August Healthcare At Leewood

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 report injuries of unknown origin to the state agency for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to report the injuries of unknown origin to the state agency. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to dementia and paralysis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/22/22, the resident scored 1 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #107's clinical record revealed a nurse's note dated 3/9/22 that documented, At exactly 0630 (6:30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate injuries of unknown origin for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to investigate these injuries of unknown origin. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to dementia and paralysis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/22/22, the resident scored 1 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #107's clinical record revealed a nurse's note dated 3/9/22 that documented, At exactly 0630 (6:30 a.m.), CNA (certified nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate MDS assessment for 2 of 47 residents in the survey sample, Residents #83 and #2. The findings include: 1. For Resident #83 the 2/7/22 quarterly MDS assessment was coded incorrectly for weight, weight loss, and weight gain. The resident was coded as having significant weight loss and significant weight gain, based on a weight obtained approximately one year prior to the MDS. The resident had no weights obtained in approximately a year. Resident #83 was admitted to the facility on [DATE] and had the diagnoses of but not limited to cerebral vascular disease, high blood pressure and Alzheimer's disease. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/7/22, the resident scored a 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 47 residents in the survey sample, Resident #30. The facility staff failed to complete a level 1 PASRR for Resident #30 who was admitted to the facility on [DATE]. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included delusional disorders, hallucinations and unspecified dementia with behavioral disturbance. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/2021, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Review of Resident #30's clinical record failed to evidence a level 1 PASRR. On 3/16/2022 at approximately 9:26 a.m., a request was made to ASM (administrative staff member) #1, 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, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 47 residents in the survey sample, Resident #315. The facility staff failed to develop Resident #315's baseline care plan to include the use of an incentive spirometer. The findings include: Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnosis included but was not limited to a heart attack. Resident #315's admission minimum data set was not completed. An admission assessment dated [DATE] documented Resident #315 was alert and oriented to person, place, time and situation. A review of Resident #315's March 2022 physician's orders failed to reveal a physician's order for an incentive spirometer. A review of Resident #315's baseline care plan initiated on 3/7/22 failed to reveal documentation regarding an incentive spirometer. On 3/15/22 at 1:15 p.m. and 3/16/22 at 8:34 a.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.

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet professional standards of practice in providing care and services to one of 47 residents in the survey sample, Resident #71. The facility staff failed to completely transcribe a physician order for Resident #71 to include the type of enteral feeding to be administered. The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. Section K documented Resident #71 as having a feeding tube and receiving 51% or more of their total calories through tube feeding. On 3/15/2022 at approximately 12:45 p.m., an observation of Resident #71 was made in their room. Resident #71 was observed in bed receiving Glucerna tube feeding at 45 ml/hr (milliliters per hour) via pump. The physician orders for Resident #71 documented in part, Enteral Feed Order every shift for Nutritional…

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 a pressure injury for two of 47 residents in the survey sample, Residents #39 and #2. The findings included: 1. For Resident #39, the facility staff failed to assess and measure a pressure injury (1) from January 2022 through March 2, 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/6/2022, Resident #39 was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. In Section M, the resident was coded as having no unhealed pressure injuries. The nurse's note dated 12/19/2021 at 3:39 p.m. documented in part, Resident has non ruptured blister noted to her rt (right) inner heel. Measured 4x4. Elevated heel on pillow. Apply skin prep bid (twice a day) and monitor any change. In house wound consult .No sign and symptoms of verbal or non verbal pain or discomfort…

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

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to implement interventions to prevent injury from a fall for one of 47 residents in the survey sample, Resident # 28. The facility staff failed to place a fall mat on the floor next to Resident # 28's bed when they are were in bed. The findings include: Resident # 28 was admitted to the facility with a diagnosis that included but was not limited to: muscle weakness and a history of falls. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On the following dates a times, Resident #28 was observed to bed, with no fall mat in place on the floor next to the bed: 03/15/22 at 12:40 p.m, 03/15/22 at 4:55 p.m., 03/16/22 at 8:05 a.m., and 03/16/22 at 12:00 p.m. At each observation, a fall mat was leaning against the wall at 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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services to two of 47 residents in the survey sample, Residents #2 and #315. The findings include: 1. The facility staff failed to provide oxygen at the prescribed rate for Resident #2. Resident #2 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia and heart failure. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O failed to evidence oxygen use. On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed receiving oxygen via a nasal cannula attached to an oxygen…

