Rose Hill Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 13 residents were free of significant medication errors, Residents #7 and Resident #10. The findings include: 1. For Resident #7, the facility staff failed to administer Lantus Insulin on 10/27/2023 and the resident's blood sugar was elevated the next morning. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/7/2023, the resident scored a five out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving insulin injections for seven days of the look back period. The physician order dated, 8/17/2023, documented, Lantus Subcutaneous Solution (1) 100 UNIT/ML (milliliters); Inject 34 units subcutaneously two times a day for diabetes. The October 2023 MAR (medication…

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

Based on resident interview, staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 13 residents in the survey sample, Resident #3. The findings include: For Resident #3, the facility staff failed to document accuracy of a podiatrist visit. The nurse's note dated 11/1/2023 at 4:53 p.m. documented, Resident received routine podiatry care on 10/31/23. A request was made for the copy of the podiatry note dated, 10/31/2023 on 12/12/2023 at 11:14 a.m. An interview was conducted with OSM (other staff member) #1 on 12/12/2023 at 12:32 p.m. OSM #1 informed this writer that Resident #3 was not seen by the podiatrist on 10/31/2023. The resident was scheduled to be seen on 11/15/2023 but due to COVID-19, the resident was not seen. OSM #1 stated the resident has not been seen by the podiatrist since September of 2023. When asked if this documentation is accurate in this resident's medical record, OSM #1 stated she doesn't know why the documentation is in (Resident #3)'s medical record. ASM #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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent with residents upon transfer to the hospital for four of 35 residents, Residents #45, #102, #43 and #89. The findings include: 1. For Resident #45 (R45), the facility staff failed to evidence the required documents were sent with the resident upon transfer to the hospital on 3/11/2023 and 4/9/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. The nurse's note dated 4/8/2023 at 6:41 p.m. documented in part, FSBS (fingerstick blood sugar) is 516. Awaiting return call and orders from on call services. The nurse's note dated 4/12/2023 at 3:54 p.m. documented in part, Resident returned from (initials of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to notify the Office of the State Long-Term Care Ombudsman and the resident and/or responsible party of a transfer to the hospital for four of 35 residents in the survey sample, Residents #45, #102, #43, and #89. The findings include: 1. For Resident #45 (R45), the facility staff failed to notify the ombudsman of transfers to the hospital on 3/11/2023 and 4/12/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. The nurse's note dated 4/8/2023 at 6:41 p.m. documented in part, FSBS (fingerstick blood sugar) is 516. Awaiting return call and orders from on call services. The nurse's note dated 4/12/2023 at 3:54 p.m. documented in part, Resident returned from…

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 3. For Resident #76 (R76), the facility staff failed to develop a care plan to address the resident's smoking. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 5/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as only requiring supervision after set up assistance if needed. An interview was conducted with R76 on 6/27/2023 at approximately 1:30 p.m. When asked if he goes out to smoke, R76 stated he goes out about three times a day for smoking and does go out other times just to walk. R76 was asked who keeps his cigarettes, R76 stated they are kept in the social workers office during the week, but the nurses have them on the weekends and after the social worker goes home. When asked where he smokes since this is a non-smoking facility, R76 stated he walks to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete smoking assessments for four of 35 residents in the survey sample, Residents #76, #38, #67, and #307. The findings include: 1. For Resident #76 (R76), the facility staff failed to complete a safe smoking assessment. During the entrance conference on 6/27/2023 at approximately 10:20 a.m. a request was made for the list of smokers. ASM (administrative staff member) #1, the executive director, presented a list of residents that smoke but stated they are a non-smoking facility. ASM #1 stated when he came, he found out that residents were going outside to smoke. He then asked where the residents keep their cigarettes and lighters and found out the residents were keeping them in their rooms. He immediately removed them from the resident rooms, and they are kept by the staff, locked up. ASM #1 stated they were in the process of assessing the residents to see if they were capable of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of medication treatment for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to inform the resident/resident representative of the risks and benefits for the use of the anti-psychotic medication Seroquel (1). R5 was re-admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder and a physician's order for Seroquel 50 mg (milligrams) in the morning and 25 mg in the evening. A review of R5's clinical record failed to reveal that the facility staff informed the resident or the resident's representative of the risks and benefits for the use of Seroquel. On 6/29/23 at 9:38 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that any time anti-psychotic medication is initiated, the staff should ask the resident or resident representative to sign 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 family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to invite the responsible party to the care plan meeting for one of 35 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100) the facility staff failed to invite the family member/responsible party, to the care plan meeting held on 6/6/2023. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/5/2023, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. An interview was conducted on 6/27/2023 at approximately 1:00 p.m. with the family member/responsible party of R100. The family member stated she was told she would have monthly meetings with the facility regarding her father's plan of care, but she hadn't had any and her father had been there since 5/26/2023. The progress note dated, 6/6/2023 at 1:15 p.m. documented, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to conduct a periodic review of advance directives with residents and/or their RRs (resident representatives) to determine if they wished to make changes to their existing advance directives or maintain them as written, for two of 35 residents in the survey sample, Residents #36 and #2. The findings include: 1. For Resident #36 (R36), the facility staff failed to conduct a periodic review of the resident's advance directives (1). R36 was admitted to the facility on [DATE]. A review of R36's clinical record revealed medical power of attorney and durable power of attorney documents dated 3/15/2015. Further review of R36's clinical record failed to reveal a periodic review of all aspects of advance directives was conducted with R36 or the resident's representative. On 6/28/23 at 3:41 p.m., an interview was conducted with OSM (other staff member) #3 (the director of social services). OSM #3 stated she holds an…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a possible need to alter treatment for two of 35 residents in the survey sample, Residents #51 and #2. The findings include: 1. For Resident #51 (R51), the facility staff failed to notify the physician when the medication Pradaxa (1) was not administered on 6/12/23 and 6/13/23. A review of R51's clinical record revealed a physician's order dated 12/3/19 for Pradaxa 150 mg (milligrams) two times a day for atrial fibrillation. A review of R51's June 2023 MAR (medication administration record) revealed the same physician's order for Pradaxa. On 6/12/23 and 6/13/23, the MAR documented the code, 7=Other/See Nurse Notes. Nurses' notes dated 6/12/23 and 6/13/23 documented, Medication on order from pharmacy. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that Pradaxa was administered to R51 on 6/12/23 and 6/13/23, and failed to reveal documentation that R51's physician was notified. On 6/28/23 at 4:18 p.m., an interview was…

