APPOMATTOX HEALTH & REHABILITATiON CENTER

Based on observation, staff interview, and clinical record review, the facility staff failed to provide dental services to one of 16 residents, Resident #1. Findings were: Resident #1 was admitted to the facility with the following diagnoses, including but not limited to: encephalopathy, diabetes mellitus, COPD (chronic obstructive pulmonary disease), major depressive disorder, vascular dementia, hypertension, and hypothyroidism. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/2023, assessed Resident #1 as moderately impaired with a cognitive summary score of 09 out of 15. During initial tour of the facility on 05/08/2023 at approximately 12:15 p.m., Resident #1 was observed in his room. While speaking, Resident #1's mouth was observed with no front upper or lower teeth. On 05/09/2023 at approximately 11:00 a.m., Resident #1 was about having a partial plate or dentures at the facility. Resident #1 stated, When I grew up, we didn't have much money, I still don't. These are all the teeth I have. Resident #1 opened to reveal approximately four teeth…

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

Based on observation, and staff interview, the facility staff failed to store, serve, and prepare food in a sanitary manner in the main kitchen. Findings were: Initial tour of the facility kitchen was conducted on 05/08/2023 at approximately 11:15 a.m., with the DM (dietary manager-other staff #1). Observed in the refrigerator next to the tray line was a plastic bag. When asked what was in the bag, the DM stated, Her lunch, nodding towards the staff member plating food on the tray line. Also observed in the refrigerator were canned sodas. When asked if those belonged to residents, the DM stated, No, employees .they shouldn't be in here and the lunch shouldn't be either. The bins storing flour, sugar, and thickening were observed. Scoops for each bin were to be stored inside the bin, affixed to the top, away from the food ingredients. The scoop for the sugar was observed out of place and laying down in the stored sugar. The can opener which was affixed to a table in the kitchen, was observed with dark, dried debris on the blade area that punctures the cans. When asked how often 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 and clinical record review, the facility staff failed to ensure an accurate clinical record for three of sixteen residents in the survey sample (Residents #24, #30 and #41). The findings include: 1. Resident #24's clinical record inaccurately documented a physician's order for enhanced barrier precautions when the precautions had been discontinued since 4/20/23. Resident #24 was admitted to the facility with diagnoses that included chronic kidney disease, atrial fibrillation, atherosclerotic heart disease, hypertension, diabetes, COPD (chronic obstructive pulmonary disease), and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #24 as cognitively intact. Resident #24's clinical record documented a current physician's order dated 3/29/23 for Enhanced Barrier Precautions for infection control. The clinical record documented the precautions were implemented due to the resident's PICC (peripherally inserted central catheter). The clinical record documented the PICC 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 clinical record review, the facility staff failed to maintain floor mats and positioning cushions in clean/intact condition for one of sixteen residents in the survey sample (Resident #4). The findings include: Resident #4's floor mats were dirty, and the surfaces were heavily torn with frayed edges. The coverings on the bolster cushions in Resident #4's bed had torn corners with exposed foam visible. Resident #4 was admitted to the facility with diagnoses that included congestive heart failure, chronic kidney disease, hypertension, anemia, aphasia, cardiomyopathy, adult failure to thrive, dementia, psychotic/mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 5/9/23 at 10:02 a.m., floor mats were observed on Resident #4's side of the room. One mat was observed rolled up by the bedside table and the other mat was…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to identify and report an injury of unknown origin to the appropriate facility staff for one of 16 residents, Resident #258. Findings were: Resident #258 was admitted to the facility with the following diagnoses, including but not limited to, Atrial fibrillation, dementia, psychotic disturbance, mood disturbance, anxiety, and urinary tract infection. Due to her recent admission, no MDS (minimum data set) information was available. Upon attempted interview with Resident #258, her speech was nonsensical and she was unable to answer questions. On 05/08/2023 at approximately 12:15 p.m., the initial tour of the facility was conducted. Resident #258 was observed sitting in a wheelchair outside of her room. An elongated area was observed on the right side of her head, from her scalp, down her forehead, running parallel to her hair line. The area was bluish/purple in color. When asked what had happened to her head, Resident #258 answered, I don't know it's [Name redacted]'s…

