Westwood Center

Based on observation, resident interview, staff interview, clinical record review, and facility document review the facility staff failed to provide adequate respiratory care for 1 of 22 residents in the survey sample, (Resident #63). The findings include: For Resident #63 the facility staff failed to label and date each component of the oxygen extension tubing and failed to provide a new pre-filled humidifier bottle for resident upon utilization of the oxygen concentrator. Resident #63's diagnosis list indicated diagnoses that included, but were not limited to, Streptococcal Arthritis to Right Knee, Sepsis, UTI (urinary tract infection), Acute Kidney Failure, Hypertensive Chronic Kidney Disease-Stage 4, Peripheral Vascular Disease, Atrial Fibrillation, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of, 8/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #63 was cognitively intact. On 8/18/24 at 3:45 PM, surveyor interviewed Resident #63…

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

Based on observation, staff interview, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 1 of 22 residents, Resident #43. The findings included: For Resident #43 the facility staff failed to ensure the medication Diltiazem was available for administration. Resident #43's face sheet listed diagnoses which included but not limited to hypertension, congestive heart failure and atrial fibrillation. Resident #43's most recent minimum data set with an assessment reference date of 08/13/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #43's comprehensive care plan was reviewed and contained a care plan for Resident exhibits or is at risk for cardiovascular symptoms or complications related to hypertension, A FIb (atrial fibrillation), CHF (congestive heart failure). Interventions for this care plan included Administer medications as ordered . 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.

2. For Resident #29 the facility failed to ensure Resident #29 was free of an unnecessary medication, Novolin. (Novolin is a medication used to treat diabetes.) Resident #29's diagnosis list indicated diagnoses that included, but were not limited to, Lung Cancer, Type 2 Diabetes Mellitus, Atrial Fibrillation, Fibromyalgia, Anxiety Disorder, Depression, and Chronic Kidney Disease-Stage 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/14/24, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #29 was cognitively intact. Resident #29's clinical record included a Nursing Report, that read in part, Includes the following Classifications: MRR (medication regimen review) For Recommendations Created Between 7/25/2024 And 7/25/2024 Includes Routings for: Nursing, IDT (interdisciplinary team) .Consultant Pharmacist .The resident has an order for NovoLIN R (regular) Injection Solution 100 UNIT/ML (milliliters) (Insulin Regular (Human)) Inject 22 (twenty-two) unit…

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, clinical record review and facility document review, the facility staff failed to ensure 1 of 22 residents was free from unnecessary psychotropic medications, Resident # 43. The findings included: The facility staff failed to monitor resident # 43 for behaviors or side effects related to psychotropic medications. Resident # 43's diagnoses included but were not limited to unspecified dementia without behavior disturbance, generalized anxiety disorder, major depressive disorder, insomnia and chronic pain syndrome. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/13/24 assigned the resident a brief interview for mental status (BIMS) score of 15 indicating they were cognitively intact. The MDS indicated the resident admitted to the presence of several mood indicators in the look back period. Resident # 43 reported little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, and feeling bad about themselves. The medication administration record (MAR) was reviewed.…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 22 residents was free from significant medication errors. The findings included: For Resident #9 the facility staff failed to administer the medication, Meropenem per the physician's orders. Meropenem is an antibiotic used to treat bacterial infections. Resident #9's face sheet listed diagnoses which included but not limited to sepsis, severe sepsis with septic shock, necrotizing fasciitis, methicillin resistant staphylococcus aureus (MRSA), extended spectrum beta lactamase (ESBL) resistance, and pseudomonas. Resident #9's most recent minimum data set with an assessment reference date of 08/08/24 assigned the resident brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #9's comprehensive care plan was reviewed and contained a plan for Patient has a suspected/actual infection and is at risk for sepsis, has history of or risk factors for sepsis related to Septic Left…