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

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 35 residents in the survey sample, Resident #51. The findings include: For Resident #51 (R51), the facility staff failed to maintain the resident's room in a clean and homelike manner. Dirt and debris were observed on the resident's floor and bed frame on 6/27/23 and on 6/28/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. On 6/27/23 at 11:39 a.m. and 6/28/23 at 9:12 a.m., observation of R51's room was conducted. The floor on the right side of the bed and under the bed contained dirt, multiple plastic medication cups, scraps of paper and a dried, brown, smeared substance. A dried brown substance, a dried orange substance and a macaroni noodle was observed on the bed frame. On 6/28/23 at 9:12 a.m., an interview…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer to the hospital for two of 35 residents in the survey sample, Residents #45 and #89. The findings include: 1. For Resident #45 (R45) the facility staff failed to provide a bed hold notice upon transfer on 3/11/2023 and 4/9/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. The nurse's note dated 4/8/2023 at 6:41 p.m. documented in part, FSBS (fingerstick blood sugar) is 516. Awaiting return call and orders from on call services. The nurse's note dated 4/12/2023 at 3:54 p.m. documented in part, Resident returned from (initials of hospital). There was no further documentation related to the 4/9/2023 transfer to the hospital. On 6/28/23, a request was made for the bed hold…

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

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to code the resident's significant weight loss on the quarterly MDS assessment with an ARD (assessment reference date) of 4/28/23. A review of R5's clinical record revealed the resident weighed 163.8 pounds on 10/4/22 and weighed 138 pounds on 4/12/23. A note signed by the registered dietitian on 4/18/23 documented R5 presented with a weight loss of 15.9 percent in the last 180 days. Section K of R5's quarterly MDS with an ARD of 4/28/23 documented no weight loss of ten percent or more in the last six months. On 6/29/23 at 9:09 a.m., an interview was conducted with RN (registered nurse) #3 (the MDS coordinator). RN #3 stated R5 clearly had a weight loss, and this should have been coded on the 4/18/23 MDS assessment. RN #3 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (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.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to clarify a physician order for the diagnosis for the use of Seroquel, for one of 35 residents in the survey sample, Resident #157. The findings include: For Resident #157 (R157) the facility staff failed to clarify the diagnosis in a physician order for Seroquel, an antipsychotic medication. The physician order dated, 6/23/2023, documented, Seroquel (1) 25 mg (milligrams) po (by mouth) TID (three times a day) 8 am, 2 pm, 8 pm. DX (diagnosis): 0.3.90. An interview was conducted with RN (registered nurse) #2, on 6/29/2023. When asked what Seroquel is used for, RN #2 stated, It's used to calm people down. Off label, it's used for sleep. It's an antipsychotic medication. The above order was reviewed with RN #2. RN #2 was asked if they knew the diagnosis for the use of the Seroquel, RN #2 stated they didn't know what that meant. When asked if this order should be clarified, RN #2 stated, yes. Review of the electronic and paper medical record, failed to evidence…