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

Based on complaint investigation, closed clinical record review, and staff interview, the facility staff failed for one of 16 residents in the survey sample, Resident # 107, to forward a notice of discharge to the local Ombudsman. Resident # 107 was transferred to the hospital without a notice of discharge being sent to the local Ombudsman. The findings were: Resident # 107, who was her own Responsible Party, was admitted to the facility with diagnoses that included status post left femur fracture, history of malignant neoplasm of the breast, hypothyroidism, depression, hypertension, difficulty walking, generalized muscle weakness, anxiety disorder, peripheral vertigo, chronic obstructive pulmonary disease, right hip pain, chronic respiratory failure with hypoxia, and COVID-19. The Progress Notes in the resident's Electronic Health Record included the following entries: 12/30/2022 - 1930 (7:30 p.m.) - O2 (oxygen) sat (saturation) reported @ 75% on 5L/M (5 liters per minute). Resident positioned sitting up, alert and oriented. Administered prn (as needed) Duoneb treatment and…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure admission orders were in place for the care of suprapubic catheter for one of 16 residents, Resident #257. Findings were: Resident #257 was admitted to the facility with the following diagnoses including but not limited to: hypertension, pulmonary edema, protein-calorie malnutrition, anemia, pneumonia, urethral stricture, and pseudomonas pneumonia. Due to his recent admission, no MDS (minimum data set) information was available. When interviewed, regarding his care at the facility Resident #257 answered questions appropriately. During initial tour of the facility on 05/08/2023 at approximately 12:15 .pm., Resident #257 was observed lying supine on his bed. His pajama top was not pulled all the way down and a suprapubic catheter was observed. The clinical record was reviewed on 05/08/2023 at approximately 2:30 p.m. The physician order section contained the following order for the care of the suprapubic catheter: Cleanse and apply split sponge to suprapubic site daily . The care plan…

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, the facility staff failed to ensure a baseline care plan for the care of suprapubic catheter was in place for one of 16 residents, Resident #257. Findings were: Resident #257 was admitted to the facility with the following diagnoses including but not limited to: hypertension, pulmonary edema, protein-calorie malnutrition, anemia, pneumonia, urethral stricture, and pseudomonas pneumonia. Due to his recent admission, no MDS (minimum data set) information was available. When interviewed, regarding his care at the facility Resident #257 answered questions appropriately. During initial tour of the facility on 05/08/2023 at approximately 12:15 p.m., Resident #257 was observed lying supine on his bed. His pajama top was not pulled all the way down and a suprapubic catheter was observed. The clinical record was reviewed on 05/08/2023 at approximately 2:30 p.m. The physician order section contained the following orders for the care of the suprapubic catheter: Cleanse and apply split sponge to suprapubic site daily . The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of sixteen residents in the survey sample (Resident #4). The findings include: Resident #4 was admitted to the facility with diagnoses that included congestive heart failure, chronic kidney disease, hypertension, anemia, aphasia, cardiomyopathy, adult failure to thrive, dementia, psychotic/mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 5/9/23 at 2:34 p.m., Resident #4 was observed seated in a wheelchair in his room. The resident had a pommel seat cushion in use with the wheelchair. Review of Resident #4's clinical record revealed an occupational therapy (OT) Discharge summary dated [DATE] recommending use of the pommel cushion to assist with proper positioning and fall prevention when in the wheelchair. Resident #4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of sixteen residents in the survey sample (Resident #41). The findings include: Resident #41's plan of care was not revised regarding discontinued use of a Foley urinary catheter. Resident #41 was admitted to the facility with diagnoses that included vertebra compression fractures, atrial fibrillation, sepsis, pneumonitis, urinary tract infection, atherosclerotic heart disease, anxiety, asthma, congestive heart failure, urine retention and kidney failure. The minimum data set (MDS) dated [DATE] assessed Resident #41 as cognitively intact. Resident #41's plan of care (revised 4/19/23) documented the resident required a urinary catheter due to retention and diagnosed bladder infection. Interventions to prevent catheter complications and resolve infection included changing catheter as ordered, anchoring catheter, provision of privacy bag, monitoring urine for dark or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint investigation, closed clinical record review, staff interview, and review of facility documents, the facility staff failed for one of 16 residents in the survey sample, Resident # 107, to administer medications in a timely manner. Six medications, administered by two different nurses, were given between 2 hours and 43 minutes, and 4 hours and 45 minutes late. The findings were: Resident # 107, who was her own Responsible Party, was admitted to the facility with diagnoses that included status post left femur fracture, history of malignant neoplasm of the breast, hypothyroidism, depression, hypertension, difficulty walking, generalized muscle weakness, anxiety disorder, peripheral vertigo, chronic obstructive pulmonary disease, right hip pain, chronic respiratory failure with hypoxia, and COVID-19. As a part of the complaint investigation process, the Medication Admin Audit Report was reviewed. Review of the report revealed the following medications were administered late. Docusate Sodium…

