Carlin Springs Health & Rehabilitation

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 ensure one of 29 residents (Resident #100) had physician's orders upon admission, for the immediate care and treatment of a full leg brace and for a deep tissue injury to the resident's left leg. Findings include: Resident #100's diagnoses included, but were not limited to: lung cancer, COPD (chronic obstructive pulmonary disease), anemia, lateral dislocation of left patella, spinal stenosis, high blood pressure, dependence on oxygen, and depression. The most recent MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance from at least one or two staff members for transfers, bed mobility, dressing, toileting and hygiene. The resident was assessed as requiring total assistance for bathing. This MDS documented and assessed 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 a Level I PASRR (preadmission screening and resident review) was completed upon admission for two of 29 residents, Resident #66 and Resident #84. Findings include: 1. Diagnoses for Resident #66 included: Unspecified psychosis, senile degeneration, and cerebral athrosclerosis. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 6/15/22. Resident #66's cognitive score was a 12 indicating cognitively intact. admission date 6/8/21. In Section A1510. Level II Preadmission Screening and Resident Review [PASRR] of the current MDS was blank; none had been marked. In Section I. Active Diagnoses, Resident #66 was assessed as having psychotic disorder. During the LTCSP [long term care survey process] review for Resident #66 on 7/26/22, the resident triggered for 'no PASRR level II with a diagnosis'. On 7/26/22 Resident #66's clinical records were reviewed. Resident #66 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to develop a CCP (comprehensive care plan) for one of 29 residents (Resident #100) regarding a leg brace/knee immobilizer and/or deep tissue injury. Findings include: Resident #100's diagnoses included, but were not limited to: lung cancer, COPD (chronic obstructive pulmonary disease), anemia, lateral dislocation of left patella, spinal stenosis, high blood pressure, dependence on oxygen, and depression. The most recent MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance from at least one or two staff members for transfers, bed mobility, dressing, toileting and hygiene. The resident was assessed as requiring total assistance for bathing. This MDS documented and assessed the resident as non ambulatory during the look back period.…

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 and staff interview, the facility failed for one of 29 residents in the survey sample, Resident # 15, to review and revise the resident's plan of care. Resident # 15's care plan for Foley catheter care was not revised following the discontinuation of the catheter. The findings were: Resident # 15 in the survey sample was admitted with diagnoses that included cerebral infarction, cerebrovascular disease, right side hemiplegia, type 2 diabetes mellitus, anemia, schizophrenia, dysphagia, hypertension, hyperlipidemia, depression, aphasia, urinary retention, acute respiratory failure with hypoxia, metabolic encephalopathy, and generalized muscle weakness. According to an readmission Minimum Data Set with an Assessment Reference Date of 4/28/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Under Section H (Bladder and Bowel), the resident was assessed as having an indwelling catheter. Resident # 15's care plan, created on 4/22/2022, included the following focus (problem),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility failed to ensure showers were being offered or provided for one of 29 resident's in the survey sample. Resident #322 was not offered a shower. The Findings Include: Diagnoses for Resident #322 included: Prostate Cancer, fractured right hip, chronic kidney disease, hematuria, and diabetes. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/22/22. Resident #322's cognitive score was a 15 indicating cognitively intact. On 07/26/22 at 9:05 AM during an interview, Resident #322 was asked if he was receiving baths or showers. Resident #322 responded that he had not had a shower or bath since being admitted (admitted [DATE]) and was unaware that he was allowed to take a shower but would love to get a shower. Resident #322 did not have odor but did have a overgrowth of facial hair. On 7/26/22, review of Resident #322's clinical record documented in section G 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 a medication pass and pour observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure a medication error rate of less than 5 percent. The facility had three errors out of twenty-eight opportunities, which resulted in a medication error rate of 10.7 percent. Findings include: 1. A medication pass and pour observation was conducted with RN (Registered Nurse) #3 on 09/27/22 at approximately 8:45 AM. RN #3 prepared medications for Resident #113. The RN began to prepare medications for Resident #113. The RN stated that the medication 'duloxetine 60 mg (milligrams) daily' was not going to be administered to the resident due to the medication not being on the medication cart. The RN looked at the EMAR (electronic medication administration record) and stated that the medication was ordered yesterday and that she would call the physician to notify that the medication was unavailable and notify the pharmacy to get the medication. The RN prepared 11…