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 family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to consistently provide ADL (activities of daily living) care for one of 35 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100), the facility staff failed to provide bathing/showers twice a week from 5/26/2023 through 6/28/2023. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/5/2023, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section G - Functional Status, R100 was coded as not received any bathing during the look back period. The resident was coded as requiring extensive assistance of two to three staff members for toileting and limited assistance of one staff member for personal hygiene. An interview was conducted on 6/27/2023 at approximately 1:00 p.m. with the family member/responsible party of R100. The…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to monitor a resident's weight for one of 35 residents in the survey sample, Resident #12. The findings include: For Resident #12 (R12), the facility staff failed to obtain physician ordered weekly weights. The weekly weights were ordered due to a significant weight loss. Review of R12's clinical record revealed a note signed by the registered dietician on 3/7/23 that documented, Summary: Significant wt (weight) loss -5% x 30 days and-9% x 90 days. PO (By mouth) intake is sufficient to meet EEN at this time. BMI (Body Mass Index) is WNL (Within Normal Limits), but on the lower end of normal (18.9-24.9 is normal). Interventions in place for wt loss. Recommend increasing fortified foods to TID (three times a day) with all meals and weekly wt x 1 month. RD (Registered Dietician) will continue to monitor. Further review of R12's clinical record revealed a physician's order dated 3/13/23 for weekly weights for one month due to significant weight loss. A review of R12's weights 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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of communication to the dialysis center for one of 35 residents in the survey sample, Resident #45. The findings include: For Resident #45, the facility staff failed to evidence communication with the dialysis center every time the resident went to dialysis. The physician order dated, 5/17/2023 documented, Dialysis (name, address and phone number of dialysis center) MWF (Monday/Wednesday/Friday) one tine a day every Mon, Wed, Fri related to end stage renal disease. Chair time 12:45 p.m. until 17:00 p.m. (5:00 p.m.). The review of the clinical record failed to evidence communication with the dialysis center on the following dates: May 2023: 5/17/2023, 5/19/2023, 5/26/2023, 5/29/2023 and 5/31/2023. June 2023: 6/2/2023, 6/5/2023, 6/7/2023, 6/9/2023, 6/12/2023, 6/14/2023, 6/16/2023, 6/19/2023, 6/23/2023, and 6/26/2023. The comprehensive care plan dated, 12/12/2022, documented in part, Focus: Alteration in Kidney Function due to end stage renal…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure residents were assessed for, informed of risk and benefits of, and signed a consent for the use of siderails/bedrails for two of 35 residents in the survey sample; Residents #40 and #96. The findings include: 1. For Resident #40, the facility staff failed to ensure that the resident was informed of the risk and benefits of, and signed a consent for the use of siderails prior to using them. On 6/28/23 at 8:35 AM, Resident #40 was observed in bed, with the head of his bed elevated and the siderails were up on both sides. A review of the clinical record revealed that on 4/14/23, the therapy department had assessed Resident #40 for the use of siderails and determined that they were necessary for the resident for increased safety and independence for bed mobility. Further review of the clinical record failed to reveal any evidence of risk and benefits of the use of siderails (i.e., entrapment) was provided to Resident #40, and there was…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration for two of 35 residents in the survey sample, Residents #51 and #2. The findings include: 1. For Resident #51 (R51), the facility staff failed to administer the physician ordered medication Pradaxa (1) on 6/12/23 and 6/13/23. A review of R51's clinical record revealed a physician's order dated 12/3/19 for Pradaxa 150 mg (milligrams) two times a day for atrial fibrillation. A review of R51's June 2023 MAR (medication administration record) revealed the same physician's order for Pradaxa. On 6/12/23 and 6/13/23, the MAR documented the code, 7=Other/See Nurse Notes. Nurses' notes dated 6/12/23 and 6/13/23 documented, Medication on order from pharmacy. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that Pradaxa was administered to R51 on 6/12/23 and 6/13/23. A review of the facility backup medication supply list revealed Pradaxa was not stocked in the supply. On 6/28/23 at 4:18 p.m., an…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 35 residents in the survey sample was free from a significant medication error; Resident #51. The findings include: For Resident #51 (R51), the facility staff failed to administer the physician ordered medication Pradaxa (1) on 6/12/23 and 6/13/23 used for the treatment of atrial fibrillation. A review of R51's clinical record revealed a physician's order dated 12/3/19 for Pradaxa 150 mg (milligrams) two times a day for atrial fibrillation. A review of R51's June 2023 MAR (medication administration record) revealed the same physician's order for Pradaxa. On 6/12/23 and 6/13/23, the MAR documented the code, 7=Other/See Nurse Notes. Nurses' notes dated 6/12/23 and 6/13/23 documented, Medication on order from pharmacy. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that Pradaxa was administered to R51 on 6/12/23 and 6/13/23. A review of the facility backup medication supply list revealed Pradaxa was not stocked in the supply. 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.

Based on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in one of one resident dining rooms. The findings include: The facility staff assembled a resident's hamburger and cut it in half using their bare hands. On 06/27/2023 at approximately 12:40 p.m., an observation of the facility's dining room during the lunch meal was conducted. CNA (certified nursing assistant) #1 was observed with bare hands, to place the top of a hamburger roll on a hamburger, then held the hamburger together and cut it in half with a knife. On 06/27/23 at approximately 2:23 p.m., an interview was conducted with CNA #1. After being informed of the observation, CNA #1 stated that recalled the incident and that she should have been wearing gloves. When asked why it was important to wear gloves when handling a resident's food CNA #1 stated that it would prevent cross contamination. The facility policy titled, Meal Distribution documented, 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician documentation of the rationale for and/or failed to provide all required documentation to the receiving facility for transfer to the hospital for five of 46 residents in the survey sample; Residents #91, #49, #26, #29 and #13. 1. The facility staff failed to evidence the physician wrote a note regarding the reason for Resident #91's hospital transfer on 10/26/21, and that all required documentation was provided to the receiving facility. 2. The facility staff failed to evidence the physician wrote a note regarding the reason for Resident #49's hospital transfer on 8/19/21 and 9/1/21, and that all required documentation was provided to the receiving facility for both transfers. 3. The facility staff failed to evidence that all required documentation was provided to the receiving facility when Resident #26 was transferred to the hospital on 9/15/21 and 11/4/21. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the Ombudsman and/or Resident Representative upon a hospital transfer for six of 46 residents in the survey sample; Residents #91, #49, #26, #29, #13 and #100. The facility staff failed to evidence that written notification was provided to the resident representative and Ombudsman for Resident #91's hospital transfer on 10/26/21, Resident #49's hospital transfers on 8/19/21 and 9/1/21, Resident #26's hospital transfer on 9/15/21 and 11/4/21, Resident #29's hospital transfer on 10/23/2021, Resident #13's hospital transfer on 8/19/21, and Resident #100's hospital transfer on 11/1/2021. The findings include: A review of the facility policy, Transfer a Resident to a Hospital documented in part, 6. Notify the family or responsible party of the pending transfer, and the reasons for the move 13. Write discharge note.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or resident representative prior to and or at the time of transfer to the hospital for three of 46 residents in the survey sample; Residents #49, #26 and #68. The facility staff failed to evidence that a written bed hold notice was provided to the resident and or resident representative for the hospital transfers of Resident #49 on 8/19/21 and 9/1/21, Resident #26 on 9/2/2021 and Resident #68 on 10/27/21. The findings include: A review of the facility policy, Transfer a Resident to a Hospital documented, Emergency Transfer 9. Send a copy of Bed Hold Policy and Involuntary Transfer form with the resident. 1. Resident #49 was admitted to the facility on [DATE] with the diagnoses of but not limited to congestive heart failure, chronic obstructive pulmonary disease, dementia, chronic kidney disease, morbid obesity,…

