharged to the hospital on 6/13/18. The finding include: 1. Resident #45 was admitted to the nursing facility on 5/16/17 with a diagnoses that included osteomyelitis of left foot and ankle and diabetes mellitus. The most recent Minimum Data Set (MDS) assessment was an Annual dated 5/18/18 and coded the resident on the Brief Interview for Mental Status…

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 interviews, and facility document review the facility staff failed to issue bed-hold notices and policy for 7 of 42 residents in the survey sample (Resident #45, #142, #91, 68, #99, #175 and #162). 1. The facility staff failed to issue a bed-hold notice and policy to Resident #45 prior to discharge to the hospital on 4/6/18. 2. The facility staff failed to issue a bed-hold notice and policy to Resident #142 prior to discharge to the hospital on 6/20/18. 3. The facility staff failed to issue a bed-hold notice and policy to Resident #91 prior to discharge to the hospital on 6/13/18. 4. The facility staff failed to issue a bed-hold notice for Resident #68 prior to a Leave of Absence (LOA), 8/20/18 through 8/23/18. 5. The facility staff failed to issue a bed-hold notice for Resident #99 prior to LOA on 8/16/18. 6. The facility staff failed to ensure that Resident #175 was issued the facility's bed hold policy and reserve bed payment policy upon transfer/discharge 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 observations, record review group interview and staff interview, the facility staff failed to maintain an effective Pest Control Program. The findings included: During the Group Interview on 8/22/18 residents complained of mice being in their rooms. The residents stated mice droppings were observed in rooms 106, 204 and 305. A review of the Pest Control Log for the North Unit indicated: On 8/15/18 a mice (sic) was sighted in room [ROOM NUMBER]. A review of the Pest Control Log for the South Unit indicated: On 2/21/18 mice were sighted in the dining room. A review of the Pest Control Log for the [NAME] 1 Unit indicated: On 8/21/18 mice were sighted in room [ROOM NUMBER]. A review of the Pest Control Log for the 300 Unit indicated: On 2/13/18 mice were sighted in the following rooms, #308, #309, #311, Office, #324, #328, #329. The log indicated: Need to seal holes in walls/trim tree away from building. A review of the Pest Control Log for the East Unit indicated: On 5/30/18 roaches were observed by 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 observations, clinical record review, staff and resident interview, and facility documentation, the facility staff failed to respect the dignity and privacy for 1 of 42 (Resident #49) residents in the survey sample. 1. The facility staff routinely sat on Resident #49's couch in her room to complete Activities of Daily Living (ADL) documentation which infringed upon her privacy. Resident #49 was admitted to the nursing facility on 4/8/14 with diagnoses that included stroke and Parkinson's disease. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 6/1/18 and coded Resident #49 on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was cognitively intact in the skills needed for daily decision making. On 8/21/18 at approximately 2:00 p.m., a surveyor observed CNA #1 sitting on Resident #49's couch using an electronic device that was similar to a cell phone. On 8/22/18 at 10:00 a.m., during a group interview with 6 facility residents, they stated the Certified Nursing Assistants use…

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 an Employee Record Review, staff interviews, and facility document review, the facility staff failed to obtain a Criminal Background Check for 1 staff member, Dietary Aide #1. The facility staff failed to obtain a Criminal Background Check for Dietary Aide #1, with a hire date of 9/15/17. The findings included: On 8/22/18 an Employee Record Review was conducted on 25 current employees from 8/20/16 to 8/20/18. The employee record for Dietary Aide #1, with hire date of 9/15/17 did not contain Virginia State Police criminal background check. On 8/23/18 at 10:24 AM an interview was conducted with the Human Resources Manager and she was asked to present documentation of the criminal background check for Dietary Aide #1, hired on the date of 9/15/18. The Human Resources Manager stated, We do not have it, I even checked with dietary department and corporate and we don't have it. On 8/23/18 at 12:11 PM an interview was conducted with the facilities Executive Director and he stated, I have spoken with the Human Resources Manager and understand we do not have this employee's criminal…