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 ensure expired medications were not readily available for distribution on 1 of 4 med carts reviewed and 1 of 4 med rooms reviewed. Observed on the 3W (3 West) medication cart was one opened bottle of Bisacodyl with a manufacture's expiration date of 02/22 (February 2022) and observed in the refrigerator of the first floor medication room were 9 single does syringes of the Influenza vaccine with an expiration date of 06/30/22. The findings include: 1. On 07/27/22 at 9:43 a.m., a medication storage observation was conducted on the 300 unit with the unit manager (RN #5). Observed on the 3W (3 West) medication cart was an open bottle of Gericare Bisacodyl 5 mg (milligram) 100 tablet (count) with a manufacture's expiration date of 02/22 (February 2022) and a handwritten open date of 04/23/21. On 7/27/22 at 9:50 a.m., RN #5 was interviewed regarding the expired medication. RN #5 was asked how often were the medication carts checked for expired medication. RN # stated, they are normally checked at least monthly, but each…

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

Based on staff interview and clinical record review, and in the coarse of a complaint investigation, the facility staff failed to ensure a complete and accurate clinical record for one of 29 residents, Resident #119. This was a closed record review. The findings included: Diagnoses for Resident #119 included: fracture of left pelvis, hypertension, anxiety disorder, hyperlipidemia, arthritis, and gastric reflux. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 3/7/22. Resident #119's cognitive score was a 15 indicating cognitively intact. Resident #119 was admitted for therapy on 3/1/22 and discharged on 3/14/22. On 7/26/22 while reviewing Resident #119's medical chart specific to a complaint allegation regarding inaccurate medical records of diagnoses and medications, the facilities diagnoses form was reviewed and documentation of a diagnoses of Chronic lymphocytic leukemia of B-cell type in remission and Hypothyroidism did not match the history and physical diagnoses from the hospital, as these diagnoses were not evident…

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, the facility staff failed to ensure policies and procedures were developed and implemented for an effective water management program for the prevention of legionella and other opportunistic pathogens in the facility's water system. Findings included: On 02/05/19 at 7:30 AM, the survey team entered the facility. Upon entry, the water fountain located on the first floor, in front of the main elevators, had a hand written sign laying on top of the fountain, that read: Out of Order-Do Not Use. On 02/05/19 at approximately 3:00 PM, the DON (director of nursing) was asked any information on the water management program. The DON stated that is the maintenance department's area. The DON later presented and binder and stated that this binder contained information regarding the water management program, but the maintenance director would have to speak to the water management program. The water management binder was reviewed and did not contain any type of facility risk assessment for the identification where legionella or other waterborne…

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 review and revise the comprehensive care plan (CCP) for the prevention of falls for two of 33 residents in the survey sample, Resident #129 and Resident #34. 1. The facility staff failed to ensure a comprehensive care plan was reviewed, revised and implemented for interventions and supervision for the prevention of falls, for Resident #129. 2. Resident #34's care plan was not reviewed and revised to included increased interventions/safety measures for her continued wandering, falls, and falls with injury. Findings include: 1. Resident #129 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: history of cerebral infarction (stroke), high blood pressure, hemiplegia and hemiparesis affecting left non dominant side, major depression, partial right nephrostomy, renal cancer and hypothyroidism. The most recent full assessment for Resident #129 was a 14 day admission MDS (minimum data set)…

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 in the coarse of a complaint investigation, the facility failed to ensure appetizing food temperatures. The staff served food on the third floor unit that was less than appetizing in temperature. The findings include: Resident #50 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: End stage renal disease with hemodialysis, depressive disorder, hypertension and COPD (chronic obstructive pulmonary disease). An annual MDS (minimum data set) with an ARD (assessment reference date) of 12/11/2018, assessed Resident #50 as cognitively intact with a cognitive summary score of 15. Resident #50 interviewed on 2/5/19 at 7:55 AM, regarding food. Resident #50 stated that breakfast will not arrive until about 10:00 a.m; We are at the end of the line, the room next to me is last and I am next to last. Asked if food was hot when he got it, stated, No. On 2/6/19 at 8:50 AM, a test tray was performed for the third floor main unit as follows: At 8:50…