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, the facility staff failed to appropriately store, prepare and/or serve resident food items. The findings included: On 8/18/24 at 2:12 PM during the initial tour of the dietary department, this surveyor and other employee # 4 entered the walk-in cooler. Employee # 4 had identified themselves as a cook/aide and stated, I'm second in command. They indicated they were in charge when the dietary manager is off. A plastic jug approximately 1/4 full, labeled peeled garlic was noted on the shelf. There were three dates written on the lid as follows, OP 3/20/24 underneath that 3/15/24 and underneath that was a date of 5/20, but the year was not legible, it had been smeared. Surveyor asked employee # 4 what each date means. They stated, This is the day it was opened pointing to the OP 3/20/24 date, and this would be the date that it came in because it's earlier pointing to the 3/15/24 date. When asked about the 5/20 date, they stated, I think that is 5/20/24. I think I need to throw it away. When surveyor asked what 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, clinical record review, facility document review, the facility staff failed to obtain physician ordered labs for 4 of 33 residents, Resident #4, Resident #42, Resident #11, and Resident#199. The findings included: 1. For Resident #4 the facility staff failed to obtain physician ordered wound cultures. Resident #4's face sheet listed diagnoses which included but not limited to multiple sclerosis, depression, anxiety, and contractures of muscles. The most recent MDS with an assessment reference date of 02/06/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section M, skin conditions, coded the resident as having one stage one pressure ulcer that was present upon admission. Section M, subsection M1040, other ulcers, wounds and skin problems coded the resident as none of the above present. This subsection includes surgical wounds. Resident #4's comprehensive care plan…

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

Based on interviews and document review, the facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification for one (1) of three (3) residents selected for SNF Beneficiary Notification Review (BNR) (Resident #2). The findings include: Three (3) residents were selected for SNF Beneficiary Notification Review. These three (3) residents were selected from the list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey; this list was provided by facility staff members. Resident #2 was marked as not being provided a SNF ABN due to resident no longer required skilled services (and) switched to Medicaid services. On 3/13/23 at 1:13 p.m., the facility's Business Office Manager (BOM) stated Resident #2 was discharged from Part A with three (3) skilled benefit days remaining; the BOM stayed Resident #2 stayed in the facility. The BOM acknowledged Resident #2 should have received a SNF ABN. On 3/13/13 at 3:35 p.m., the BOM provided 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 interviews and record reviews, the facility staff failed to ensure one (1) of 33 residents had orders, at the time of admission, to guide care (Resident #46). The findings include: Resident #46 was documented as being readmitted to the facility on [DATE] at 4:35 p.m. Resident #46 was transported via ambulance to a local emergency department on 2/16/23 at 11:56 a.m. The facility staff failed to promptly obtain wound care and medication orders, for Resident #46, at the time of the readmission. Resident #46's minimum data assessment (MDS), with an assessment reference date (ARD) of 12/15/22, was dated as being completed on 12/29/22. Resident #46 was documented as never or rarely able to understand others and as never or rarely able to make self understood. Resident #46 was documented as being totally dependent on others for eating, bed mobility, dressing, toilet use, and personal hygiene. Resident #46's diagnoses included, but were not limited to: hemiplegia/hemiparesis, seizure disorder, irregular…