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

Based on observation, staff interview and facility document review it was determined that the facility staff failed to ensure medications were labeled and stored in a secure manner in two of four medication carts, (South Wing medication cart-one and South Wing medication cart-three). Observation of the South wing medication cart-one revealed two half-loose unidentified pills in drawer one, three whole-loose unidentified pills in drawer three and one whole-loose unidentified pill in drawer four of the medication cart. Observation of the South wing-cart three revealed, one whole-loose unidentified pill in drawer two, two half and one-loose unidentified pills in drawer three of the medication cart. The findings include: On 11/29/21 at approximately 5:35 PM, an observation of South wing-medication cart-one was conducted with LPN (licensed practical nurse) #5. Observation inside the drawers of South wing-medication cart-one revealed the following: -Drawer one: two half-loose unidentified pills. -Drawer two: three whole-loose unidentified pills. -Drawer four: one whole-loose unidentified…

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

Based on observation, staff interview, and facility document review it was determined that the facility staff failed to store food in two of two nourishment rooms in accordance with professional standards for food service safety. The findings include: A. The facility failed to properly label and date resident food items on the North unit nourishment room. On 11/30/2021 at 8:45 a.m., an observation was conducted of the nourishment room on the north unit. Observation of the refrigerator revealed a salad in a plastic container with no date or name, a 31 ounce container of spinach artichoke parmesan dip without a name or date, a container of an unidentified green paste without a name or date, two plastic food containers undated without names and a foil packet with the contents not visible and no date or name on them. Further observation revealed a pitcher of an orange colored liquid approximately 1/4 full without a cover, label identifying the contents or a date. Observation of the freezer revealed one ham and cheddar hot pocket without a name or date and a frozen meal out of it's box…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to maintain an effective Quality Assurance program. The facility staff failed to ensure the physician attended quarterly quality assurance meetings for three of three quarters The findings include: On 12/02/2021 at approximately 10:30 a.m., a review of the facility, QAPI [quality assurance performance improving] Meeting sign-in sheets dated April 2021 through October 2021 failed to evidence the signature of the facility's medical director. On 12/02/2021 at approximately 10:45 a.m., an interview was conducted with ASM [administrative staff member] # 1, interim administrator, regarding the missing signature of the medical director for the dates listed above. When asked about the missing signature of the facility's medical director ASM # 1 stated that they did not have any evidence that the medical director had attended. The facility's policy Quality Assurance Improvement Process documented in part, Procedure: 1. The committee may consist of: A. Medical Director. B. Administrator. C.…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to respond to a grievance expressed during a resident council meeting for one of three resident council meetings reviewed. The facility staff failed to ensure a concern expressed regarding laundry during the August 2021 resident council meeting was responded to and addressed. The findings include: A review of Resident Council Minutes from August 2021 revealed the following entry: Residents complained that laundry isn't coming back and or they are getting the wrong clothing items. On 12/1/21 at 4:50 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #4, the regional director of clinical operations, and ASM #5, the regional vice president of operations, were informed of these concerns. Evidence that the concern regarding laundry had been addressed and resolved was requested. On 12/2/21 at 8:56 a.m., ASM #1 presented a facility concern form. This form stated: 7/13/21 Resident Council .Documentation of Concern: 10 residents…

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, facility document review and staff interview it was determined that the facility staff failed to notify the physician that a resident's medications were not available for administration for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to notify Resident # 201's physician that the medications, metoprolol, zestoretic, gabapentin, glimepiride, and ozempic, were not available for administration on 05/22/2021 and 05/23/2021. The findings include: Resident # 210 was admitted to the facility with diagnoses that included but were not limited to: breast cancer, pain, diabetes mellitus [6] and kidney disease, high blood pressure. Resident # 201's MDS (minimum data set), an admission 5-day assessment with an ARD (assessment reference date) of 05/24/2021 coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of Resident #201's clinical record revealed a physician's order dated 5/21/21, signed by the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for one of 46 residents in the survey sample, Resident #7. The facility staff failed to implement the facility abuse policy for investigating and reporting an injury of unknown origin when Resident #7 sustained a bruise on 8/5/21. The findings include: The facility policy titled, Resident Abuse- Injuries of Unknown Origin documented, 4. The Administrator, Director of Nursing, or their designee, must begin a documented investigation for the cause of the injury. 5. The investigation will include interviews with the resident, all staff involved (directly or indirectly), any family, visitors or volunteers which may have had contact with the resident and may help with the investigation. Obtain written statements as deemed necessary. 7. All injuries of unknown origin must be reported to the appropriate agencies per state specific protocols . Resident #7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an injury of unknown origin for one of 46 residents in the survey sample, Resident #7. Resident #7 sustained a bruise of unknown origin on the right arm extending from the shoulder to elbow that was found on 8/5/21. The facility staff failed to report this injury of unknown origin to the SA (state agency) and other required agencies. The findings include: Resident #7 was admitted to the facility on [DATE]. Resident #7's diagnoses included but were not limited to diabetes, paralysis and dementia. Resident #7's five day Medicare minimum data set assessment with an assessment reference date of 11/11/21, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #7 as requiring extensive assistance of two or more staff with bed mobility. Review of Resident #7's clinical record revealed a nurse's note dated 8/5/21 and signed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate an injury of unknown origin for one of 46 residents in the survey sample, Resident #7. Resident #7 sustained a bruise of unknown origin on the right arm extending from the shoulder to elbow on 8/5/21. The facility staff failed to complete a thorough investigation to determine the cause of the bruise. The findings include: Resident #7 was admitted to the facility on [DATE]. Resident #7's diagnoses included but were not limited to diabetes, paralysis and dementia. Resident #7's five day Medicare minimum data set assessment with an assessment reference date of 11/11/21, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #7 as requiring extensive assistance of two or more staff with bed mobility. Review of Resident #7's clinical record revealed a nurse's note dated 8/5/21 and signed by LPN (licensed practical nurse)…