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 the Employee Record Review, staff interviews, and facility document review, the facility staff failed to implement their abuse policy and procedure to obtain a Criminal Background Check for all newly hired employees. The facility staff failed to obtain a criminal background check for 1 current staff member (Dietary Aide #1) with a hire date of 9/15/17. The findings included: On 8/22/18 an Employee Record Review was conducted on 25 current employees hired from 8/20/16 to 8/20/18. The employee record for 1 current employee (Dietary Aide #1) with a hire date of 9/15/17 did not contain a Virginia State Police criminal background check. On 8/23/18 at 10:24 AM an interview was conducted with the Human Resources Manager and she was asked to present documentation of criminal background check for Dietary Aide #1's record with hire date of 9/15/18. Human Resources Manager stated, We do not have it, I even checked with dietary department and corporate and we don't have it. On 8/23/18 at 12:11 PM an interview was conducted with the facility's Executive Director and he stated, I have…

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, clinical record review, staff interviews, and facility document review the facility staff failed to develop and implement a comprehensive person-centered care plan to include the risk of unsafe wandering for 1 of 42 resident in the survey sample, Resident #162. The facility staff failed to develop and implement a comprehensive person-centered care plan to include the risk of unsafe wandering after the resident was identified as a significant risk of getting to a potentially dangerous place on the admission Minimum Data Set (MDS) for Resident #162 who eloped from the facility on 8/19/17. The findings included: 1. Resident #162 was a [AGE] year old admitted to the facility originally on 6/29/17 and then re-admitted on [DATE] with diagnoses of (1). Dementia, (2). Liver Carcinoma, and (3). Communication Deficit. The Resident #162's admission 5 day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/6/17 was reviewed. The Brief Interview for Mental Status (BIMS) was 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 observations, clinical record review, staff interviews, and facility document review the facility staff failed to maintain an environment as free as possible of accident hazards for 3 of 42 Residents in the survey sample (Residents #241, #47, and #28). 1. For Resident #241, who required supervision with smoking, the facility staff failed to ensure that his smoking materials were secured outside of the designated smoking activity. 2. For Resident #47, the facility staff failed to ensure that his smoking materials were secured outside of the designated smoking activity. 3. For Resident #28 the facility staff failed to ensure that his smoking materials were secured outside of the designated smoking activity. The findings included: 1. Resident #241 was observed to have smoking materials which included cigarettes and a lighter. Resident #241 was re-admitted to the facility on [DATE] with diagnoses of renal disease, muscle weakness, neurogenic bladder, and hypertension. Resident #241 had a Brief Interview 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 observations, medical record review, a Resident Interview, staff interviews, and facility document review the facility staff failed to ensure a dialysis Resident received the necessary care and services to include assessment of an Arteriovenous (AV) fistula hemodialysis access site for bruit and thrill for 1 of 42 Residents in the survey sample, Resident #67. The Facility staff failed to ensure that Resident #67's Arteriovenous fistula hemodialysis access site was adequately assessed for bruit and thrill. Description from https://www.davita.com/treatment-services/dialysis/vascular-access-your-lifeline-to-hemodialysis: Learn the feel of the thrill or vibration of blood going through your access and check it several times a day. Call your dialysis care team immediately if the flow stops or changes. This could mean a blood clot. With quick action, many clots can be dissolved or removed. Learn to listen with a stethoscope to the sound (called bruit) of blood flowing (whooshing) through your access. If 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, medical record review, a Resident Interview, staff interviews, and facility document review, the facility staff failed to ensure competency in assessing an Arteriovenous Fistula hemodialysis access for bruit and thrill for 1 (Resident #67) of 42 residents in the survey sample. The facility staff failed to ensure that Resident #67's Arteriovenous Fistula hemodialysis access was adequately assessed for *bruit and thrill. The findings included: Resident #67 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include (1.) Chronic Kidney Disease, Stage 3, and (2.) Dependence on Renal Dialysis. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 5/3/18. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated that Resident #67 cognitively intact and capable of daily decision making. Under Section O Special Treatments, Procedures, and Programs, Resident #67 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 staff interviews, observation, clinical record review and facility documentation review the facility staff failed to ensure complete and accurate clinical records for 2 of 42 residents (Resident #440 and #240) in the survey sample. 1. The facility staff failed to ensure the clinical record was accurate for Resident #440; a progress note indicated resident was a status post right hip fracture with staples when in fact was not. 2. The facility staff failed to retain Resident #240's clinical record after new management took over the facility. The findings included: 1. Resident #440 was admitted to the facility on [DATE]. Diagnosis for Resident #440 included but not limited to *Dementia with behavioral disturbance. *Dementia with behavioral disturbances is frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. https://www.ncbi.nlm.nih.gov/pubmed/22644311 The current Minimum Data Set (MDS), a quarterly assessment with an 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.