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 ensure an accurate minimum data set (MDS) assessment for 1 of 33 residents, Resident #4. The findings included: For Resident #4 the facility staff failed to properly code a wound on the MDS. Resident #4's face sheet listed diagnoses which included but not limited to multiple sclerosis, depression, anxiety, and contractures of muscles. The most recent MDS with an assessment reference date of 02/06/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section M, skin conditions, subsection M1040, other ulcers, wounds and skin problems coded the resident as none of the above present. This subsection includes surgical wounds. Resident #4's comprehensive care plan was reviewed and contained care plans for Resident at nutrition risk r/t (related to) . Wounds: Surgical PI Open wound to R (right) hip skin fold, healing .and . is at risk for continuing impaired skin integrity related 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 staff interview and clinical record review, facility staff failed to initiate a care plan within 48 hours that addressed the resident's clinical needs for 2 of 33 residents, Resident #36 and #149 1. For Resident #36, facility staff failed to implement a baseline care plan to address the resident's needs as evidenced by failure to address surgical wounds on the care plan within 48 hours of admission. Resident #36 was admitted to the facility with diagnoses including (by listed date of diagnosis) type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, morbid obesity, obstructive sleep apnea,muscle weakness, hypertensive heart and chronic kidney disease with heart failure, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, chronic obstructive pulmonary disease with acute exacerbation, atrial fibrillation, sepsis due to escherichia coli, and bacteremia. On the minimum data set assessment with assessment reference date…

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

Based on staff interview, family interview and clinical record review, the facility staff failed to initiate interventions to address the resident's wound care needs for 1 of 33 residents reviewed (Resident #149). Resident #149 was admitted to the facility with diagnoses to include encounter for orthopedic aftercare following surgical amputation, diabetes mellitus due to underlying condition with diabetic nephropathy, atrial fibrillation, hypertensive heart disease with heart failure, asthma, infection following a procedure-superficial incisional surgical site-subsequent encounter, muscle weakness, and difficulty walking. The minimum data set assessment (MDS) with the assessment reference date 1/19/2023 was reviewed. The resident scored 13/15 on the brief interview for mental status, and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The MDS also documented the resident had surgery during the prior 100 days, recent surgery requiring SNF care, infection of the foot, surgical wounds, and surgical wound care. The resident's comprehensive 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, clinical record review, facility document review, the facility staff failed to review and revise the comprehensive person-centered plan of care for 1 of 33 residents in the survey sample, Resident #299. The findings included: For Resident #299, the facility staff failed to revise the comprehensive person-centered plan of care following the development of a pressure injury. This was a closed record review. Resident #299's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Aftercare following Joint Replacement Surgery, Dislocation of Internal Right Hip Prosthesis, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, and Type 2 Diabetes Mellitus. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/25/22 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. The resident was coded as being at risk 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, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for the notification and assessment of critical laboratory test results for 2 of 33 Residents, Resident #10, and Resident #14 The findings included: 1. For Resident #10 the facility staff failed to notify the provider, assess and/or treat the resident for a critical potassium (K) level and a critical glucose level. Resident #10's face sheet listed diagnoses which included but not limited to anemia, chronic obstructive pulmonary disease, dementia, basal cell carcinoma of skin, and hypertension. Resident #10's most recent minimum data set with an assessment reference date of 02/07/23 coded the resident as 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #10's comprehensive care plan was reviewed and contained a care plan for Resident is at nutrition risk r/t (related to) need for altered…

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 interviews and document review, the facility staff failed to ensure that admission orders included nutrition and fluid orders for one (1) of 33 residents, Resident #46. Resident #46 received their nutrition and fluids via enteral means. Resident #46 was not able to intake nutrition and/or fluids orally. (Enteral nutrition is a way of providing nutrition, via tube, directly to an individual's stomach or small intestine.) The findings include: Resident #46 was documented as being readmitted to the facility on [DATE] at 4:35 p.m. Resident #46 was transported via ambulance to a local emergency department on 2/16/23 at 11:56 a.m. The facility staff failed to obtain tube feeding orders for Resident #46 during the aforementioned stay at the facility. Resident #46's minimum data assessment (MDS), with an assessment reference date (ARD) of 12/15/22, was dated as being completed on 12/29/22. Resident #46 was documented as never or rarely able to understand others and as never or rarely able to make self…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and physician's orders for 1 of 33 residents in the survey sample, Resident #38. The findings included: For Resident #38, the facility staff failed to administer oxygen as ordered by the physician and according to the resident's comprehensive person-centered care plan. Resident #38's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Nontraumatic Subarachnoid Hemorrhage, Type 2 Diabetes Mellitus, Asthma, and Bipolar Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/24/22 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #38 was coded as requiring extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was also coded as receiving…