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 failed to follow physician orders for the treatment of a pressure ulcer for one of 23 resident's. Resident #6 did not have physician ordered elbow protector in place. The Findings Include: Diagnoses for Resident #6 included; Hemiplegia, contractures, bursa right elbow, dementia, and pressure ulcers. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/30/23. Resident #6 was assessed with long and short-term memory problems and severely cognitively impaired. On 5/8/23 Resident #6's clinical record was reviewed. An active physician's order read: Right Elbow: Cleanse with wound cleanser, pat dry, Apply Silver Alginate, Collagen Particles, cover with kerlix and elbow protector. Review of Resident #6's most recent skin assessment dated [DATE] documented Resident #6 had a stage 4 pressure ulcer to the right elbow. On 5/8/23 at 2:25 PM Resident #6 was observed lying in bed with 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 observation, staff interview and clinical record review, the facility staff failed to administer oxygen as ordered by the physician for one of sixteen residents in the survey sample (Resident #24). The findings include: Oxygen was administered to Resident #24 at 4 lpm (liters per minute) when the physician's order required a rate of 2 lpm. Resident #24 was admitted to the facility with diagnoses that included chronic kidney disease, atrial fibrillation, atherosclerotic heart disease, hypertension, diabetes, COPD (chronic obstructive pulmonary disease), and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #24 as cognitively intact. On 5/9/23 at 10:20 a.m., Resident #24 was observed in bed with oxygen being administered at 4 lpm via a nasal cannula. Resident #24's oxygen was observed again on 5/9/23 at 2:11 p.m. running at 4 lpm. Resident #24's clinical record documented a physician's order dated 4/12/23 for oxygen at 2 lpm via nasal cannula. On 5/9/23 at 2:20 p.m., the licensed practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess one of sixteen residents (Resident #4) for entrapment risks, attempt alternatives, or obtain informed consent prior to use of bed rails. The findings include: Resident #4, with multiple falls from the bed, had no assessment for bed rails, which were in use with bolster cushions, no documented attempts at alternatives to the rails and no informed consent from the resident's responsible party about risks/benefits of the bed rails. Resident #4 was admitted to the facility with diagnoses that included congestive heart failure, chronic kidney disease, hypertension, anemia, aphasia, cardiomyopathy, adult failure to thrive, dementia, psychotic/mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 5/8/23 at 2:05 p.m., Resident #4 was observed…