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 and staff interview, it was determined that the facility staff failed to ensure an accurate MDS [minimum data set] assessment for one of 46 residents in the survey sample, Resident # 86. The facility staff failed to code Resident # 86 for the use of oxygen in Section O Special Treatments on the residents 5 day MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/05/2021. The findings include: Resident # 86 was admitted to the facility with diagnoses that included but were not limited to: shortness of breath, respiratory failure [1], and congestive heart failure [2]. Resident # 86's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 11/05/2021, coded Resident # 86 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs failed to code Resident # 86 for the use of oxygen. On 11/29/21 at approximately 3:45 P.M., 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 staff interview and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 46 residents in the survey sample, Resident # 62. The facility staff failed implement Resident # 62's comprehensive care plan to keep the catheter collection bag off the floor and failed implement Resident # 62's comprehensive care plan to administer oxygen at two liters per minute. The findings include: Resident # 62 was admitted to the facility with diagnoses that included but were not limited to: obstructive uropathy [1]. Resident # 62's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/02/2021, coded Resident # 62 as scoring a 9 [nine] on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 - being moderately impaired of cognition for making daily decisions. Section H Bladder and Bowel coded Resident # 62 as having an indwelling catheter. Observations of Resident # 62 on 11/30/21 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 facility document review it was determined facility staff failed to review and revise the comprehensive care plan for three of 46 residents in the survey sample, Resident #3, Resident #31 and Resident #15. 1. The facility staff failed to revise the Resident #3's comprehensive care plan to address the resident beginning a restorative program following completion of physical therapy on 3/26/21. 2. The facility staff failed to review and revise Resident #15's comprehensive care plan to address the administration of an anticoagulant prescribed by the physician on 05/27/2021. 3. The facility staff failed to review and revise Resident #31's comprehensive care plan for the use of bed rails. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: multiple sclerosis (progressive disease in which the nerve fibers of the brain and spinal cord lose their myelin cover) (1), scoliosis (abnormal lateral 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.

Based on clinical record review, facility document review and staff interview it was determined that the facility staff failed to ensure treatment and care in accordance with professional standards of practice, and the comprehensive plan of care for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to administer Gabapentin to Resident #201 on 05/22/2021, according to the physician's orders. The findings include: Resident # 210 was admitted to the facility with diagnoses that included but were not limited to: breast cancer, pain, diabetes mellitus [2] and kidney disease, high blood pressure. Resident # 201's MDS (minimum data set), an admission 5-day assessment with an ARD (assessment reference date) of 05/24/2021 coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of Resident #201's clinical record revealed a physician's order dated 5/21/21 and signed by the physician on 5/24/21 documented in part: Gabapentin Capsule. Give 300 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 observation, resident interview staff interview and facility document review it was determined that the facility staff failed to provide treatment and services to maintain or improve mobility for one of 46 residents in the survey sample, Resident #3. The facility staff failed to implement a RNP (restorative nursing program) for Resident #3 following completion of physical therapy 3/26/21. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: multiple sclerosis (progressive disease in which the nerve fibers of the brain and spinal cord lose their myelin cover) (1), scoliosis (abnormal lateral or sideward curve to the spine) (2) dementia (progressive state of mental decline, including memory function and judgement) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/21, coded Resident #3 as scoring a 14 out of 15 on the BIMS (brief interview for mental…

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, it was determined that facility staff failed to ensure care and services for an indwelling catheter to prevent infection for one of 46 residents in the survey sample, Residents # 62. The facility staff failed to keep Resident # 62's catheter collection bag off the floor. The findings include: Resident # 62 was admitted to the facility with diagnoses that included but were not limited to: obstructive uropathy [1]. Resident # 62's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/02/2021, coded Resident # 62 as scoring a 9 [nine] on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 - being moderately impaired of cognition for making daily decisions. Section H Bladder and Bowel coded Resident # 62 as having an indwelling catheter. On 11/30/21 at approximately 8:45 a.m., an observation of Resident # 62's catheter collection bag revealed it was lying on the floor next 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.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory services according to the physician's orders one of 46 residents in the survey sample, Residents # 62. The facility staff failed to administer Resident # 62's oxygen at two liters per minute according to the physician's orders. The findings include: Resident # 62 was admitted to the facility with diagnoses that included but were not limited to: respiratory failure [1] and chronic obstructive pulmonary disease [2]. Resident # 62's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/02/2021, coded Resident # 62 as scoring a 9 [nine] on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 - being moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 15 for Oxygen Therapy while a resident. On 11/30/21 at approximately 8:45 a.m., an observation of Resident # 62 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.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for two of five CNA record reviews, CNA #6 and CNA #7. The facility staff failed to complete an annual performance review for CNA #6, hired on 8/29/19 and CNA #7, hired on 1/7/20. The findings include: CNA #6 was hired on 8/29/19. Review of CNA #6's record revealed a performance review with no date. CNA #7 was hired on 4/2/18. Review of CNA #7's record revealed the last performance review was completed on 1/7/20. On 12/1/21 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #5 (the regional vice president of operations). ASM #5 stated CNA performance reviews should be completed by the CNA's supervisor annually. At this time, ASM #1 (the interim administrator), ASM #2 (the director of nursing), ASM #4 (the regional director of clinical operations) and ASM #5 were made aware of the above concern. The facility policy titled, Performance Evaluations documented, 2. A performance…