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

Based on interviews and document review, the facility staff failed to ensure Medication Regimen Reviews (MRRs) were addressed by a medical provider for three (3) of five (5) residents selected for unnecessary medication review (Resident #14, Resident #17, and Resident #26). The findings include: 1. The facility staff failed to ensure three (3) of Resident #14's Medication Regimen Reviews (MRRs) were documented and addressed by a medical provider. Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/16/22, was dated as being completed on 12/29/22. Resident #14 was assessed as sometimes able to make self understood and as sometimes able to understand others. Resident #14 was assessed as having problems with short-term and long-term memory. Resident #14 was assessed as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #14's clinical documentation included the same note on the following three (3) dates: (a) 10/25/22; (b) 11/21/22; and (c) 1/26/23. The note read as A medication regimen review was…

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

Based on observation, staff interview and clinical record review the facility staff failed to ensure one out of 21 residents were free from medication errors, Resident #104. The findings included: For Resident #104 the facility staff administered the medications enalapril and metoprolol outside the physician ordered parameters on separate occasions. Enalapril and metoprolol are both medications used to treat high blood pressure. Resident #104's face sheet listed diagnoses which included but not limited to essential (primary) hypertension (high blood pressure). The most recent minimum data set with an assessment reference date of 02/07/23 assigned the resident a brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #104's comprehensive care plan was reviewed and contained a care plan for Resident exhibits or is at risk for cardiovascular symptoms or complications related to HTN (hypertension), edema, increasing risk of CVA (cerebrovascular accident [stroke])/kidney disease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to promptly notify a medical provider of Resident #14's critically low blood glucose level. A blood glucose test is a blood test that measures the level of sugar (glucose) in the blood. Low blood sugar (also called hypoglycemia) has many causes, including missing a meal, taking too much insulin, taking other diabetes medicines, exercising more than normal, and drinking alcohol. Blood sugar below 70 mg/dL is considered low . Low blood sugar can be dangerous and should be treated as soon as possible. (Downloaded from https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html on 3/16/23) Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/16/22, was dated as being completed on 12/29/22. Resident #14 was assessed as sometimes able to make self understood and as sometimes able to understand others. Resident #14 was assessed as having problems with short-term and long-term memory. Resident #14 was assessed as requiring assistance with bed…

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, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to discard an out-of-date food item and failed to label opened food items in the refrigerator. The findings include: The facility staff failed to label a bag of shredded cheese that had been opened and failed to discard an opened bottle of Worcestershire Sauce with a use by date of 9/13/22. On 3/12/23 at 2:30 P.M. during the initial tour of the kitchen, surveyor observed an opened, clear bag of shredded cheese with no label or date on it in the walk-in cooler. Other staff member # 3 stated, they just opened that the other day, we go through cheese fast. Surveyor asked if the bag should have a label on it and they stated that it should have a date on it when it was opened. Surveyor then observed a large, opened bottle of Worcestershire Sauce with a use by date of 9/13/22. Other staff #3 stated, I didn't even know that was in here, I'll throw it away. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record/documentation for four of 21 sampled residents, Resident #103, Resident #108, Resident #117, and Resident #106. The findings were: 1. The facility staff failed to document Resident #103's dressing changes accurately. Resident #103's minimum data set with an assessment reference date of 02/01/2023 coded the resident as a 14 out of 15 in the brief interview for mental status (BIMS) summary score in Section C - cognitive patterns. Resident #103 required assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene as coded in Section G (Functional Status). Resident #103's clinical record contained a provider order dated 05/04/23 for wound care/surgical incision right below knee amputation (BKA): cleanse with inhouse wound cleanser (IHWC), pat dry, cover small open area with xeroform, then with non-stick telfa and ABD pad. Secure with…