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

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to communicate consistently with the dialysis center for one of 47 residents in the survey sample, Resident #44. For Resident #44, the facility staff failed to evidence consistent communication via the dialysis communication book on multiple dates in 2022. The findings include: Resident #44 was admit to the facility on 4/5/2019 with a diagnosis of end stage renal failure requiring hemodialysis. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/11/2022, the resident scored a 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section O, Resident #74 was coded as receiving dialysis while a resident at the facility. The physician order dated 10/3/2020 documented, Dialysis Services [address of dialysis center] on Monday, Wednesday and Friday at 11:00 a.m. An interview was conducted with…

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

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medication in a sanitary manner for 1 of 6 residents in the Medication Administration observation, Resident #35. The facility nurse administered a medication which had been handled in an unsanitary manner to Resident #35. The findings include: Resident #35 was admitted to the facility with diagnoses including alcohol abuse and alcohol related hepatitis. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/7/22, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of the clinical record revealed a physician's order dated 9/1/20 for Vitamin B1 (Thiamine) (1) 50 mg (milligrams) . On 3/16/22 at 8:17 AM, LPN #9 (Licensed Practical Nurse) was observed to prepare and administer medications for Resident #35. One of the medications prepared and administered was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for three Residents (Residents #43, #20, and #59) of the 34 residents in the survey sample. 1. Resident #43 did not have a comprehensive care plan for dementia care. 2. Resident #20 did not have a comprehensive care plan for dementia care. 3. Resident #59's care plan did not describe, nor address, his dementia needs, or behaviors. The findings included: 1. Resident #43 did not have a comprehensive care plan for dementia care. Resident #43 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, muscular dystrophy and high blood pressure. Resident #43's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 9-7-18 coded Resident #43 with severe cognitive impairment. The MDS was completed as a significant change in status assessment as the resident had completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #43 did not receive care and services for treatment of her dementia and was placed on an antipsychotic. Resident #43 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, muscular dystrophy and high blood pressure. Resident #43's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 9-7-18 coded Resident #43 with severe cognitive impairment. The MDS was completed as a significant change in status assessment as the resident had completed Hospice. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with no behaviors during the seven day lookback. 11/07/18 01:35 PM, a clinical record review revealed Hospice was initiated 6-5-18 for senile degeneration and muscular dystrophy. On 11/08/18 at 10:00 AM, a review of the meal intakes for September, October and November, 2018 revealed 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, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement policies and procedures regarding a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. The findings include: 1. For Resident #82, the facility staff failed to investigate a choking incident. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for eating 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 observations, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to investigate a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin. The findings include: 1. For Resident #82, the facility staff failed to investigate a choking incident. Resident #82, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include dysphagia and dementia. Resident #82's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 08/09/2018. Resident #82 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision making were coded as severely impaired. Functional status for eating was coded as requiring extensive assistance. 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 observation, staff interview and clinical record review, the facility staff failed for 1 resident (Resident #82) of 34 residents in the survey sample to review and revise the comprehensive care plan. 1. For Resident #82, the facility did not discontinue the use of adaptive utensils on the comprehensive care plan. The findings included: Resident #23, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, dysphagia, paralytic syndrome, hypertension, diabetes and chronic kidney disease. The most recent Minimum Data Set assessment was significant change assessment with an assessment reference date of 8/14/18. The resident was coded with a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment and required extensive assistance with activities of daily living. On 11/7/18, Resident #23 was observed eating breakfast and lunch in her room. She was observed to use regular utensils during both meals. Resident #23's comprehensive care plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility failed for 1 resident (Resident #29) in a survey sample of 34 Residents to provide medications as ordered by physician. For Resident #29 the facility failed to obtain medication ordered by physician or obtain substitute until the medication was available. The findings include: Resident #29, a [AGE] year old man, was admitted to the facility on [DATE] with diagnoses including but not limited to Dysphagia, Muscular weakness, Aphasia (inability to talk), Parkinson's disease, and Hemiplegia. The most recent (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 02/19/2018 coded the Resident as having a (Brief Interview of Mental Status) of 15 indicating no cognitive impairment. On 11/7/2018 during clinical record review it was noted that Resident had order for Protonix Suspension 40 (milligrams) mg (by mouth) PO every day for (Gastro Esophageal Reflux Disease). The medication had been originally ordered on 10/13/2017.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility failed to ensure that 2 Residents (Resident #4 and #82) in a survey sample of 34 Residents were free from unnecessary medications. 1. For Resident #4, the facility failed to attempt gradual dose reduction of Psychotropic Drug Temazepam for a year. 2. For Resident #82, the facility staff failed to ensure she was free from the psychotropic medication Seroquel which is not indicated for residents with a diagnosis of dementia. The findings included: Resident #4, a [AGE] year old man, was admitted to the facility on [DATE] with diagnoses of but not limited to Diabetes, Hypertension, Atrial Fibrillation, and Depressive Disorder. On 11/06/2018 during clinical record review it was noted that Resident #4 had orders for Temazepam 15 (milligram) mg 1 capsule by mouth at bedtime and that order started on 5/7/2017 he also had an order for Wellbutrin ER 75 mg. (an antidepressant) twice daily. On 11/08/2018 at 11:00 AM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff Interview, and facility Record Review, the facility staff failed to ensure that medications were not in an unlocked area, and available to residents. A wall cabinet on the [NAME] unit was open, unlocked, and could be easily accessed by wandering Residents. The cabinet contained 2 open gallon sized zip lock bags of various medications, on the bottom shelf, closest to the counter top. The findings include: On 11-17-18 at 9:17 a.m., The wall cabinet directly over the nursing station counter top, was opened by surveyors from the hallway. The cabinet contained 2 large gallon size zip lock bags full of open, and unopened medications. No nursing staff were in the nursing station, and Residents were wandering the halls freely. Some residents were noted to be in wheel chairs, and some were ambulatory. On 11-17-18 at 9:30 a.m., A Licensed Practical Nurse returned to the nursing station (LPN F), and surveyors pointed to the medications from the cabinet at that time, and asked her why 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 documentation and clinical record review the facility failed to ensure that 1 Resident (Resident #55) of 34 residents was provided the therapeutic diet as ordered by physician. For Resident #55 the facility failed to ensure Resident was given the correct amount of fluids on his fluid restricted Renal Diet. The findings included: Resident #55 a [AGE] year old man was admitted to the facility with diagnoses of but not limited to End Stage Renal Disease, Dependent on Renal Dialysis, Dysphagia, (Methicillin Resistant Staphylococcus Aurous) MRSA to (Peripherally Inserted Central line Catheter) PICC line. On 11/7/2018 it was noted during clinical record review that Resident was on a fluid restricted renal diet due to his diagnosis of End Stage Renal Disease. The order in the chart dated 10/23/2018 that read Fluid Restrictions: Day 150 (milliliters) ml. Evening 100 ml, Night 50 ml, Total 300. The Remaining Fluid to Be Provided By Dietary. The order did not specify how much 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 on observation, staff interview, facility documentation review and clinical record review, the facility staff failed, for one resident (Resident #6) in the survey sample of 24 residents, to provide a dignified living experience during medication administration. The facility staff applied a pain patch to Resident #6's back, asked her to lean forward, and then used a black marker to write the day, month and year on it. The Findings included: Resident #6 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #6's diagnoses included a facial bruise from a fall, Hypertension, Atrial Fibrillation, Cardiovascular accident, and Asthma. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 6/5/17, coded Resident #6 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 8/29/17 at 8:30 A.M. an observation was conducted of the facilities' medication administration process. The Licensed Practical Nurse (LPN-A) placed…