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, staff interview, and review of facility policies, the facility failed to store food in a sanitary manner in the main kitchen. The findings include: The initial tour of the kitchen was conducted on 02/05/19 at 7:45 a.m. A dietary aide, identified as OS#9 accompanied this surveyor during the tour. In the walk-in refrigerator was an opened pack of hot dogs laying on a flat pan. The package was not sealed or marked with an open date. OS#9 stated, I am not sure when these were opened. I was off yesterday. A stand alone refrigerator labeled Cooks Box II was observed. A metal container that contained spicy green peppers was loosely covered with plastic wrap, dated 1/29. A small plastic baggie contained chopped onion without a date and a partially cut whole onion was laying on top of this baggie without any covering or date. OS#9 went to OS#8 (the morning cook) and asked her when these items had been opened. OS#8 gave OS #9 dates. OS#9 wrote those dates on the opened, undated containers and placed them back into the refrigerator. A second stand alone refrigerator…

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 identification of Immediate Jeopardy and Substandard Quality of Care, as well as observations and staff interviews, the facility Administrator failed to exercise due diligence in the day-to-day operation of the facility. The Administrator failed to ensure a paraplegic smoker was assessed for safe smoking, failed to ensure the resident was care planned for smoking, and failed to ensure the resident was supervised during smoking. In addition, door alarms in the building were sounding without a response from the staff. The Administrator failed to ensure there was a specific policy in place that provided staff with direction as to how to respond to door alarms. The findings were: 1. During the survey, a female paraplegic resident was identified as a smoker. Thorough review of the resident's clinical record revealed she had not been assessed for safe smoking. She was not identified on her most recent Minimum Data Set as using tobacco, and she had not been care planned for smoking. The resident was observed in a smoking area located outside the main Dining Room without 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.

Based on staff interview and facility document review, the facility staff failed to develop and implement an appropriate plan of action for an identified quality deficiency regarding smoking. The facility QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) committee failed to develop and implement an appropriate plan of action for an identified deficiency with residents' smoking; the facility failed to ensure that an action plan was in place to ensure safe smoking for residents. Findings included: The administrator was interviewed 2/07/19 at 9:14 a.m. He was asked if the QAA committee had identified any problems with the smokers who should have direct supervision. He stated When I came here we put together the smoking times, had meetings with families, residents and activities. Then met with the people who be providing supervision; the expectation was they were to stay out in the smoking area with the residents. On weekends the staff are smokers and they do stay out there with them. One staff member stated they had asthma, and could they stand…