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 it was determined that the facility staff failed to provide pharmacy services for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to ensure the medications, Metoprolol [1] Zestoretic [2], Glimepiride [3] and Ozempic [4] were available for administration to Resident # 201 as ordered by the physician on 5/22/21, 5/23/21 and 5/24/21. The findings include: Resident # 210 was admitted to the facility with diagnoses that included but were not limited to: breast cancer, pain, diabetes mellitus [5] and kidney disease, high blood pressure. Resident # 201's MDS (minimum data set), an admission 5-day assessment with an ARD (assessment reference date) of 05/24/2021 coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of Resident #201's clinical record revealed a physician's order dated 5/21/21, signed by the physician on 5/24/21, that documented in part: Metoprolol ER [extended release] 25mg…

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 facility staff interview it was determined that the facility staff failed to maintain a complete and accurate record for one of 46 residents in the survey sample, Resident #29. The findings include: Resident #29 was admitted to the facility with diagnoses that included but were not limited to sepsis (1) and gastrostomy (2). Resident #29's most recent MDS, a quarterly assessment with an ARD of 9/3/2021, coded Resident #29 as being moderately impaired for making daily decisions. Section M documented Resident #29 having one stage III pressure ulcer (3) on admission and three stage IV pressure ulcers, one being present on admission. The eTAR (electronic treatment administration record) for Resident #29 dated 10/1/2021-10/31/2021 failed to evidence documentation of the following treatments completed on the following dates, - On 10/14/2021 and 10/21/2021- Night, Cleanse around g-tube (gastrostomy tube) site with wound cleanser pat dry apply zinc oxide around g-tube site…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service training for two of five CNA record reviews, CNA #2 and CNA #8. The facility staff failed to ensure CNA #2 and CNA #8 completed annual dementia training. The findings include: CNA #2 was hired on 12/16/16. Review of CNA #2's record failed to reveal evidence that the CNA had completed annual dementia training. CNA #8 was hired on 12/16/16. Review of CNA #8's record failed to reveal evidence that the CNA had completed annual dementia training. On 12/1/21 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #5 (the regional vice president of operations). ASM #5 stated dementia training should be completed annually by the CNAs within the computer training system and the human resources department tracks the percentage of completion in the computer training system. At this time, ASM #1 (the interim administrator), ASM #2 (the director of nursing), ASM #4 (the regional director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify the physician and/or responsible party of resident to resident incidents or the need to alter treatment for one of 50 residents in the survey sample, Residents #18. The facility staff failed to notify the physician and/or the nurse practitioner when Resident #18's medications were not administered on 12/31/19. The findings include: Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to dementia, high cholesterol and major depressive disorder. Resident #18's annual MDS (minimum data set), assessment with an ARD (assessment reference date) of 12/10/19, coded the resident's cognitive skills for daily decision-making as moderately impaired. Review of Resident #18's clinical record revealed a physician's order dated 12/14/18 for simvastatin (1) 40 mg (milligrams) by mouth at bedtime, a physician's order dated 1/3/19 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain the resident right to be free from abuse for nine of 50 residents in the survey sample, Residents #69, #67, #650, #652, #7, #651, #22, #41, and #39. - On 1/22/19, facility staff failed to ensure that Resident #69 and Resident #67 were free from abuse from each other. Resident #67 hit Resident #69, and then Resident #69 hit Resident #67 back. - On 2/26/19, facility staff failed to ensure that Resident #650 was free from abuse, when Resident #69 hit Resident #650 in the face on the nose and forehead. - On 2/15/19, facility staff failed to ensure that Resident #652 was free from abuse, when Resident #69 grabbed Resident #652 by the neck. - On 3/18/19, facility staff failed to ensure that Resident #7 was free from abuse, when Resident #69 hit Resident #7 in the face without injury. - On 6/20/19, facility staff failed to ensure that Resident #651 was free from abuse, when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy to report and investigate allegations of abuse to the required State agency for eight of 50 residents in the survey sample, (Residents #69, #67, #7, #41, #22, #39, #650, and #652). On 1/22/19, Resident #67 hit Resident #69, and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. The facility staff failed to implement the facility abuse policy to investigate and report the incident to the required state agency and failed to notify Resident #67's, #7's and #41's physicians and responsible parties per the policy. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. On 3/6/20, Resident #69 pulled Resident #39 out of his chair to the floor. On 2/26/19, Resident #69 hit Resident #650 in the face.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse, for eight of 50 residents in the survey sample, (Residents #69, #67, #7, #41, #22, #39, #650, and #652). On 1/22/19, Resident #67 hit by Resident #69 and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. On 3/6/20, Resident #69 pulled Resident #39 out of his chair to the floor. On 2/26/19, Resident #69 hit Resident #650 in the face. On 2/15/19, Resident #69 grabbed Resident #652 by the neck. The facility staff failed to report immediately the allegations of abuse for Resident # 69, #67, #7, #41, #22, #39, #650 and #652 to the required state agency. The findings include: A review of the facility policy, Resident Abuse dated February 2017 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate allegations of abuse, for seven of 50 residents in the survey sample, Residents #69, #67, #7, #41, #22, #650, and #652. On 1/22/19, Resident #67 hit by Resident #69 and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. On 2/26/19, Resident #69 hit Resident #650 in the face. On 2/15/19, Resident #69 grabbed Resident #652 by the neck. The facility staff failed to investigate the allegations of abuse for Residents# 69, #67, #7, #41, #22, #650 and #652. The findings include: A review of the facility policy, Resident Abuse dated February 2017 and revised January 2020, documented, Policy: It is inherent in the nature and dignity of each resident at Facility that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the required information to the receiving facility at the time of facility initiated transfers for six of 50 residents in the survey sample, Residents #114, #60, #36, #7, #59 and #40. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility for: Resident # 114 transferred on 01/03/2020; Resident # 60 transferred on 02/27/2020 and for Resident # 36 transferred on 01/09/2020. For Resident #7's transfer on 1/3/2020, for Resident #59's hospital transfer on 1/13/20 and for Resident #40's hospital transfer on 12/29/19. The findings include: 1. Resident # 114 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, sepsis [1], and diabetes mellitus [2]. Resident # 114's MDS [minimum data set], was not due at the time of survey. The facility's admission Assessment for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification to the ombudsman and/or the resident and the resident's representative of a facility/resident-initiated transfer for six of 50 residents in the survey sample, Residents #114, #60, #36, #7, #59 and #40. The facility staff failed to evidence that written notification of the reason for transfer was provided to resident # 114 and Resident # 114's responsible party for the resident hospital transfer on 01/03/2020. To Resident # 60, Resident # 60's representative and /or the ombudsman for the facility-initiated transfer of Resident # 60 on 02/27/2020, and to Resident # 36, Resident # 36's representative and the ombudsman for the facility-initiated transfer of Resident # 36 on 01/09/2020. The facility staff failed to evidence written notification was provided to the responsible party for a facility-initiated transfer of Resident #7, and to Resident #59'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 observation, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 50 residents in the survey sample, (Residents #313, 18, 11, 87, and 61). The facility staff failed to develop and implement a comprehensive care plan to address Resident #313's fall risk. The facility staff failed to implement Resident #18's comprehensive care plan for medication administration, failed to implement Resident #11's comprehensive care plan for oxygen administration, and failed to implement Resident # 87's comprehensive care plan for the use of oxygen. The facility staff failed to develop a comprehensive care plan to address Resident # 61's use of a C-PAP [Continuous Positive Airway Pressure]. The findings include: 1. The facility staff failed to develop and implement a comprehensive care plan to address Resident #313's fall risk. Resident #313 was admitted to the facility 3/2/2020 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 6. The facility staff failed to review and revise Resident #39's comprehensive care plan for the use of halo assist bar bed rails. Resident #39 was admitted to the facility on [DATE]. Resident #39's diagnoses included but were not limited to seizures, high blood pressure and muscle weakness. Resident #39's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/14/20, coded the resident's cognition as severely impaired. Section G coded Resident #39 as requiring extensive assistance of two or more staff with bed mobility. Resident #39's comprehensive care plan dated 11/5/19 failed to document information regarding the resident's use of halo assist bar bed rails. On 3/9/20 at 8:21 a.m., Resident #39 was observed in bed with bilateral halo assist bars up. On 3/9/20 at 5:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1 regarding comprehensive care plan revisions for halo assist bars. LPN #1 stated the nurses obtain a recommendation from the therapy staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review it was determined facility staff failed to follow professional standards of practice for two of 50 residents in the survey sample, Resident #99 and Resident #61. The facility staff failed to follow medication administration standards of practice during the administration of Protonix delayed release tablet on 3/9/20. RN (registered nurse) #1 crushed, opened and mixed the contents of one 40 mg (milligram) Protonix delayed release capsule with pudding and administered the medication to Resident #99. The facility staff failed to obtain an order for Resident #61 use of a CPAP [continuous positive airway pressure]. The findings include: 1. Resident #99 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pulmonary embolism (2) and major depressive disorder (3). Resident #99's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/19/2020 coded Resident #99 as scoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services in accordance with professional standards of practice and the comprehensive plan of care for two of 50 residents in the survey sample, (Residents #18 and #40). The facility staff failed to administer physician prescribed medications to Resident #18 on 12/31/19. The facility staff failed to maintain a current physician's order for Resident #4 to received Hospice care and services. The findings include: 1. Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to dementia, high cholesterol and major depressive disorder. Resident #18's annual MDS (minimum data set), assessment with an ARD (assessment reference date) of 12/10/19, coded the resident's cognitive skills for daily decision making as moderately impaired. Review of Resident #18's clinical record revealed a physician's order dated 12/14/18 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for four of 50 residents in the survey sample, Residents #11, #87, #99 and #61. The facility staff failed to administer oxygen to Resident #11, #87 and #99, at flow rate prescribed by the physician. The facility staff failed to store Resident # 61's C-PAP [Continuous Positive Airway Pressure] mask in a sanitary manner. The findings include: 1. The facility staff failed to administer oxygen to Resident #11 at the physician prescribed rate of two liters per minute. Resident #11 was admitted to the facility on [DATE]. Resident #11's diagnoses included but were not limited to diabetes, heart failure and high blood pressure. Resident #11's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/10/19, coded the resident's cognition as moderately impaired. Section G coded Resident #11 as requiring…