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

Based on staff interview and facility document review, the facility staff failed to ensure a Quality Assurance and Performance (QAPI) Program to meet the needs of the facility as evidenced by repeated deficiencies in the area of Quality of Care related to wound management. The findings included: Quality of Care was previously cited with the 2/21/20 and 5/20/21 Medicare/Medicaid standard surveys for failing to follow physician's orders in regard to treatment administration and/or wound care. On 3/20/23 at 12:29 pm, surveyor met with the administrator and discussed the facility QAPI Program. The administrator stated the QAA (Quality Assessment and Assurance) Committee met monthly and consisted of the administrator, director of nursing, interdisciplinary team members, the infection preventionist, and the medical director. The administrator stated the medical director attended at least quarterly and often additional staff members attended. The administrator stated QAA Committee information was entered into a computer system and accessible by the facility governing body. Surveyor…

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, the facility staff failed to perform hand hygiene after cleaning the wound and placing a clean dressing for 1 of 33 residents in the survey sample, Resident #36. Resident #36 was admitted to the facility with diagnoses including (by listed date of diagnosis) type 2 diabetes mellitus with diabetic polyneuropathy,peripheral vascular disease, morbid obesity, obstructive sleep apnea,muscle weakness, hypertensive heart and chronic kidney disease with heart failure, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, chronic obstructive pulmonary disease with acute exacerbation, atrial fibrillation, sepsis due to escherichia coli, bacteremia. On the minimum data set assessment with assessment reference date 2/1/23, the resident scored 14/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor interviewed the resident on 3/12/23 concerning life in the facility. The resident had no…

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

Based on staff interview, employee record review and facility documentation review, the facility staff failed to obtain verification of licensure from the Department of Health Professions prior to hire for 2 (Employees # 15 and # 24) of 5 Registered Nurses, for 1 (Employee # 13) of 5 Licensed Practical Nurses and the facility staff failed to ensure a criminal background check was obtained timely for 1 (Employee # 26) of 27 employees in the Employee Records Check sample. The Findings included: 1. For Employee # 15, the facility staff failed to obtain licensure verification prior to hire. On 5/19/2021- 5/20/2021, review of employee records was conducted. Review of the personnel file for Employee # 15 was conducted and revealed Employee # 15 was hired on 9/28/2020 as a Registered Nurse, Unit Manager. Employee # 15's Registered Nurse license was not verified by the facility staff with the Department of Health Professions until 5/19/2021 at 13:23 (1:23 p.m.), during the survey. . On 5/20/2021 at 3:34 p.m., an interview was conducted with the Human Resources Director who confirmed 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.

19. For Resident 196, the facility staff failed to administer a PPD per the physicians orders. A (PPD) purified protein derivative skin test is a test that determines if you have (TB) tuberculosis. The face sheet in Resident 196 clinical record included the diagnosis degenerative diseases of basal ganglia, hemiplegia, epilepsy, and hypertension. Resident 196 was a new admit and had no completed MDS assessment. Resident 196 was unable to communicate with the surveyor. Resident 196's (EHR) electronic health record included an order dated 05/06/2021 for tuberculin PPD solution inject 0.1 ml intradermally one time only for screening. This was a verbal order that had been confirmed by the (DON) director of nursing. 05/08/2021 the nursing staff documented that they would obtain information regarding the residents previous PPD from another nursing facility. This information was not obtained and the PPD was not administered. The facility staff administered the PPD on 05/10/2021. The facility nursing staff failed to read the results. The facility policy titled, 20.2 Tuberculosis Screening…