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 observation and staff interview, the facility staff failed for one of 33 residents in the survey sample (Resident #119), to ensure a dignified dining experience during breakfast on 02/5/19. Staff served residents # 105 and # 16 on paper plates on the weekends without a valid reason. The findings include: Resident #119 was admitted to the facility was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included gastroesophageal reflex disease (GERD), peripheral vascular disease, hypertension, hypothyroidism, hyperlipidemia, and dementia without behavioral disturbance. The most recent minimum data set (MDS) dated [DATE] assessed Resident #119 as severally cognitive impaired with a score of 04. A dining observation was conducted on the second floor during breakfast on 02/5/19 at approximately 9:00 a.m. During the observation at 9:13 a.m., Resident #119 was observed seated in the the second floor dining room alone. There were no other residents or staff members in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to ensure a safe, clean, homelike environment on two of seven living units. A mechanical lift, chair scale, and floor scale were stored in the residents' dining/activity room on the 100 unit. This room also had damage along the wall where the equipment was stored and a cabinet door in disrepair. The floor covering in room [ROOM NUMBER] was torn and loose across the entrance to the bathroom. The wall near the first bed in this room had widespread vertical scrapes with torn wallpaper. In room [ROOM NUMBER], the drywall behind the bed was in disrepair and the coaxial cable cover was not mounted to the wall. The findings include: 1. On 2/5/19 at 7:39 a.m., the dining/activity room on the 100 unit was inspected. A mechanical lift and chair scale were stored along the left wall near entrance to the room. A floor scale was positioned on the wall across from the doorway. The left wall where the lift and chair scale were stored had widespread scrapes 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 observation, staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment was completed for one of 33 residents in the survey sample, Resident #21. Resident #21's MDS assessment did not accurately reflect the resident's status regarding dental health. Findings include: Resident #21 was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. Diagnoses for Resident #21 included, but were not limited to: anemia, high blood pressure, PVD (peripheral vascular disease), renal failure dependent upon hemodialysis, DM (diabetes mellitus), depression, and bilateral AKA (above the knee amputations.) The most current full MDS (minimum data set) was an annual assessment dated [DATE], which assessed the resident as 99 cognitively, indicating the resident was unable to complete the interview; the resident was assessed with short term memory impairment with modified independence in daily decision making skills. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 32 residents, Resident #117 and Resident #50. 1. Resident #117 did not have a comprehensive care plan to address smoking. 2. Resident #50 did not have a care plan for the use of oxygen. Findings were: 1. Resident #117 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Paraplegia, acute kidney failure, hypertension, chronic obstructive pulmonary disease, and neuromuscular dysfunction of the bladder (requiring indwelling catheterization). A significant change MDS (minimum data set) with an ARD (assessment reference date) of 1/14/2019, assessed Resident #117 as cognitively intact, with a summary score of 15. Section J: Health Conditions, J1300 Tobacco Use was checked No. In the course of the survey process a list of residents who smoke was requested from the administrative staff. Resident #117 was identified on 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, for one of 33 residents in the survey, to ensure a nurse was knowledgeable of the resident's resuscitation status. A nurse caring for Resident #101 stated the resident's resuscitation status was a DNR (do not resuscitate) when the resident was actually a full code, requiring resuscitation in case of cardiac arrest. The findings include: Resident #101 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, tachycardia, congestive heart failure, high blood pressure, deep vein thrombosis, anxiety, depression and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed Resident #101 with short and long-term memory problems and severely impaired cognitive skills. The first page of Resident #101's clinical record stored on the unit documented a Durable Do Not Resuscitate Order (DDNR) dated and signed by the physician on 1/12/19. The record documented a physician's progress note dated 1/12/19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, the facility staff failed to ensure two of 33 residents (Resident #119 and Resident #45) were provided with care and services to carry out activities of daily living (ADL's). 1. The facility staff failed to provide Resident #119 with feeding assistance during a breakfast meal service. 2. The facility staff failed to provide Resident #45 with nail care. The findings include: 1. Resident #119 was admitted to the facility was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included gastroesophageal reflex disease (GERD), peripheral vascular disease, hypertension, hypothyroidism, hyperlipidemia, and dementia without behavioral disturbance. The most recent minimum data set (MDS) dated [DATE] assessed Resident #119 as severally cognitive impaired with a score of 04. A dining observation was conducted on the second floor during breakfast on 02/5/19 at approximately 9:00 a.m. During the observation at 9:13 a.m., 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 medication pass and pour observation, staff interview, resident interview and clinical record review, the facility staff failed to administer medications per physician order. Resident #117's Symbicort inhaler was not administered per physician orders. Findings were: Resident #117 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Paraplegia, acute kidney failure, hypertension, chronic obstructive pulmonary disease, and neuromuscular dysfunction of the bladder (requiring indwelling catheterization). A significant change MDS (minimum data set) with an ARD (assessment reference date) of 1/14/2019, assessed Resident #117 as cognitively intact, with a summary score of 15. On 02/05/2019 at approximately 8:15 a.m., a medication pass and pour observation was conducted with LPN (Licensed practical nurse) #3 on the third floor. LPN #3 prepared morning medications for Resident #117, which included but were not limited to: Spiriva 18 mcg inhaler (2 puffs), Symbicort 160-4.5 mcg…

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, resident interview and clinical record review, the facility staff failed to provide care and services related to a Foley catheter for one of 16 residents, Resident #116. Resident #116 did not have orders for an indwelling catheter, the catheter was not care planned, the catheter was not anchored, and when the facility staff anchored the catheter it was not done per manufacturer's recommendations. Findings were: Resident #116 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. His diagnoses included but were not limited to: dysphagia, chronic kidney disease, congestive heart failure, hypertension, diabetes mellitus, obstructive and reflux uropathy, and vascular dementia. A significant change MDS (minimum data set) with an ARD (assessment reference date) of 01/22/2019, assessed Resident #116 as severely impaired with a cognitive summary score of 06. On 03/26/2019 at approximately 08:05 a.m., during initial tour of the facility, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure oxygen administration was properly administered for one of 33 residents (Resident #19) and failed to obtain an oxygen order for one of 33 residents (Resident # 50). 1. The facility staff failed to administer oxygen appropriately via trach for Resident #19. 2. Resident #50 did not have a physician's order for the use of oxygen. Findings include: 1. Resident #19 was originally admitted to the facility on [DATE]. The most current readmission was on 12/13/17. Diagnoses for Resident #19 included, but were not limited to: anoxic brain injury/damage resulting in a persistent vegetative state, gastronomy tube, aphasia, anemia, high blood pressure, tracheostomy with continuous oxygen use, and intermittent asthma. The most current full MDS (minimum data set) assessment dated [DATE] documented the resident as being in a persistent vegetative state. The resident was totally dependent upon at least…