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 interviews, facility document review, and staff interview, the facility staff failed to respond to call bells in a timely manner for 5 of 18 residents in the survey sample, Resident #15, #50, #45, #6 and #34. All five residents stated that due to staffing, it takes a long time to answer call bells. Staffing issues were also annotated in the July resident council minutes. The findings include: Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The most recent Minimum Data Set (MDS) dated [DATE] was a Quarterly assessment and assessed Resident #15 as cognitively intact for daily decision making with a score of 15 out of 15. On 07/27/2021 at 10:51 a.m. during the initial tour, Resident #15 was interviewed regarding call bell response time. Resident #15 stated, I have to wait 15 to 30 minutes sometimes. I have to stay in the bathroom [ROOM NUMBER] minutes. I used to time them, but my watch is broken. Resident #50 was admitted to the facility on [DATE]. The most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete an accurate Minimum Data Set (MDS) for one of eighteen residents in the survey sample, Resident #45. An admission MDS for Resident #45 inaccurately assessed the presence of pressure ulcers. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included right hip peri-prosthetic fracture, humerus fracture, congestive heart failure, atrial fibrillation, chronic kidney disease, anemia, hypothyroidism and urinary tract infection. The MDS dated [DATE] assessed Resident #45 as cognitively intact. A weekly skin evaluation sheet dated 6/25/21 documented the resident was assessed upon admission with the following skin impairments: Left buttock - stage II pressure ulcer measuring 0.5 x 0.3 x 0.0 (length x width x depth in centimeters); Sacrum - skin tear measuring 0.8 cm x 0.5 cm x 0 cm. The assessment documented, Alevyn foam to sacrum and left buttock q [every] three days. Bruising to right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of eighteen residents in the survey sample, Resident #24. Resident #24 had no plan of care regarding behaviors and use of an anticoagulant. The findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, rectal prolapse, congestive heart failure, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, osteoarthritis, hypertension and gout. The Minimum Data Set (MDS) dated [DATE] assessed Resident #24 with severely impaired cognitive skills. Resident #24's clinical record documented the resident was admitted with a diagnosis that included dementia with behavioral disturbance. Resident #24's clinical record documented the following nursing behavior notes. 3/11/21 - .Increasingly agitated with staff when asked to sit down .re-direct with no success . 3/16/21 - Resident exit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to follow professional standards of practice for one of eighteen residents in the survey sample, Resident #24. Nursing failed to document an incident and physical assessment of Resident #24 after a hairbrush was found in her incontinence brief. The findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, rectal prolapse, congestive heart failure, COPD (chronic obstructive pulmonary disease), chronic kidney disease, anemia, atrial fibrillation, osteoarthritis, hypertension and gout. The Minimum Data Set (MDS) dated [DATE] assessed Resident #24 with severely impaired cognitive skills. On 7/29/21 at 8:17 a.m., the Director of Nursing (DON) was interviewed about Resident #24's behaviors related to use of the antipsychotic medication Seroquel. The DON stated the resident rummaged in others' belongings, was exit seeking and had a recent incident of putting a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to follow physician orders for 1 of 18 residents in the survey sample, Resident #6. Fluid intake was not monitored and documented for Resident #6. The findings include: Resident #6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia, type 2 diabetes, depression, end stage renal disease, renal dialysis dependent, colostomy, congestive heart failure, and hypertension. The admission assessment dated [DATE] assessed Resident #6 as alert and oriented to person, place, time and situation. On 07/27/2021 Resident #6's clinical record was reviewed. Observed on the physician's order summary was the following order: .1500ml (milliliters)/day fluid restriction every shift. Order Date: 07/23/2021. Start Date: 07/23/2021 . Observed on the care plans was the following focus area: .The resident has potential fluid deficit/excess r/t (related to) dialysis, non-compliant with fluid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a pressure ulcer dressing change in a manner to prevent infection for one of eighteen residents in the survey sample. Nursing failed to follow infection control practices during a dressing change to Resident #45's pressure ulcers. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included right hip peri-prosthetic fracture, humerus fracture, congestive heart failure, atrial fibrillation, chronic kidney disease, anemia, hypothyroidism and urinary tract infection. The MDS dated [DATE] assessed Resident #45 as cognitively intact. Resident #45's clinical record documented the resident was currently treated for a stage 2 pressure injury on the sacrum and the left buttock. A physician's order dated 7/21/21 required cleansing the pressure ulcers with wound cleanser, Hydrogel to the wound bed, and a silicone foam dressing each day. On 7/28/21 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 observation, staff interview, and clinical record review, the facility staff failed to ensure proper wheelchair positioning for 1 of 18 residents in the survey sample, Resident #36. Resident #36 was observed seated in a wheelchair without footrests and her feet not touching the floor. The findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, hypertension, dysphasia, depression, anxiety, and gastro-esophageal acid reflux (GERD). The most recent Minimum Data Set (MDS) dated [DATE] was a Quarterly assessment and assessed Resident #36 as severely impaired for daily decision making and having long and short term memory problems. Under Section G - Function Status, the MDS assessed Resident #36 requiring extensive assistance with one-person physical assistance for locomotion /mobility with the use of a wheelchair. On 07/27/2021 during the initial tour, Resident #36 was observed seated in her wheelchair in her room. 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 clinical record review, facility document review, and staff interview, the facility staff failed to provide a rational for pharmacy recommendations for 2 of 18 residents in the survey sample, Resident #36 and Resident #24. The facility physician failed to provide a rational for a pharmacy recommendation for Donepezil 10 mg (Aricept) and Memantine 5 mg (Namenda). The facility physician failed to provide a rational for a pharmacy recommendation for Seroquel for Resident #24. The findings include: 1. Resident #36 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, hypertension, dysphasia, depression, anxiety, and gastro-esophageal acid reflux (GERD). The most recent Minimum Data Set (MDS) dated [DATE] was a Quarterly assessment and assessed Resident #36 as severely impaired for daily decision making and having long and short term memory problems. On 07/28/2021 Resident 36's clinical record was reviewed including the pharmacy consultation report for…