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, clinical record review, facility document review, and during the course of a complaint investigation, facility staff failed to inform the resident's responsible party and physician of a change in skin status for 1 complaint resident (Resident #246). The findings were: 1. For Resident #246, facility staff failed to immediately notify the resident's responsible party (RP) and physician when there was a change in the resident's mid back skin integrity. Resident #246 diagnoses included but were not limited to dementia with behavioral disturbance, transient ischemic attack (TIA - mini stroke) and cerebral infarction (stroke), atrial fibrillation (irregular heart rate), and hemiplegia (severe loss of strength on one side of the body) and hemiparesis (mild or partial weakness of one side of the body). On the minimum data set assessment (MDS) with assessment reference date (ARD) 12/02/2020, Section G (Functional Status) noted the resident was totally dependent and required two + person physical assist for transfers. For bed mobility, the resident required extensive…

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, resident interview, and clinical record review, facility staff failed to determine that an assessment needed to completed for a significant change regarding the development of what was stated to be a deep tissue injury for 1 of 12 residents in the survey sample (Resident #6). The findings were: 1. For Resident #6, Facility staff failed to assess skin condition and to treat what was stated to be a deep tissue injury at a pressure point on the resident's left heel. Resident #6 was admitted to the facility with diagnoses including Type 1 diabetes mellitus, traumatic brain injury, history of falls, major depression, convulsions, polyneuropathy, pain in knee and hip, and hypertension. During the initial contact on 5/18/21, the surveyor asked the resident if there were any wounds or skin injuries. The resident showed the surveyor a blackened place on the left side of the left heel that was nickel-sized blackened skin with a distinct reddened border. It was the size and in the location where the resident's foot rested on the mattress. The resident…

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

Based on staff interview, resident interview, and clinical record review during review of a complaint, facility staff failed to provide necessary care and services for prevention and treatment of pressure ulcers for 1 of 12 residents in the survey sample (Resident #246). The findings were: 1. The facility staff failed to prevent Resident #246 from developing a pressure ulcer to his mid back. Resident #246 diagnoses included but were not limited to dementia with behavioral disturbance, transient ischemic attack (TIA - mini stroke) and cerebral infarction (stroke), atrial fibrillation (irregular heart rate), and hemiplegia (severe loss of strength on one side of the body) and hemiparesis (mild or partial weakness of one side of the body). On the minimum data set assessment (MDS) with assessment reference date (ARD) 12/02/2020, Section G (Functional Status) documented the resident was totally dependent and required two + person physical assist for transfers. For bed mobility, the resident required extensive assistance by two + persons physical assist. This MDS did not have a BIMS…

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

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure a resident's respiratory/oxygen equipment was appropriately changed for one (1) of 15 sampled residents (Resident #40). The findings include: The facility staff failed to ensure Resident #40's tracheostomy oxygen collar and oxygen humidification device was appropriately changed. Resident #40 minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/5/21, was signed as completed on 5/12/21. Resident #40 was assessed as being usually able to make self understood and as being usually able to understand others. Resident #40's brief interview for mental status (BIMS) summary score was documented as five (5) out of 15. Resident #40 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #40's diagnoses included, but were not limited to: heart failure, hyperlipidemia, diabetes, dementia, kidney disease, and lung disease. On the afternoon of 5/18/21, Resident #40's oxygen administration equipment…

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 interviews, the review of documents, and during the course of a complaint investigation, it was determined the facility staff failed to ensure the competition of orientation was documented for a staff member (Licensed Practical Nurse (LPN) #21) prior to the staff member being scheduled to work independently. The findings include: The facility staff failed to have documentation to show LPN #21's completion of the facility's orientation process prior to LPN #21 being scheduled to work independently. The facility's administrative team was asked for policies and procedures for new LPN orientation. On 5/20/21 at 9:21 a.m., the Administrator provided a document titled NURSING ORIENTATION ROADMAP. This document indicated a nurse would receive between 40 - 120 ours of orientation time depending on their amount of previous long-term care experience. This document did not address how completion of LPN orientation would be documented. The Administrator reported no additional policies and/or procedures related to orientation was found. On 5/20/21 at 9:25 a.m., the Administrator…

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.