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 record review, and clinical record review, the facility staff failed to devise, and implement a comprehensive care plan for the use IV (intravenous) potassium and antibiotics for one Resident (Resident #1) in a survey sample of 24 Residents. For Resident #1, IV antibiotics, fluids, and Potassium were not appropriately care planned, and skin breakdown was care planned inappropriately. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical Assist. Resident #1 was first observed laying in bed, on her back, on 8-28-17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to maintain the highest practicable well being for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, and provide care and services during an acute illness. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to provide specialized intravenous antibiotic and potassium infusion nursing care for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, during an acute illness. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's current diagnoses included; pneumonia, urinary tract infection, Dementia, congestive heart failure, and Hypertension. The most recent Minimum Data Set, (MDS) was a Significant change Assessment, with an Assessment Reference Date of 7-21-17. the MDS coded Resident #1 as severely cognitively impaired. Resident #1 was coded as being extensively dependent for all activities of daily living, and requiring a 1 person physical…

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, the facility staff failed to ensure staff were trained in emergency procedures. Licensed Practical Nurse D (LPN D), and Certified Nursing Assistant A (CNA A) could not describe fully what response should be made to fire, disaster, and elopement protocols. The findings included: LPN D, and CNA A were interviewed by phone on 8-29-17 at 11:30 p.m. They both identified themselves, and were asked to describe what to do if a fire alarm sounded. Neither could state Extinguish the fire and continued to say evacuate. When asked if they had emergency power, they stated yes at the nursing station, and seemed unaware of any other emergency power outlets for Resident use. When asked about elopement protocols both stated they would report to the supervisor, and the supervisor would report to the administrator, and the administrator would call the state. Neither could answer how long that would take, and could not describe that police would be called even with cueing from the surveyor about calling the police if a Resident could not be located. The issues were reviewed…

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.