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

Based on a medication pass observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 %. A medication pass resulted in two errors out of 27 opportunities for an error rate of 7.41%. The findings include: On 7/27/21 at 3:52 p.m., Licensed Practical Nurse (LPN #3) was observed preparing and administering medications to Resident #46. Included in medications administered to Resident #46 was aspirin 81 mg (milligrams) enteric coated and two tablets of Senna 8.6 mg. Resident #46's clinical record documented a physician's order dated 6/28/21 for aspirin 81 mg chewable to be administered once per day for heart health. The record documented a physician's order dated 6/28/21 for Senna Plus (senna + docusate) 8.6 mg/50 mg with instructions for two tablets to be administered twice per day for constipation prevention. On 7/28/21 at 11:46 a.m., the Registered Nurse Unit Manager (RN #1) was interviewed about orders not followed for the aspirin and Senna during the medication pass to Resident #46. RN #1 reviewed the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during a dressing change for one of eighteen residents in the survey sample, Resident #45. A nurse failed to perform timely hand hygiene and glove changes during a dressing change for Resident #45 and applied topical medication to two wounds using the same applicator. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included right hip peri-prosthetic fracture, humerus fracture, congestive heart failure, atrial fibrillation, chronic kidney disease, anemia, hypothyroidism and urinary tract infection. The MDS dated [DATE] assessed Resident #45 as cognitively intact. Resident #45's clinical record documented the resident was currently treated for a stage 2 pressure injury on the sacrum and the left buttock. A physician's order dated 7/21/21 required cleansing the pressure ulcers with wound cleanser, Hydrogel 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, clinical record review, and staff interview, the facility staff failed to ensure a dignified dining experience for one of 16 residents in the survey sample (Resident #45). Resident #45, who was identified as needing to be fed, was fed by a staff member who stood over the resident while feeding him. The findings include: Resident #45, was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included type 2 diabetes, hypertension, poly-osteoarthritis, hyperlipidemia, dementia with behavioral disturbance, difficulty walking, muscle weakness, lack of coordination, depression, mood disorder, bipolar disorder and benign prostatic hyperplasia (BPH). The most recent minimum data set (MDS) dated [DATE], was a significant change assessment and assessed Resident #45 as being severely cognitive impaired with a score of 0 out of 15. The MDS dated [DATE], under Section G (Functional Status), at item G0110 (H), Eating, assessed Resident #45 as requiring extensive assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to follow physician's orders for two of 16 resident's, Resident's #2 and #37. 1. The facility did not make an orthopedic appointment as ordered by the physician for Resident #2. 2. Resident #37 was not administered calcium carbonate as ordered by the physician. The Findings Include: 1. Resident #2 was admitted to the facility on [DATE]. Diagnoses for Resident #2 included: Muscle Weakness, rheumatoid arthritis, and difficulty walking. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 2/18/19. Resident #2 was assessed as being cognitively intact with a score of 15 of 15. On 03/05/19 at 2:21 PM, Resident #2 was interviewed. When asked about any concerns of pain, Resident #2 verbalized that she has pain to the right knee and it had been going on for quite some time. On 3/6/19 Resident #2's medical chart was reviewed. A physicians progress note dated 2/4/19 documented […

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide supervision for fall prevention for one of 16 residents in the survey sample. Resident #18, with cognitive impairment, poor safety awareness and need for extensive assistance with transfers, fell after being left unsupervised on the commode. The findings include: Resident #18 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #18 included dementia, high blood pressure, glaucoma, right eye blindness, heart disease, anemia, anxiety and cerebral infarction. The minimum data set (MDS) dated [DATE] assessed Resident #18 with severely impaired cognitive skills. MDS assessments dated 1/15/19 and the previous assessment dated [DATE] indicated the resident had impaired vision and required the extensive assistance of one person for toileting. Resident #18's clinical record documented a nursing note dated 12/30/18 stating, Resident had fall in bathroom while attempting to transfer self . 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.