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 it was determined facility staff failed to ensure expired medications and biological's were not available for use in two of four medication carts observed, (North Unit yellow and North Unit one medication cart), and one of one medication rooms observed, (South Unit medication room). On the North Unit yellow medication cart 2 bottles of medication expired were observed available for use a bottle of zinc sulfate (mineral supplement) 220mg (milligram) with Best by 12/19 labeled on the bottle, and a 10 (ten) oz. (ounce) bottle of Geri-mucil fiber laxative and dietary supplement with 09/19 printed on the bottle. On the North Unit Medication cart 1 (one) eleven plastic vials of Albuterol Sulfate inhalation solution 0.083% (percent) 2.5mg (milligram)/3ml (milliliter), labeled, Exp [expire]: Sep 2019, were available for resident use. In the medication room located on the South Unit of the facility, nine containers of expired Nepro with Carb steady 1.8cal (calorie) (ready to hang…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to prepare food in the facility's kitchen in a sanitary manner and store food in a sanitary manner in two of two nutritional rooms. The findings include: On 03/08/2020 at 11:45 a.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, dietary manager with the following results: An observation of OSM # 3, dietary aide, revealed they were preparing resident lunch trays in the kitchen without their mustache covered. An observation of OSM # 2, cook, revealed they were handling dinner rolls with gloved hands after handling packages of salad dressings that had been stored facility's dry storage room without changing their gloves. Observation on 03/08/2020 of the south unit's nutritional room with OSM # 1, fine dining coordinator at 4:00p.m., revealed a plastic container containing eight slices of cheesecake in the refrigerator. Further observation revealed two slices of cheesecake wrapped in a napkin sitting on top of the cheesecake container.…

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 facility staff failed to implement infection control practices for the storage of a C-PAP mask for one of 50 residents in the survey sample, Residents # 61; in the laundry room and in one of two dining rooms, (the facility's main dining room). The facility staff failed to store Resident #61's CPAP [continuous positive airway pressure] mask in a manner to prevent infection. The facility staff failed to maintain the clean laundry area in a clean and sanitary manner. Dust, dirt and lint were observed on the metal overhead conduit piping, vents and support beams. During the lunch meal service in the main dining room on 3/8/20 at approximately 12:10 p.m., CNA (certified nursing assistant) #1 was observed touching resident food items, without changing gloves that were worn while touching multiple other items, such as serving trays, and stands. The findings include: 1. Resident # 61 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for one of 50 residents in the survey sample, Resident #18. Multiple brown stains were observed on the resident's privacy curtain. The findings include: Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to repeated falls, diabetes and major depressive disorder. Resident #18's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/10/19, coded the resident's cognitive skills for daily decision-making as moderately impaired. On 3/8/20 at 1:09 p.m., and 3/9/20 at 8:21 a.m., observation of Resident #18's room was conducted. The resident was lying in bed. Approximately 15 brown stains were observed on the privacy curtain. All of the stains were approximately the size of a penny or smaller. On 3/9/20 at approximately 2:15 p.m., an interview was conducted with OSM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that the facility staff failed to provide treatment and services to maintain and/or restore a resident's bladder function for one of 50 residents in the survey sample, Resident #78. The facility staff failed to identify and address Resident #8's decline in urinary continence between a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/9/19 and a quarterly MDS assessment with an ARD of 2/12/20. The findings include: Resident #78 was admitted to the facility on [DATE]. Resident #78's diagnoses included but were not limited to diabetes, urinary incontinence and high blood pressure. Resident #78's quarterly MDS assessment with an ARD of 12/9/19 coded the resident as being cognitively intact, scoring a 14 out of 15 on the brief interview for mental status. Section H coded Resident #78 as occasionally incontinent of urine (less than seven episodes of incontinence during the seven-day 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.

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 implement bed rail requirements for three of 50 residents in the survey sample, (Residents #39, #107 and #43). The facility staff failed to assess Resident #39, #107 and #43 for the use of halo assist bar bed rails, failed to review risks and benefits with the residents (or the resident's representative) and failed to obtain informed consent for the use of halo assist bar bed rails. The findings include: 1. Resident #39 was admitted to the facility on [DATE]. Resident #39's diagnoses included but were not limited to seizures, high blood pressure and muscle weakness. Resident #39's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/14/20, coded the resident's cognition as severely impaired. Section G coded Resident #39 as requiring extensive assistance of two or more staff with bed mobility. Review of Resident #39's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure physician prescribed medication were available for administration as ordered for one of 50 residents in the survey sample, Resident #18. On 12/31/19, the facility staff failed to administer the medication trazadone (1) to Resident #18 because the medication was on order from the pharmacy. The findings include: Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to dementia, high cholesterol and major depressive disorder. Resident #18's annual MDS (minimum data set), assessment with an ARD (assessment reference date) of 12/10/19, coded the resident's cognitive skills for daily decision-making as moderately impaired. Review of Resident #18's clinical record revealed a physician's order dated 11/7/19 for trazodone 25 mg (milligrams) by mouth at bedtime. The medication was scheduled for 8:00 p.m. on Resident #18's December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to administer the pneumococcal immunization for one of five influenza and pneumococcal resident reviews, Resident #7. Consent for Resident #7 to receive the pneumococcal immunization was obtained on 10/5/19 and the facility staff failed to administer the immunization. The findings include: Resident #7 was admitted to the facility on [DATE]. Resident #7's diagnoses included but were not limited to stroke, diabetes and muscle weakness. Resident #7's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/6/19 coded the resident as being cognitively intact. Section O0300 documented Resident #7's pneumococcal vaccination was not up to date. Review of Resident #7's clinical record revealed a pneumococcal vaccine consent form dated 10/5/19, that was signed by two nurses and documented Resident #7 did wish to receive the pneumococcal vaccine (immunization).…

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.