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 failed to ensure expired medications were not available for use on one of five medication carts inspected. A vial of Lantus insulin, opened for more than 28 days, was available for use on a third floor medication cart. The findings include: On 2/5/19 at 3:45 p.m., accompanied by licensed practical nurse (LPN) #9, a medication cart on the third floor unit was inspected. A vial of Lantus insulin marked as opened on 12/14/18 was stored and available for use on this cart. LPN #9 was interviewed at this time about the insulin that had been opened for 52 days. LPN #9 stated he thought the insulin was to be discarded 28 days after opening. LPN #5 stated the insulin was for a current resident in the facility. The manufacturer's label on the vial of Lantus insulin was printed with instructions to discard after 28 days from initial use. On 2/6/19 at 11:00 a.m., the corporate nursing consultant was interviewed about a facility or company policy related to insulin storage. The nursing consultant stated they did not have a policy about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure routine and emergency dental services for one of 33 residents in the survey sample, Resident #21. The facility did not provide routine and/or emergency dental services to Resident #21. Resident #21 had poor dental health and had not been seen by a dentist. The resident began having dental pain and was prescribed an antibiotic without being seen by a dentist and/or a physician; no followup care was provided. Findings include: Resident #21 was admitted to the facility originally on 02/28/11, with the most current readmission on [DATE]. Diagnoses for Resident #21 included, but were not limited to: anemia, high blood pressure, PVD (peripheral vascular disease), renal failure dependent upon hemodialysis, DM (diabetes mellitus), depression, and bilateral AKA (above the knee amputations.) The most current full MDS (minimum data set) was an annual assessment dated [DATE], which assessed 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 and facility document review, the facility staff failed to ensure no more than 14 hours elapsed between the evening meal and breakfast, and failed to offer a nourishing bedtime snack on one of seven units, three main. Findings were: Resident #50 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: End stage renal disease with hemodialysis, depressive disorder, hypertension and COPD [chronic obstructive pulmonary disease]. An annual MDS (minimum data set) with an ARD (assessment reference date) of 12/11/2018, assessed Resident #50 as cognitively intact with a cognitive summary score of 15. During initial tour of the facility on 02/05/2019 at approximately 7:55 a.m., Resident #50 was observed sitting in his room. He was interviewed regarding life at the facility. During the interview, Resident #50 was asked if he was waiting on breakfast. He stated, It will be two hours before I see my breakfast. He was asked to explain.…

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, resident interview, and staff interview, the facility staff failed for one of 24 residents in the survey sample (Resident # 17) to develop a plan of care that included non-pharmacological interventions to address pain control for the resident. The findings were: Resident # 17 in the survey sample, a [AGE] year-old male, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included rheumatoid arthritis, gastroesophageal reflux disease, anemia, rheumatoid lung disease, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, status post right below the knee amputation, and sleep apnea. According to the most recent Minimum Data Set, with an Assessment Reference Date of 9/29/17, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 14 out of 15. According to Resident # 17's electronic clinical record, he takes two medications, Oxycodone 5 mg…

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 facility document review, the facility failed to ensure staff members were knowledgeable of emergency procedures. One of 8 employees interviewed were not familiar with protocols for power outage and/or fire emergencies. The findings include: On 10/03/17 at approximately 11:15 p.m., the facility was contacted by telephone to conduct interviews regarding abuse policies and emergency preparedness. CNA (Certified nursing assistant) #1 was interviewed about her role if there was a fire or power outage. CNA #1 stated that she was hired on 08/10/2017 and had not worked at the facility very long. She was asked if she had received training during orientation regarding power outages and fires. She stated that she probably did, but she had gone over a lot of information at the time of her hire. CNA #1 was asked if she knew whether or not the facility had a generator. She stated, I think we do. She was asked if she know how long it took the generator to come on in the event of a power outage, 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.